Probe the system to improve opioid use disorder treatment

A recent Open Minds piece entitled “Untangling the Access Issues for Addiction Treatment” points to four reasons as to why addiction services are rarely or never accessible. Briefly, those reasons are as follows:

  1. Lack of insurance for approximately 20 percent of consumers with opioid use disorder (OUD)
  2. Available detoxification program capacity, with uneven distribution of beds
  3. Provider lack of knowledge of available resources
  4. Lack of consensus on what “clinically appropriate” treatment looks like

Most people wouldn’t argue the role these factors play in contributing to access challenges for OUD treatment. However, some people might argue that we need to probe further to untangle what access really looks like in the larger health care delivery system – that the solutions to these challenges are systemic and not singularly focused.

Bed availability in detoxification programs is an excellent example. What really is the issue here? Bed availability in detoxification programs? Or is it the lack of knowledge that withdrawal management can occur anywhere along the care continuum? Some experts argue that it’s time to stop viewing “bed availability” in these programs as a fall-back position. The “number of beds”, they suggest, is a misguided issue. While sometimes a detoxification program is the best solution for any given individual, it’s not the only solution, and often it’s not the best solution. To complicate the issue further, most clinicians – and consumers – are not aware of preferable alternatives.

Chronic disease model of care: a more global view

To think of access a little differently, perhaps the best approach is to adopt a system-wide outlook that includes points of access across the care continuum. As described in Beacon’s 2015 white paper, “Confronting the Crisis of Opioid Addiction”, the chronic disease model of care does just that: it not only promotes treatment access at variable points along the care continuum but also the ability to re-engage treatment at lower and often more appropriate levels of care.

To think of access a little differently, perhaps the best approach is to adopt a system-wide outlook that includes points of access across the care continuum.

Indeed, the chronic disease model of care offers a framework for a more global point of view. Through six fundamental tenets, this model incorporates the necessary societal, systemic, and legislative overhaul to promote real improvements in care and clinical outcomes, as follows:

  1. Community resources and policies
  2. Health care organization
  3. Self-management support
  4. Delivery-system design
  5. Decision support
  6. Clinical information systems

The chronic disease model of care at work

Many, if not all, of these six tenets address the four access challenges referenced above, but they don’t restrict our focus to single-factor solutions. For example, “delivery-system design” calls for an overall structure that delineates acute care from the planned management of ongoing care, as described in Beacon’s white paper. Indeed, member long-term engagement, key to the chronic disease model, is more successful when members initiate treatment in the least restrictive setting as promoted by the American Society of Addiction Medicine’s 10 levels of care, whose goal is to achieve recovery in the community. Thinking this way, we don’t restrict our solution to increasing the number of beds; instead, we solve access issues by tapping into what the entire system has to offer – at the maximum benefit for the consumer.

Another example is the lack of trained clinicians in OUD treatment. We can’t force providers to become OUD specialists, but the system can certainly incentivize them to do so, and even more importantly, to excel at it. One “health care organization” strategy posited in Beacon’s paper calls for value-based payments – pay-for-performance, capitated or bundled service arrangements, etc. – that realign incentives with comprehensive, high-quality treatment and improved outcomes. Such strategies can promote access to evidence-based medication-assisted treatment, as well as accompanying psychosocial and medical modalities, by tying reimbursement to outcomes and the promotion of full-service, chronic disease management.

In summary, by adopting a more global viewpoint, we don’t restrict ourselves to single-factor solutions. Instead, we can start seeking out broader, more innovative solutions. Who knows what untapped solutions are lying fallow in the larger system.

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