Whose evidence?

You ever notice that the people most enthusiastic about quality of care are in business development and marketing?

If you were to judge by the web presence and marketing efforts, every program is individualized, trauma-informed, culturally-sensitive, evidence-based, and essentially a gift to suffering individuals and families everywhere. But, once you pull back the covers, you realize that the electronic medical record won’t even allow for individualized treatment plans, “evidence-based” means describing a random potpourri of approaches, and quality is defined by organizational dashboards that measure census, bed count, and conversions of residential care to IOP.

When you ask about patient outcomes, you either get a data set that doesn’t include anyone who is discharged AMA or you are looked at like you descended from Neptune.

Somehow, many programs are both person-centered and also 12-step focused. Most programs define addiction as a continuation of symptoms despite consequences, yet if you demonstrate these symptoms in these same programs, you’re getting booted. “What’s your model of care?” ends up being the entry point to a disjointed treatise that culminates in “Good, Orderly Direction.” And somehow, medications that support recovery and save lives aren’t considered the ethical floor of any discussion of treatment.

This fascinating disinterest in holding the line when it comes to intellectual honesty leaves an incredible vacuum, one that allows reality to be defined by salespeople, policymakers and payers.

The approach that has filled this vacuum — a profit-driven approach to healthcare — has been a colossal failure in every way. Many systems of care achieve financial stability by rationing or denying care. Many programs substitute muddy, poorly- disguised, financially-driven thinking for clinical rationale. This leads to poor outcomes at the population level while contributing to the continued stigmatization of the populations that have always been victimized by our system.

In the systems I have worked with, quality is often measured by instruments that intersect, but don’t completely align, with quality of care. The Press-Ganey survey, CARF, JCAHO, HEDIS, and more recent efforts in the SUD space, like Shatterproof's Atlas and NAATP’s Quality Assurance work, have done very little to actually shift our industry toward a focus on quality. While all of these attempts are welcome steps toward The Grail, I don’t think that even the most passionate boosters would say that they are as effective as they would like.

Attempts to define measurements of quality are fraught with perceived business risk. Efforts to measure granular patient outcomes are thwarted by concerns about reliability and validity of the instruments. Efforts at reform are watered down to placate those who aren’t terribly interested in letting the ideologically-driven rigidity go. And while I am typically in the cheering section when it comes to pointing out the need for healthcare reform focused specifically on payers and MCOs, the fight against quality measures by those providers invested in the status quo is as deserving of our ire.

I was invited to attend a roundtable around quality standards in addiction treatment a few years back. Lots of big players (and payers) gathered in a swank conference room off K Street. Several nationally-recognized nonprofit and for-profit providers were in the meeting as well. At one point, a provider at the table mentioned that they don’t use medications at their facility. Thinking that they meant they didn’t use medications like buprenorphine to treat opioid use disorder, I mentioned that it is unfortunate, but common that specialty treatment providers don’t use these approaches because of stigma and bias. I was then told that they didn’t use any medications. Any. I was floored. I was lectured on how this “innovative” treatment model had a 90% success rate and consisted of psychoeducation, 12-Step meetings and exercise.

At a table filled with CEOs of payers representing hundreds of millions of covered lives, we couldn't even enter the 21st century by consensus.

This inability to define standards that drive quality and aren’t serving a larger agenda is one of the largest missing pieces in our effort at reform. The work of luminaries like William White, folks like Dr. Bob Lynn, the next wave of recovery researchers like Robert Ashford, and the work of Recovery Community Organizations around the country demonstrate the power of recovery.

And, further translation is needed. Our understanding of substance use issues is light years beyond the thinking that drove the arrangement of our systems of care and the calcified, outdated payment models which support their continued dominance. We need specific, replicable models of care that leverage harm reduction and abstinence-based efforts, lived experience and manualized programming, science and wisdom.