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Chapter 3 of TAP 16: Purchasing Managed Care Services for Alcohol and Other Drug Treatment: Essential Issues and Policy Issues

Chapter 3–Comprehensiveness of Treatment

Comprehensiveness in the context of alcohol and other drug (AOD) treatment is a very broad umbrella term that may encompass numerous key aspects of service delivery. For purposes of this discussion, "comprehensiveness" refers to the capacity to:

• Provide a full continuum of AOD treatment services

• Base treatment on ongoing bio-psychosocial assessments

• Utilize standardized patient placement criteria (PPC)

• Facilitate appropriate linkages with medical, psychiatric, and/or social support services

• Meet the cultural, gender, ethnic, and other specialized needs of those served

• Utilize a network of providers experienced in serving the covered population

Full Continuum of AOD Treatment

The managed care organization (MCO) shall ensure that enrollees have access–directly or through functional affiliations–to a full continuum of prevention, treatment, and rehabilitation services. These services include:

• Prevention/pretreatment

• Screening, assessment, diagnosis, intervention, and referral

• Outpatient counseling

• Psychiatric services

• Structured day treatment

• Short- and long-term residential treatment services

• Opioid substitution therapies, such as methadone treatment

• Freestanding and outpatient detoxification

• Hospital-based detoxification

• Case management services

When such services do not exist in the community, the MCO shall create these services.

The need for a full continuum of care is critical. However, continuing care (often called aftercare) needs to be clearly distinguished from acute, or initial, care. This distinction is important. Irrespective of the care received in the initial recovery phases, the extent to which the individual gets periodic services for the first 6 months to a year after treatment is strongly related to the probability that the person will continue recovery.

Continuing care services should be widely available and strongly supported by all MCO systems. Also, there may be value in trying to create a separate entity of the benefit package, ideally 6 months of weekly outpatient visits, that cannot be eroded by other services and are available for relapse prevention on an "as needed" basis (Hoffmann 1993).

Assessment

Standardization of assessment processes is an essential developmental step that is urgently needed in the AOD treatment field. Such standardization will:

• Improve the overall quality of assessments

• Allow less trained staff to perform adequate assessments

• Provide a consistent data base to compare the effectiveness of different treatment protocols upon different types of people with AOD problems

Any transition to managed care should include consideration of more standardized assessments.

The requirement for standardization must be balanced, however, with the requirement for the flexibility to meet the needs of the particular population being served. Assessment instruments may necessarily vary across different types of treatment settings, clinical needs, and geographic situations. However, they all should contain a core set of State and nationally standardized data elements. The policies of the MCO should aggressively facilitate such standardization. In addition, these assessment data should be retrievable for review as agreed upon by the contract with the MCO.

There are difficult tradeoffs when determining the location, type, and number of assessment sites. MCOs use a variety of models to assess and triage individuals into and within the treatment continuum. These may include:

• Assessment and triage capacity at all treatment sites

• Walk-in and call-in access

• 24-hour hotlines

• Central intakes

• Local community-based assessment sites

• Employee assistance program (EAP) triage centers

All models have advantages and disadvantages. In many ways, implementation is more important than the model. It is important to analyze local needs, clients served, previous experience, and current patterns of service delivery. Based on these factors, one can develop the assessment and entry systems that are most likely to achieve desired goals for a given State, region, or system.

Screening

It has been estimated that 75 to 85 percent of individuals with AOD problems never receive formal AOD treatment. To achieve middle-term savings through early identification and intervention, state-of-the-art models of AOD treatment must provide comprehensive screening for problems throughout the health and human services system. Ideally, systematic screening for AOD problems will be available or done in psychiatric settings, correctional settings, medical settings, and in a broad range of social service settings.

Early intervention and referral to outpatient AOD services should be seen as a hallmark of quality AOD treatment. Infrequent use of the simple, inexpensive screening devices that are available for AOD problems leads to insufficient early case identification. This failure to identify AOD problems early results in missed treatment opportunities, increased AOD treatment costs at a later stage, and increased overall medical costs.

Prevention

As the managed care field matures, increasing attention is being focused on longer term outcomes, demand reduction, and cost savings. A number of technologies are being increasingly used. These include:

• Prevention

• Wellness training

• Early identification

• Pretreatment

• Targeted outreach

• Brief interventions

• Other clinical technologies

Many expect that the focus of managed behavioral health care will substantially move in this direction, especially among systems that are financially "at risk." These systems will be motivated to become proactive in reducing the likelihood that clients will subsequently need more intensive and costly care.

Increasing the capacity of a system to screen for AOD problems is essential in being able to offer targeted prevention efforts and to intervene earlier in the course of an individual's substance use disorder.

The sources of referral for individuals with AOD problems is one key component of any managed care system that needs to be understood. These referral sources should be systematically monitored as closely as possible. Common referral sources for the publicly insured–the courts, child protection agencies, welfare systems–must be borne in mind when developing and monitoring systems.

