Measuring
g performance
p
in use of
pharmacotherapy for substance
use disorders
di
d
in
i three
th
health
h lth
systems
Cindy Parks Thomas
Deborah Garnick
Melissa Rosen Seidmann
Constance Horgan
Brandeis University
Kay Miller
Thomson Reuters
Alex Harris
Veterans Administration
William M.
Willi
M Morris
M i
Claire M. Spettell
Aetna
Academy Health
Annual Research Meeting Boston June 28, 2010
Acknowledgments
•
Funded by:


•
The Brandeis/Harvard NIDA Center (Grant no. DA010233)
Substance Abuse and Mental Health Services
Ad i i t ti *
Administration*
Development through the Washington Circle
Medication Assisted Treatment Work Group and
others

C. Thomas
C
Th
(Chair),
(Ch i ) D.
D G
Garnick,
i k J
J. Albright,
Alb i ht A.
A Harris,
H i C.
C
Horgan, D. Gastfriend, S. Gelber, M. Chalk, R. Lubran, F.
McCorry, K. Miller, C. Weisner, R. Saitz
*SAMHSA Contract #: HHSS283200700071I/HHSS28300001T subcontract #1028
2
Overview of presentation
•
Background: context for pharmacotherapy
measure useful to measure claims
•
Methods: preliminary pilot testing across health
systems: Aetna, MarketScan private, MarketScan
Medicaid
•
Findings: overall use and relation of
pharmacotherapy to other treatment components
(i visits)
(i.e.
i it )
•
Implications for policy and practice
•
Next research steps
p
3
Background: Need for performance
measures for SUD pharmacotherapy
•
•
•
Evidence for treatment effectiveness1,2
National quality forum evidence
evidence-based
based practice
No standardized tools for claims-based measure of
use

•
Increasing accountability of providers

•
“Pharmacotherapy offered” measure (AMA)
V l b
Value-based
d purchasing
h i in
i SUD,
SUD public
bli and
d private
i t
Set benchmarks early in evolution of use


Low but rapidly expanding (42% annual growth3)
Identify process areas for improvement
1Buprenorphine:
Johnson et al,
al 1995; Ling et al,
al 1998; Fudala et al
al, 2003; SAMHSA TIP 40
2Alcohol treatment : Volpicelli et al, 1992; OMalley et al, 1992; Anton et al, 2006; SAMHSA TIP 28
4
Tempesta et al, 2000; Mann et al, 2004
3 Mark et al, 2009
Medications addressed In this work:
FDA approved office-based
FDA-approved
office based prescription
medications
•
Opioid abuse and dependence:

•
buprenorphine oral
Alcohol abuse and dependence:
p



Naltrexone short and long acting
Acamprosate
Disulfiram
5
Background: Intended scope of a
Washington Circle pharmacotherapy
claims-based p
process measure
•
•
•
Outpatient non-methadone SUD pharmacotherapy
Adult age 18
18-64
64
Measures for both opioid and alcohol dependence


•
•
•
•
•
Report and analyze separately
B
Brevity
it versus specificity
ifi it
Initiation, duration, follow up
Primary and specialty setting
Counseling/ clinical visits considered
Measure at provider and plan level
EHR and database applicable
6
Components of a proposed
performance measure
Of patients with appropriate SUD diagnosis:
1.
2.
3.
4.
Percent of individuals with diagnosis at any
time during year who are on appropriate
pharmacotherapy at any time during year
Timing
g from index visit to initiation of
medication (new episodes)
Percent receiving follow up after medication
prescribed
ib d (new
(
episodes)
i d )
Medication adherence or persistence
7
Specification challenge: Intersection
Between Diagnosis and
Pharmacotherapy Treatment
Diagnosis
Visit or claim
(type of service)
Counseling
Medication
F ll
Follow
up
Other dx:
e.g. pain
8
Specification challenge: Timing of
diagnosis, visits, and medication
Individual: New episode,
episode
Clean period 60 days no SUD
Visit
Visit
Med
Refill
Visit Refill
M d first
Med
fi t then
th visit
i it (occurs
(
often)
ft )
Med with no substance abuse related visit any
y time during
g year
y
(occurs up to 50% of time depending on medication/condition)
9
Methods Overview
•
•
•
•
Specify denominator population diagnoses codes
appropriate for pharmacotherapy
Specify NDC codes for relevant medications
Specify exclusions
Create numerator and denominators under
alternative specifications

