Volume 3, Issue 1

Payment Mechanisms Drive Service Modalities
By Michael Boyle, University of Wisconsin

The National Advisory Council on Drug Abuse Workgroup report, Adoption of NIDA's Evidence-Based Treatment in Real World Settings identifies one of the barriers to the adoption and implementation of evidence-based practices as:

"The "individual-based" approach of most evidence-based behavioral treatments is an obstacle for most public and private treatment services which are "group-based". Even as substance use services become integrated in primary care, it is likely that these services will continue to be group-based treatments by primary care teams, as is the case for behavioral treatments for other health conditions."

I believe this issue deserves further exploration.

As a former CEO of a behavioral healthcare treatment organization, I first wish to explore why substance abuse treatment is predominantly group-based. I start with the simple premise of "providers do what they are paid to deliver." The payment system for substance use disorders usually rewards group treatment over individual or family sessions. For example, the state where my organization was located paid for treatment through fee-for-service. The individual hourly rate from Medicaid or state payments was $60.32. The group rate was $22.80 per hour. Thus, when we provided a group session with eight patients, the revenue per hour of clinician time was $182.40, representing a three-fold increase over the payments for a typical individual treatment session.

Insurance and managed care contracts offer similar incentives for provision of group treatment. One managed care company we worked with paid $121 for an individual session and $45 for a 90-minute group. The financial benefits of providing group services were clear. Executive leaders face a dilemma even if they support using evidence-based treatments (EBPs): "How can I afford to reduce our revenues by two-thirds and remain in business?"

In addition, research shows that training alone does not support widespread adoption of EBPs. (Glasner-Edwards & Rawson, 2010). Ongoing supervision including the review of taped sessions is required to achieve high fidelity. Consequently, adopting EBPs reduces income, and supporting adoption increases expenditures. In the current financing environment, senior leaders are unlikely to champion changing treatment approaches to adopt EBPs. And without support from senior leaders, widespread change is even less likely.

I do not know why the group approach was originally adopted for substance use treatment. I suspect it evolved from the 12-step orientation of the early alcohol treatment organizations and was a key component of the therapeutic community approach for treating drug addiction. Groups remain an efficient means to providing services. Regardless of the evolution of the group approach, it is time for a revolutionary change to individual and family therapy modalities. I am not advocating that groups never be utilized. They can serve a supporting role in skill training, role-playing, and problem solving activities. Treatment manuals are available for implementing evidence-based cognitive behavioral treatments in group settings. Still, it is challenging to provide truly individualized, tailored, and adaptive treatment in a group setting. Most groups are still "one size fits all" and fill the time with less effective treatment approaches such as lectures and general group counseling.

New funding methods may and hopefully will replace the current fee-for-service or grant payment mechanisms. These may include episode of care payments, bundled payments to the newly formed accountable care organizations, or capitation. These contracts will likely include pay-for-performance clauses tied to both performance measures and outcomes. Such new payment systems will reward achieving better results more efficiently; they should be an incentive to providing individualized care that focuses on adaptive treatment and utilizes evidence-based practices.

I disagree with the report's premise that primary care will adopt the group treatment approach as substance use is integrated into these settings. First, I think physical health care is oriented toward science and research rather than being tied to someone else's tradition. Primary care physicians will look toward implementing the most effective practices in their approaches to substance use disorders (SUDs).

Second, primary care settings are already providing individual treatment for behavioral health problems, particularly for mental health issues. At a SAMHSA/HRSA Invitational Conference on integrated treatment in 2008, virtually all the examples of behavioral health treatment in primary care utilized individual therapy. Of interest, the majority utilized a 15-30 minute session rather than the traditional one-hour approach that dates back to early psychoanalytic treatment. The sessions in primary care clinics were focused on progress, further assessment, and tailoring of next steps rather than "free association" or finding something to talk about to fill the hour, again "someone else's" tradition.

A third reason why I believe primary care will not adopt the group treatment approach again regards the payment mechanisms. Integration is likely to occur initially in Federally Qualified Health Centers (FQHCs) that are mandated by their Federal funding to address behavioral health problems. The FQHCs patient population usually includes a high percentage of persons insured by Medicaid, a group that will increase under the Affordable Care Act. The individual states' Medicaid programs have discretion on coverage for group treatment of behavioral health disorders; according to a report from the National Association of Community Health Centers (2011), group services are almost never covered. FQHCs have no financial incentive to address substance use illnesses through group interventions. Individual treatment is reimbursed at a cost-based encounter rate. Whether a service lasts for 15 minutes or an hour, the reimbursement is the same—a compelling incentive to deliver the focused individual sessions previously noted.

If brief, individual-based treatment in primary care becomes commonplace, and if studies show that a new approach produces better results, the existing specialty addiction treatment system may be in jeopardy of extinction. The "real world" of treating substance use illnesses will change dramatically from what exists today.

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