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Special Report: Annotated Bibliography for
Managed Behavioral Health Care 1989-1999
Substance Abuse
353. Alexander, J. A., & Lemak, C. H. (1997). The effects of managed care
on administrative burden in outpatient substance abuse treatment
facilities. Medical Care, 35(10), 1060-1068.
This article describes a study of the burden (in hours per week and per client) of administra-tive
functions related to managed care on outpatient substance abuse treatment facilities. The
authors focus in particular on the effects of four dimensions: managed care oversight proce-dures,
organizational experience with managed care (length of time), managed care penetra-tion,
and complexity of managed care arrangements. The sample was drawn from the 1994
to 1995 National Frame of Substance Abuse Treatment Programs and prior waves of the
National Drug Abuse Treatment System Survey. A telephone survey was conducted of the
facilities’ administrative and clinical directors. The authors’ findings support their hypothesis
that administrative requirements imposed by managed care create a significantly increased
burden on these facilities. They find that managed care penetration and managed care over-sight
procedures are most strongly associated with this increased burden.
Keywords: community providers, substance abuse
354. Alexander, J. A., & Lemak, C. H. (1997). Managed care penetration in
outpatient substance abuse treatment units. Medical Care Research and
Review, 54(4), 490-507.
This article reports the first national data on the impact of managed care at the provider
level. The study used data from a 1995 national survey of 618 outpatient substance abuse
treatment (OSAT) units. The sample was categorized by treatment modality, ownership status,
and organizational affiliation. The study investigated the level of managed care penetration
into OSAT units and found that they were not affected by managed care. However, for-profit
OSAT units were more involved in managed care than public and private not-for-profit units.
OSAT units involved with managed care utilized multiple arrangements and on average are
involved with eight separate managed care arrangements that conform to a series of different
and even competing requirements. Hospital-affiliated OSAT units are more likely to have
multiple managed care arrangements. The study indicates that OSAT units are participating
in very few public managed care arrangements, whereas private managed care arrangements
occur at a greater frequency and with a constant distribution across types of arrangements.
Keywords: community providers, substance abuse
355. Caplan, R. (1992). Treatment of drug abuse in the managed care
setting. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health
care: Administrative and clinical issues (1st ed., pp. 305-320). Washington,
DC: American Psychiatric Press.
In this chapter, the author demonstrates how the philosophy of managed care can be well
integrated with a clinically sound approach to drug treatment. He outlines the specific ele-ments
that make managed care different from other settings, and describes a treatment
model developed for a staff model HMO. In this model, major clinical decisions are made
using a clinical algorithm. He explains how a managed care system can handle the four
major phases of drug treatment—evaluation, stabilization, relapse prevention, and mainte-nance—
and addresses additional issues of contracting for services, staffing, the role of the
case manager, and employer groups. Alternative approaches to dealing with the small but
difficult group who experience chronic relapse are presented.
Keywords: models, substance abuse
356. French, M. T., Dunlap, L. J., Galinis, D. N., Rachai, J. V., & Zarkin, G. A.
(1996) Health care reforms and managed care for substance abuse
services: Findings from eleven case studies. Journal of Public Health
Policy, 17(2), 181-203.
This paper presents data from case studies of 11 drug treatment programs, on their current
funding and level of cost, as well as their perceptions about the current or forthcoming impact
of behavioral managed care on their delivery of services. The programs included in the study
cover a broad geographic, programmatic, and organizational range. They include public and
private facilities, inpatient and outpatient models, and a variety of modalities of care. The
authors used two instruments developed by the Research Triangle Institute—the Drug Abuse
Treatment Cost Analysis Program (DATCAP) and the Drug Abuse Treatment Financing
Analysis Program (DATFin)—to gather data on cost and financing of the facilities. Perceptions
of the impact of managed care varied among the programs depending on the type of site. For
example, many of the residential treatment facilities expressed concern that case management
strategies would result in more patients being referred to outpatient modalities, even though
they may not be the ideal treatment type for some patients, simply because they offer lower
intensity and lower cost care.
Keywords: costs, evaluation, substance abuse
357. Gondolf, E., Coleman, K., & Roman, S. (1996). Clinical-based vs.
insurance-based recommendations for substance abuse treatment level.
Substance Use & Misuse, 31(9), 1101-1116.
This article reports on an exploratory study created to determine the extent of the disagree-ment
between clinical-based and insurance-based recommendations for level of care in sub-stance
abuse treatment. The study included 250 patients from three treatment facilities in the
Western Pennsylvania region, and compared treatment recommendations based on criteria
developed by the American Society of Addiction Medicine (ASAM) to those based on criteria developed by managed care organizations. The study showed that 85 percent of the insurance-based
and clinical-based recommendations for treatment level were in agreement and that 93
percent of the cases coincided with ASAM recommendations for care. These findings suggested
that even when there was disagreement in treatment, clinical-based recommendations were
most likely to be followed.
Keywords: standards of care, substance abuse
358. Gragg, D. M. (1991). Managed health care systems: Chemical
dependency treatment. In C. S. Austad & W. H. Berman (Eds.),
Psychotherapy in managed health care: The optimal use of time and
resources (1st ed., pp. 202-219). Washington, DC: American Psychological
Association.