Although health maintenance organizations (HMOs) and other capitated systems have economic incentives to promote wellness, the results are mixed. In situations where managed care is provided through HMOs, physicians are the source of referral about 40 percent of the time. This is despite the fact that physicians are often ill trained to screen for and diagnose substance use disorders. Therefore, physicians should be thoroughly trained in screening technologies, in conducting brief interventions, and in the use of standard AOD screening tools (Levin 1993).

As one component of continual improvement activities, the physicians should also be systematically monitored for their rate of referrals to AOD caregivers for evaluation and treatment. AOD providers should be monitored for their response to the referrals in a timely, professional, and collaborative manner.

Contracts with MCOs should emphasize the importance of early identification and screening of AOD problems, and purchasers of managed care should closely monitor performance. Many standardized screening tools are available. Brief intervention techniques (mild clinical interventions that can be provided at a variety of settings by trained individuals) hold promise for the less severely impaired. The Center for Substance Abuse Treatment (CSAT) has recently developed a Treatment Improvement Protocol (TIP) on simple screening instruments for alcohol and drug abuse and infectious diseases; this TIP is an excellent resource for States to use when implementing screening systems (CSAT 1994).

Patient Placement Criteria (PPC)

Some believe that the short-term financial incentives to cut and/or contain costs can create a powerful conflict of interest regarding quality care for the purchasers of managed care. They would prefer to see the government–preferably State alcohol and drug authorities–establish criteria on the environment, intensity, and duration of services. Others believe that this approach would be too restrictive, too intrusive, and would undermine the capabilities of the MCO to innovate and improve systems of care. Most would agree that the best case scenario would be that such criteria–and the implementation of these criteria–be created and continually refined through an active collaboration between the MCO, the State financing authority, consumer advocacy groups, and the State alcohol and drug authority.

A standard set of written patient placement criteria for a State is a reasonable goal. In this way, the placement process can be more understandable and acceptable to providers and clients alike. Standardized criteria also help create a level playing field in which competing MCOs will operate. In a collaborative system, the standards can be openly discussed and amended as understanding increases. All gatekeepers should be trained in the use of the PPC adopted and used in the State.

There are many different routes to follow in implementing statewide patient placement criteria. Insurance statutes can be used to govern how MCOs determine AOD benefits. Regulations can be developed to govern eligibility for funds or licenses. Contracts can be written between providers, MCOs, and/or the State.

The Patient Placement Criteria developed by the American Society of Addiction Medicine (ASAM) have stimulated much discussion and action in the field. Many States have adapted these criteria to fit individual State circumstances. CSAT recently sponsored a Treatment Improvement Protocol (TIP) on Patient Placement Criteria, which should be available in 1995. A review of these publications would be helpful for State planners and AOD providers.

Core Set of Wraparound Services

Wraparound services are services provided to individuals and families to enhance, supplement, and support AOD treatment services. They are an essential adjunct to treatment and are often a key to successful outcomes, although they are not usually considered treatment services. They are usually not–but can be–funded under AOD treatment benefits. It is imperative that any MCO managing the care of these beneficiaries ensure effective access to these wraparound services. Successful linkages to primary care, mental health care, and social services are essential to coordinated care and positive outcomes.

Most healthcare reform discussions separate social and public health services from general healthcare services. At the same time, there is a possibility that some of the dollars spent on treatment-related social services will be mixed with healthcare dollars and that certain services, such as housing and transportation, will fall into a financial vacuum. Thus, it may be important to identify and publicly fund certain wraparound services as separate from health care and as an MCO's responsibility.

One can divide wraparound services into (1) those that are essential to access and (2) those that contribute to positive outcomes. At a minimum, essential wraparound services include child care and transportation.

Wraparound services that contribute to positive outcomes include:

• Primary health care

• Screening and referral for HIV disease, tuberculosis (TB), and other infectious diseases

• Mental health services

• Legal aid

• Vocational training

• Education services

• Supportive living arrangements

• Domestic violence services

• Financial assistance

• Liaison services with Immigration and Naturalization services

• Other social services

Often, MCOs rooted in the private sector are not well linked to many of these wraparound services. The contractor should identify the most salient services for its population and determine the most effective way to ensure access. The contractor should also contractually ensure that:

1. The MCO provides and covers certain services that have not been considered traditional healthcare services, such as transportation and child care, or
2. The MCO develops effective linkage mechanisms to these services

Medical Linkage

In the United States, $1 of every $7 spent on health care is related to complications of AOD problems. More than 70 medical conditions and diseases are attributable, in whole or in part, to alcohol abuse. These conditions and diseases include cancer, cardiovascular disease, trauma, birth complications, and acquired immunodeficiency syndrome (AIDS) (Merrill et al. 1993).

It is therefore crucial that medical care be closely integrated with AOD treatment. In behavioral healthcare carveouts, there must be a clearly established and functionally feasible linkage with primary care services (e.g., with adjoining primary care clinics and primary care physicians). In HMOs, there must be close monitoring of the expertise of the gatekeepers and the effectiveness of the internal referral systems. In all cases, the primary care linkage to AOD treatment programs must be considered a priority and must be systematically measured as well as possible.

