Best Practices and Barriers to Engaging People with Substance Use Disorders in Treatment. APPENDIX D: Site Visit Discussion Guide

03/06/2019

Overview

Purpose. This Site Visit Discussion Guide is for use in the research study, Identifying Best Practices and Barriers to Engaging People with Substance Use Disorders (SUD) in Treatment. This study is being funded by ASPE.

The purpose of this Site Visit Protocol is to establish a semi-structured discussion guide that will be used when interviewing health plans about their successes and challenges in improving beneficiaries' ability to initiate and engage in SUD treatment. In addition, the protocol will be used to organize background information about the health plan.

How to use. The initial Logistics section of this Site Visit Protocol is a template that will be tailored to each of the six site visits conducted. Tailored Site Visit Protocols will include logistics specific to the site visit including an agenda for the visit and contact information for the interviewees and research team.

The Discussion Guide included in this resource provides both a quick reference checklist of the key topics to be discussed and the discussion guide by topic. The research team anticipates that the guide will be modified for each health plan to include specific health plan profile and background information. The research team will decide which topics will be covered for each meeting arranged during the site visit. The interviewer can use the checklist to ensure that major topics have been covered during the site visit. The Discussion Guide will be used to provide primary and probing questions for each topic area. Additionally, the team anticipates that the guide will be modified using lessons learned or new focal areas discovered as a result of conducting the site visits. Any changes to the guide will be discussed with, reviewed, and approved by ASPE prior to implementation in subsequent site visits.

The Health Plan Background section is another template document that will be tailored to each of the six site visits conducted using information gathered about the health plan prior to the site visit. This section provides useful background information on the health plan and the marketplace in which it is operating.

Table D.2 offers a brief eight-step overview of the interviewer and note-taking process that the researchers will review prior to each site visit. Finally, Table D.3 is the physical note template that the researchers will use to document each interview.

Logistics

TABLE D.1. Site Visit Agenda
[Health Plan Name]
Site Visit Agenda
Date and Time Task Location
Day One: MONTH DD, YYYY
HH:HH a.m. - HH:HH p.m. Meet and Greet: NAMES  
HH:HH a.m. - HH:HH p.m. Meeting: NAMES
Topics:
 
HH:HH a.m. - HH:HH p.m. Tour: NAMES
Topics:
 
HH:HH a.m. - HH:HH p.m. Lunch
[NAMES]
 
HH:HH a.m. - HH:HH p.m. Meeting: NAMES
Topics:
 
HH:HH a.m. - HH:HH p.m. Meeting: NAMES
Topics:
 
HH:HH a.m. - HH:HH p.m. Day 1 Wrap-Up
Review Day 2 Agenda
[NAMES]
 
Day Two: MONTH DD, YYYY
HH:HH a.m. - HH:HH p.m. Meet and Greet: NAMES  
HH:HH a.m. - HH:HH p.m. Meeting: NAMES
Topics:
 
HH:HH a.m. - HH:HH p.m. Tour: NAMES
Topics:
 
HH:HH a.m. - HH:HH p.m. Lunch
[NAMES]
 
HH:HH a.m. - HH:HH p.m. Meeting: NAMES
Topics:
 
HH:HH a.m. - HH:HH p.m. Meeting: NAMES
Topics:
 
HH:HH a.m. - HH:HH p.m. Day 1 Wrap-Up
Review Day 2 Agenda
[NAMES]
 

Logistics

Contact Information: The following lists include site visit interviewees and interviewers.

Interviewees at Site Visit

  • NAME, Chief Executive Officer, ###-###-####, email

  • NAME, Chief Medical Officer, ###-###-####, email

  • NAME, Outreach Coordinator, ###-###-####, email

  • NAME, Title, ###-###-####, email

  • NAME, Title, ###-###-####, email

  • NAME, Title, ###-###-####, email

Interviewers Traveling for Site Visit

  • Peggy O'Brien, [phone redacted], marbrien@us.ibm.com

  • Erika Crable, [phone redacted], ecrable@us.ibm.com

Discussion Guide

Key Points Checklists

Purpose. Use these checklists to ensure that all major subtopics are covered during the health plan site visit. Phrasing of questions will be based on questions described in the sections that follow this checklist; this checklist is simply a topic area reminder tool for the interviewers. Each checklist is specified to the interviewee's role.