This chapter describes the Chemical Dependency Recovery program at Kaiser Permanente
Medical Center in Los Angeles. The author discusses treatment philosophy, guidelines, pro-gram
design and development, general principles of addictions treatment, psychotherapeutic
goals and issues, and specific influences of managed health care on treatment programs such
as this one. He describes key elements in an evaluation of this and similar programs to ensure
quality of care, and a philosophy of critical "self-study" among staff of an addictions treat-ment
program.
Keywords: substance abuse
359. Kushner, J. N., & Moss, S. (1995). Purchasing managed care services
for alcohol and other drug treatment: Essential elements and policy issues:
Vol. 16. Technical assistance publication series. Rockville, MD: Center for
Substance Abuse Treatment.
As States consider or move forward with the decision to redirect public funds for the treatment
of substance abuse to private managed care organizations (MCOs), they face certain opportu-nities
and challenges. This document serves as a brief technical assistance manual for State
AOD (alcohol and other drug) agencies. Chapter 1 provides an overview of current State man-aged
care arrangements and urges States to use their contracts with MCOs as a means of
enforcing standards of treatment. Chapter 2 discusses access issues that emerge under managed
care, ranging from geographic accessibility of services to the cultural, ethnic, and gender sensi-tivities
of providers. Chapter 3 discusses the importance of ensuring the provision of wrap-around
services, targeted outreach to special populations, and inclusion of publicly funded pro-grams/
essential community providers, especially because private managed care companies may
be inexperienced in the treatment of populations receiving publicly funded AOD treatment
services. Chapter 4 discusses financial considerations that should be taken into account—risk
management strategies, potential benefits restrictions, the elimination of opportunities for cost-shifting
the burden of uncompensated care, and the importance of understanding and being
able to challenge actuarial analysis. Chapter 5 addresses key consumer protections such as out-of-
plan services, disenrollment processes, "consumer-friendly" materials, and appeals. This
document also provides examples of model contract language for the establishment of stan-Annotated dards, as well as a Managed Healthcare Organizational Readiness Checklist—a resource
designed to help States take into account the broad spectrum of policy issues that enter into
effectively contracting for services through the private managed care market.
Keywords: contracting, public sector, substance abuse, technical assistance
360. McNeese-Smith, D. K. (1998). Program directors’ views of the effect
of managed care on substance abuse programs in Los Angeles County.
Psychiatric Services, 49(10), 1323-1329.
Fifty program directors, representing 134 substance abuse treatment centers in Los Angeles
County, responded to a survey in early 1997 soliciting their views about the impact of man-aged
care on their facilities. The primary topics of the survey were changes in the programs
since 1994 resulting from managed care, major concerns about the influence of managed care
on substance abuse programs, advantages and disadvantages of managed care, and anticipated
future changes to promote success in the managed care environment. Responses indicated that
outreach and marketing had increased while length of treatment and staffing levels had
decreased. There were concerns that incentives to provide the least costly service posed a threat
to quality. Advantages described were an increasing focus on outcomes, the opportunity to
contract with managed care providers, and the establishment of consistent program standards.
Disadvantages named were contractual restrictions on services, increasing paperwork, restric-tions
on length of treatment, and decreasing quality. Directors described a wide array of antici-pated
future changes including changes in structure, type of program, sources of referral, staff
composition, revenue generation, and increased focus on prevention.
Keywords: community providers, substance abuse
361. Rawson, R. A., Obert, J. L., McCann, M. J., Marinelli-Casey, P., & Suti,
E. (1991). Outpatient chemical dependency treatment and the managed
care system: An unrealized symbiosis. Journal of Ambulatory Care
Management, 14, 48-59.
This paper traces the rise of outpatient treatment models for chemical dependency as it relates
to the managed care movement. The authors draw on their own clinical experience to argue
that there are serious problems in the coordination of outpatient drug and alcohol abuse pro-grams
by the managed care industry. They point to poor communication with providers, tech-nical
"sloppiness," and idiosyncratic, unscientific treatment programs as just some of the pit-falls
of managed chemical dependency services. Suggestions are offered for how managed care
organizations and chemical dependency treatment providers can work together.
Keywords: models, substance abuse
362. Renz, E. A., Chung, R., Fillman, O., Mee-Lee, D., & Sayama, M. (1995).
The effect of managed care on the treatment outcome of substance use
disorders. General Hospital Psychiatry, 17, 287-292.
This article examines the effect of managed care and other reimbursement mechanisms on the
outcome of substance abuse treatment at a single treatment facility. Data were collected from 1,594 patient records at the Castle Medical Center of Hawaii. Patients in the study were adults
admitted for treatment of substance use disorders. The study looked at the incidence of recidi-vism
in each patient over a 2-year period. The sample was divided into four groups: intensive
managed care, traditional managed care, private pay, and State-funded. The study concluded
that managed care patients are not more likely to return to treatment because of truncated
treatment episodes. Also, no difference was found between managed and nonmanaged patient
populations on relapse rates. The authors discuss the need for future research to include other
outcome measures besides recidivism rate.
