General questions about the Rating System

General data & metrics questions

Treatment program survey questions

Claims measures questions

Consumer survey questions


General questions

Why do we need a Rating System? Why now?
Addiction can be treated with the same effectiveness as other chronic diseases, but the use of evidence-based best practices varies widely across the addiction treatment field. Rating systems currently exist for many other health care and commercial sectors, bringing transparency and information on program quality to the public, which can help guide decisions— but no such system exists for addiction treatment. To fill this gap, Shatterproof’s Rating System for Addiction Treatment Programs will standardize quality expectations for addiction treatment programs across all levels of care and types of treatment. This will allow market forces to drive adoption of evidence-based best practices and track quality improvement in the addiction treatment space. This tool will be critical to those navigating the addiction treatment field.

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What types of programs are included in the Rating System?
At this time, the Rating System will examine specialty addiction treatment programs included in SAMHSA’s Inventory of Behavioral Health Services (the listserv used to create the National Survey of Substance Abuse Treatment Services - NSSATS). This includes residential, outpatient, and intensive outpatient programs that are licensed, certified, or otherwise approved by the state to provide substance use disorder (SUD) treatment, as well as facilities that for a variety of reasons the state does not fund, license, or certify. It will also include programs operated by federal agencies, like the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service.

The system will assess any facility who is identified as offering withdrawal management (detox) OR addiction treatment (services that focus on initiating and maintaining an individual’s recovery from substance abuse and on averting relapse) in the Inventory of Behavioral Health Services. It will not include halfway houses that do not provide substance use disorder treatment, individual practitioners, including individual prescribers of buprenorphine, or jails, prisons, or other organizations that treat incarcerated clients exclusively.

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Will the Rating System only look at the quality of opioid use disorder treatment?
No, the Rating System will report on the quality of treatment programs for all substance use disorders. Some of the measures will be specific to the treatment of opioid use disorder, if applicable to the treatment program. Ratings based on these measures will be marked as such.

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In what geographic areas will the Rating System be available? How were these areas chosen? 
The Rating System is being pilot-tested in a select group of states. States selected for the initial pilot will be announced during the first quarter of 2019. States have been selected based on several criteria, including readiness for successful implementation of the pilot and a demonstrated potential to scale the Rating System after the pilot. Throughout 2019, Shatterproof, state partners, and the data analytics contractor, Research Triangle Institute (RTI), will finalize the measure set, collect and analyze data, and engage with stakeholders within the pilot states. Following successful completion of the two-year pilot, the Rating System will be scaled nationwide.

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When will the Rating System be live?
The Rating System will go live in 2020.

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What will the Rating System look like when it launches?
The public will be able to access Rating System information through a new, free website. This website will be searchable by information that is important to those seeking addiction treatment for themselves or a loved one, including location, insurance coverage, and quality of care.  It will provide transparent information on whether programs offer services that align with evidence-based best practices that are shown to improve patient outcomes. It will also allow the public to report their experience with addiction treatment programs.

Shatterproof and the analytics contractor, Research Triangle Institute (RTI), are conducting user-requirement testing to determine exactly how this information will be displayed on the website: for example, what scale will be used, and whether benchmarks will be provided. These decisions will be guided by conversations and focus groups with experts, clinicians, and the public.

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How will providers and payers be able to use the Rating System?
In addition to the public-facing platform, there will be password-protected portals. These portals will be places where providers can access their own data with benchmarks against industry data to drive quality improvement, where payers can access data on treatment programs in their network, and where states can access data to inform technical assistance and other state-based initiatives. The features and display options of the portals are being determined through work with these stakeholder groups during the pilot.

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How much will it cost to use the Rating System?
There will be no cost to access the Rating System. The Rating System will be free to all users, including treatment programs and payers during the pilot. After the two-year pilot, there may be fees introduced to payers or providers, but the general website will remain free to the public.

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Who will use the Rating System?
The Rating System will be a free, public website accessible to anyone who needs it. In particular, it is a resource for those seeking treatment for themselves or a loved one, treatment programs, referral sources such as drug courts and guidance counselors, policymakers, and payers.  

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How will the Rating System benefit…

  • The public?
    The Rating System gives those seeking care for themselves or a loved one the opportunity to identify high-quality and evidence-based treatment options. This does not replace a consultation with a health care provider to determine the appropriate course of care.
  • Treatment programs?
    The Rating System will give treatment programs the opportunity to benchmark themselves against their colleagues throughout the state, engage in quality improvement, and attract or steer patients. Programs may be able to leverage their participation or rating to secure enhanced reimbursement from their contracted payers.
  • Payers?
    The Rating System will allow payers to identify, reward, and promote high-quality addiction treatment, and to deliver this information to their clients and beneficiaries, better aligning market forces behind evidence-based addiction treatment.
  • States?
    The Rating System will provide states with the necessary quality data to inform treatment access and other state-based initiatives, such as technical assistance.
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How is the Rating System pilot funded?
This roughly $5 million pilot is funded by a coalition of stakeholders. Two-thirds of the project are funded by Arnold Ventures and the Robert Wood Johnson Foundation. The other third is funded by a group of six health insurers: Aetna, a CVS Health Business, Anthem, Beacon Health Options, Cigna, Magellan, and UnitedHealth Group.