Health Plan Description
  1. Management structure
  2. Location of SUD services
  3. Carve-in or carve-out benefits
  4. Relationship between physical health, mental health, and SUD benefits
  5. Management and oversight of SUD benefits
Benefit Design
  1. Coverage of continuum of care
  2. Incorporation of ASAM levels of care
  3. Case management or care coordination for individuals with SUD
  4. Contracted provider types
  5. Coverage of MAT
  6. Coverage of support services
Reimbursement Procedures and Rates
  1. Payment types used by the health plan
  2. Development of reimbursement rates
  3. Impact of reimbursement on access
  4. Reimbursement differences for in-network and out-of-network providers
  5. Use of any alternative payment models, including incentives
Community and Market Characteristics
  1. Provider availability
  2. Regulation of SUD providers
  3. SUD billing
  4. State and community attitudes toward SUD treatment
Network Adequacy
  1. Measuring and maintaining network adequacy
  2. Managing low service availability
Quality Improvement Methods
  1. Quality improvement initiatives
  2. Monitoring provider performance
  3. Reporting measures
Facilitators and Barriers to Engagement
  1. Facilitators to initiation and engagement
  2. Barriers to initiation and engagement
 

Warm-Up Questions

  • Discuss goals of this research. Do you have any additional questions about this project before we get started?

  • How long have you been with this health plan?

  • What are the major responsibilities in your current position?

Discussion Questions: Health Plan Description

Discussion Goals: To understand the health plan's organizational design and management

Key Points That Need to Be Clarified by Discussion's Close:
  • Roles and responsibilities of the health plan's leadership team
  • Management and oversight of SUD benefits
  • Organization of SUD benefits in relation to other behavioral health and physical health benefits
Key Words: governance, organizational structure, management, decision-making, integration

Health Plan Description Discussion Questions
(If already know answer, use questions to confirm)

  • How is your organization structured at a high level?
    PROBES:

    • Do you have any major partners?

    • Do you provide behavioral health benefits or pharmaceutical benefits directly, or do you use a behavioral health carve-out or pharmacy benefit manager?

      • If so, who are they?

      • How are those benefits coordinated with the rest of the organization?

    • What different lines of insurance do you manage (e.g., Medicaid, commercial,) and how do the partners and carve-outs differ?

      • Is your state (or health plan and/or national plan) involved in any SUD care delivery or financing reform changes? If so, how is your health plan involved in those changes?

      • [If Medicaid] What impact does your state Medicaid authority's innovation initiatives have on your plan's care delivery or reimbursement practices?

      • [If Medicaid] What impact has your state Medicaid authority's innovation initiatives had on quality improvement initiatives?

  • What is your current management structure, particularly as it relates to behavioral health or SUD services?
    PROBES:

    • Who has primary oversight of SUD services?

      • What type of clinical expertise is included?

    • Who has primary oversight of pharmaceutical services? Do they differ for oral versus injection medications?

    • Who are the other key players and key departments?

    • Where do case management or care coordination services fit in the structure?

  • How does your health plan approach the relationship among physical health, mental health, and SUD benefits?
    PROBES:

    • Do you have any integration initiatives? If so, please describe?

      • Care management services to aid members in coordinating benefits?

      • Office-based MAT (opioid or alcohol) providers?

      • Co-location of services?

    • Do these differ among plan types?

  • How does your health plan approach the development and implementation of new SUD strategies?
    PROBES:

    • Are initiatives developed at the national or local level?

    • Who is responsible for implementing these strategies?

    • How is the process monitored?

  • Does your health plan have clinical or member advisory committees or similar structures that inform how you approach your SUD benefits?

  • Are you noticing any trends among your beneficiary population with SUD needs?
    PROBES:

    • Which age groups seem to be more affected than others?

    • Other demographic and geographic trends?

    • Co-occurring needs? [relate back to the integration question]

  • Describe your beneficiary population's SUD needs.
    PROBES:

    • Do SUD issues lie more in alcohol, opioid or other chemical dependencies?

    • Among opioids, distinguish between prescription misuse or heroin use.

Discussion Questions: Benefit Design

Discussion Goals: To understand the health plan's SUD service benefit design

Key Points That Need to Be Clarified by Discussion's Close:
  • Coverage throughout the care continuum
  • ASAM levels of care
  • Case management services
  • Contracting with providers
Key Words: provider type, provider qualifications, benefit array, parity ASAM

Benefit Design Discussion Questions
(If already know answer, use questions to confirm)

  • Describe your health plan's SUD treatment benefit array. For each service discussed, who is contracted to provide this service?
    PROBES:

    • What types of detoxification services are covered?

    • What types of residential services are covered if any?

    • Are IOP services or partial hospital services covered?

    • Are outpatient medical and counseling services covered?

      • What, if any, are the limits to counselling services? Does your plan require prior authorization, utilization review, medical management activities?

      • Describe the prior authorization/utilization review process for service coverage.

