Quality Standards in Addiction Treatment

As anyone who has searched for addiction treatment knows, there's no shortage of options, approaches and specialty programs available. What's missing are quality standards that consumers can use to determine the most effective care for their situation. Listen in as host William C. Moyers talks with psychiatrist and author Joseph Lee, MD, about what consumers need to know—and should expect—when considering treatment providers and programs.

0:00:13 William Moyers
Hello and welcome to Let's Talk, a series of podcasts produced by the Hazelden Betty Ford Foundation on substance use issues. Issues that matter to us and issues that matter to you, including research, prevention, treatment, addiction, and recovery from substance use disorders. I'm your host William Moyers, thank you for joining us today. Our topic for today's Podcast is Quality Standards in Addiction Treatment. And there is nobody better positioned to talk about this than my colleague, our expert, Dr. Joseph Lee. Welcome, Dr. Lee.

0:00:48 Dr. Joseph Lee
Thanks! Great to be here.

0:00:50 William Moyers
You are now the President and CEO of the Hazelden Betty Ford Foundation. But you're also an expert on quality standards. And I think the first question we wanna really get to is what is quality in addiction treatment?

0:01:06 Dr. Joseph Lee
Yeah this is an area that we're lagging behind in, compared to other fields of medicine. If you look at cardiology or cancer treatment, they have standards for what good treatment is, what the evidence-based is, but also how people are actually implementing that. And whether hospitals are actually doing what they say or what the research papers say. And I think in addiction that's lagged behind and there's many reasons for that. But over the past decades, there have been many iterations of trying to get quality standards. Usually by academics. I was groomed to be an academic and I don't function as an academic, but a lot of academics would get together and say, we need to have these standards or those standards. The problem with the past iterations is that they didn't get payers to the table, it didn't have the same kind of motion and energy. But I think people are trying enough times and talking about it that it's important. It’s important from a customer standpoint, they need to know the kind of treatment they're getting. It's important from a payer standpoint. They need to know what they're paying for. And it's important from a professional standpoint. Because we need to have an integrity about what we're doing. And I think people have seen the news a lot about people who over-promise treatment or say things that are incorrect, or say that they do X, Y, or Z, but don't really do it. So for all those reasons, quality assurance, quality standards, are very critical in our field.

0:02:14 William Moyers
But why now as you eluded to we've wrangled with this issue probably since treatment was begun. We were marking our 70th anniversary as an addiction treatment provider. Why is it taking to now to get to this issue?

0:02:29 Dr. Joseph Lee
Well I'm speculating a bit but I think we live in a culture where people have information at the tip of their fingertips and they have more information than they know what to do with. And—and that's good but it's also bad. In that, information can be misrepresented and we see that in politics and everywhere else. And it happens in healthcare where people can promise that you're gonna get X, Y, or Z treatment but you're not. And so, I think there's a cultural shift where people have access to information, but not necessarily wisdom and they need a way to be able to calibrate the data that they're seeing. To make sure that they're getting good treatment. And then I think the opioid crisis has brought the chickens home to roost so to speak. It's really held treatment centers accountable. You know we use Buprenorphine and other medications for opioid use disorder. There are a lot of centers that still don't. And—and I think there has gotta be a transparency and it can't be a philosophical issue, it's just gotta be a science-based issue. And so I think there's been an outpouring of support and—and energy behind trying to get some quality standards.

0:03:23 William Moyers
So quality isn't about the thread count on the sheets or the tastiness of the food or the appearance of the grounds, quality is equal to the delivery of care, right? And the outcomes of that delivery of care.

0:03:39 Dr. Joseph Lee
That's right. If—if I'm a parent in rural Arkansas or Kentucky or West Virginia or Oregon and I have a loved one who is addicted to substances, where do I send them for treatment and how do I know that this place will deliver you know the basics of evidence-based care? You know, I have this anecdote where my air conditioner broke over the summer. It was a real bummer. And I have certain expectations as a customer. Because I want a new air conditioning unit. And they're very expensive. But I don't know anything about air conditioners. So, the experts who you know installed the air conditioners have to tell me kind of what they had, what the options are, and then my expectations get sharper, and then they're able to meet my capacity and expectations. And we don't do that in substance use treatment. People are trying to get help, but they don't know what they're looking for. They're kind of blind-sided; they're in a desperate state. And so they come to treatment centers and clinics and methadone clinics asking for a kind of help and they don't even know what they're really expecting. And we don't do a good job of explaining our capacity.

