Treating Substance Abuse

May. 10, 2021

To support quality care, we are providing information to providers and members to encourage discussions on health topics. Watch for more on health care quality in News and Updates.

More than 20 million people ages 12 and older in the U.S. struggle with a substance use disorder each year. Fewer than 20% of them receive treatment, according to the Substance Abuse and Mental Health Services Administration Learn more about third-party links.

We encourage providers to talk with our members about the signs of substance abuse disorders Learn more about third-party links and how alcohol can affect them Learn more about third-party links. Consider urging the member to seek help, if appropriate.

Treatment, including medication-assisted treatment (MAT) with counseling or other behavioral therapies, can help reduce substance abuse mortality, according to the National Committee for Quality Assurance (NCQA) Learn more about third-party links. Treatment may also help improve health, productivity and social outcomes.

Closing Care Gaps
As part of monitoring and improving quality of care, we track two measures related to substance abuse:

Both are Healthcare Effectiveness Data and Information Set (HEDIS®.) measures from the NCQA.

What IET Measures
IET applies to members ages 13 and older with a new episode of alcohol or other drug (AOD) abuse or dependence. The measure captures two stages of adequate and timely follow-up treatment:

  • Initiation of treatment, one treatment within 14 days of the diagnosis
  • Engagement of treatment, at least two additional treatment sessions within 34 days of the initiation appointment

Treatment may occur in an inpatient, residential, outpatient or telehealth setting or as MAT.

What FUA Measures
FUA applies to members ages 13 and older with a principal diagnosis of AOD abuse or dependence during an emergency department (ED) visit. The measure captures rates for AOD follow-up visits after an ED visit:

  • Within seven days of the ED visit (eight total days)
  • Within 30 days of the ED visit (31 total days)

If the first follow-up visit is within seven days after discharge, both rates are counted for this measure.

For more information, see our HEDIS tip sheets.

  • Discuss the importance of timely follow-up visits.
  • Use the same diagnosis for substance use at each follow-up.
  • Coordinate care between behavioral health and primary care physicians. Share progress notes and include the diagnosis for substance use.
  • Reach out to members who cancel appointments and help them reschedule as soon as possible.
  • For FUA, ED providers can help members schedule an in-person or telehealth follow-up visit within seven days. Send ED discharge paperwork to the appropriate outpatient provider within 24 hours of discharge.

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.

HEDIS is a registered trademark of the NCQA.

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