    • Do you have other specialized providers?

      • Pain clinics who can manage members with SUDs?

      • HIV clinics?

    • Which SUD treatment medications do you cover?

      • (If plan has members in more than one state) Does it vary by state of residence?

      • Do you require prior authorization for these medications?

        • Describe the prior authorization process for medications.

        • (If not mentioned) Describe any precertification requirements for specific services.

      • Do these medications have dosage limits or limits to how long individuals can remain on them?

    • What types of additional crises or support services does your health plan provide?

      • Crises services?

      • Peer counseling?

      • Aftercare services?

      • Case management services?

      • Relapse prevention?

      • Patient activation, family activation or engagement?

    • Do these services differ by health plan type?

  • Does your health plan use the ASAM criteria to assess patients and recommend levels of care? If yes, please describe how.

  • What case management or care coordination services are available to individuals with SUDs?
    PROBES:

    • What services are provided (i.e., mostly utilization review or prior authorization versus social service linkage)?

      • Describe the utilization review or prior authorization process.

    • Are these services provided directly by the health plan or under contract through providers?

    • Is there any level of integration with physical health?

    • How do these services assist with transitions in care?

      • If yes, how?

      • If no, who assists with transitions of care?

  • Describe the types of SUD providers that the health plan contracts with?
    PROBES:

    • Specialized providers?

  • How have SUD benefits changed since the implementation of MHPAEA?

  • What have been the barriers to providing the SUD services?
    PROBES:

    • How have you attempted to address them?

Discussion Questions: Reimbursement Procedures & Rates

Discussion Goals: To understand how reimbursement procedures for SUD services, care coordination, and recovery support services may be influencing SUD treatment initiation and/or engagement

Key Points That Need to Be Clarified by Discussion's Close:
  • Reimbursement rates for SUD services
  • Rate setting process and impact on access
  • Alternative payment models
Key Words: reimbursement, rate setting, risk, care coordination, cost sharing

Reimbursement & Rate Discussion Questions
(If already know answer, use questions to confirm)

  • What is the payment mechanism you use to reimburse different levels of care for substance use treatment services?
    PROBES:

    • Is it primarily fee for service?

    • Do you use bundled payments? If so, please describe.

    • Do you use any incentive payments? If so, please describe.

    • Do you use any financial penalties? If so, please describe.

    • Do you use other alternative payment models? If so, please describe.

  • Does your payment mechanism differ depending on provider types? How so?
    PROBES:

    • Differences for inpatient versus outpatient providers?

    • Differences between psychologists, psychiatrists, PCPs, masters level counselors, peer supports, others?

  • How does your reimbursement differ for in-network and out-of-network providers?
    PROBES:

    • Are there differences in the amount that providers get reimbursed or in the amount that the plan member has to pay out-of-pocket for services provided by non-preferred providers compared with preferred providers?

    • Which services, if any, are most frequently accessed out of network?

  • Do you use any financial mechanisms to ensure smooth transitions of care or care integration?
    PROBES:

    • Incentive payments or penalties for providers?

  • Describe the process for rate setting?
    PROBES:

    • Have your rates changed over time?

    • Do you use a negotiated rate?

  • Do you think reimbursement rates impact treatment access and continued engagement?

  • Do you think reimbursement rates affect network adequacy; for example, which providers decide to join your network?

  • Do you reimburse for naloxone/Narcan®?
    PROBES:

    • How is that reimbursement structured for naloxone vs. Narcan vs. Evzio®?

    • Are rebates available to the plan or the beneficiary?

    • Do you reimburse third parties (e.g., family members, others) who purchase naloxone when the beneficiary is the end user?

Discussion Questions: Network Adequacy

Discussion Goals: To understand how network adequacy for substance use treatment services is impacting initiation and/or engagement

Key Points That Need to Be Clarified by Discussion's Close:
  • Measuring and maintaining network adequacy
  • Managing inadequate service availability
Key Words: adequacy, availability, geographic distribution, wait times

Network Adequacy Discussion Questions
(If already know answer, use questions to confirm)

  • Describe your health plan's process for measuring and maintaining network adequacy?
    PROBES:

    • What standards are you currently required to follow as a result of state, federal, or accreditation guidelines?

    • Do you use time and distance criteria?

    • Do you use wait times?

    • Are you using provider-to-member ratios?

    • Do your requirements change by geography?

  • Main challenges to developing network adequacy?
    PROBES:

    • Geographic challenges?

    • Provider availability?

  • How does your health plan manage a lack of SUD service availability?
    PROBES:

    • Is the plan working with providers to develop any new, specialized services?

