A Chronic Care Model for Addiction
*Note: This article originally appeared on Health Affairs.
While the current opioid epidemic has captured the attention of the country and its policy makers by becoming the leading cause of death in the United States for those younger than age 50, addiction to a broader range of substances has pervaded US culture for decades. Current health system resources remain inadequate to thwart the rising tide of addiction, as demonstrated by recently released federal data that estimate a persistent 88 percent substance use disorder (SUD) treatment gap for those in need. This gap reflects inadequate infrastructure—resources, clinical settings, and workforce—for supporting the more than 18 million Americans suffering from addiction without appropriate treatment for their potentially fatal health problem.
The chronic nature of addiction means that it requires the same approach any chronic disease model would demand in integrating provider resources, coordinating information, providing continuity in patient engagement, and ideally, including a payment model that incentivizes these features. A longer-term focus on and support for patients managing a litany of care transitions in their recovery journey has the potential to markedly improve recovery rates and serve more people in need. For example, a patient in sustained recovery for one year can see remission of the worst symptoms of the SUD, while those in sustained recovery for five years can reduce risk factors close to population health baselines. Yet, despite research telling us what is possible, we are a long way from providing payment and treatment models that can produce these types of outcomes for addiction. US health care payment reform has only begun to scratch the surface on driving risk-based provider integration in core health care domains.
A Chronic Care Model for Addiction
In August 2017, Leavitt Partners and Facing Addiction with the National Council on Alcoholism and Drug Dependence convened a group of 40 health care thought leaders including senior representatives of various health care organizations ranging from health insurers, hospital systems, subject matter experts, behavioral health executives, employers, and others. The purpose of this meeting was to discuss the future of addiction treatment and recovery in the US and determine if the market conditions were right to explore the creation of alternative payment and delivery pathways designed to promote long-term recovery. In the months that followed, this group organized the Alliance for Recovery-Centered Addiction Health Services (Alliance) to develop and promote an innovative approach to payment, patient engagement, and delivery of addiction treatment and recovery services.
The addiction recovery medical home alternative payment model (ARMH-APM), the concept ultimately developed by the Alliance, represents a cross-sector attempt to establish a structure that promotes health system integration resulting in improved outcomes for all stakeholders, most importantly the patient.
The ARMH-APM is built on five elements. The model itself was established with a commercial context in mind and flexibility for payers and providers that adopt the model to adjust the application of the model’s principles to meet the specific situational and population dynamics.
Element No. 1—Payment
At the core of the ARMH-APM is a multifaceted payment model that carves out financial resources for addiction treatment and recovery services. The payment and its underlying calculation transcend three different phases of a patient’s recovery, beginning with pre-recovery and stabilization (fewer than 30 days), recovery initiation and active treatment (0–12 months), and community-based recovery management (up to five years).
The first phase remains under the auspices of fee-for-service given its higher volatility and the underlying difficult of projecting and pricing risk factors. However, the latter two phases, which comprise a five-year period, are remunerated through risk-based payments to a risk-bearing provider entity. Case rates for episodes of care payments are derived through risk stratification using retrospective patient claims and adjusted in later months on the basis of decreased clinical acuity and reduced risk factors.
The payment itself is comprised of three mechanisms:
- Capitated/bundled payments: Risk and reward are tied to the provision of more integrated and personalized care.
- Quality achievement payment: A portion of the capitated/bundled payment is tied to achievement of successful patient outcomes.
- Performance bonus: Providers may be eligible to share in additional savings created from better coordinating patient care across all health care services, including addiction, behavioral, and physical services.
Element No. 2—Quality Metrics
There are currently no widely adopted long-term quality measures that are useful in gauging addiction health service efficacy or aspects of recovery success itself. However, the ARMH-APM establishes several requirements across its payment, network, and care team domains that should be adhered to by the participating parties. Hence, any application of the ARMH-APM should consist of established process measures that ensure fidelity to the model.
Furthermore, the Alliance has partnered with the National Committee for Quality Assurance to pursue the development of quality measures that can more accurately reflect patient outcomes and performance in the future.
Element No. 3—Integrated Treatment and Recovery Network
Critical to the success of the ARMH-APM is the establishment of a network comprised of a breadth of clinical settings (emergent, detox, inpatient, rehabilitation, intensive outpatient) and community resources that meet the needs of the patient through the different phases of their recovery journey. This network should be clinically integrated and promote seamless care transitions in partnership with a care recovery team’s care coordinator. The flow of clinical information within the network should occur unimpeded through the care team and clinical or community supports to assure continuity in treatment. To circumvent restrictions in data sharing posited by 42 CFR Part 2, the ARMH-APM requires the patient to allow for the sharing of his or her information through the network. Finally, the network’s organizer or steward should also function as the risk-bearing entity and adjudicate payment for services throughout network participants.
Element No. 4—Care Recovery Team
Team-based care is a critical feature to managing chronic disease. The ARMH-APM requires a para-professionally trained peer recovery coach, care coordinator, behavioral health specialist, licensed counselor, and a primary care professional. The model establishes engagement protocols and requirements for the nature of this team’s engagement of the patient in care, focused on sustaining interaction and supports through the patient’s recovery journey. A sustained team-based care approach built on a collaborative structure engages the patient as a partner with a trusted team of recovery specialists who can support the patient in his or her recovery throughout the care continuum.
Element No. 5—Treatment And Recovery Plan
All recovery-oriented systems of care should be focused on building a patient’s recovery capital. This capital is derived from a myriad of different sources, most of which transcend health care and focus on various social and economic determinants such as diet, exercise, sleep, vocation, family, coping strategies, spirituality, and related areas (Note 1). The ARMH-APM adopts an evidence-informed planning structure that includes 12 key recovery dimensions and advances specific guidelines on structuring recovery planning in collaboration with the patient.
These 12 dimensions, developed and promulgated by FAVOR Greenville of South Carolina, cover the breadth of biopsychosocial determinants and include: living situation of the patient, recovery assets, relationships, healthy body, healthy mind, counseling, medication, school, work, treatment plan compliance, spirituality, interests, and coping skills.
The Alliance published the first draft of the ARMH-APM, a consensus-learning model, on September 7, 2018. The group is actively working with several commercial health plans exploring the adoption of this model in pilots to demonstrate the efficacy of the underlying principles. As evidence is gathered, the Alliance will continue to adjust the payment and delivery model, including expanded adoption and implementation considerations.
The health system has gone from viewing SUD as a moral failing to recognizing it as a chronic disease. This has been an important transformation, allowing researchers to expand the science and evidence required to improve treatment. However, the system is fundamentally too fragmented and diffuse, with limited coordination or sustained management of patients. If we are to improve treatment of SUD as a chronic disease, we must organize clinical and non-clinical resources in a way that provides long-term and sustained supports with an economic structure that holds each part of the system to account for its contribution and performance.
See Addiction Recovery Management: Theory, Research, and Practice, chapter 5, page 69.