Rewarding Recovery: Value-Based Substance Use Disorder Treatment for Veterans

Key Takeaways

• Groups Recover Together (US, value-based addiction care): CEO Cooper Zelnick highlights a model combining evidence-based medicine, group therapy, and wraparound services, showing reduced relapse, overdose, and mortality, along with lower emergency room/inpatient use and criminal justice recidivism.
• Medicaid and veteran care: Zelnick urges shifting from fee-for-service to outcome-based reimbursement, using 6-month treatment retention as a benchmark of clinical success; emphasizes rapid access, weekly community engagement, and abstinence as key metrics.
• Policy implications: Warns that restricting Medicaid or Affordable Care Act (ACA) access could endanger patients with substance use disorder; calls for integration between the Department of Veterans Affairs (VA) and community providers and incentives for TRICARE/Centers for Medicare and Medicaid Services (CMS participation to expand veteran care access.

Please introduce yourself by stating your name, title, and any relevant experience you’d like to share.

Cooper Zelnick: I'm Cooper Zelnik. I'm the CEO of Groups Recover Together. We are the nation's largest value-based provider of addiction treatment. Fundamentally, the way I describe our work is, we serve folks who are struggling with addiction using a unique model that includes evidence-based medicine but also community, group therapy, and wraparound services. That model drives powerful clinical outcomes for the folks we serve, reducing relapses, overdoses, and mortality.

Those clinical outcomes translate into cost outcomes for our health plan and state partners, including reductions in total cost, reductions in recidivism and return to custody rates in the criminal justice setting, and reductions in emergency room and inpatient utilization. We help reduce health care spend by helping people get healthy.

What does it mean to “reward recovery” in Medicaid, and how would you measure real success for veterans in treatment for substance abuse?

Zelnick: It's worth noting that, historically, our health care system has not paid for outcomes. Specifically, in behavioral health and substance use disorder treatment, reimbursement and payments have been tied to the delivery of services, not to the achievement of outcomes or milestones.

For us, rewarding recovery is two things. The first thing is that we have to agree on what success looks like. The second thing is that we have to compensate for success to incentivize more of that success. What does success look like?

The easy answer is, success looks like retention in treatment at 6 months. It's the key benchmark of clinical efficacy in our industry. If a provider can retain a patient in outpatient care for 6 months, then it is less likely that that person will relapse, less likely that they'll overdose, less likely that they will die from this disease, and cost goes down. When we think about rewarding success, that's the easiest place.

It's not the whole story. Rapid access to care really matters. Weekly engagement with a supportive community really matters. Abstinence from illicit substances really matters. What we believe is that we should affect a switch in this country from paying for delivering services to paying for delivering outcomes.

How could value-based payment models change the way care is delivered to veterans struggling with substance use disorder?

Zelnick: Care is delivered based upon what is reimbursed. The things that are reimbursed off a traditional Centers for Medicare and Medicaid Services (CMS) fee schedule, which is driving how most veterans receive care, are individual appointments with a doctor, drug screening, and drug testing. Those activities are not the activities that most promote recovery. The activities that most promote recovery are therapy, peer interactions, care coordination, and activities that foster and build community.

Value-based payment models that align around outcomes and incentivize services that help people achieve those outcomes are the way that I would recommend transforming payment systems around addiction and recovery.

What are the biggest barriers that keep veterans from getting consistent care between the VA and community-based programs?

Zelnick: The VA does an amazing job. Many veterans rely upon the VA for any number of services, including addiction treatment services. The folks who work at VA hospitals across the country are dedicated, committed, passionate, and amazing.

It is also the case that, at many VA hospitals, there are wait lists for services. There are moments where veterans are unable to access care through the VA and need to go to community providers. That interaction is challenging. Community providers could probably do a better job of integrating with local VA hospitals. In certain cases, the same is true in the opposite direction. Building a more integrated system of care helps to eliminate a barrier.

It's been our experience that many local community providers don't contract with TRICARE, aren't Medicare enrolled, and, as a result, actually aren't contracted or empowered to serve this population. We work with TRICARE, we work with CMS, and we are really passionate about that work. It's super important to us. We're really proud of it and we do it everywhere. But it's challenging. There are documentation requirements, enrollment requirements, and contracting requirements.

I actually don't know whether it's possible to reduce those barriers, but I think incentivizing providers to serve that population would be really valuable as a way of expanding access to care.

If Congress moves forward with major health care reform, what changes would make the biggest difference for veterans’ recovery outcomes?

Zelnick: The two big proposed health care changes are the potential expiration of the Affordable Care Act (ACA) subsidies and the significant constriction of Medicaid. That's not the intent. The intent is to include work requirements, but, as a practical matter, there will be a greater number of folks who cannot access ACA marketplace insurance and a greater number of folks who will no longer be Medicaid eligible.

The big thing that would make a difference is being thoughtful about maintaining access, specifically for folks struggling with active substance use disorder. If they lose insurance, those patients are at high risk. If they lose access to care, they are super vulnerable and costly to our system. It is the right investment to make, to preserve access to health insurance and access to health care services for those who are struggling with substance use disorders. Anything we can do as a society to help those folks keep access to care, keep access to insurance, and keep getting the lifesaving medications and services they need is the right answer.

Is there anything else you hope that the audience will take away from this?

Zelnick: Veterans have done an amazing service for our country and they disproportionately need help. A disproportionate number of veterans struggle with substance use disorders. It is our responsibility as a society to take care of the folks who take care of us. We're enormously proud to serve this population. We're really grateful for the opportunity to do it. I urge all other providers to make sure that they're serving this population because it's the right thing to do on every possible metric.