None of the treatment programs in the Rating System, or pilot states, will provide funding. There is no direct cost to the pilot states, but they are responsible for any costs associated with additional promotion and administrative time to partner on the pilot. Shatterproof is currently exploring strategies for long-term maintenance and scaling of the Rating System post-pilot, with the goal of developing a system that is self-sustaining.

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What is the role of health insurance companies in this pilot?
Health insurers play a critical role in transforming the addiction treatment system. Aligning payment practices with evidence-based medical treatment for substance use disorders is critical to improving accessibility of these services to those in need and integrating the addiction treatment system with mainstream health care. Recognizing this, Shatterproof has engaged several health insurers in our work across key programs and is committed to working with these payers to optimize practices. For the Rating System pilot, six healthcare companies are collectively funding less than one third of the pilot (Aetna Behavioral Health, Anthem, Inc., Beacon Health Options, Cigna, Magellan Health, and UnitedHealth Group). These companies do not have a governance role in the project.

Importantly, these companies, and additional key health insurers in pilot states, will also support the Rating System’s implementation by informing claims-based measures (for more information on the background of the Rating System and its metrics, please view this webinar). This is critical to our approach to triangulate quality information from multiple data sources. Health insurers, along with state partners, will also encourage participation in the Rating System by treatment programs in their networks. Shatterproof is seeking to partner with all commercial payers with market share in pilot states to implement strategies that incentivize and reward participation in the Rating System. In some cases, these groups have also committed to requiring reporting to the Rating System for eligibility for higher network tiers or distinctions.

Finally, when the Rating System website launches, there will be a portal available to health insurers to view and analyze quality data. This will be the same data available to treatment programs, states, and the public, but will include different displays and analysis features. These data will become available to payers at the same time as they are launched publicly, following a preview period by treatment programs. The information produced by the Rating System will aid in a critical shift by health insurers to improve access to high-quality addiction treatment.

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Who is developing and implementing the Rating System?
The Rating System is being developed and implemented by Shatterproof and the analytics contractor, Research Triangle Institute (RTI) International, in partnership with the five pilot states and engaged payers.

RTI, an independent research institute, currently supports five national health quality reporting efforts and one large private rating system. RTI has developed and obtained National Quality Forum (NQF) endorsements for over 40 quality measures that use data from provider assessments, claims data, and consumer surveys. RTI leads large-scale quality measure collection efforts with healthcare providers including supporting over 3,000 providers in reporting measures for the Centers for Medicare & Medicaid Services’ (CMS’) Comprehensive Primary Care Plus (CPC+) project. RTI employs over 250 staff focused on substance use research, including addiction psychiatrists, former behavioral health directors, economists, epidemiologists, psychologists, and survey researchers.

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How can I receive updates on the Rating System?
If you would like to receive regular updates about the status of the Rating System, contact RatingSystem@Shatterproof.org to be added to our email list. 

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General data & metrics questions

What is the basis for the measures that will be used in the Rating System?
When developing draft measures for the Rating System, we didn’t want to recreate the wheel. So we started by reviewing national-level measures vetted by the National Quality Forum (NQF), the National Committee for Quality Assurance (NCQA), and others, as well as other initiatives by national organizations aimed at developing or recommending measures for SUD treatment. We then identified the possible strategies for accessing data on these measures.

From there, a Quality Measure Committee comprised of subject matter experts refined these draft measures. The committee collected and reviewed existing measures, aligning them with the Shatterproof National Principles of Care. The Committee then followed several criteria for distilling draft measures, including measuring consistency with the Principles, relevance to providers, and ease of collection. From there, the Committee discussed the measures and received feedback on the draft measures from key stakeholder groups, including payers and providers across all levels of care.
The measures will be finalized after recommendations are developed by a committee of experts convened by NQF.

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Is there an opportunity to have input on the measures?
In early 2019, the National Quality Forum (NQF) convened an expert panel strategy session to review the measure set and to provide recommendations for its implementation over the pilot. In late February 2019, the NQF will host a comment period during which anyone can submit feedback on the measures. This feedback will be incorporated into recommendations for the final measure set for the Rating System pilot. The measure set for the pilot will be finalized in spring 2019. 

Information gleaned throughout the pilot will be used to finalize the measures and methodology for future phases of the Rating System. The measures used for the Rating System will likely evolve each year as new measures are introduced and existing measures are further refined.

