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August 20, 2020
“I want to give up heroin, but I still want to have a beer on the weekend with my friends.” The simple desire was from Ben, a patient, referred to as community members, at Eleanor Health in Mooresville, NC. He had tried giving up heroin on his own, and continually relapsed, but no other treatment provider would accept him into their program. Other programs require full abstinence with the belief that if he wasn’t willing to give up every substance, he “wasn’t ready” and wouldn’t be successful in treatment. What resulted was a lack of trust in the healthcare system, and a spiral that made Ben feel like a failure. He lost his job and his partner, moved back home, and cycled in and out of hospital emergency rooms and 28-day rehabs.
Ben’s story is one we hear frequently. He was given opioids for an injury in high school, and ultimately became addicted. He had untreated anxiety, and the impact the injury had on his life — taking away his identity as a 3-sport athlete — led him to substances to cope and self-manage. His story with treatment is also one we hear frequently. The treatment landscape in this country and in his community, based on stigma, abstinence, and weak evidence, failed him.
Other segments of healthcare have embraced population health and value-based care — an approach that focuses on improvements in health, addresses care longitudinally, and works with the whole person. Newer financial models pay for healthcare differently and support population health and achieved outcomes, a move from fee-for-service to value-based payments. In mental health and addiction, these payment and care delivery models are only just emerging, but they have the potential to dramatically improve the health and outcomes for patients like Ben.
For payers looking to implement effective payment models, and providers that want to focus on outcomes, below are four critical components:
1. Not firing patients
Traditional addiction treatment programs only offer “one-size-fits-all” or abstinence-only care approaches that prevent treatment for patients who aren’t completely abstinent from all substances. Historically, these types of programs have “fired” patients — kicked them out of the program for non-compliance with certain criteria including negative urine drug screens and unwavering abstinence — a practice rooted in stigma and the false belief that addiction is a choice and moral failing.
As a result, many patients’ treatment journey consists of various starts and stops through several recurrent episodes of expensive, out-of-network treatment or inpatient treatment programs that aren’t evidence-based. And even newer innovative models of care require adherence to all components of the program, like attending a group meeting in order to get life-saving medication, a practice that further marginalizes those struggling with addiction.
Value-based programs are personalized and recognize that addiction is a relapsing condition just like other chronic conditions.
2. Taking care of the whole person
Many providers are unequipped to address whole-person needs and instead focus narrowly on presence or absence of substance use despite the evidence that the majority of patients have other physical and mental health needs that occur alongside their substance use disorder. Roughly 80% of patients with SUD have other co-occurring psychiatric disorders, including trauma, depression, and anxiety. Additionally, the bidirectional relationship between physical and mental health drives higher rates of chronic physical health conditions among patients with SUD. Untreated physical health conditions can trigger SUD to relapse. Finally, social drivers of health such as housing and income instability and lack of meaningful connectedness and life purpose, substantially impact SUD outcomes.
Any program that is not addressing co-occurring mental health symptoms, physical health, and social drivers of health is not providing adequate treatment.
3. Reimbursing based on the quality, not quantity
Historically, payments for healthcare services are determined by the number of services provided. This fee-for-service reimbursement system has contributed to an overall increase in the amount of services and cost of care, without a commensurate improvement in the quality of services provided.
This is especially prevalent in the addiction treatment landscape, which relies on predetermined 28-day stay durations and compulsory urine drug screens despite evidence that neither alone improves health outcomes. Value-based care demands addiction treatment providers demonstrate measurable outcomes aligned with the quadruple aim:
Improved health of populations
Improved patient experience
Improved care team experience
Reduced total cost of care
Alternative payment models support the ability to improve quadruple aim outcomes by reimbursing for interventions that are critical, yet traditionally not reimbursable in fee-for-service arrangements, including proactive outreach and engagement to remove barriers to initiating care and maintaining retention; healthcare navigation to prevent disjointed care journeys and resultant attrition; and community-based interventions to address social drivers of health; and peer recovery support services to mitigate risk of illness relapse.
Payers who don’t reimburse, and providers who won’t be reimbursed, based on quality, not quantity, are not committed to improved outcomes.
4. Taking on the Financial Risk of Entire Populations
Value-based care requires a change from an individual patient mindset to a population-based mindset. Instead of being siloed and focused on one illness or one individual, value-based providers build systems and partnerships that enable more efficient and effective touchpoints across an entire patient population, thereby improving the care journey and health outcomes while reducing per capita cost of care. Benchmarked to the quadruple aim, value-based providers should be able to demonstrate process and target outcomes in several domains, including:
Access — Time from request to first appointment is associated with one-year remission rates. Value-based providers must offer on-demand access to addiction treatment.
Improved health outcomes — Improved health cannot be narrowed to abstinence and negative urine drug screens. Longitudinal harm reduction models have been shown to reduce overdose deaths and improve health over time, more so than disjointed, abstinence-based episodic care.
Superior experience — Individuals with addictive disorders routinely face marginalization, stigma, shame and discrimination. Value-based providers must be measuring and constantly improving both the staff experience and the patient experience.
Total cost of care — Being truly value-based requires a willingness to put revenue at risk if total cost of care doesn’t decrease and health outcomes don’t improve, ideally by population to prevent “cherry-picking” of patients.
Taking on financial risk is the true test of value — and belief in a program and its outcomes — but rarely seen in mental health and addiction treatment.
Fast forward nine months to what really matters — Ben. After relapsing two weeks into his recovery journey at Eleanor Health, Ben has been sober from heroin ever since. While he started his journey unwilling to take medication assisted treatment (MAT), he recognized the need to alter his plan after his relapse. He has repaired his relationship with his family, has a new job, and is moving in with his partner. He also drinks less on the weekend since he started engaging with a different social circle, one developed through the relationship connections made through his Community Recovery Partner. His bi-weekly trips to the Emergency Room have ended. Not every urine drug screen has been negative, and that’s ok — he recognizes that he has to work on his sobriety every day and that it isn’t something that can be “fixed” in 28 days.
Ben’s story is not unique. It is based on a model built on data and evidence, which means thousands came before him. The addiction treatment system is just beginning to recognize the need for value-based care and alternative payment models towards the goal of adequately managing SUD as the chronic medical condition it is. Many providers and payers are piloting bundled payments, but this alone does not represent value-based care. Assuming the financial risk for an individual episode of care is a positive first step, but is only the beginning. To be truly value-based, care providers must be held responsible for the health and satisfaction of populations, and alternative payment models must reimburse for quality and outcomes, not quantity.
Corbin Petro is the CEO & Co-Founder of Eleanor Health, the first addiction and mental health services provider designed to deliver long-term patient recovery outcomes and modeled on value-based care delivery and payments. Eleanor provides whole-person, comprehensive care for mental health and substance misuse in outpatient clinics, virtually, and in the community and patient’s homes.
If you need help with your substance use disorder, we are here to help you build your confidence and momentum towards the future you want. We provide treatment services for adults with alcohol, opioid, and other substance use disorders. We are currently located in Louisiana, Massachusetts, North Carolina, New Jersey, Ohio, and Washington.