0:04:39 William Moyers
But isn't it ultimately though if they want success, but what is success particularly in this day and age where there are so many pathways to recovery?

0:04:47 Dr. Joseph Lee
That's right. And until they get the menu choice of options and the pros and cons of each treatment option, I'm not sure they can really fine-tune their expectations. I'm not sure it's reasonable to expect that people can fine-tune their expectations. Once they've been to a couple of treatment clinics, seen a couple therapists, they get a better idea of what they really want for themselves.

0:05:05 William Moyers
Now you see patients all the time. You see family members all the time. Every day of the week that you're not out speaking somewhere in the country or internationally. Most people want their loved one to get well. But what does it mean in the context of a chronic illness, substance use disorder, what does it mean to get well?

0:05:25 Dr. Joseph Lee
That's right. And people want different things. Some people, they wanna go to a methadone clinic and they don't wanna get Hepatitis and they don't want to overdose and they don't wanna get HIV and that's their end goal. Family members might want Grandfather to stop drinking altogether. Grandfather might want to have a—a glass of wine every two months. So, when they are at the outside of treatment, they all have very different expectations of what they're wanting. But they don't know how to vet those expectations through quality assurances. That they're gonna actually get this, the treatment they're looking for. And I think all of us have to do a better job at it. Because customers are the ones that suffer, families are the ones that suffer, not knowing how to navigate this maze of various treatments. It's hard for them 'cause they also have to get insurance companies to play ball. And insurance companies can be squeamish if they don't know what they're paying for. And so then their criteria can be rather arbitrary. Which then affects payment and access.

0:06:17 William Moyers
Mmm-hmm.

0:06:18 Dr. Joseph Lee
And then you've seen online you know we—we've called for standardization of treatment for a long time. A lot of people you go on their website, it looks nice, they say they do XYZ treatment, and—and XYZ therapy, who knows if that's really even happening? [chuckles] You know. And so, there are so many stakeholders that deserve and should be responsible for some kind of standards. I will tell ya that one thing we can be proud of at Hazelden Betty Ford is we're ahead of the game in this.

0:06:45 William Moyers
How so?

0:06:46 Dr. Joseph Lee
Well, you know, one of the things we realized in that in—in this quality standardization is that you can build a better mousetrap and there's tons of data out there, but you gotta ask important questions like who—who pays for the data? And then just because one company has the data, why would they share it with somebody else? And you're seeing the same problem happening in electronic health records in medicine. They thought electronic health records would transform everything.

0:07:07 William Moyers
Right.

0:07:08 Dr. Joseph Lee
But why does one hospital system want to share records with another hospital system? [They both chuckle] You know? And then who's gonna pay for the research to keep these metrics? Well what we've done is we've created this real great live data stream. Where patients have a patient portal, they have evidence-based questionnaires they do, weekly, biweekly. And they track their own progress, which allows us to individualize care. We've done outcome studies on our treatment for a long time. So this actually makes me feel really good in terms of what we're doing. 'Cause we've been ahead of it before there was any cry for standardization, we've already looked at our own data, we've done our own research, we already have a system of metrics built into our electronic health records to show people this is what you're getting. This is what we're responding to.

0:07:54 Dr. Joseph Lee
Uh 'cause people need more than how many days here, how many days there? What they need to know this is the problem I'm having. Here are some rough expectations. Can you meet those expectations?

0:08:02 William Moyers
Can success be defined even if the patient or the client isn't able to maintain continuous abstinence or continuous sobriety? Can they still be a success?

0:08:14 Dr. Joseph Lee
Absolutely. You know and for—we've always had the most stringent outcome criteria, but if you look at research studies, there are things like do they go back to the emergency room? And then that—do they overdose? Do they get chronic illnesses or STDs? Are they the victim of trauma? Do they have legal issues? You know does their child come back into their custody? These are all measures of success. They may not be the homeruns that make for a great afterschool special movie, but they're really important gains that change people's lives. And they're important. And we do a good job of tracking those things. In fact, we partnered with an insurance company, HealthPartners, to track some data and we published a paper on it. Where we track things like emergency room visits and whether they're going to meetings or not. And it worked out in our favor. Because we're already doing that work. So, I think we've shown great integrity in this. I think this is going to happen. I think families deserve it. I think families need to know what they're getting into for healthcare. I think payers need a rubric.

0:09:08 William Moyers
Yes. Yes.