Keywords: outcomes, performance measurement, substance abuse
363. Schneider, R. J., & Herbert, M. (1992). Substance abuse day treatment
and managed health care. Journal of Mental Health Administration, 19,
119-124.
For a variety of reasons, not the least being availability of reimbursement, inpatient care
has been viewed as the treatment of choice for substance abuse over the past three decades.
However, with the rise of managed health care, prospects for greater acceptance of day
treatment programs have improved. This article describes the day treatment program at
the Harvard Community Health Plan, a 2-week program that uses a variety of approaches
including group work, family meetings, and individual treatment sessions. The authors dis-cuss
ways of marketing day treatment and overcoming patient resistance to day treatment.
Keywords: substance abuse
364. Shwartz, M., Mulvey, K. P., Woods, D., Brannigan, P., & Plough, A.
(1997). Length of stay as an outcome in an era of managed care.
Journal of Substance Abuse Treatment, 14(1), 11-18.
With their emphasis on cost reduction, managed care systems reimburse only for "appropri-ate"
lengths of stay. Yet there is no research base for determining what is an appropriate length
of stay for a client in substance abuse treatment, and previous studies have found lengths of
stay to be important predictors of client outcomes. In this paper, the authors identify length of
stay categories within four treatment modalities such that program completion rates are consis-tent
within category and differ among categories. The four treatment modalities are short-term
residential, long-term residential, outpatient, and detox. The authors demonstrate that future
utilization over a 2-year period differs between categories, with those clients in short-length-of-stay
categories being admitted more frequently and spending more days in treatment over the
followup period than the long-length-of-stay clients. The researchers conclude that length of
stay is an easily measured proxy for treatment success and should be considered by managed
care companies in constructing length-of-stay cutoffs.
Keywords: outcomes, performance measurement, substance abuse
365. Sturm, R., Zhang, W., & Schoenbaum, M. (1999). How expensive are
unlimited substance abuse benefits under managed care? The Journal of
Behavioral Health Services and Research, 26(2), 203-210.
With the Federal Mental Health Parity of 1996, legislators prohibited dollar limits on mental
health benefits, but not on substance abuse benefits because of the high cost associated with
substance abuse treatment. In response, many employers have begun to decouple the two types
of services in their behavioral health contracts, which could lead to less efficient care and diffi-culties
in coordinating treatment. In this paper, the researchers examine how many patients are
affected by substance abuse coverage limits and the implications of limits on insurance pay-ments.
They find that removing an annual limit of $10,000 per year on substance abuse treat-ment
would increase insurance payments by only 6 cents per member per year while affecting
a large percentage of patients needing the care. The authors conclude that "parity" for sub-stance
abuse in employer-sponsored health plans is not very costly.
Keywords: parity, substance abuse
366. Wilson, C. V. (1993). Substance abuse and managed care.
New Directions for Mental Health Services, 59, 99-105.
This chapter discusses the problems that exist in the coverage of substance abuse. Dissatisfied
with high costs and ineffective treatment for substance abuse, employers are turning to man-aged
care. A case example illustrates the benefits of this approach. The author suggests that
case managers and payers use a standardized intake, assessment, and outcome method devel-oped
by the American Society of Addiction Management in order to address concerns about
cost and quality.
Keywords: substance abuse
367. Woodward, A. (1992). Managed care and case management of
substance abuse treatment. In R. S. Ashery (Ed.), Progress and issues in
case management (DHHS Publication number ADM 92-1946). Rockville,
MD: National Institute on Drug Abuse.
This monograph discusses the relevance of managed care to case management of substance
abuse programs. The author argues that the goals of the two are contradictory; whereas the
focus of case management is on providing comprehensive, coordinated care, managed care is
concerned primarily with cost-effectiveness. Yet despite the differences in their goals, both case
management and managed care have similar shortcomings. Among these are lack of criteria in
assessment, referral, intervention activities, and followup as well as lack of documented cost-effectiveness.
Keywords: case management, substance abuse
Annotated Bibliography 143
368. Zwick, W. R., & Bermon, M. (1992). Spectrum of services for
the alcohol abusing patient. In J. Feldman & R. J. Fitzpatrick (Eds.),
Managed mental health care: Administrative and clinical issues
(1st ed., pp. 273-304). Washington, DC: American Psychiatric Press.
This chapter discusses the elements of a successful program for alcohol-abusing patients
in a managed care environment. The authors outline four assumptions that they believe
should guide the design of a cost-effective managed program for the treatment of alcohol
abuse and dependence. They discuss cost, staffing issues (type of staff and staffing ratios),
and marketing of alcohol treatment services (to primary care providers, mental health
providers, and the corporate community). They also describe integration of substance
abuse in general mental health through education and suggest ways of overcoming some
of the traditional conflicts between alcohol specialists and other mental health providers.
Finally, they outline priorities and program qualities of an exemplary alcohol abuse pro-gram
and describe the ideal spectrum of services that should be offered. Issues regarding
referral to appropriate level of care are also described in detail.
Keywords: models, staffing, substance abuse
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