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Amid the opioid crisis, West Virginia is introducing a new way to encourage addiction treatment providers to do better. That new idea is to pay providers based on how stable and sober their clients are months and even years after initial treatment.
“It’s not just a medical issue, it’s a societal issue … because you want to get these folks back in the workforce, paying taxes, staying clean, taking care of their kids,” said Sen. Ron Stollings, D-Boone.
Senate Bill 419, sponsored by Sen. Ryan Weld, R-Brooke, will change up how addiction treatment centers are paid. Providers that offer the absolute best care and support to clients, will get paid more than others that don’t offer as much, or at least that’s the intent.
“So it’s a carrot to provide what most people think would be best practices,” Stollings said.
Stollings thinks state lawmakers don’t always get it right when it comes to legislating around addiction. But he said the recent bipartisan bill that is now awaiting the governor’s signature is a step in the right direction.
“If we really want to get our arms around this problem, it’s going to require some investment … because this impacts all segments of society,” Stollings said.
Risks and Rewards for Providers
This new way of payment won’t be widespread anytime soon. The state will start with just 15 percent of treatment centers and study the new process in a three year-pilot program.
But at first glance, Dr. Jim Berry is excited about this. He studies and treats addiction at WVU’s Department of Behavioral Medicine.
“I think certainly the goal is a novel one,” Berry said. “Unfortunately, much of substance use disorder or addiction treatment, for so long has not had any real standards by which the public and regulators and payers could hold us accountable to. So in many ways, much of this has been the wild west for decades.”
Berry expects he, and treatment providers like him, will come out on top. The pay incentive won’t line his own pockets, he said.
It will help pay for more wraparound services, the extra things like mental health and peer support that don’t just keep people alive, but help them thrive. Berry said providers can’t just offer that through the kindness of their hearts. Insurers and Medicaid should help pay for it.
“So we shouldn’t be asked to do something without payment to provide those necessary resources as well,” Berry said.
Berry and other providers say the potential rewards also come with some risks. Providers can’t just show that they are offering these services, they have to prove that it’s making a difference in their clients’ lives.
“The devil is in the details,” Berry said “And it’s really important that we get this right, and that we’re measuring things correctly in order to do it.”
The metrics providers will be judged on specifically consider whether a client has stable housing, they have a job, and they are “drug-free” months or years after initial treatment.
Dr. Michelle Lofwall said these aren’t things doctors and nurses have much control over. Lofwall
runs an addiction treatment clinic in Kentucky and is a professor and researcher at The University of Kentucky.
“Addiction is a chronic disease. The medications help manage it, they don’t cure it … but the medication to help with an illness doesn’t make them into model citizens,” Lofwall said. “If this is what you’re being told that you have to do to to get payment, I think the provider would have to look really hard and say, ‘Am I going to be able to pay rent, pay my malpractice insurance, pay my staff?’”
Lofwall said addiction is messy and it looks different for everybody. Relapsing is a normal part of the process. And beyond the walls of treatment, there’s stigma at every corner.
If West Virginia wants folks to find jobs and secure housing, Lofwall challenges lawmakers to scrutinize how employers and landlords might discriminate against those with substance use disorder. For instance, someone well on the road to recovery may still have past drug charges that can hurt their chances of success in society.
“If they already have a criminal record with lots of felonies, and it’s not hard to pick up a felony for having a pretty modest amount of illicit drugs on you … it’s really hard to get a good job.” Lofwall said.
Benefits and Risks for Clients
This new law is calling for value-based payments. This payment model isn’t a brand new idea, but it isn’t prevalent either.
“So the idea is that you can tie payments to some sort of quality measures,” said Tom Bias, a professor of health policy at WVU’s School of Public Health. He’s most familiar with this model in hospital settings, where possible goals are to prevent patients from having to be readmitted for preventable infections.
But Bias said quality has to be in balance with equity. Patients with compounding mental health, substance use or financial difficulties are more likely to end up in emergency departments again, but that doesn’t mean they don’t deserve care.
“So we have to be careful when we structure those types of payment programs to make sure that not only are we rewarding quality, which is obviously important, but also that maybe we’re taking into consideration the population that’s being served,” Bias said.
When addiction treatment providers take notice that some folks might have a harder time getting hired or approved for apartments, they might not take those clients, said Sharon Reif, a behavioral health researcher at Brandeis University. Reif has co-authored several publications that look at value-based payments for substance use disorder treatment.
“We call this in the research world ‘gaming’ or ‘cherry picking’. You choose the people who you think are going to succeed, because you’re being measured on success,” Reif said. “If you’re not careful on how you set up those performance metrics, and set up the payment system, you may have that kind of danger.”
Appalachia Health News is a project of West Virginia Public Broadcasting with support from Charleston Area Medical Center and Marshall Health.