The readiness of addiction treatment agencies for health care reform

On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA) was signed into law, heralding imminent and significant reform for health care delivery and health insurance coverage in the United States [1]. The PPACA expands essential benefits for the insured, increases eligibility for public programs among the underserved, and offers the uninsured and underinsured greater access to affordable health insurance through state and federal health insurance exchanges [2‐9]. Health reform seeks to reduce health care costs by improving prevention and wellness [10]; integrated care [11]; health information technology implementation [12‐14]; evidence-based treatment [15, 16]; workforce development [17]; and quality management [18] in the health care delivery system.

Within this context, we wanted to gauge the addiction treatment field’s readiness for health reform. The Health Reform Readiness Index (HRRI) survey was developed through the Accelerating Reform Initiative (ARI) conducted by NIATx, a process improvement learning collaborative at the University of Wisconsin–Madison. Through a competitive request for proposal process, ARI selected 21 community-based behavioral health organizations committed to preparing for the PPACA. In ARI, these organizations began to confront the practical implications of the PPACA requirements on care delivery and business operations. Their experiences provided the foundation for development of the HRRI survey.

The HRRI survey was designed as:

The HRRI development process had four phases. In the first phase, a survey instrument was drafted based on the researchers’ knowledge of the PPACA and what the ARI organizations reported they needed to do in order to prepare for this legislation. The feedback mostly focused on what organizations would need in order to participate in state-based health insurance exchanges. Organizations anticipated these health insurance mechanisms would require having infrastructure for billing systems, electronic health records, outcomes tracking, and quality management, as well as being part of a continuum of care that included primary health care services. In the second phase, the ARI organizations were asked to pilot test the survey by applying the instrument to their organization. After the pilot test, organizations gave feedback on the clarity of the survey questions and how they measured intended PPACA constructs. As a result of the focus group feedback, one indicator was removed. The excluded item was related to facilities and asked participants to rate if their facilities were up to date and modern. The participants felt this indicator was too subjective and did not coincide with the intent of the PPACA. The feedback also resulted in several wording changes to the survey. During the final phase of survey development, the ARI participants, as part of their completion activities in the nine-month ARI project, applied the survey one more time and provided feedback to assure the survey’s ability to measure intended constructs. The feedback provided supported the construct validity of the revised survey and this version of the survey was used for the Health Reform Readiness Index (HRRI) assessment described in this study.

The final HRRI included two categories of reform readiness conditions: “Building Blocks,” and “Your Organization.” The Building Block conditions were 1) Consumer/Family Role, 2) Evidence-Based Treatment, 3) Accountability for Patient Care, and 4) Integrated Continuum of Care. “Your Organization” conditions were 5) Board of Directors, 6) Workforce, 7) Patient Records, 8) Holistic Care, 9) Outcomes Measurement, 10) Quality Management, 11) Health Technology, 12) Information Technology, and 13) Finance. Each condition had an indicator of health reform readiness. (Table 1)

The HRRI scores suggest that addiction treatment organizations are in the early stages of preparing for changes anticipated with the PPACA. Accordingly, most organizations will have to address many areas in order to prepare for the PPACA and to be successful in the future. Organizational size does affect readiness for PPACA. Larger organizations scored better for all conditions. Smaller organizations are going to have to make significant changes to patient records, evidence-based treatment application, quality management functions, and become part of the health care continuum of care. To achieve these goals, they may need to look more aggressively for partnerships and collaborations, and pursue specific actions to prepare for health reform.

Specifically, organizations need to implement electronic health records that can efficiently report quality data and bill health insurers for services. Once implemented, organizations should strive to achieve electronic connectivity with other providers in their community hopefully using the inter-operability standards developed by the area’s Community Health Information Network (CHIN).

For evidence-based treatments, the HRRI emphasized the use of medication-assisted therapy (MAT). Organizations needed to have, at a minimum, MAT referral capacity in order to gain a score of “On the Way” or higher in the HRRI. Pharmacotherapy is a standard approach in general medicine and it was projected by HRRI developers that MAT capacity would be a necessary competency needed to participate in health networks.

