1. 1 Performance Measurement for Medication-Assisted Treatment with Buprenorphine: Translating Evidence-Based Practices Such as Medication- Assisted Treatment into Public Purchasers’ Performance Measures Suzanne Gelber, MSW, Ph.D. March 20-21 Summit on Performance Measurement for California’s Division of Alcohol and Drug Programs

2. 2 Performance Measurement Incorporating Evidence-Based Medication-Assisted Buprenorphine Treatment  States and counties are increasingly required to make maximum use of nationally accepted evidence-based practices, widely accepted performance and accreditation measures and outcomes reports in MAT as in other types of treatments  Payer-specific fiscal and clinical performance-based accountability reports have proliferated and include the GPRA measures, NOMS/CalOMS and other reporting/performance required by the Legislature and/or the courts/criminal justice system  To support the wider dissemination of EBP’s in SUD treatment, as well as to provide consensus measures, the National Quality Forum (NQF) issued a landmark report on “Evidence-Based Treatment Practices for Substance Use Disorders” (NQF 2005), including opiod therapies as examples of Evidence-Based Practices  CSAT’s Washington Circle Group, cooperating with the NQF, is developing and pilot testing performance measures for Medication Assisted Treatment (www.washingtoncircle.org/medtreatment)www.washingtoncircle.org/medtreatment

3. 3 Performance Measurement for Buprenorphine Treatment: A Public Purchaser’s Challenge  NQF EB Practices reports (2004-05) highly recommend adopting therapeutic addiction-focused pharmacotherapy and counseling for all patients (adolescents and adults) with alcohol and/or opiod dependence  Performance measurement in EBP MAT is complicated by historical public sector benefit designs and funding that did not envision MAT and/or MAT in MD offices, programs, pharmacy benefits, counseling, recovery support, continuing care  Requires long-term monitoring of combined or separate funding streams and providers for each person receiving MAT

4. 4 Performance Measurement for Buprenorphine Treatment: A Public Purchaser’s Challenge  Pelletier’s 2004 report to NQF includes these EBP’s related to buprenorphine/methadone: Buprenorphine/methadone/other appropriate detoxification and treatment, use of VHA/DOD/CSAT SUD practice guidelines, methadone maintenance therapy at differing dosages, and EBP’s in accompanying psychosocial treatment for these patients: treatment matching, community-oriented recovery support programs, continuing care to prevent acute episodes, promote long-term retention in treatment/recovery  Buprenorphine performance measurement requires tracking and integrating several different funding streams and different providers over time for detoxification, medication and therapy/recovery support and continuing care (treatment) for the same treatment recipient  Changing eligibility for different funding streams/benefits makes such tracking difficult; requires unique patient ID’s maintained over time

5. 5 Purchasers’ Concerns Can Become Internal Performance Measures  Primary MAT concerns voiced by public purchasers and policymakers : cost of MAT (especially in fixed pie situations); clinical safety/overdose potential; diversion/public safety potential of medications; needs for documented savings in 12-36 month timeframes to offset public sector investments in MAT – can become “internal” performance measures  Immediate internal concerns need to be added to current external PM’s and outcomes reports for WC or NOMS/SOMS/other paradigms  After a slow start in the public sector, buprenorphine now has more public sector momentum (NY, PA, VT, FLA, WA, other states in process), using Medicaid and other funding streams  MAT for alcoholism will require similar system attention  Internal and external performance measurement and EBP’s for SUD must and can now accompany wider initiation of accountable buprenorphine/other MAT treatments in the public sector

6. 6 Washington Circle Medication- Assisted Treatment Measure Process  WC measures that purchasers can use for MAT performance are in progress (MAT Workgroup)  WC measures are built on the stages of the treatment process itself and the chronic disease model, including: Identification Initiation Engagement in treatment Retention/Continuing Care Recovery Support Services

7. 7 Washington Circle Medication- Assisted Treatment Measure Process for Buprenorphine and Alcohol WC measures for MAT include these features:  Measures of processes of care for adults  Combined measure for opiod and alcohol dependence with separate reports for each  Excludes methadone (developed elsewhere)  Initiation and duration of treatment measures  Utility for primary and specialty treatment settings  Counseling considered where data permits  Measured prescribing  EHR and database friendly

8. 8 Next Steps  Assess immediate and longer term performance measurement needs and applicability to buprenorphine and other MAT’s for alcohol, opiods  Actively review work of WC MAT workgroup and NQF  Decide which performance measures to use for immediate and longer term purposes to satisfy accountability AND continuous improvement challenges, including establishing benchmarks  Special role for CA: one of the biggest and most influential markets that other states imitate; t is not too late for CA to once again set the standard nationally in PM for MAT’s  Late initiation of public sector buprenorphine treatment in CA provides opportunity to pilot performance measurement process that works for all stakeholders