1. Making the Best Use of Performance Data Connie Weisner, DrPH, MSW University of California at San Francisco and Division of Research, Northern California Kaiser Permanente Summit: Using Performance and Outcomes Measures to Improve Treatment Los Angeles, California March 20-21, 2008

2. Background A perspective from working with Kaiser and HMO Research Network health plans, public clinics and CD programs in using performance measures  Lessons learned in using measures to do work in quality improvement  Work in public clinics

3. Overview Purpose and description of performance measures  How to get at what you want to measure  Using for good and ill - examples Current opportunities for expanding scope of care and for continuing care – implications for performance measurement  Increasing collaboration with other systems (e.g. health clinics) Lessons learned about who and when we count  Lessons from health plans and from Prop. 36

4. Ability to Change Treatment Health care performance measurement is the process of using a tool based on research to evaluate a health plan, program, or practitioner. Performance implies that the responsible health care providing entity can be identified, held accountable, and has control over the aspect of care being evaluated. (system, program, staff) (Source: Understanding Performance Measurement www/ahcpr.gov/chtoolbx)

5. Uses for Performance Measures: Mixed Messages? Accreditation Regulatory oversight Purchasing and contracting Competition Quality improvement

6. Performance Measures in HEDIS Identification -- Percent of adult enrollees with an AOD claim, defined as containing a diagnosis of AOD abuse or dependence or a specific AOD-related service, on an annual basis. Initiation -- Percent of adults with an inpatient AOD admission or with an outpatient claim for AOD abuse or dependence and any additional AOD services within 14 days. Engagement -- Percent of adults diagnosed with AOD disorders that receive two additional AOD services within 30 days of the initiation of care.

7. Problems: the “telephone answering time” phenomenon Some program types meet criteria without really being treatment engagement (e.g., inpatient detox) Measuring continuity in moving from levels of care or referrals Cherry-picking – is it really possible to adjust for complex patients? (where to measure initiation?) Good overall rates, but uneven across particular populations (e.g., age, co-occurring problems) Distance factor – convenience trade-off Initiation where? (how “point of identification” makes a difference)

8. Pilot Test Results Source: Garnick DW, Lee MT, Chalk M, Gastfriend D, Horgan CM, McCorry F, McLellan AT and Merrick EL. Establishing the Feasibility of Performance Measures for Alcohol and Other Drugs, Journal of Substance Abuse Treatment, 23:375-385, December 2003

9. How to measure what you want to measure: Lessons learned Include providers in what and how to measure: what is fair and how they can use the information Not useful without feedback  Providers are on the right side and are creative  Natural experiments:  changing intake systems  special population groups (move staff to other systems)  telephone calls (outreach)

10. A Challenge: Opportunities for expanding scope of care (and improvement in performance measures?) Why we need to increase collaboration with other systems (health clinics)

11. Coding for SBI Reimbursement February 2008 PayerCodeDescriptionFee Schedule Commercial Insurance CPT 99408 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $33.41 CPT 99409 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $65.51 Medicare G0396 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $29.42 G0397 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $57.69 Medicaid H0049 Alcohol and/or drug screening $24.00 H0050 Alcohol and/or drug service, brief intervention, per 15 minutes $48.00

12. Community Epidemiology Laboratory Alcohol Treatment (22) Criminal Justice (1) Drug Treatment (8) Emergency Room (4) Primary Health Care (5) Welfare (7) Mental Health (8) General Population Survey Agency Systems

13. Distribution of New Admissions 1 of Alcohol Dependent 2 Individuals in Community Agency Systems Primary Care 55.7% 1 Data weighed for design effects, non-response, and to a common fieldwork duration so that each agency system sample is shown to its size. 2 Dependence rates over a base of those meeting DSM-III-R criteria across all agency systems. Welfare 6.6% Criminal Justice 23.5% Mental Health 3.0% Substance Abuse Treatment 11.1%

14. Distribution of New Admissions 1 of Weekly Drug Users 2 in Community Agency Systems Primary Care 43% 1 Data weighed for design effects, non-response, and to a common fieldwork duration so that each agency system sample is shown to its size. 2 Weekly drug use rates over a base of weekly drug users across all agency systems. Welfare 11% Mental Health 3% Criminal Justice 39% Substance Abuse Treatment 6%

15. Distribution of New Admissions of Female Weekly Drug Users 2 in Community Agency Systems 1 Primary Care 64% 1 Data weighed for design effects, non-response, and to a common fieldwork duration so that each agency system sample is shown to its size. 2 Weekly drug use rates over a base of women weekly drug users across all agency systems. (Weighted N=286) Welfare 20% Mental Health 3.8% Criminal Justice 15.7% Drug Treatment 1.7% Alcohol Treatment 2.1%

16. What does that mean for our treatment population? What does that mean for improving performance?

17. CD Patients and Matched Health Plan Members: ICD-9 Medical Conditions* CD Patients (N=747) Matched Members (N=3,690) Injury and Overdoses25.6%12.5% Lower Back Pain11.2%5.8% Headache9.6%3.8% Hypertension7.2%3.4% Asthma6.8%2.6% Acid-related Disorders4.3%2.1% Arthritis3.9%1.3% *all p<.001 Mertens JR, Lu Y, Parthasarathy S, Moore C, Weisner CM. (2003). Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO:Comparison to matched controls. Arch Int Med 163:2511-17

18. Medical Conditions of Adolescents in CD Treatment vs. Matched Controls Adolescents in alcohol and drug treatment had significantly higher prevalence of several medical conditions, including:  Asthma  Injury  Sleep disorders  Pain conditions (abdominal pain, muscle pain, and headaches)  STDs  Benign conditions of the uterus  Dermatology conditions  Gastroenteritis Mertens J, Flisher A, Sterling S, Weisner C. Medical conditions in adolescent alcohol and drug treatment patients in a private health plan: comparison with matched controls. Scientific Meeting of the Research Society on Alcoholism, Santa Barbara, CA, June 29, 2005.

19. HIV Risk Behaviors among Adolescents in CD Treatment 14*3Male homosexual activity/female bisexual activity 37 52 39 43 Sex with multiple partners, past 6 months + never/inconsistent condom use 53*35 Never/inconsistent condom use (of those reporting ever having sex) 11Sharing needles or works 42Injection drug use (IDU) Girls (N=143) % Boys (N=276) % Risky Behaviors Ammon L, Sterling S, Mertens J, Weisner C. Adolescents in private chemical dependency programs: who are most at risk for HIV? J Subst Abuse Treat. Jul 2005;29(1):39-45.

20. So what? Services for these problems make a difference, and also likely show improvement in performance measures How to measure?

21. Medical Services Improve substance use outcomes short and long-term Are cost effective “Probably” increase retention Parthasarathy S, Mertens J, Moore C, Weisner C. Utilization and cost impact of integrating substance abuse treatment and primary care. Med Care. 2003;41(3):357-67. Weisner C, Mertens J, Parthasarathy S, Moore C. Integrating primary medical care with addiction treatment: A randomized controlled trial. JAMA 286(14):1715-1723.

22. One last point An important fundamental issue from performance measurement about who and when we count: Lessons from health plans and from Prop. 36

23. The public wants to know the population base of all treatment intakes: Who do they consider you responsible for? Lessons for continuing care approaches "Users kicking Prop. 36, not drugs; With offenders failing to enroll in or complete treatment, the initiative is a `get out of jail free' card, critics say.“ Los Angeles Times, April 1, 2007 Employer purchasers want to know how the people they refer to treatment do, not just those who continue.

24. Discussion