Measurement-based care has been hailed by payers and providers as essential to promoting evidence-based, individualized treatment.
Substance use disorder (SUD) providers hoping to craft new reimbursement arrangements or improve patient outcomes must establish robust internal measurement systems.
Collecting patient data alone does not drive change, however. Providers must also leverage their findings to adjust treatment courses, engage patients and inform payers.
“When we’re looking at how to use data to improve patient outcomes and to inform patient care, it’s important to think about it as a measurement-based care model so you’re actually doing something with the data that you gather that directly impacts the course of treatment that an individual is experiencing,” Dr. Suzette Glasner, chief scientific officer of Pelago, said at the Behavioral Health Business Autism & Addiction Treatment Forum.
New York City-based Pelago offers virtual care to patients with tobacco, alcohol, opioid and cannabis use disorders using cognitive behavioral therapy, motivational enhancement therapy and contingency management.
Pelago is among the SUD treatment providers that collect extensive data at both patient and enterprise level
Identifying what to measure
Before providers can implement changes, or even start collecting data, they must determine which outcomes are most crucial to their patients.
Digital SUD provider Boulder Care tracks metrics including patient satisfaction, the speed at which the company can get patients into care and quality of life outcomes, according to Rose Bromka, the company’s chief operating officer.
Reuniting with family members, regaining driver’s licenses, returning to school and getting a work promotion are examples of quality of life outcomes.
The company’s “gold standard quality metric” is its retention in care rate, Bromka said.
“We primarily serve a Medicaid population, and our payer partners can use their own claims data to validate that members in care with Boulder see reduced emergency room visits and inpatient stays by about 40 to 70%,” Bromka said.
Boulder Care offers virtual, app-based treatment for opioid and alcohol use disorders, including offering medications for addiction treatment (MAT). Over 85% of the provider’s patients are Medicaid beneficiaries, and over half of the company’s business comes from value-based arrangements.
In May, Boulder raised $35 million in a Series C round, bringing the company’s total raise to $85 million.
Recovery Centers of America (RCA) also measures treatment retention and engagement, measured by the rate at which patients who have completed treatment leave its inpatient programs and length of engagement in care. It also bases this metric on the extent to which patients step down through the provider’s full continuum of care, rather than leaving care immediately following an inpatient stay.
King of Prussia, Pennsylvania-based RCA has 11 inpatient facilities in Maryland, Massachusetts, Pennsylvania, Illinois, Indiana, New Jersey and South Carolina. Many of its facilities also provide outpatient services through both in-person and telehealth modalities.
The provider also measures patient satisfaction. Surveying patients after they lead care creates the potential for actionable, system-level changes.
Yet post-treatment surveys do not open opportunities for RCA to adapt systems at a patient level, Dr. Pete Vernig, the company’s vice president of mental health services, said.
RCA therefore established an additional patient satisfaction survey, administered after three days of treatment through a digital platform that provides immediate feedback to operational and clinical leadership.
“If a patient identifies a problem, we’re able to be on that immediately before that problem becomes a barrier to their ongoing treatment,” Vernig said.
Pelago tracks many of the same measures based on harm reduction principles, Glasner said, as well as return on investment and cost-effectiveness. While she describes complete abstinence from a harmful substance as the “gold standard” for outcomes, reduction in substance use can make care more accessible for patients who say they do not feel ready to stop using substances.
Keeping harm reduction principles in mind, Pelago measures the proportion of days its patients are abstinent as well as the quantity of alcohol they consume on a day they choose to drink.
Pelago’s alcohol use disorder patients have a daily abstinence rate of about 68% after 12 weeks, compared to a rate of 10% or 15% when they enter treatment, Glasner reported. When entering treatment, patients consume an average of six to seven drinks on drinking days. After 12 weeks of treatment, the number of drinks drops to around two per drinking day.
Patients often shift their goals throughout the course of treatment, Glasner said. People who initially only sought to control their alcohol use may, upon developing a trusting relationship with a provider and seeing initial progress, decide they want to eliminate their substance use completely.
Additionally, Pelago tracks patients’ drinking risk levels, which are established by the World Health Organization (WHO). The four levels, which range from low risk to very high risk, are based on the amount of alcohol consumed per day.
“Studies have shown that when an individual reduces by one or two levels, [which] corresponds to a certain quantity of alcohol that they’ve reduced, that the health-related outcomes tied to that are sustained over longer periods of time,” Glasner said. “We find that close to 70% of our population reduces by two levels.”
Implementing outcomes-backed measures
Once SUD providers determine which outcomes are the most important to track, they must tackle implementation, a process that can require a significant overhaul of existing systems.
Around 2020, RCA retooled its entire clinical model to make way for measurement-informed systems.
“We basically took our whole clinical model down to the studs and started over and used database decision making in order to classify our patients when they come in into different care pathways,” Vernig said.
The care pathways include a track for people who have never received treatment before, a track for people with a history of treatment recidivism and a track for people with co-occurring substance use and psychiatric conditions.
“We’re able to classify individuals into these pathways based upon data and then provide them with truly individualized treatment plans, down to the level of provider involvement, the actual curriculum that they receive and the course of treatment that they’re on, which then allows us to move them through the continuum in a way that is more meaningful for them,” Vernig said.
The provider hopes to use its new system as the basis for risk stratification for future value-based reimbursement arrangements.
A challenge associated with implementing outcomes-based measures is aggregating and utilizing data on the level of an individual patient, Vernig said. While electronic health records (EHR) allow providers to collect enterprise-level data, fewer tools exist to track individual outcomes.
Once data has been collected, challenges around how to utilize it emerge.
“A lot of organizations will collect lots and lots of data and then they can report on outcomes, but they’re not leveraging it to yield maximum benefit to their patients,” Glasner said.
Pelago collects member data on an ongoing basis using its digital app, Glasner said. Clinicians can use the digital dashboard to determine if patients are stable or experiencing a relapse and respond immediately via asynchronous chat, rather than waiting for their next therapy appointment.
The provider also evaluates individual patients’ metrics monthly and updates treatment pathways accordingly.
Boulder also takes a one-size-does-not-fit-all approach to care, Bromka said, and also implements shared decision-making with patients in which patients inform the provider what they need.
“We’ve got folks who are coming into care in many cases for the first time,” Bromka said. “Often they’ve had pretty negative experiences with the health care system where they felt judged or stigmatized. That patient’s going to benefit from outreach from a peer specialist who has walked that journey before them and doesn’t have the scariness of a ‘clinical white coat.’ On the other hand, we’ve got folks in care … who are unstably housed. That person is not going to be focusing on their recovery while they are looking to meet material needs like housing and food. They’re going to benefit from our case management reaching out to them.”
Used data collected across tens of thousands of clinical encounters allows Boulder to offer those services when they would be most impactful, Bromka said.
One key hurdle to implementing measurement-based care is the fee-for-service reimbursement model that has historically been standard across the behavioral health industry. This model incentivizes large volumes of clinical visits and drug screens, which Bromka says are not clinically aligned with patient health outcomes.
“The alternative payment models that Boulder is engaged in are vital to systematically changing the industry toward outcomes-based care,” Bromka said.
