Adapting to a Managed Care Environment

These are important questions, but it may not be possible to answer all of them. State AOD agencies need to decide which questions are essential for them, and then figure out how to get relevant information in this new environment.

Build on existing systems where possible. In States that have already developed sound reporting systems for CD services, try to convince those who are in charge of the larger health care data systems to use or adapt existing systems. In Minnesota, we are fortunate to have a well-established client tracking system, the Drug and Alcohol Normative Evaluation System (DAANES). All licensed providers must use the DAANES to report data. It may not be possible to convince those who are contracting with managed care firms to require such detailed client reporting on one "diagnosis," especially when such systems do not exist for other illnesses. In this case, build the detailed client reporting into your program licensing requirements and oblige managed care firms to use licensed programs. It is less important who collects and analyzes the data, than that someone does it.

Recognize that to those responsible for providing all health care, substance abuse is just a small part of the picture. If those in charge don't seem to pay much attention to your issues, it may not be that they don't care, but rather that they have so much else to deal with. Be persistent, proactive, and helpful. Offer to collect and analyze the CD data for them, take the lead in responding to Medicaid waiver issues related to CD or in training providers or producing reports. Don't just complain — help solve their problems.

Try various approaches. If one approach doesn't work, try another. Adapt your systems to meet the needs of this new environment, keeping your overallgoals and indicators in mind.

In Minnesota, rather than requiring the managed care organizations themselves to report on our client data collection systems, we worked with them to devise a brief, half-page form on their assessment and placement activity. These data have enabled us to track placement patterns and to link the data to our DAANES for further analysis.

If some other State agency, such as the Health or Commerce Department, already collects some data on CD clients served by HMOs, build on that. Don't duplicate it. Similarly, if whatever will be collected on all managed care services (e.g., encounter data) will be useful for some purposes, find a way to access and use it to complement the other data needed to address your State's key questions.

Use the data. It is important to get the results of any data collection and monitoring effort to those who need them. This includes providers, legislative staff, managed care organizations, and your own agency. We have published the results of our data collection in a variety of ways, such as in our quarterly newsletter Research News that is distributed to over 900 individuals and organizations. A recent issue compared placement patterns, completion rates, and lengths of stay for clients placed by prepaid managed care plans vs. Minnesota's Consolidated Chemical Dependency Treatment Fund. These clients were matched on age, sex, race, and other factors. We have also produced one-page handouts on topics of high interest, such as the cost-offsets of CD treatment in Minnesota. These handouts have been widely quoted and used.

Work closely with the CD field and others who have a mutual interest in providing adequate treatment to CD clients, such as providers and consumers. There are times when our constituency can promote things (such as uniform placement criteria or uniform reporting requirements) that government employees can't because of our position in the bureaucracy. Take advantage of these common interests and let our constituents do the lobbying, if that's necessary.

Get involved. My staff and I have served on every health care reform committee in our department. Because of the uncertainty of health care reform at the Federal level, many of these efforts have not gone anywhere. Nevertheless, you need to be seen as a player in the larger issues involved, not just as an advocate for CD clients. Contribute what you can of your time and expertise to broader issues, such as health care cost containment, Medicaid, block grants, and performance measurement for managed care in general. Make yourself useful in helping to solve the larger issues facing your agency and State.

Future Challenges

What challenges still lie ahead? We have made progress in some areas, but we are still struggling with a number of issues.

Influencing the overall evaluation plan for managed care in the State. While we have tried to build in whatever CD measures we can, the overall design for evaluating managed care in Minnesota is still not well developed. We have a State Data Institute that produces report cards on all HMOs in the State, based mainly on consumer satisfaction surveys. Our Medicaid agency is pursuing encounter data. However, no one seems to have articulated the questions that need to be answered, which should be the first step. We will continue to try to be involved in these efforts, but it is often frustrating.

Not losing what we have. In Minnesota, the CD field is ahead of many others in terms of collecting data, measuring client outcomes, and having uniform assessment and placement criteria. There is a danger that the State AOD agency's concerns could be swallowed up by health care reform and managed care, either in terms of reorganization or in going to the lowest common denominator in quality assurance and reporting. Without strong support from the CD field and legislators, we may go backward rather than forward. We will have to fight for the appropriate balance between accountability and freedom to "manage" in a managed care environment.