    • How frequently does the plan re-examine reimbursement rates?

    • Has the plan undertaken any initiatives to expand SUD treatment services to primary care sites?

    • Is the plan implementing or considering the use of telehealth or other mobile enhancements?

      • Describe how your team is using telehealth. For which services?

      • When did this start and what percent of your SUD population is utilizing this service?

      • Are providers required to have any kind of specialized training to receive reimbursement for this service?

      • What barriers do you think exist to offering telehealth?

  • Do you think provider wait times are affecting members' treatment initiation or continued engagement in care?
    PROBES:

    • What is the average wait time for the first SUD appointment?

  • What is your health plan's experience with out-of-network providers?
    PROBES:

    • Are you experiencing any out of state treatment center solicitation of beneficiaries?

    • Are there limitations on the types of SUD services that beneficiaries can access out of network?

    • What costs do beneficiaries face when out-of-network providers are utilized?

    • Are there any OUD services that are only available out of network?

Discussion Questions: Quality Improvement Methods

Discussion Goals: To understand how the health plan is monitoring provider performance and what kinds of improvement initiatives exist to increase substance use treatment initiation and/or engagement

Key Points That Need to Be Clarified by Discussion's Close:
  • Quality improvement initiatives
  • Process for monitoring provider performance
  • Reporting measures
Key Words: provider performance, quality measures, penetration rates, utilization review, P4P, data monitoring

Quality Improvement Discussion Questions
(If already know answer, use questions to confirm)

  • How are new SUD quality improvement initiatives developed for your health plan?
    PROBES:

    • Are they developed at the national, regional, or local level?

    • Are they implemented at the national, regional, or local level?

    • How is the process monitored?

  • What types of quality improvement initiatives has your health plan utilized to improve SUD services and SUD service engagement?
    PROBES:

    • Provider education?

    • Transitions in care? Warm hand-offs, case management, care coordination?

    • Pharmaceutical data monitoring to identify high-risk members?

    • Improving members' access to MAT?

    • P4P or other value-based purchasing?

    • Follow-up programs for individuals who drop out of treatment?

    • Recovery support services?

  • Do you have any initiatives to engage groups of people who have been traditionally hard to engage?

  • What are some of the main challenges you have encountered with your quality improvement efforts?

  • How does your health plan monitor performance?
    PROBES:

    • Do you use performance metrics? What are they?

    • Do you use quality measures? Which ones?

      • The IET Measure?

    • What member satisfaction or experience of care measures do you use?

    • Do you monitor any of the following?

      • Penetration rates

      • Outcomes of utilization review

      • Member outcomes

      • Successful or non-successful care transitions

      • Any pharmaceutical data monitoring for maintenance of MAT?

  • What is your health plan's measurement reporting process?
    PROBES:

    • Are you reporting results publicly and/or privately?

    • Do you look at measures at a provider level? If so, do you share it with providers?

Discussion Questions: Community & Market Characteristics

Discussion Goals: To understand how community and market factors including attitudes toward SUDs, provider availability, billing proficiency, and support services are affecting treatment initiation and/or engagement

Key Points That Need to Be Clarified by Discussion's Close:
  • Provider availability in the market area
  • SUD billing proficiency
  • Attitudes toward SUD treatment
  • State support/funding for recovery support services
Key Words: provider availability, billing, stigma, housing, social services, state funding, state regulation, community attitudes

Community and Market Discussion Questions
(If already know answer, use questions to confirm)

  • Describe the provider availability in the community for SUD services (note for the community overall versus the health plan's specific network).
    PROBES:

    • Residential service providers?

    • MAT providers?

    • IOP or partial hospital providers?

    • SUD specialty service providers?

    • Peer support services?

    • Housing and social services?

    • Community mental health centers, federally qualified health centers?

  • In your areas, how much experience do SUD treatment providers have at billing services to insurance versus using grant funding?

  • What are the attitudes toward SUDs and SUD treatment by various members of your community?
    PROBES:

    • Does your community approach SUDs as a chronic condition using a chronic care model or as an acute condition using an acute care model?

    • What are local attitudes toward MAT versus abstinence treatment?

    • How have these attitudes affected availability of substance use treatment, if at all?

    • What are the attitudes of law enforcement or criminal justice toward SUD treatment?

  • How are SUD providers generally regulated and funded in your state or community?
    PROBES:

    • Residential services?

    • SUD specialty services?

    • MAT services?

  • What kinds of recovery support services are provided by the state or community to individuals with SUDs?
    PROBES:

    • Is the state addressing housing and/or social services for this population?

      • From a housing first approach?

    • How are these services funded?

