Payer consensus: A new era for substance use disorder treatment

The prevalence of substance use disorder (SUD), highlighted by the opioid crisis, is not new news. Approximately, 21 million Americans have an SUD. In 2015 alone, opioids killed more than 33,000 people in the United States, more than any previous year on record, according to the Centers for Disease Control.

Explanations, or some might say blame, are cast everywhere: overprescribing doctors, a zealous pharmaceutical industry, demanding patients, and even the health insurance industry reluctant to cover alternative treatments to pain medications. Regardless, the exposure to opiates for many has created brain-based changes resulting in an SUD condition.

Therein lies the challenge. From what angle do we devise a solution to a problem that many argue has so many roots?

That’s where Shatterproof comes in, a national nonprofit organization dedicated to reducing the devastation of SUD, started by Gary Mendell, businessman and CEO who founded HEI Hotels & Resorts, after losing his son to an SUD in 2011. Shatterproof seeks to put some order around the chaos by adopting evidence-based principles of care for SUD treatment, with the ongoing goal of identifying, promoting and rewarding treatment proven to improve health outcomes and save lives.

[The principles of care] stand out because 16 major players, including Beacon Health Options, have signed off on them — agreeing that these principles should be promoted and rewarded.

What does that look like?

Shatterproof stands behind eight fundamental principles of care, announced by the organization’s Substance Use Disorder Treatment Task Force after its September 19 kick-off meeting. While people familiar with SUD treatment will recognize many, if not all of the principles, they stand out because 16 major payers, including Beacon Health Options, have signed off on them – agreeing that these principles should be promoted and rewarded.

“From a health care standpoint, addiction is the medical condition where the majority receiving treatment do not receive best-practice care. This concerted effort is like none we’ve seen before,” commented Beacon’s Dr. Steve Bentsen, Senior Vice President and Chief Medical Officer, Federal/Employer Division and member of Shatterproof’s SUD task force. “These 16 payers can influence nearly every contracted provider in the country, guiding, promoting and rewarding evidence-based standards of care. This will also empower consumers of care to appropriately chose providers and treatment. To my knowledge, such consensus is unprecedented.”

Backed by three decades of research, the principles stem from the Surgeon General’s Report on Alcohol, Drugs, and Health. The eight principles are as follows:

  1. Universal SUD screening across all medical settings. As with other chronic diseases, SUD screening should be integrated into primary care settings.
  2. Personalized diagnosis, assessment and treatment planning. Individuals are unique, and their treatment plans should be as well. Optimal SUD treatment is not a one-size-fits-all proposition as has been shown with other chronic diseases.
  3. Rapid access to appropriate SUD care. As the saying goes, timing is everything, and SUD treatment is no exception. Individuals recovering from SUD don’t easily tolerate stress and therefore motivational readiness is difficult to sustain, requiring rapid access to care.
  4. Engagement into continuing long-term care with monitoring and adjustments to treatment. Intensive detoxification and residential treatment may be necessary to stabilize an individual, but it does not promote sustained recovery. Monitoring care allows adjustments to that care as individuals go through the long process to recovery.
  5. Concurrent, coordinated care for physical and mental illness. Most people with an SUD have a co-occurring mental and/or physical illness, and the most effective path to health is coordinating care to treat the whole person.
  6. Access to fully trained behavioral health professionals. Evidence-based care is most effective when delivered by appropriately trained providers.
  7. Access to FDA-approved medications. Medications, particularly medication-assisted treatment, can not only save lives (prevent overdose) but also sustain recovery.
  8. Access to non-medical recovery support services. Sustained recovery involves addressing other needs, such as housing and employment challenges, and recovery support services, including peers (people with lived experience), can provide ongoing emotional and practical support.

Payer consensus behind these principles has the potential for establishing a new level of accountability among providers. In brief, it’s quite literally systematic change, and Beacon Health Options is thrilled to be part of this groundbreaking effort.


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