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Performance measure development for addiction docs requires balancing act

March 28, 2015
by Gary A. Enos, Editor
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The American Society of Addiction Medicine's (ASAM's) newly released Performance Measures for the Addiction Specialist Physician stand to be as noteworthy for what they don't include as for what is part of the nine-measure set. A diverse panel of researchers and clinical experts concluded that they could not incorporate certain widely used addiction treatment practices into their measurement set for reasons such a lack of uniformity in how they are delivered, or their insufficient basis in rigorous research.

An example of this is the team-based care that is offered to patients in many addiction treatment settings, explains Corey Waller, MD, a Michigan physician who chaired ASAM's Performance Measures Expert Panel. “Those who do it know it's effective, but there aren't any randomized controlled trials out there to demonstrate this.”

ASAM this month released its set of performance measures designed to evaluate addiction specialist physicians' performance against the Standards of Care for the Addiction Specialist Physician that ASAM finalized last year. A consensus process that took about a year considered which measures would most significantly move the needle clinically, as well as whether they would be feasible for professionals to use and would not create unintended consequences such as payment system changes that would hurt patients.

Waller, who sees patients with addictions at the organization Spectrum Health in Grand Rapids, says a final-round list of 15 measures was whittled down to nine based on an absence of good data for some potential measures. Medication-assisted treatment (MAT) has a strong presence in the final nine and behavioral therapies do not, partly reflecting the fact that many of the latter interventions are carried out “behind closed doors” and are not clearly documented in electronic medical records (EMRs), Waller explains.

Here are the nine performance measure areas that made the ASAM panel's final cut:

  • The percentage of patients with an alcohol use disorder who are prescribed a medication.

  • The percentage of patients with an opioid use disorder who are prescribed a medication.

  • The number of patients who initiate treatment within seven days of detox/withdrawal management.

  • The percentage of patients receiving addiction treatment services who are formally screened for psychiatric illness.

  • The percentage of patients receiving addiction treatment services who are formally screened for a tobacco use disorder.

  • The percentage of addiction treatment patients who receive a primary care visit within six months of treatment initiation.

  • The rate of unplanned readmissions to an inpatient or residential treatment facility within 90 days of initial inpatient or residential treatment.

  • The extent to which clinicians document a substance use disorder diagnosis in their patients.

  • The extent to which clinicians document the presence or absence of a mental health disorder in their addiction treatment patients.

These measures are specifically designed for use by addiction specialist physicians, as opposed to primary care doctors offering substance use-related services. As the ASAM panel states in the report released this month, “While many public and private efforts are developing, endorsing, and implementing [substance use disorder] measures, virtually none of the initiatives apply specifically to addiction specialist physicians. Measures developed, to date, are mostly intended for broader use—either for primary care providers, hospitals, health systems or health plans.”

Specification documents will be drawn up for each of the nine performance measures in the initial set. Waller says that the first three measures to be addressed in this effort will be the two MAT measures and the seven-day follow-up care measure.

Guesswork not welcome

As all of healthcare practice moves toward value-based service, Waller sees the physician performance measures as helping to move the addiction treatment field into more of an evidence-based model.

“Right now we can have one professional seeing things totally different from the other guy,” Waller says. “It should no longer be a case of, 'I believe this is what we should do.'”

He adds in regard to the importance of the MAT measures, “People who malign medicine, despite the massive mortality for the opioid issue, and massive data supporting medications in urban and rural treatment, that's not OK anymore. That also doesn't mean that every single patient needs to be on medication.”

The development of these measures is seen as enhancing the effort to standardize care in addiction treatment. “If we write a good measure, and it gets used, it eventually becomes the standard of care and we don't have to measure it anymore,” says Waller.

The panel's report points to several shortcomings that make it difficult to call for use of certain performance measures; a lack of billing codes specific to addiction services constitutes one of these problems. Authors wrote that coding issues “prevented the panel from developing a measure specifically tracking utilization of psychosocial interventions, such as social skills training, individual, group and couples counseling, cognitive behavioral therapy, motivational enhanced therapy and family therapy. It is difficult to determine which, if any, of these are administered during a psychosocial intervention.”