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Where will the data come from for the Rating System?
The Rating System will utilize data from three sources: insurance claims, treatment program surveys, and a consumer experience survey (or crowd-sourcing). Shatterproof is utilizing a mixed-method approach to ensure the Rating System can capture as much quality information as possible given the fragmentation of the addiction treatment system. Insurance claims and treatment program survey data will be supplied and reported on at the facility level.

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Treatment program survey questions

I’m a treatment provider in a Rating System pilot state, but I’m not really interested… why should I participate?
Beyond the general benefits for programs described above, participating during the pilot will allow you to have a more direct say about the design and impact of the Rating System. Your feedback will enable Shatterproof to structure the Rating System so that it best serves the needs of all stakeholders, including the general public, programs, payers, and states. Shatterproof is currently working with state partners and commercial payers to develop strategies that incentivize and reward treatment program participation in the Rating System, such as requiring reporting to be eligible for higher network tiers or alternative payment models, or to contract with Medicaid.

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What are the risks of not participating in the Rating System?
As the state and payer strategies are implemented, the specific risks of not participating will be identified for programs in each state. If a treatment program does not respond to the survey, the program will still be listed on the Rating System website, with an indication that this quality data is not available. When the public examines treatment programs on the Rating System website, it will be clear if a program did not participate.

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My treatment program already reports on so many measures – how will the Rating System data collection process fit in?
The treatment program survey that treatment programs will be asked to respond to (starting in summer 2019) is still in development. The survey is being designed to align with metrics that are already being reported, and when possible this information will be pre-populated in order to reduce the reporting burden. Program administrators will be able to contact the Rating System Help Desk for technical assistance at any time. Shatterproof is working with the pilot states and the involved payers to ensure that this process aligns as best as possible with current data collection, with the aim that it may reduce future reporting to multiple stakeholders.

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How will the treatment program self-reported information be validated?
Within the treatment program survey itself, there will be validation checks, asks for attestation, as well as a spot check via additional questions for select programs. Data from alternative sources will also be used to validate self-reported information when feasible, for example triangulating from claims.

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Won’t certain programs choose not to accept ‘high-risk’ patients because they’re worried about lowering their score? How will the Rating System ensure this doesn’t happen?
‘Gaming’ of measures and ‘cherry-picking’ patients are serious consequences associated with Rating Systems. This occurs when providers choose to treat easier or lower risk patients because they have a better chance of successful outcomes and avoid difficult or high-risk patients to ensure they don’t damage their scores. This is very problematic, as often the most high-risk patients are those in the greatest need of care and support.

These consequences are mostly associated with outcomes measures, because many factors at play outside of the control of the program can impact patient outcomes. However, when outcome measures are used in other fields, these consequences have been mitigated by using risk-adjustment, or similar techniques.

The measures being reported within the Rating System pilot are focused on the structure of the treatment programs and the processes that they have in place, which tend to be less impacted by their patient population.  If we include outcome measures in the future, we will consider how best to risk-adjust them to avoid adverse consequences. Some current measures may still differ by program characteristics (such as acceptance of Medicaid), and we are currently considering how to account for these differences.

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Will I have a chance to see my rating before it is publicly available?
There will be a preview period in advance of the Rating System’s publication in 2020 in order to allow programs to contest any potential misinformation, and for user testing.

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What if my program needs additional help responding to the treatment program survey?
Program administrators will be able to contact the Rating System Help Desk for technical assistance at any time. This Help Desk is managed by the Rating System’s data analytics contractor - the Research Triangle Institute (RTI). Contact details for the help desk will be made available to treatment programs in the pilot states at or before the release of the treatment program survey.

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Claims measures questions

How will the Rating System include measures using health insurance data?
The state partners have committed to share Medicaid claims data (aggregated and de-identified) for the Rating System. Additionally, Shatterproof already has commitments from six national health care insurance companies to analyze their data to inform claims-based measures and will work with additional payers that have substantial market share in pilot states. If you're a health care company interested in being involved in the pilot, contact RatingSystem@Shatterproof.org.

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What if a treatment program does not accept insurance?
If a treatment program does not accept insurance, and therefore has no claims data, this will be displayed. While claims-based measures will not be included for these programs, measures will be calculated from other sources, including treatment program survey responses and consumer experience responses.

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Consumer survey questions

How will the consumer surveys be conducted?
We are in the process of testing two approaches to capturing consumer experience information: surveys and crowdsource reviews. In the first case, we will work with treatment programs to connect patients and family members to a website where they will take the survey, using a unique identifier that establishes which treatment program the patient or family member is reporting on. In the second case, we are exploring the benefits and drawbacks of a crowdsource platform (for example, like Yelp) for use in the future. This research will inform the final decision for how to best gather experience data from individuals and families.

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What if a someone goes to multiple programs for addiction treatment?
We recognize that people with substance use disorders may see many different providers for addiction treatment. To account for this, programs will have a unique identifier for reporting that establishes which treatment program is being reported on. People will be able to report on multiple treatment programs.

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