In Minnesota, AOD system developers wanted to create financial incentives for providing clients with efficacious levels of AOD treatment the first time they enter treatment. The Minnesota system developers found it essential to insert legislative language that directed decision makers and their numbers-crunchers and/or actuaries to look at cost offsets in creating these financial incentives. They incorporated the following language into law as a factor to be considered when developing a universal standard benefit set:

In developing the universal standard benefits set, the commissioner shall take into account factors including, but not limited to, cost savings resulting from the inclusion of healthcare services that will decrease the utilization of other health care services.

Assuming that this would not be fully understood by the actuaries, they followed it up by inserting specific actuarial assumptions into the commissioner's quasi-rulemaking directive to the actuary "for public and private plans." In Oregon, the medical/surgical capitation rate was reduced in anticipation of offsets resulting from AOD treatment.

Special Populations

In any given pool of enrollees, there are "special populations" that require responsive treatment facilities, staff, outreach, and case management. Such populations include, but are not limited to:

• Women–especially pregnant women

• Intravenous drug users

• People exposed to human immunodeficiency virus

• Those with coexisting AOD and psychiatric disorders ("dually diagnosed")

• The criminally involved

• The elderly

• Cultural and ethnic minorities

• Adolescents

• People with multiple disabilities

Underserved populations require targeted outreach efforts to assist them in getting into and staying in care. Contractual financial incentives often discourage such outreach, and many MCOs are not sufficiently community-based to provide this outreach effectively. This type of outreach may be best achieved by a separate party (e.g., the AOD authority). A thoughtful decision must be made regarding who is best positioned to reach out effectively to these populations.

Provider Network

Incorporating managed care into a publicly funded AOD treatment system will have a dramatic impact on the providers in that system. Some will adapt quickly to the new environment and prosper, some will fight to remain viable, and others will not survive the transition. Mergers, new affiliations, and new system developments will radically change the service-delivery landscape. The MCOs may be inclusionary or exclusionary in how they implement systems development. However, the MCOs should only be able to use licensed facilities.

It is therefore crucial that State AOD authorities do their best to support the initial inclusion of these existing licensed programs and assist them in adapting to the new environment. Extensive training may be required to assist some providers. Information regarding managed care should be systematically forwarded to them. Trainings and educational forums can be provided or strongly encouraged. (Note: Appendix C, "Managed Healthcare Organizational Readiness Guide and Checklist," which is a tool to help analyze a provider's capacity to function successfully in a managed care environment, can be used by both programs and State systems to identify their strengths and weaknesses.)

Needed consultative or technical assistance services can be arranged. Strategic planning processes–both at the system and provider levels–can be implemented. Within the limits of resource capabilities, State AOD authorities should provide leadership in designing and implementing strategies that will enable publicly funded AOD providers to participate successfully in the managed care system.

"Any Willing Provider"

Many States are now adopting or considering "any willing provider" legislation in an attempt to lessen the exclusionary power of MCOs. This type of legislation–mandating that all providers who are willing to meet specified standards and accept a given rate will not be excluded from a managed care network–is highly controversial. Fundamentally, the advantage of such legislation is that it can prevent a provider or group of providers from being formally excluded from a managed care network. The disadvantage is that it can substantially restrict the capacity of an MCO to accomplish clinical goals and that de facto exclusion could still probably occur. State AOD authorities must examine the individual circumstances of their particular State to decide whether or not to support such initiatives.

Essential Community Providers

The financial and societal consequences of undetected, untreated, or inadequately treated AOD problems are enormous. During a transition to managed care, it is essential to the public safety, welfare, and economy of a State that the treatment offered to the uninsured or publicly insured populations not be dramatically reduced or made less available. Measures must be implemented to ease the inevitable problems of such a transition and to ensure that the provider systems in place are not abandoned in a wholesale and reckless manner.

Many MCOs are not highly experienced in treating addictions among the type of clientele that is characteristic of publicly funded programs. For this reason, many believe that new systems should encourage the initial inclusion of the local, publicly funded AOD treatment programs that have been serving this population. Traditionally, these publicly funded programs have operated for years with insufficient funding. They are at a distinct disadvantage relative to providers who have been funded in the private sector for treating the commercial population.

However, these publicly funded providers offer major strengths and advantages. These providers have:

• Developed strong community linkages with key supportive services

• Demonstrated sensitivity and commitment to the needs of the publicly insured individual

• Demonstrated that they are capable of being, by necessity, highly cost-efficient in the delivery of clinical services

The loss or functional exclusion of such services in the name of reform would represent a substantial step backwards in attempting to meet the needs of the publicly insured population.

As healthcare delivery systems are transformed, planners need to be creative in combining the community-based strengths of the publicly funded system with the technical and managerial strengths of the managed care industry. One way to facilitate a successful transition to managed care–while still protecting the public good–is to encourage contractually the inclusion of community-based providers as "essential community providers" for a designated transitional period.

Exhibit 2 provides sample contract language relating to the comprehensiveness of treatment.

Last Updated 11-7-02