Determining where substance abuse services fit in a new and constantly changing environment. Health care reform and other changes at the Federal level (e.g., rescinding Supplemental Security Income benefits for those disabled by AOD abuse) have forced us to rethink where substance abuse services belong in the new scheme of things.

Are substance abuse services really "health care"? If so, do these services belong under "acute" or "long-term care" benefits? What about the nonmedical aspects of treatment (such as housing, child care, and vocational counseling) that are necessary for some clients' successful treatment? Should these be part of a "social services" package, perhaps funded through block grants to counties? How can "medical" and "social" services be coordinated so clients do not fall through the cracks? Where does prevention fit, and how will community-based prevention programs be funded in the future?

All of us will need to reconceptualize how adequate CD services can be provided in this new environment, at a time when much is still unknown. We do not, for example, know the future of Federal block grants or the changes that may occur in Medicaid. At the State and county levels, we may need to utilize whatever funding we do control in very different ways, such as separating funds for treatment services from funds for housing. How we use the Federal alcohol and drug abuse block grant may change radically, at least in Minnesota. And we will have to figure out how to provide essential services, such as case management, to those terminated from the Social Security Income and Social Security Disability Insurance programs. The impact of welfare reform on AOD clients must also be assessed (e.g., the denial of benefits to convicted drug felons).

Determining how to assure accountability for public funds and public clients in a privatized, deregulated system. As systems of care become more competitive and the distinction between public and private systems of care blurs, it will be increasingly difficult to ensure accountability. Private HMOs are not anxious to share their data or placement criteria with others in the marketplace. Many States are becoming less regulatory, based on the philosophy that the private sector has the right to manage care and should be accountable only for the outcomes.

This leaves a potential gap in accountability. State agencies will have to devise more sophisticated ways to ensure accountability. One way would be to use needs assessment data on whole populations. These data could then be compared with services actually delivered by various managed care firms to various population groups. In Minnesota, our legislature has asked the State AOD agency to develop utilization standards and financial or other incentives for all health plan companies in the State. These will provide a way to measure the adequacy of CD services in a managed care environment. Along with encounter data, we will be using the results of our CSAT-funded adult household survey, plus student surveys, to address this issue.

Clearly, many of the challenges faced by AOD agencies in the coming years will be political, not just technical. They will test our human relations, communications, and collaboration skills as much as our technological or substantive knowledge. While we can learn from what others have done, each State's approach will be different based on its history, politics, and philosophy. Hopefully, our agencies can be a significant factor in building new systems that will meet the needs of substance-abusing clients.

Key Questions: The Effects of Managed Care On Mental Health and Substance Abuse Services

1. Does the plan for providing mental health and substance abuse services through managed care create additional barriers to accessing needed treatment, especially for hard-to-reach populations (e.g., through delays in obtaining referrals, having to go to multiple clinics, or choosing a health plan)? 2. Is the treatment provided (or authorized) under managed care of sufficient duration, type, and quality to obtain acceptable client outcomes, given the types of clients being served? 3. Are the "gatekeepers" under managed care adequately trained to detect, assess, and refer these disorders? 4. Do the definitions of "medical necessity" used by managed care firms deny care to certain categories of clients (e.g., those who are court-ordered)? 5. Does the lack of independent assessors and/or uniform assessment and placement criteria result in referrals that are subjective, inconsistent, or motivated by financial vs. clinical considerations? 6. Under managed care, are adequate services being provided to special populations (such as minorities, dual or multiply disabled clients, the homeless, pregnant women, or injecting drug users)? 7. Is there evidence that some models of managed care work better than others (e.g., "carve outs," HMOs, preferred provider organizations [PPOs], Point-of-Service)? 8. Are the health, mental health, and substance abuse services provided under managed care adequately coordinated with the social and other "supplemental" or "wraparound" services needed by public clients? 9. Is there adequate monitoring and evaluation of the mental health and substance abuse services provided under managed care? Are data on assessment criteria, placement patterns, length of stay, program completion, and client outcomes regularly reported to a neutral oversight agency? Are there sanctions (either positive or negative) for poor/excellent performance? 10. Do managed care organizations provide adequate protection of clients' rights?

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