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Reducing Stigma and Improving Quality of Care: Shatterproof

March 27, 2018

Samantha Arsenault,
Director of National Treatment Quality Initiatives

More than 42,000 opioid-related overdose deaths last year. Over 2 million people addicted to opioids. Costs to society exceeding $500 billion per year in lost productivity, healthcare, and criminal justice costs. The tragic opioid-related statistics continue to soar—and so too does public awareness about this crisis. Newspaper headlines share heartbreaking stories of loss, advocates work diligently to spread messages of hope, providers deliver care to those in need even in trying conditions, and the President declared a public health emergency. Despite these facts, too few understand that addiction is a chronic disease, and that decades of medical research show it can be treated with the same effectiveness as other chronic diseases. 
The pervasive stigma around substance use disorders has resulted in a fragmented treatment system that has been geographically, administratively, financially, and culturally separated from the rest of healthcare. While healthcare providers are working to reverse the historically engrained infrastructure of addiction treatment, in which specialty “programs” offer time-limited or standardized regimens of therapies, and instead move to evidence-based individualized disease management, a massive gap remains in accessing quality care.  

National Principles of Care

Shatterproof, a national nonprofit organization dedicated to ending the devastation that addiction causes families, is working to help close that gap. The organization is the lead convener of the Substance Use Disorder Treatment Task Force, a cross-sector stakeholder group working to reduce barriers to and incentivize addiction treatment practices under the National Principles of Care. While there is no standard regiment to treat addiction, these core concepts derived from The Surgeon General’s Report on Alcohol, Drugs, and Health, are shown by rigorous research studies in multiple settings and with different populations to improve patient outcomes.  The Principles are:

  1. Universal screening for substance use disorders (SUDs) across medical care settings
  2. Rapid access to appropriate SUD care
  3. Personalized diagnosis, assessment, and treatment planning
  4. Engagement in continuing long-term outpatient care with monitoring and adjustments to treatment
  5. Concurrent, coordinated care for physical and mental illness
  6. Access to fully trained and accredited behavioral health professionals
  7. Access to FDA-approved medications
  8. Access to non-medical recovery support services
We advance this work by engaging stakeholders at all levels – from individuals affected by substance use disorders (SUDs), to medical and criminal justice professionals, to health insurers, researchers and policymakers – to end stigma and ensure these Principles are delivered in practice. 

Payer-Based Reform

Historically, many policy and payment systems around addiction treatment were formed on a basis of stigma, even criminalizing this disease and its treatment. This has resulted in barriers and constraints, limiting availability of lifesaving care. Fortunately, more recent legislation and regulatory mechanisms— including the Mental Health Parity and Addiction Equity Act (MHPAEA), Affordable Care Act (ACA), Comprehensive Addiction Recovery Act (CARA), and Twenty-First Century Cures Act—seek to undo these disparities by expanding treatment and requiring insurance coverage on par with physical medical conditions. However, adoption of lifesaving treatment modalities has remained slow. 
Recognizing that even change among highly innovative providers is constrained within existing payment models, Shatterproof’s SUD Treatment Task Force has identified payment reform as a key catalyst in advancing the SUD treatment system. Health insurers, confronted with the wake of the opioid epidemic and equipped with the knowledge that aligning payment for addiction treatment with evidence-based modalities can yield a positive return on investment, were also eager to improve access to this care for their beneficiaries and realized progress could be accelerated by acting together. Thus, the first deliverable of the Task Force was a publicly signed agreement by seventeen large insurers, representing over 248 million lives, to recognize and adopt the National Principles of Care
The agreement among payers included a commitment to identify, promote, and reward addiction treatment practices that are consonant with the Principles; to work with the Task Force to monitor and evaluate implementation strategies; and to learn and share with the other organizations. The Task Force will support implementation of payer-based strategies around reimbursement, coverage, benefit design, utilization management, and other policies that incentivize and remove barriers to quality addiction treatment.

Quality Improvement 

Shatterproof is also working with stakeholders to drive adoption of evidence-based practices consonant with the Principles of Care and to bring credibility and transparency to the addiction treatment system through quality measures.

Consistent with the Donabedian model for examining healthcare quality, a team of experts is working to identify structure, process, and outcome measures aligning with the Principles of Care. Like approaches used in other healthcare sectors, the measures will be used to inform provider report cards.

The report cards, which will function as a treatment “rating system,” are being designed to drive quality improvement among the provider community, serve as a resource for referral sources, a tool for insurers and states in making payment and network decisions, and to inform consumer decisions when seeking care. 

For decades, there has been a call to put consumers in the driver’s seat of healthcare decisions to allow market forces to spur productivity, innovation, and quality improvement. But the industry has been slow to make information on quality, cost, and value transparent and understandable to the average consumer. Combine that with seeking care in a time of chaos and navigating unscrupulous and sometimes fraudulent ad-word schemes or patient brokers, and the consumer can easily fall prey to sub-par or even harmful interventions. The rating system will provide reliable information directly to the induvial seeking treatment, or their loved ones, to make decisions in times of need.

As the Payer-Based Reform and Quality Improvement initiatives develop in tandem, the rating system can be used by payers to implement supply-side strategies that promote value, such as performance incentives, risk-sharing models, and bundled payments. 

While measurement systems have been met with some criticism and resistance, comprehensive reviews show they provide value to patients and help improve the quality of care long term. Other benefits include the notion that the use of measures improves measurement, and that these systems drive provider and program level decisions. 

Consumer Education and Stigma Reduction

Closing the gap on high-quality addiction treatment also involves removing the stigma of this disease, and educating consumers about treatment options. Shatterproof’s grassroots base is one of our greatest strengths and has been critical to state and federal advocacy successes. Building on the success of our ambassador program, Shatterproof has launched the largest national event series focused on addiction: The Rise Up Against Addiction 5K Walk/Run. These events unite thousands of supporters in 11 cities across the country, bringing the disease of addiction out of the shadows and into the light. 

In 2018, Shatterproof will also launch Family Support Groups, focused on helping families overcome the chaos and confusion of this disease. Groups led by clinicians and peers will incorporate modules to debunk common myths and learn about evidence-based treatment interventions, and most importantly to share stories, challenges, and triumphs for individuals who have a loved one dealing with a substance use disorder. 

It’s time to change the headlines from a message of tragedy to one of hope. Addiction is a treatable disease, and through holistic multi-pronged initiatives, there is hope for recovery as a nation.

Our guest blogger:

Samantha (Sam) Arsenault is the Director of National Treatment Quality Initiatives for Shatterproof. In this role, Sam manages the Substance Use Treatment Task Force, and provides strategic guidance and support to critical stakeholders across sectors to improve the quality of substance use disorder treatment nationally. Sam is an impact-driven public health professional with demonstrated experience managing multi-stakeholder collaborations for systems-level changes and a personal commitment to reduce the stigma around substance use disorders and their treatment.  Read her full bio here

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The opinions expressed herein are the views of the authors and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA, CSAT or the ATTC Network. No official support or endorsement of DHHS, SAMHSA, or CSAT for the opinions of authors presented in this e-publication is intended or should be inferred.