0:09:98 Dr. Joseph Lee
To know what they're paying for. And so I think it makes sense. Uh there are some obstacles in—in how it gets done. But overall, I think it's here to stay. And I hope it has some traction.

0:09:17 William Moyers
And in fact, the payers, in our case the insurance companies, they expect it, they demand it, because they're paying for it.

0:09:26 Dr. Joseph Lee
That's right.

0:09:26 William Moyers
And we've seen at Hazelden Betty Ford a dramatic expansion in the utilization of insurance by our patients and our clients to access our system of care. So not only do we have a relationship and not only do we need to meet the expectations of the family or the patient, but we need to meet the expectations and the needs of the insurance companies.

0:09:45 Dr. Joseph Lee
That's right. That's right. We've already evolved, but the rhetoric out in society is still you know go to rehab and 28 days of that. But we're not there anymore. We haven't been there in years.

0:09:54 William Moyers
Right. Right.

0:09:55 Dr. Joseph Lee
All our treatment is already individualized and I think people deserve that and I'm glad about—I'm glad about the general trend of this.

0:10:02 William Moyers
Yeah.

0:10:02 Dr. Joseph Lee
I'm glad that the discussion is going in this direction.

0:10:05 William Moyers
Well a matter of fact you've just recently were participating I believe in a gathering of a national group of people I believe it was on the national principles of quality care, can you talk a little bit about that? What does that mean?

0:10:17 Dr. Joseph Lee
Yeah there's an organization called Shatter Proof. Been a tremendous advocate for all kinds of addiction efforts. And they're really focused on having standardized quality measures. For different treatment clinics. Whether it's methadone clinics, whether it's government-funded programs, insurance-based programs, state-run programs, and they want some quality standards. And so they convened a kind of a think tank of people from you know lots of different sectors and we talked about various criteria they had to try to sharpen it. It's part of a multi-pronged plan they have. I really like the plan as a whole and I think it's gonna make some positive changes for people. Get people to think differently about this—

0:10:54 William Moyers
Mmm-hmm.

0:10:55 Dr. Joseph Lee
So that we can really show what we're doing. I'd say as an organization people use our branding as kind of a cover to do whatever they want. You know and say that they kinda do it like us, but I think we're invested in this as an organization 'cause we wanna be able to show that we do great work. And so I think we're gonna be willing partners in this. I think it's gonna be good for us, I think it's gonna be good for the American people.

0:11:17 William Moyers
At the end of the day, the experts can come together and can set these standards and so on but when it comes down to a parent or a family that is in crisis and needs to access care for their loved one, what should the consumer, what should the family look for, when they're trying to decide where to send a loved one to treatment?

0:11:40 Dr. Joseph Lee
You know there are some tell-tale signs and without these standards being out there, there are some good questions that you can ask that really cut to the chase. If I were the parent of somebody struggling with addiction, I generally tend to gravitate towards nonprofits like us. Because there's a financial transparency. There's a lot of venture capital in healthcare now. And it's only gonna grow. And it's not good or bad, it spawns some innovation and so there's some good things that come from it. But, if there's a conflict between mission and margin, as a family member, I want to know that the mission is gonna get served first. And financial transparency serves as a custodian for that. The second thing is things like that having full-time medical and mental health staff. That really shows that an organization is willing to invest the overhead. So that their practitioners don't go have a side practice and don't really have skin in the game in their business. And so, we have dedicated full-time mental health staff. We have contract workers and part-time people, but we have full-time psychiatrists who don't work anywhere else other than Hazelden Betty Ford. Physicians who do the same. Psychologists who do the same. And I think if I'm a family member, I'm really looking for those kinds of things. 'Cause it says that they have skin in the game and they're willing to make an investment.

0:12:50 William Moyers
Mmm-hmm.

0:12:51 Dr. Joseph Lee
There are state laws that in California and other places there are some hiring practices that are different, but in general, I wanna know that they've invested in the overhead to help my loved one.

0:13:00 William Moyers
Dr. Joseph Lee, thank you for joining us and for being such a great advocate. Not just for youth in the continuum of recovery but also in this whole issues of quality standards and addictions treatment. Thank you for joining us today and for sharing your expertise.

0:13:14 Dr. Joseph Lee
Thank you!

0:13:14 William Moyers
And on behalf of Dr. Joseph Lee, I'm William Moyers from the Hazelden Betty Ford Foundation. You've been participating here in another edition of Let's Talk, a series of podcasts on the issues that matter to us and matter to you. So we hope that you will join us again for another Let's Talk Podcast.