Substance Use Disorders: The Devil Is in the Lack of Details

The adage — the devil is in the details — implies that by getting more information about something (the details), an individual is bound to uncover problems or complexities (the devil).

In working with employers to address the challenge of substance use disorders among their employees, we found that the devil is in the lack of details.

That is, employers feel they do not have the data they need to make strategic decisions about their substance use disorder strategies, like reducing barriers to care through benefit design or driving members toward high-value providers.

Our organization, the Catalyst for Payment Reform, an independent nonprofit corporation to help employers and other health care purchasers get better value for their health care dollar, was surprised to find this for a few reasons. The nation is in the midst of an opioid epidemic; data analytics and reporting in health care, along with the technology that supports it is at an all-time high; and trend data about behavioral health should be as readily available to employers as medical data.

What should employers be pushing for when it comes to improving their substance use data? We recommend evaluating your data to understand the scope in your population, and monitoring demographic, prevalence, cost, quality and health care use data together, on an ongoing basis.

 Evaluating your data to understand the scope of substance use in your population. The prevalence of employees with substance use disorders and of what type varies by industry. In food service, construction and mining, alcohol and tobacco use disorder is more prevalent, while in nursing, transportation and among laborers, opioid use disorder is more common.

If you’re looking to quantify the scope of substance use in your employee population, consider the following metrics:

• Frequent emergency room usage.
• Patients on controlled substances such as opioids, benzodiazepines and stimulants for a long period.
• Patients on opioids with a high daily morphine equivalent dosage.
• If your employees work the traditional Monday through Friday, the number of filed workers’ compensation injury claims on a Monday versus Tuesday.
• Absences on a typical Monday compared to the Monday after the Super Bowl.
• Sexual harassment complaints.

By tracking these metrics, you can take early action rather than waiting for the costs of substance use disorders (such as health care costs for treatment, lost productivity, increased absenteeism or workers’ compensation) to pile up.

 Ongoing monitoring of demographics, prevalence, cost, quality and health care utilization. In addition to monitoring the potential scope of substance use in the employee population, employers looking to take their understanding of how substance use is impacting their population to the next level must evaluate several other categories of data in tandem, including demographics, prevalence, health care costs and use, and provider quality data.

 Demographic data. To understand its profile, employers need the basic demographics of its population to start, such as employee vs. dependent headcounts, headcount by key locations and category (e.g., technical, manufacturing, sales), salary breakdowns, etc.

 Prevalence. Employers will want to understand the volume of substance use disorder diagnoses in the population and the potential number of people with undiagnosed substance use disorders. Such disorders tend to be underreported in the medical record for multiple reasons. Patients may underreport or not report use of a substance; it’s difficult to diagnose; and screening is inconsistent, so employers that request aggregate reporting are setting the expectation that consistent screening and accurate diagnosis is important for addressing its substance use disorder strategy.

Health care cost and utilization. For benefit managers trying to get a handle on substance use disorders, health care cost and utilization should be another area of focus. Employers may want to approach reporting using the different levels of care — identification, outpatient treatment, medication assisted treatment, residential treatment and inpatient treatment. Consider the following specific areas of concern:

• Screening and costs: Employers can track the number of screenings and associated cost to determine whether screening is happening more frequently.
• Prescriptions and cost for controlled substances: Tracking this allows employers and their vendor partners to identify over-prescribing.
• Prescriptions and cost for medication assisted treatment: Such treatment is an underutilized, evidence-based treatment. Employers should ensure their members are getting access to and filling medication assisted treatment prescriptions when appropriate. Only a small proportion of providers prescribe medication assisted treatment today, so employers will want to be aware of key providers or locations where such treatment isn’t as accessible to close the gap.
• In-network versus out-of-network facility usage and cost: An employer will want to track facility usage and cost if it has concerns about members seeking care from out-of-network facilities that either have exorbitant costs, poor quality (high readmission or relapse rates), or both.
• Average morphine milligram equivalent rate for opioids: Employers will want to track this, as a high average puts members at risk for accidental overdose.

 Quality measurement. While many employers are focused on access issues for substance use disorder care, the quality of care matters greatly, too. By asking for data on provider performance on quality metrics, employers send the message that standardized quality measurement is critical to their ability to evaluate providers. Employers can leverage measures from external sources, such as HEDIS, the National Quality Forum and the American Society of Addiction Medicine. In addition, Shatterproof is creating a public rating system of substance use disorder providers that will utilize standard quality measures. It just completed a public comment period in collaboration with NQF on its proposed measures. The rating system should be available in a couple of years.

By evaluating the scope of substance use disorders in an employee population and by creating metrics for continuous monitoring, employers will be better positioned to combat this issue. Meaningfully addressing substance use disorders among a workforce is the real devil, after all.