By Bob CurleyThe addiction treatment field needs better standards, more links with primary care, and less interference from managed care if treatment quality is to improve, witnesses told a Join Together policy panel.
Chaired by Jerome Jaffe, M.D., clinical professor of psychiatry at the University of Maryland School of Medicine, the Join Together Treatment Quality Improvement Panel held public hearings on Feb. 3-4 in Houston, Texas.
Witness Mady Chalk, director of the office of quality improvement and financing at the Center for Substance Abuse Treatment, aptly summed up the tenor of the hearings when she said, "The only way to provide quality is to come at it from every angle." Testimony before the panel covered a broad range of topics, from managed care to the need for improved training of primary-care physicians, better pay for counselors to adopting universal patient-placement criteria and accreditation standards.
For example, Marcy Hoerster, coordinator of Employee & Family Resources in Des Moines, Iowa, said that screening and brief interventions for addiction must be available "at many doors," including in primary care, from OB-GYNs, and even at dentist's offices (since many drug addicts have serious dental problems).
Bill Layfield, director of the Mobile, Ala., Drug Education Council and project coordinator of Mobile's Demand Treatment! project, said his group has developed a guide to brief interventions that was distributed to local doctors by the county medical society. The result: the Demand Treatment! group received more than 200 inquiries from physicians, and has begun training staff at a local clinic as well as University of Alabama medical-school students.
"During treatment, I think every federally funded program should have to have a demonstrated relationship with a mental-health center," Hoerster added, citing the large numbers of patients who have co-occurring disorders.
Without enough money to compensate staff adequately, she continued, treatment quality suffers. "The staff has to have hope if they are going to give it to the patients," Hoerster said.
Jennifer Smith, M.D., a physician with the Cook County (Ill.) Bureau of Health Services, called for greater cooperation between the primary-care system and the addiction-treatment system, and said medical schools have to do a better job of educating doctors to recognize, screen, and refer addicted individuals to treatment
For their part, treatment programs need to keep primary-care doctors informed about patients' progress in treatment, said Tanya Magness, director of substance-abuse services at Baptist Hospital in Knoxville, Tenn. "Doctors need to see outcome data so they will continue to make referrals," she said.
Joan McNamara, CEO of Compass Health Care of Tucson, Ariz., was one of a number of speakers who called for treatment programs to use common patient-placement criteria, such as those developed by the American Society of Addiction Medicine.
"Very often the reason that people fail in treatment is because they didn't get what they needed," she noted. Panel chairman Jaffe said that the state of Tennessee got providers to adopt common criteria by linking compliance to funding.
Other speakers called for more attention to the special needs of women and the elderly in treatment. Many also noted the importance of having people in recovery advocate for treatment quality, a point driven home when policy-panel member Ron Corbett, executive director of the Massachusetts Supreme Judicial Court, asked why there weren't more malpractice cases revolving around addiction treatment and referrals.
"There's great stigma, so if a patient isn't well cared-for, it's difficult to go to an attorney and complain," said Joseph Harding, executive director of Friends of Recovery New Hampshire. "All of a sudden, you have to go public. But there's a rumbling out there -- the pressure to rush people through and cut costs are enormous."
Jaffe said that while problems of coverage limitations may be more extreme in the addiction field, no area of medicine is exempt. "Managed-care companies will tell you 'use your best medical judgment, but we're not going to pay for it,'" he said.
"Any discussion about quality of treatment is almost academic without engaging the managed-care organizations and insurers in this field, because they are running the show," said David Bandler, a social worker and consultant from Pittsburgh, Pa. "In Pennsylvania, large companies with good contracts are not getting the level of care they pay for ... We need an attitude change and a behavior change by managed care; otherwise, this is just a wish list."
Accelerating Accountability
In the meantime, however, change is rapidly coming to the addiction-treatment field, particularly regarding programs in the public sector. CSAT's Chalk said that the federal government is intent on using data to improve treatment quality, even if setting up reporting systems and accountability systems could imperil some of the nation's 14,000-plus treatment programs.
"To measure and monitor is insufficient," said Chalk. "We will put into place incentives for programs to do better, and disincentives to do what doesn't make sense." The latter, she said, could include tying funding decisions to program compliance.
That message resonated strongly with the policy panel, particularly when Antoinette Krupski, chief of the division of research and evaluation at the state of Washington's Division of Alcohol and Substance Abuse, spoke. Krupski told the panel how her state was using administrative data, such as peer review, patient-satisfaction standards, and tracking of admissions and discharge, to track program performance.
"We are using data to improve program quality in partnership with providers," she said. "We would not use it in a punitive way, but to empower."
"The comment that you consider [providers] partners raises an ethical dilemma for the future," replied Jaffe. "When people have the choice between a collegial and supervisory relationship, they lean to the collegial because there's less grief."
Jaffe said the perils of such relationships was demonstrated during the federal Target Cities research project, designed to test the efficacy of various treatment projects. "The assumption was that people running programs would look at data like this and take action against low performers, but it rarely happened," he said. "Everybody went on as usual."
Witness Marc Bencivengo, assistant commissioner of Philadelphia's Coordinating Office for Drug and Alcohol Abuse Programs, said that his city acts as the managed-care organization in providing treatment to local residents in a system based on performance-based contracting. The 300 providers in the system are periodically judged on their performance in order to maintain their accreditation. "Ultimately, providers will be dropped from the network if their scores don't come up," he said.
"Moving from having the data to doing something with it is critical," said Chalk. And panel member Saul Feldman, chairman and CEO of the managed-care firm United Behavioral Health, added, "Accountability is an empty phrase if there's no teeth in it."
The policy panel will use the testimony received in Houston to guide the creation of policy recommendations around the issue of treatment quality. Recommendations are expected to be released this fall.
COMMENTS ON THIS ARTICLE: