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Performance Measurement for Medication-Assisted Treatment with Buprenorphine:

Translating Evidence-Based Practices Such as Medication-Assisted Treatment into Public Purchasers’ Performance Measures

Suzanne Gelber, MSW, Ph.D.

March 20-21 Summit on Performance Measurement for California’s Division of Alcohol and Drug Programs

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Performance Measurement Incorporating Evidence-Based Medication-Assisted Buprenorphine Treatment

States and counties are increasingly required to make maximum use of nationally accepted evidence-based practices, widely accepted performance and accreditation measures and outcomes reports in MAT as in other types of treatments

Payer-specific fiscal and clinical performance-based accountability reports have proliferated and include the GPRA measures, NOMS/CalOMS and other reporting/performance required by the Legislature and/or the courts/criminal justice system

To support the wider dissemination of EBP’s in SUD treatment, as well as to provide consensus measures, the National Quality Forum (NQF) issued a landmark report on “Evidence-Based Treatment Practices for Substance Use Disorders” (NQF 2005), including opiod therapies as examples of Evidence-Based Practices

CSAT’s Washington Circle Group, cooperating with the NQF, is developing and pilot testing performance measures for Medication Assisted Treatment (www.washingtoncircle.org/medtreatment)

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Performance Measurement for Buprenorphine Treatment: A Public Purchaser’s Challenge

NQF EB Practices reports (2004-05) highly recommend adopting therapeutic addiction-focused pharmacotherapy and counseling for all patients (adolescents and adults) with alcohol and/or opiod dependence

Performance measurement in EBP MAT is complicated by historical public sector benefit designs and funding that did not envision MAT and/or MAT in MD offices, programs, pharmacy benefits, counseling, recovery support, continuing care

Requires long-term monitoring of combined or separate funding streams and providers for each person receiving MAT

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Performance Measurement for Buprenorphine Treatment: A Public Purchaser’s Challenge

Pelletier’s 2004 report to NQF includes these EBP’s related to buprenorphine/methadone: Buprenorphine/methadone/other appropriate detoxification and

treatment, use of VHA/DOD/CSAT SUD practice guidelines, methadone maintenance therapy at differing dosages, and

EBP’s in accompanying psychosocial treatment for these patients: treatment matching, community-oriented recovery support programs, continuing care to prevent acute episodes, promote long-term retention in treatment/recovery

Buprenorphine performance measurement requires tracking and integrating several different funding streams and different providers over time for detoxification, medication and therapy/recovery support and continuing care (treatment) for the same treatment recipient

Changing eligibility for different funding streams/benefits makes such tracking difficult; requires unique patient ID’s maintained over time

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Purchasers’ Concerns Can Become Internal Performance Measures Primary MAT concerns voiced by public purchasers and policymakers : cost

of MAT (especially in fixed pie situations); clinical safety/overdose potential; diversion/public safety potential of medications; needs for documented savings in 12-36 month timeframes to offset public sector investments in MAT – can become “internal” performance measures

Immediate internal concerns need to be added to current external PM’s and outcomes reports for WC or NOMS/SOMS/other paradigms

After a slow start in the public sector, buprenorphine now has more public sector momentum (NY, PA, VT, FLA, WA, other states in process), using Medicaid and other funding streams

MAT for alcoholism will require similar system attention Internal and external performance measurement and EBP’s for SUD must

and can now accompany wider initiation of accountable buprenorphine/other MAT treatments in the public sector

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Washington Circle Medication-Assisted Treatment Measure Process

WC measures that purchasers can use for MAT performance are in progress (MAT Workgroup)

WC measures are built on the stages of the treatment process itself and the chronic disease model, including: Identification Initiation Engagement in treatment Retention/Continuing Care Recovery Support Services

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Washington Circle Medication-Assisted Treatment Measure Process for Buprenorphine and Alcohol

WC measures for MAT include these features: Measures of processes of care for adults Combined measure for opiod and alcohol

dependence with separate reports for each Excludes methadone (developed elsewhere) Initiation and duration of treatment measures Utility for primary and specialty treatment settings Counseling considered where data permits Measured prescribing EHR and database friendly

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Next Steps Assess immediate and longer term performance

measurement needs and applicability to buprenorphine and other MAT’s for alcohol, opiods

Actively review work of WC MAT workgroup and NQF Decide which performance measures to use for immediate

and longer term purposes to satisfy accountability AND continuous improvement challenges, including establishing benchmarks

Special role for CA: one of the biggest and most influential markets that other states imitate; t is not too late for CA to once again set the standard nationally in PM for MAT’s

Late initiation of public sector buprenorphine treatment in CA provides opportunity to pilot performance measurement process that works for all stakeholders