Value-Based Care in Addiction Treatment: Why It’s Essential and How We Get There

The move toward value-based care (VBC) is gaining traction in the healthcare field, with providers, insurers, and analysts agreeing it’s the most effective way to improve efficiency, quality of care, and patient outcomes. As a form of reimbursement that focuses on patient outcomes, it’s the best shot we have at lowering the staggering, fast-growing cost of care in this country by leveraging high quality care to achieve successful outcomes and better overall, long-term health.

Unfortunately, we’ve not seen the same push toward VBC in substance use disorder (SUD) treatment, where fee-for-service remains the status quo. And this lack of momentum is having severe consequences for patients, providers, payers, and overall public health. 

In the current SUD model, payers are incentivized to limit and restrict substance use treatment to drive profit, despite research that proves a longer window of patient engagement is much more effective for supporting long-term sobriety. As a result, providers are forced to spend significant time and energy obtaining treatment authorization rather than treating the patient and achieving improved outcomes while providing evidence-based, client-centered care. Because treatment is not approved at the right level or duration, relapses are frequent, and payers often end up spending more money to treat the same patients repeatedly, driving up costs without achieving positive outcomes for the patient. As a result, providers—who are already facing significant staff shortages—are overburdened with relapsed/readmitted patients. 

Meanwhile, patients in relapse are at an extremely high risk of overdose, creating additional burden on already-strained first responders, emergency departments and the entire healthcare system. Not to mention, the quagmire of addiction takes an immeasurable toll on families, our economy, law enforcement and the penal system. 

But it’s the patients who suffer the most. Unable to get the long-term care they need, many are caught in an endless cycle of relapse, struggling with their disease and the serious, long-term health consequences—or worse, dying from overdose.

With 60 million people in the US using substances and OD rates on track to reach a new and tragically unnecessary all-time high, the need for effective, affordable SUD treatment has never been greater. 

That’s why transitioning to VBC in addiction treatment is essential for overcoming these challenges, for getting people the treatment they need, and for reducing the risk of relapse for vulnerable individuals. Fortunately, states like Illinois have pioneered superior strategies that directly improve patient outcomes and can be replicated throughout the country. 

 Make no mistake: Implementation may not be simple, but by implementing these key strategies, we can deploy a value-based care model successfully. 

1. Require the use of scientifically supported patient placement tools. The American Society of Addiction Medicine (ASAM) is the organization in the US that has consistently set the standard of patient placement for over 50 years, leveraging empirical research to establish a standard of care for patients that improves outcomes and long-term recovery. Many states require insurers and providers to exclusively use the ASAM placement criteria to determine what care a patient receives.
2. Create a longer window of engagement. Research shows that longer treatment at the right level of care secures reduced relapse rates, improves quality of life, reduces overdose, and reduces levels of incarceration. Providing patients with a 12-month period of uninterrupted treatment can increase treatment success from 30% to 80%—a huge advantage for patients.
3. Implement a risk-shared model. To expand the treatment window, providers and payers must be willing to share the risk. A risk-shared model can give providers the revenue necessary to treat a patient for 12 months, but they are required by contract to provide whatever treatment is needed, presenting the risk of high cost if they do not provide good care. Insurers, on the other hand, may have a bigger front-end expense but will realize total overall savings that come with a patient in long-term recovery.
4. Establish quality standards. The key to value-based care is quality measures: Insurers set standards providers must achieve to maximize payments. In the case of a knee replacement, for example, those quality metrics might include no infection, no complications, and no repeat office visit or hospital readmissions. In SUD treatment, those standards could include reduced medical utilization, reduced or eliminated substance use, specific treatment parameters, long-term access to therapy (including virtual), and lifestyle support to help patients navigate post-acute treatment recovery. 
5. Support social determinants of health (SDoH). Similar to diseases like hypertension and diabetes, factors such as lack of employment, food insecurity, and safe housing impact patients’ treatment compliance and long-term disease management. Those same factors influence long-term sobriety. By including SDoH support and resources into the VBC treatment model, patients have a much greater chance of managing the disease of addiction long term. 
6. Monitor progress. Just as a physician would be reimbursed and incentivized for monitoring for diabetes, heart disease and other chronic diseases, SUD treatment providers should be reimbursed and incentivized for monitoring patients in recovery. For example, the Brief Addiction Monitor (BAM) is designed to assess the risk of SUD and relapse, and with long-term disease management through VBC, this could be used over time as standard practice to create a feedback loop that helps hold patients accountable and keeps providers in touch for rapid intervention if/when needed. 
7. Invest in VBC expertise. Because VBC is a new concept in substance use treatment, many treatment providers don’t have the expertise on staff to implement it. Providers and payers must fill those roles in order to move in this direction. That includes hiring specialists in payer management, quality measurement, and finance—ideally with experience on the payers’ side—who understand the structures and systems supporting VBC.
8. Deploy technology. VBC requires an entirely new system of billing, of course, but it also requires new treatment modalities, such as AI chat bots and virtual counseling. While a 12-month engagement is ideal, it’s not reasonable or necessary for the treatment to be exclusively inpatient, or even in-person care. Providers should not only embrace virtual counseling technology, but also teach patients how to benefit from it. They must also recognize that not all clinicians are skilled or effective in this medium, so providers should identify those with an interest and affinity, and train them to deliver superb virtual care.

VBC has the potential to deliver outstanding results for the SUD treatment industry. In addition to getting patients the extended care they need for the greatest likelihood of long-term success, by some estimates, it could save our healthcare system as much as $1 trillion nationally. That’s great news for payers whose primary motivation is to lower the cost of care. 

 But it’s not just about saving insurance companies money—it’s also about improving overall public health and the impact that can have on our economy, our families and our communities. SUD is a family disease that often spans multiple generations. For each person who stops misusing substances, we see a tremendously positive ripple effect on everyone around them, including the potential for huge reductions in family violence, suicide, overdoses, and overdose deaths. If we can interrupt that cycle through the deployment of VBC, the trajectory of the entire family and community can change, and we can save countless lives.

Thomas Britton, PhD, is CEO of American Addiction Centers.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Addiction Professional, Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.

References

Kurani N, Ortaliza, Wagner E, et al. How has US spending on healthcare changed over time? Health System Tracker. Published February 25, 2022.

Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2020 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Publis