Managed care organizations, accountable care organizations, and other health insurers prefer to work with health networks that provide a continuum of care because they can more efficiently deliver a comprehensive set of health services. This approach has been the case in general medicine as health insurance plans develop contractual relationships with networks of hospitals and primary care providers. Addiction treatment organizations that can demonstrate they are part of existing health networks can more easily be integrated into the provider panels of health insurance plans. These networks should be able to provide multiple levels of addiction and mental health services as well as provide primary care access.

Managed care organizations also typically seek evidence that an organization has a quality management function. This is often a necessary function and, when in place, can sometimes allow treatment agencies to request a higher fee for their services. Addiction treatment organizations should have a quality management function that conducts regular quality reviews of clinical management and business and operating processes. This function should be able to quantify the quality of services provided, explain how poor performance can be identified, and provide examples of how quality performance has been improved.

The study design had limitations that should be taken into consideration when interpreting the results. Although the results are based on a large sample of organizations (n = 276), the results were derived from a convenience sample of visitors to the NIATx website and a set of conference attendees. Of the 276 HRRI respondents, 20.7% were conference attendees, representing 54 organizations. Conference attendees have discretionary resources that may not be present for non-attendees. Both the conference and the NIATx website had a process improvement focus and may attract organizations that demonstrate more organizational flexibility to conduct organizational change. Those who completed the survey on the NIATx website could be considered to be motivated to learn more about PPACA and how it might impact their organization. Moreover, the sample represented organizations that tended to have greater variety of services than organizations nationally due to greater provision of outpatient, residential, and detoxification services. Overall, survey participants may have been more apt to have resources available for conference attendance, a process improvement focus, an interest in the ramifications of PPACA, and offer a greater variety of services to clients.

While these factors limit the study, they also provide an interesting perspective. If many of the HRRI respondents are indeed motivated to improve their delivery of care, offer a greater variety of services, and are better resourced to prepare for health reform, but still lag behind in terms of reform readiness (as our results suggest), then we may infer that less motivated addiction treatment organizations are even further behind in preparation for changes the PPACA brings when fully implemented in 2014. Educating and equipping unprepared organizations is imperative if they are to compete and flourish in a changing environment that requires patient-centered services, evidence-based treatment, accountability for outcomes, effective use of health information technologies, and fiscal agility to provide better addiction treatment. Organizations with smaller budgets may have greater needs to prepare for reform. Hence, many smaller substance abuse treatment agencies will need to prepare for a broad set of organizational changes or consider partnering with other organizations to access greater resources.

A recurring refrain in the field is that addiction agencies are reacting slowly to the potential changes by the PPACA due to doubt that the legislation will be fully enacted. This may not be a prudent strategy because many of the changes called for by the PPACA are consistent with macro-environmental changes already in process for addiction services, such as use of managed care and electronic health records. Failure to adequately prepare could give other health care providers the opportunity to offer addiction services instead. In sum, the PPACA attempts to make provisions for modernizing the delivery of health care services. The HRRI provides a stark reminder to the addiction field that historic changes to service delivery and structures are anticipated, and that the field must adapt and keep pace in order to survive and thrive in this new environment.

TM, VC and MB designed the study. TM and CS collected and analyzed the data. All authors participated in drafting the manuscript. All authors read and approved the final manuscript.

TM is an assistant scientist at the University of Wisconsin–Madison College of Engineering and a deputy director in the Center for Health Enhancement System Studies (CHESS). He has been a principal investigator and deputy director on multiple grants and has spent the last 20 years studying, planning, and leading organizational and individual change efforts. VC is a senior scientist at the University of Wisconsin–Madison College of Engineering’s Center for Health Enhancement System Studies. He has been working for the last 10 years with foundations and government on programs to improve access to and quality of addiction and mental health services. MB is associate researcher at the University of Wisconsin–Madison College of Engineering’s Center for Health Enhancement System Studies. He is the former CEO of Fayette Companies, a behavioral health treatment organization located in Peoria, Illinois. CS is an outreach specialist at the University of Wisconsin–Madison College of Engineering’s Center for Health Enhancement System Studies.