Performance Measurement for Medication-Assisted Treatment with Buprenorphine:

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. 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)

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. 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. 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. 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. 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. 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