Di
Diagnosis
i denominator
d
i t specifications
ifi ti





Specificity of diagnosis
Timing
Visit type
Clinical follow up post medication initiation
Persistence


Total
T
t l days’
d
’ supply
l
Proportion of days covered
10
Pilot Test Methods: Data and
P
Population
l ti
Aetna
MarketScan
Private health
plans
MarketScan
Medicaid
(at least 3 states
combined)
Years of study
2006-2008
2006-2007
2006-2007
N per year with any claims for
substance
b
abuse
b
(HEDIS
(HEDIS
definition)
40-49,000
30-37,000
15-16,000
Average age
40 yrs
41 yrs
44 yrs
Average percent female
39.6%
35.8%
44.0%
Restrictions:
• All individuals enrolled for 12 months per year
• Ages 18-64
• Full medical and pharmacy claims
• HMO or PPO for private claims
• Medicaid state must have evidence of coverage
11
Component 1: Basic proportion on
medication
Alcohol
dependence
Numerator: Number of individuals on naltrexone (short or long
g), acamprosate,
p
, or disulfiram at any
y time during
g year
y
acting),
Denominator (1): Number of individuals with any encounter
claim at any time during the measurement year associated
with diagnosis of alcohol dependence (ICD9 codes 303
303.9090303.92)
Denominator (2): Number of individuals with any encounter
claim at any time during the measurement year associated
with diagnosis of alcohol dependence or alcohol abuse (ICD9
codes 303.90-303.92, 305.00-305.02)
Opioid
dependence
Numerator: Number of individuals on oral buprenorphine
p
p
at
any time during year
Denominator: Number of individuals with any encounter claim
at any time during the measurement year associated with
diagnosis of opioid dependence (ICD9 codes 304.00-304.02)
Service
S
i codes:
d
outpatient,
t ti t intensive
i t
i outpatient,
t ti t ED,
ED detox,
d t
categories
t
i
based on NCQA specifications for substance abuse treatment
12
% o f p a tie n ts w ith d ia g n o s is w h o a re
n g m e d ic a tio n
re c e iv in
Component 1:
Alcohol pharmacotherapy measure
30%
Aetna
30%
MarketScan private
MarketScan Medicaid
20%
18.6%
18
6%
16.3%
18.0%
16.6%
20%
16.7%
10.7%
10
7%
10.2%
10%
8.3%
8.3%
10%
4.1%
0%
11.5%
11.1%
9.5%
4.1%
0%
2006
2007
2008
Alcohol dependence
303.90-303.92
Pharmacotherapy = 0.08% of total population
2006
2007
2008
Alcohol dependence or abuse
303.90-303.92; 305.00-305.02
13
% of patien
nts with dia
agnosis w
who are
rec
ceiving me
edication
Component
p
1: Opioid
p
dependence
p
measure
50%
39.7%
40%
34.9%
30%
Aetna
28.2%
MarketScan private
25.8%
24.1%
MarketScan Medicaid
20%
10%
8.6%
5.5%
0%
2006
2007
2008
Opioid dependence 304.00
304.00-304.02
304.02
Pharmacotherapy = 0.04% of total population
14
Component 2: Index visit to medication
initiation
Numerator: Individuals with index visit and medication dispensed / within 4 weeks
D
Denominator:
i
I di id l with
Individuals
i h iindex
d visit
i i and
d relevant
l
di
diagnosis
i after
f 60 d
days clean
l
period
i d
% of p
population w
with diagnosis
s
Alcohol dependence 2007
Opioid dependence 2007
30%
30%
25%
25%
20%
22.3%
23.9%
21.0%
18.6%
18.4%
16.5%
15%
24.9%
15.7%
16.5%
13.1%
21.3%
20%
18.2%
18.3%
17.2%
15 0%
15.0%
15%
11.3%
10%
10%
5%
5%
0%
0%
Outpt,
intensive
outpt
ED
Outpt, proc
non-detox
non
detox or
ED
% individuals index visit followed by med
