Developing evidence-based tools for accessible and quality care in the substance use disorder space

It’s no secret that we have been in the midst of a mental health crisis in recent years, with alarmingly high rates of substance use and overdose deaths¹. Millions of Americans seek treatment for mental health and substance use disorders (SUD) each year, making access to quality care imperative². Potential barriers to these lifesaving treatments include a lack of available treatment resources when patients need them, provider shortages and the complexities of our health care system³. Another challenge facing the behavioral health industry is labor shortages, with up to 47% of the United States considered to be in areas with insufficient resources⁴.

My journey to working as a Senior Medical Director leading the InterQual^® Behavioral Health content development team was a winding path that included stops working in the field as an addiction psychiatrist and as a health plan medical director. During my journey, several themes became apparent, including:

1)  The SUD industry needed clear evidence-based guidance to build quality programs.

2)  Payers and providers needed a common language to communicate effectively.

3)  The communication needed to happen efficiently – and within existing workflows – so that patients could move along the care continuum and access life-saving treatment when they needed it.
 

The use of evidence-based criteria to assist payers and providers in navigating the full continuum of care is one way to approach the judicious and safe use of our industry’s scarce services. The ASAM Criteria^® Navigator and InterQual^® Substance Use Disorders Criteria are two such evidence-based tools that help guide the least restrictive level of care (LOC) that can safely and effectively meet patient needs. 

The ASAM Criteria^®, developed by the American Society of Addiction Medicine (ASAM), are evidence-based standards that promote individualized care and treatment planning, guiding treatment providers to ensure that patients receive safe, high-quality care. First published in 1991 and most recently updated in 2023 with the 4^th Edition for Adults, The ASAM Criteria were authored by leaders and practicing clinicians in the field of addiction medicine and SUD treatment, utilizing a strict methodology to promote adherence to highest standards of evidence-based practice. More information regarding ASAM’s overall content development process can be found here.

The ASAM Criteria facilitate a common language between payers and providers, setting program standards for delivering optimal care. The criteria have become even more critical with the increasing number of state mandates and regulations that require the use of medical society guidelines and evidence-based treatment plans; payers are now mandated in 14 states, and providers in 23. 

Having served as a health plan medical director in a state where The ASAM Criteria were mandated, I personally witnessed the practical value of utilizing these clear, evidence-based guidelines to support optimal allocation of limited SUD treatment capacity. My journey came full circle when I joined the InterQual team and began collaborating directly with ASAM leadership to create an interactive version of their content. 

When our team interviewed payers and providers across the country during the initial development stages for this new solution, we discovered that the methodology of text-based content application was “consistently inconsistent,” and most organizations found it challenging to share information uniformly with their payer or provider partners. Utilizing The ASAM Criteria in its book or digital asset format was a great starting point for users, but they needed a more efficient and intuitive way to consistently apply the content within their reviews.

Developed through an exclusive partnership between ASAM and Optum, The ASAM Criteria Navigator brings The ASAM Criteria into a structured, interactive tool that helps streamline and improve the medical review process for SUD patients. Our solution is considered “fully consistent” with The ASAM Criteria, including all LOC and withdrawal management services as well as covering all six dimensions of assessment. With this unique solution, we’re helping organizations solve the challenge of effectively applying The ASAM Criteria while keeping users in their familiar workflow. 

In reflecting on our partnership, I believe Maureen Boyle, Chief Quality and Science Officer at ASAM, captures its essence perfectly. She notes, “substance use disorders are complex; many factors influence treatment needs, often including significant medical and psychiatric comorbidities. Achieving reproducible application of The ASAM Criteria can be challenging. We are very proud that, through our partnership with Optum, we are helping the field with an easy-to-use tool that seamlessly integrates our criteria into existing utilization management workflows, assisting reviewers in safely, efficiently and consistently transitioning patients through the continuum of care.”

We’re committed to our clients’ success and therefore, our team offers ASAM-approved, in-depth supplemental education to help clients transition from the 3^rd to the 4^th Edition of The ASAM Criteria. Additionally, ASAM-developed training courses will soon be available through the InterQual® Learning Management System to support clients who may want or be required by state mandates to receive training directly from medical societies.

Organizations may choose which criteria to utilize based on user preferences and/or regulatory requirements. The InterQual Substance Use Disorders Criteria within our Behavioral Health content suite are another evidence-based tool for determining the clinical appropriateness of the current or proposed LOC for patients with addiction and co-occurring conditions. When determining the most appropriate LOC, the depth of the criteria helps care managers consider the patient’s symptoms, comorbidities, treatment history, and functional status, as well as their social drivers of health risk factors, support system, living environment, potential interventions and the quality of the patient’s participation. These criteria are developed using the same evidence-based rigor and peer review standards that we apply to our medical and surgical criteria and are aligned with The ASAM Criteria, CARF requirements and other key critically appraised literature and guidelines that define quality SUD care standards. 

Both mechanisms – The ASAM Criteria Navigator and the InterQual Substance Use Disorders Criteria – package medical necessity criteria into an efficient, user-friendly one-stop-shop that can be used as a common language between payers and providers to ensure patients receive the right care, in the right setting, at the right time. These tools offer robust features and capabilities, including informational notes at the click of a button to reinforce key educational points related to the criteria, the ability to integrate into existing workflow systems and the availability of cloud-based application offerings. 

One of the most rewarding aspects of leading the InterQual Behavioral Health team is tackling real-world challenges by developing content and technology that supports improved clinical decision-making, outcomes, quality and value. Given the limited capacity of behavioral health providers in many states, using a structured, interactive and evidence-based approach to utilization review helps ensure patients receive care when they need it most. Our trusted solutions are helping organizations alleviate administrative burden, allowing clinicians to spend their valuable time focusing on patient care.