# Presentation: 042317

## Exploring Substance Abuse Treatment Centers

** ****Sayeda Haq**

**Improving Quality by Aligning Physicians**

## Substance Abuse Care & Alignment

- Alignment is crucial in SA care as...
- Most physicians work for specialized treatment centers, often for multiple organizations
- Treatment modalities vary sharply
- Diverse treatment philosophy and orientation among all providers
- Large number of non-physician providers

**Thomas 2007**

## Quality Chasm in Substance Abuse Care

- People with a substance use disorder:             22 million*
- People receiving care:                                     3.5 million*

**SAMHSA, DHHS Pub #SMA 05-3999, 2005**

***2001 (aged 12 or older)**

**IOM Quality Chasm Series, 2006**

***Effective treatments exist and continually improve. However, as with general health care, deficiencies in care delivery prevent many from receiving appropriate treatments.***

## New Medication - Buprenorphine

- Offers several clinical advantages over Methadone
- Can be prescribed in physicians’ office
- Does not have severe withdrawal symptoms
- Daily dosing not needed due to long-acting effects
- No detectable ‘high’
- 2000: Federal Legislation allows MDs to prescribe in office visits
- 2002: FDA approves outpatient prescription
**However...**
- Four years after legislation, not incorporated into common treatment of substance abuse

## An Alignment Problem?

**Thomas 2007**

**Org**

**Recommends**

**MD Prescribes**

**74%**** **

**MD does not**** **

**Prescribe**

**26%**

**Org does not**

**recommend**

**MD Prescribes**

**44%**

**MD does not**** **

**Prescribe**

**56%**

- In multivariate result, organizational support remained important in MD’s adoption decision, after controlling for MD demographics, case mix, practice characteristics etc.

## What Determines Alignment?

- Financial incentives - most studied domain
- Administrative strategies, e.g. utilization review, referral requirements
- Significant number of studies
- Structural characteristics of organization, e.g. location of practice site, availability of services, supporting staff and governance style
-  Some studies
- Normative influence, e.g. formal and informal interaction and feedback from professional colleagues, organizational culture
- Very few studies
- Difficult to measure

**Landon et al (1998)**

## Conceptual Framework

|   | Enabling | Coercive |
| --- | --- | --- |
| High Formalization | Enabling bureaucracy
Encourage motivation based on identification
Efficiencies of high formalization as well as positive attitudinal outcomes  | Mechanistic
Negative attitudinal outcomes, low levels of motivation/satisfaction
Formalization seen as a necessary evil |
| Low Formalization | Organic
Empowers employees in non-routine tasks
Encourage motivation based on identification, positive attitudinal outcomes | Autocratic
Negative attitudinal outcomes, low levels of motivation/satisfaction |

**Adler and Borys, 1996**

## Research Question & Hypotheses

- Physicians’ alignment (loyalty, commitment) increases when
- Organizations offer value-added services, such as training, supporting staff, etc.
- Governance-style is consensus-based and participatory
- Leadership shares information leading to goal-congruence
- Free flow of information, frank discussion of failures, collegial relationship exists among employees

- What specific structural or normative strategies used by organizations are effective in aligning physicians?

## Analytical Model 

- Organizations

- Strategies
- (independent variables)

- Alignment
- (dependent variable)

- Treatment
- Organization

- Structural
- Value-added
- Operational
- Normative/
- Informative
- Formal
- Informal

- When
- Organization
- adopts and
- affiliated
- MDs prescribe

## Sample – Study Population

- Part of a larger study by Schneider Institute
- MD Survey – Addiction specialists and facility directors
- N = 271 (69% response rate)
- Organization survey – Facility directors
- N = 125 (51% response rate)
- Analysis on merged dataset
- N = 72 MDs, representing 46 organizations
- Unit of analysis is respondents (N = 72)
- Aligned = 24 (33%); Not-aligned = 48 (67%)
- 6-point scale independent variables
- 1 through 4 ==> not much
- 5,6 ==> very much

## Preliminary (Bivariate)  findings

*** p-value < 0.1,**   ****** **p-value < 0.05, *** p-value < 0.01**

## Research Implications

- Health services research is consistent with broader organizational theory of governance
- Organizations indeed affect physician’s practice-behavior
- This study explicitly measures, specifies and evaluates strategies that organizations can adopt to align autonomous professionals
- Policy Implication
- Findings help bridge the gap between knowledge and practice both in SA treatment and in general health care system