A Join Together policy panel on improving the quality of addiction treatment services is calling on purchasers -- both public and private -- to reward programs that deliver better outcomes. It's a message that many purchasers seem primed to hear.

Chaired by Jerome Jaffe, M.D., clinical professor of psychiatry at the University of Maryland School of Medicine and the nation's drug czar under the Nixon administration, the panel called on the federal government to lead the way in expanding systems for measuring performance and outcomes of individual treatment programs. At the same time, however, the panel urged other purchasers -- including employers, state and local governments, public-welfare agencies, and the criminal-justice system -- to move forward on their own.

Purchasers "should meet with providers to establish appropriate expectations for results, and develop pay-for-performance contracts with incentives to meet the desired results," the panel said in its report, "Rewarding Results: Improving the Quality of Treatment for People with Alcohol and Drug Problems."

The panel also called on community leaders to advocate for development of results-oriented treatment systems "by holding institutions accountable for improving treatment quality and assuring collection of local data to feed the results-management system."

Hoping a Simple Message is Heard

At a January Washington, D.C., event to roll out the report, Jaffe said that the recommendations in the 30-page report are simple and straightforward, and repeatedly told questioners that the panel's intent was not to address every issue surrounding outcomes measurement. "We felt it was better to have one idea and have it noticed," said Jaffe. "Our message is that unless the people who fund treatment demand results, treatment won't improve."

The panel took pains to stress that many factors go into treatment quality and outcomes, including some that are out of the control of treatment programs themselves. "The panel members recognize in the report that treatment resources are inadequate, and that treating people with substance-abuse disorders with such inadequate support is often challenging, frustrating, and unfair," the report said.

But the panel clearly wants to get the ball rolling, even as members said that tying payment to performance would yield pain as well as progress. "There are 12,000 treatment programs in the U.S., and there may be some that will be unable to respond," said Jaffe. Nevertheless, the report said, the panel "believes and argues strongly that rewarding results will provide the basis for improvement, which will lead to the evolution of a more stable treatment system that is capable of responding to more traditional quality-improvement strategies."

Few at the D.C. meeting seemed to disagree with the basic premise of rewarding outcomes, but the report raised at least as many questions as it answered. Experts like Alan Leshner, M.D., former head of the National Institute on Drug Abuse, and Ronald Hunsicker, president of the National Association of Addiction Treatment Providers, peppered Jaffe with questions about the type of outcomes that should be rewarded.

Herman Diesenhaus, Ph.D., an evaluation expert at the Substance Abuse and Mental Health Services Administration, expressed concern that the recommendations were "naive regarding financing," noting that different funders (such as the prison system and Medicaid) desire different outcomes. "My opinion is that our outcomes are too distal," added Tom McLellan, a University of Pennsylvania who has published some of the seminal research on measuring treatment outcomes. "Our outcomes are during the course of treatment. More than 90 percent of treatment is outpatient. Results are ongoing, and there are many things that treatment programs can't take responsibility for."

Jaffe acknowledged the questions but tried to resist wading into issues he considered second steps and beyond the scope of the panel's work. "We are not ready to reward results today," said Jaffe. "That does not mean we won't be in the not-too-distant future ... If we're willing to start with small steps, we can build toward it."

First Steps Being Taken

Some significant steps have already taken place. SAMHSA has rebranded many of its grantmaking programs as "performance partnerships" and has begun the process of defining treatment outcomes, although tying funding to a defined set of outcome measures still appears to be well off in the future. The National Committee for Quality Assurance (NCQA), a nonprofit group that accredits managed-care organizations, recently incorporated alcohol-treatment performance measurement in its Health Plan Employer Data and Information Set (HEDIS) report, used by most of the nation's health plans to track the performance of healthcare providers. The NCQA developed its alcohol measurements with the Washington Circle Group, which is dedicated to defining addiction outcomes.

Employers also are paying more attention to treatment outcomes. Last year, for the first time, the National Business Coalition on Health (NBCH) began gathering performance data on alcohol screening and treatment as part of its "eValue8 Health Care" initiative. The NBCH's membership includes 90 employer-led healthcare coalitions nationally, representing 7,000 employers such as Marriott, American Express, General Motors, and Wells Fargo.

NBCH Assistant Vice President Dorothy Jeffress told Join Together that the purpose of eValue8 is to educate employers and encourage them to seek high-quality healthcare services from providers. More than 90 health plans across the country take part in the eValue8 survey, and some employers and local healthcare coalitions require providers to do so if they want to bid for contracts. NBCH passes along to its members the results on various focus areas -- such as treatment for alcohol, depression, asthma, and cardiovascular health -- who then decide what further action should be taken.

The first year of alcohol-treatment evaluation was sobering. "Very few plans had very consistent guidelines or treatment policies in place," said Jeffress. The results prompted changes in some communities: as a result of the report, the Maryland Health Care Coalition made its displeasure known to local treatment providers, Jeffress noted, and systemic changes are in the works locally.

The NBCH is planning a series of regional meetings (in Chicago, New York, and San Francisco) to help members flesh out their concerns and positions regarding treatment outcomes. Meanwhile, Join Together is distributing its panel report to key policymakers in the public and private sector, as well as treatment providers and advocates for improved treatment quality, access, and availability.

"As we work to drive up demand for treatment, we need leadership to drive up the quality of care," said David Rosenbloom, director of Join Together. "We hope that this report will spark a real debate around the country on improving the quality of treatment."