  • Is the state tracking treatment initiation and engagement rates for individuals receiving these services?

Discussion Questions: Facilitators and Barriers to Engagement

Discussion Goals: To understand what key informants feel are the primary facilitators and barriers to initiating and/or engaging in SUD treatment services

Key Points That Need to Be Clarified by Discussion's Close:
  • Primary facilitators of initiation and engagement
  • Primary barriers of initiation and engagement
Key Words: member characteristics, service availability, specialty services, stigma, evidence-based treatments, chronic care model

Facilitators and Barriers Discussion Questions
(If already know answer, use questions to confirm)

  • What are the main factors that you see that facilitate engagement in treatment for individuals with SUDs?
    PROBES:

    • Member characteristics such as sex, age, comorbid conditions, type of substance used?

    • Geographic characteristics?

    • Provider availability?

    • Provider attitude and culture?

    • Transition in care programs?

    • MAT utilization and availability?

    • Reimbursement?

    • Specialized services such as specialized pain clinics?

  • What do you see as the main barriers to treatment engagement in SUD services in your health plan or community?
    PROBES:

    • Stigma?

    • Geography or local culture?

    • Provider culture?

    • Lack of evidence-based treatments in practice?

    • Poor transitions of care?

    • Focus on acute care episodes versus chronic care?

    • Housing and social services?

    • Logistical barriers (e.g., transportation, child care, translation)?

  • What kind of initiatives is your health plan implementing to reduce the barriers described above?

  • Are there any barriers not mentioned above that are specific to MAT?
    PROBES:

    • Administrative issues around MAT?

    • Prior authorizations? (If so, please describe that process.)

    • Issues working with multiple insurance companies to cover the different services required for effective treatment with MAT?

    • Adequate access and provider availability?

  • Does your health plan have any initiatives to improve access to MAT?

Discussion Questions: The Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) Measure

Discussion Goals: To understand what key informants feel are deficits in how the IET measure captures initiation and engagement

Key Points That Need to Be Clarified by Discussion's Close:
  • Primary problems with measurement using the current IET measure
Key Words: MAT, data, coding

The IET Measure Discussion Questions
(If already know answer, use questions to confirm)

  • Can you identify any problems with how the IET measure does or does not capture initiation and engagement in SUD treatment?
    PROBES:

    • MAT not included?

    • Data access for all forms of treatment (e.g. residential) or all providers?

    • Impediments to coding by primary care providers for behavioral health or vice versa?

    • Other issues?

 

Health Plan Profile/Background: NAME OF PLAN

Health Plan Overview

Summary

Performance on NCQA metrics

Provider Network

Marketplace and Environment

Summary (including location)

Largest Employers

Leading Health Plans

Largest Healthcare Providers

State Demographics Snapshot from State Variables

[Insert tables for demographics]

Health Plan in the News

[Insert news clippings and summaries of recent and noteworthy headlines]

TABLE D.2. Interviewer/Notetaking Process
  1. Review Discussion Guide questions and health plan information, including notes from preliminary outreach calls with the health plan and interviewee background prior to the interview.

  2. The lead interviewer and notetaker will pre-select key discussion topics based on the interviewee's position. They will designate pre-determined timing for each topic area based on interviewee's position and keep track of time to assure coverage of all key topics.

  3. Inform the interviewee that specific respondents will not be revealed to ASPE. No interviewees or health plans will be identified by name in any reports or publications. Information gained from the interviewee will be aggregated with data from other health plan interviews for any reporting.

  4. Provide a project overview (e.g., major goals) and an overview of the topics that will be covered during the interview.

  5. Ask warm-up questions to start the interview and create a comfortable environment with the interviewee.

  6. Conduct interview.

  7. Close interview by asking, "Is there anything else you would like to share?"

  8. Review notes at the end of the interview day to fill in any gaps and record impressions and other useful observations.

 

TABLE D.3. Template for Site Visit Notes
Interview Information
Date and time MM/DD/YYYY, HH:MM a.m./p.m.
Interviewer's name  
Note-taker's name  
Participant Information
Health plan name  
Health plan's location (general region)  
Interviewee(s) Name(s) and titles  
Participant Types
Executives (i.e., CEO, CMO, COO) [# interviewed]
Managers (i.e., Directors of Quality, Behavioral Health, Contracting, Care Management) [# interviewed]
Affiliated case managers [# interviewed]
Key providers [describe role, # interviewed]
Other stakeholders [describe role, # interviewed]
Topics covered in interview [cross out any topics not covered]
  • Topic 1
  • Topic 2
  • Topic 3
  • Topic 4
Discussion
[hand written notes section]