Research has shown that physicians' health programs achieve extraordinary outcomes in substance use disorders (SUDs). One recent study demonstrated nearly 80 percent abstinence at five years. The success of physicians' health programs (PHP) in driving superior outcomes in addiction treatment raises critical questions about how treatment can be improved for all with SUDs.
Physicians who must pay for PHP-driven treatment are getting a better return when long-term results are considered. So, if treatment centers would adopt and demonstrate the superior value of PHP-style treatment and case management, they would win the case for it from payers. Why pay for multiple detoxes and no follow-up, indeed?
PHPs get better results and offer a means of improving all programs, but for two reasons:
Systems of care haven't recognized/used all of the critical ideas-many use some, though.
Even if they did, payment is a problem because the value to third-party payers hasn't been made clear. Therefore cheaper alternatives, and lower levels of treatment, prevail.
Core elements of the PHP-approach
Systems of care and reimbursement have failed to distill the core elements from the PHP model and export them to the general population. The primary reasons are a failed understanding of what, specifically, makes the PHP approach work and how consumers and payers can derive value from the improved treatment outcomes.
Of course, some of the ingredients of the PHP approach are used in other programs with a degree of success. For example, drug courts have benefitted from the best practices of drug screening and contingency management (attaching consequences to positive drug tests).
Even with the fear of incarceration, however, participants in drug courts fail to achieve the extraordinary outcomes found in the physician health approach-making the benefit of PHPs even greater than the threat of incarceration.
Furthermore, providers haven't figured out how to solve the contingency management problem for extralegal populations; i.e. how to attach consequences to drug screen results for individuals outside the court system.
The gap between drug court outcomes and physicians' health outcomes establishes that while drug screening is helpful, it's not enough. The gap also is not entirely attributable to baseline demographics or professional status.
The physicians' health programs successes derive from a combination of key practices, and these practices can, with some creativity, be applied to other cohorts. I suggest that the superior results of PHPs are attributable to differences in how these programs handle additional key factors:
Loose or non-application of 12 step philosophy
Limited stakeholder involvement
Absence of contingency management
Inadequate levels of care-bias toward least intrusive care
12-Step approaches are central to the PHP model and are emphasized almost universally. Despite debate in the field over modalities and significant legal and participant pressures, PHPs have generally maintained their bias toward 12-step programs, having seen its clear advantages.
Individuals must be case managed in a way that connects key stakeholders in all phases of the care continuum. PHPs do this extremely well. Significant involvement by stakeholders is required to ensure that providers and payers can respond to relapse in a meaningful way.
Unless key parties are actively involved, providers, payers and consumers will continue to suffer the economic effects associated with managing a chronic disease with an acute-care model: repeated detoxes, attrition and impaired outcomes.
Nearly everyone “gets” that drug screening and contingency management improve abstinence. Drug courts, schools, employers and athletes have all seen improvements resulting from screening. Interestingly, the classic medical ethics problem of autonomy vs. beneficence has been largely resolved in these cohorts by connecting other stakeholders.
For example, a physician may not be able to force an individual to take a drug screen, but the International Olympic Committee can. So how can other groups of addicted clients benefit, if they have no licensing entity insisting on abstinence?
Most addicts have people who deeply care about them, but don't know how to help. Case management that connects key stakeholders around the individual's sobriety and 12-step participation is very labor-intensive, but critical to success.
Many PHP directors respond seriously to indicators that a participant is struggling-whether it's losing a sponsor, reducing meeting attendance or struggling in a marriage. This level of intensity far exceeds what is usually provided in addiction case management.
Several firms have emerged that provide these services for self-pay consumers who see their value, but a failure to rigorously and collaboratively collect outcomes data has obscured the value of these “high-touch” services to other payers.
Individuals who agree to participate in case-managed, drug screened programs that are built around multiple, highly engaged stakeholders should be significantly incentivized by payers who should pay more for treatment that includes this type of service, based on reduced chronic demand for services and better outcomes.
The value of more intensive service to payers
It's easy to be frustrated when we see individuals continue to cycle through inadequate levels of care. Patients undergo dozens of detoxification admissions, but never enter residential treatment because payers insist they fail ambulatory approaches first.
What do these failures illustrate? In addiction treatment, it illustrates that the discipline of level-of-care decision-making remains grossly underdeveloped.
While ASAM standards for multidimensional assessment and disease management are significant leaps forward, it's still unknown whether the criteria we use to assign an individual (for example, to level II.5 vs. level III.1) are working. In terms of value, this level of care also may not allow individuals to accrue all of the benefits that a higher level of care can offer.
This could be why the vast majority of PHP participants have undergone residential treatment or partial hospitalization with boarding-despite ASAM criteria that would have suggested lower levels of care. In fact, the mean duration of treatment for physicians in residential or partial hospitalization care is over 70 days.
Insisting on these intense levels of service is one of the keys for success. Outpatient care is successful in many cases, but systems must be prepared to make significant investments. That means providing higher levels of care earlier in the disease course, rather than simply expecting existing level-of-care criteria to drive better results.
For this to occur, the value argument will need to be clarified. For example, it's more cost-effective to pay for a full course of residential treatment than multiple detoxes.
To solve the payer problem, the value must be clearly defined. Treatment providers need to clarify the economic value to all parties of the multiple-stakeholder model. The current healthcare climate is trending towards shifting allocation of risk to treatment providers.
One example of this trend is the push for accountable care organizations (ACOs). The apparent mismatch between risk and return to payers has been a longstanding barrier to solid outcomes in addiction treatment. Why pay for more when the benefits aren't clear?
In the current system, payers either don't accrue the benefits associated with superior outcomes, or cannot transparently “see” the improvements. On the other hand, many PHP participants simply pay cash for treatment, and can easily speak to the benefits of their investment.
All stakeholders-employers, families, and patients-have seen significant return on investment from the PHP approach. By tying reimbursements to the best practices seen in physicians' health treatment, all three addiction treatment customers-the individual who selects treatment, the individual who uses it, and the payer-will benefit.
However, providers themselves must take the lead by implementing successful PHP-style treatment and case management, and measuring the results.
Superior addiction treatment outcomes are within reach, but will require bold, innovative approaches that involve value-based reimbursement, multiple-stakeholder involvement, drug screening and contingency management, level-of-care decision making and emphasis on 12-step approaches.
Meaningful collaboration among employers, treatment providers and third-party payers will result in shared value creation that is not possible under current disaggregated approaches.
Psychiatrist Omar Manejwala, MD, MBA, FAPA, CPE, serves as medical director of addiction treatment programs for Hazelden in Center City, Minn. Dr. Manejwala is a fellow of the American Psychiatric Association and a diplomate of the American Board of Addiction Medicine. BACK TO THE APRIL 2011 ISSUE