Oupt, proc
including
detox or ED
Outpt, intensive
outpt
ED
Outpt, proc, nonoutpt, proc
detox or ED
including detox
or ED
% with med within 4 weeks
15
Component 3: Follow-up after
medication prescribed
Numerator: Number of individuals with follow up visit any type after initiation of medication
/ within 4 weeks
Denominator: Number of individuals after 60 days clean period with visit and medication rx
MarketScan private claims
2006
MarketScan Medicaid
2007
2006
Alcohol dependence, truncated 30 days prior to end of measure year
Number of individuals with prior visit and medication
visit and medication
1483
1682
Follow up: % of individuals with any SUD claim after medication initiation
30.6%
32.5%
% f ll
% follow up within 4 weeks
ithi 4
k
24 4%
24.4%
25 2%
25.2%
Opioid dependence truncated 30 days prior to end of measure year
Number of individuals with prior visit and medication
455
697
Follow up: % of individuals with any SUD claim after medication initiation
24.6%
24.5%
% follow up within 4 weeks
18.9%
18.5%
2007
221
220
24.0%
10 0%
10.0%
24.5%
11 8%
11.8%
48
107
25.0%
20.8%
21.5%
10.3%
16
Component 4: Persistence
25%
20%
15%
Private 2006
(n=2256)
Private 2007
(n=2575)
10%
5%
Any alcohol medication
in individuals with diagnosis
of alcohol dependence
10
0%
0%
09%
10
-1
9%
20
-2
9%
30
-3
9%
40
-4
9%
50
-5
9%
60
-6
9%
70
-7
9%
80
-8
9%
90
-9
9%
proportion off individualswith diagn
nosis
Proportion of days covered from first prescription to end of measurement year
Proportion of days covered until end of measure year
A
Average:
50
50-51%
51% PDC
17
perc
cent of individua
als
Component 4: Number of
prescriptions per user
Opioid dependence
Buprenorphine 2007
Alcohol dependence
Any alcohol medication 2007
60%
60%
50%
50%
40%
40%
MarketScan private
30%
30%
Medicaid
20%
20%
10%
10%
0%
0%
1 rx
2 rx
3 rx
4 rx
5+ rx
1 rx 2 rx 3 rx 4 rx 5 rx 6 rx 7 rx 8 rx 9 rx 10+
18
Summary of Results
•
•
Simple numerators and denominators
feasible measure, as broad indicator of use
of pharmacotherapy
Timing of pharmacotherapy after visit not
consistent

•
•
Medication claim often not preceded by visit
Follow up after medication initiation
feasible to measure and clinically
warranted
Persistence measure important
p
to refine

Indication of underuse but also overuse (long
tail on high number of rxs)
19
Conclusions/
Research and Practice Needs
•
•
What components are realistic and cost effective to
measure in
i what
h t systems?
t
?
Measurement benchmarks

•
A staged or set of measures, with use based on
system
y
needs

•
•
Drive practice?
comparison to diabetes performance measure evolution
Can reimbursement be tied to these components?
Relevance to public, non-claims-based systems
20
Next Steps
•
•
Additional refinement to measures
Obtain consensus on definitions



•
Consider accuracy of coding versus precision of
diagnosis
Consistent with other measures for similar population
Definition of index visit/claim for episodes
Further work on relation of visit / claim to
pharmacotherapy and follow up



Visit
Vi
it / follow-up
f ll
ti i restrictions
timing
t i ti
Consideration of exclusions, methadone
Apply
pp y measure as pilot
p
test in the Veterans Health
Administration
21
Questions?