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{X The Evolution of Financing Policy As treatment has advanced and become more specialized, there have been significant changes in the financing and organization of treatment services. Financing the treatment perhaps more accurately the custodial care-of persons with alcohol problems was previously seen as primarily the responsibility of the states as part of their mental health program. Until the early 1970s, the majority of individuals admitted for inpatient treatment of alcohol problems went to state mental hospitals, fewer than 10 percent of which had special wards or programs for such treatment. Indeed, in the 1960s, up to 40 percent of all the admissions to state hospitals were "chronic problem drinkers" (Glasscote et al., 1967; Plaut, 1967~. There were few general hospitals that had special wards or programs; those that did have such units provided primarily emergency care and detoxification. Most private psychiatric hospitals also lacked separate programs; persons with alcohol problems (who constituted approximately 6 percent of admissions) were treated in their general psychiatric units (Glasscote et al., 1967~. By 1986, the situation had changed dramatically: in a survey conducted by the American Hospital Association, there were 1,097 hospitals reported offering treatment for alcohol problems in a specialized program (1,039 general, psychiatric, and other specialty hospitals had designated units and 58 specialty hospitals offered "alcoholism/chemical dependency treatments) (AMA, 1987~. The number of outpatient and nonhospital residential facilities and programs has seen similar growth. There were only 130 outpatient clinics and 100 halfway houses and recovery homes which specialized in providing care for alcohol problems when the original survey was conducted in 1967 (Glasscote et al., 1967~. Many of the halfway houses surveyed were privately funded clinics that provided safe withdrawal and supportive care for the well-to-do; others had been started by AA members as Twelfth Step houses to provide similar services on a voluntary basis. In contrast, in 1987, there were over 5,700 distinct specialty programs that reported providing treatment for alcohol problems within an identifiable unit (NIDA/NIAAA, 1989~. More than 2,000 were outpatient facilities, and more than 1,300 were residential facilities (e.g., halfway houses, recovery homes). Since the early 1970s and the first efforts to develop separate funding and organizational structures for specialty, high-quality treatment for alcohol problems, the mechanisms for funding such treatment have undergone a number of shifts. The first shift was from state and local undifferentiated funding to state, local, and federal government categorical grants and contracts. (Categorical grants and contracts are funds targeted to meet a specific need of a specific population through an application process with tightly defined program and administrative requirements.) Indeed, categorical government appropriations became the major sources of funding for treatment of persons with alcohol problems (Booz-Allen and Hamilton, Inc., 1978; USDHHS, 1981; Akins and Williams, 1982; Cahalan, 1987; Butynski and Canova, 1988~. With this change came a different notion of what treatment should be. Financing treatment for alcohol problems was formerly seen as the responsibility of state and local governments; they were most likely to fund emergency care for public inebriates in jails and in public hospital emergency rooms and custodial care for chronic alcoholics in state mental hospitals. Together with the shift toward government categorical funding of treatment came the concept of a shared federal-state responsibility to develop a continuum of specialist treatment services in each community. The federal government thus provided categorical grants for community-based services and encouraged the states to increase their categorical funding of these programs (President's Commission on Law Enforcement, 1967a,b; Boche, 1975; Weisman, 1988~. The second important shift in funding that has occurred since the 1970s has been the move toward increased coverage of specialized treatment for alcohol problems as a 406

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IlIE EVOLUTION OF FINANCING POLICY 407 separate, discrete benefit by public and private third-party payers. As a result, financing treatment for alcohol problems is now accepted, albeit not without reservations, as also the responsibility of the federal government (acting on behalf of the categorically needy, the elderly, and the chronically disabled) and of private insurers (acting on behalf of employers and individuals who purchase health insurance) (e.g., Leland et al., 1983; Sievert, 1983~. As discussed in Chapter 8, initiating these shifts in funding sources and developing a stable financing base have been major priorities of the voluntary associations and governmental agencies involved in specialty treatment for alcohol problems. All of these groups placed major emphasis on moving the financing of treatment for alcohol problems into the mainstream of health care financing; their efforts have led to a substantial increase in the total contribution of private health insurance, state and local categorical funds, and self-payment. There is continuing involvement of the federal government as a source of financing as well, but its relative contribution through both categorical funds and public health insurance has diminished. One consequence of the lessening of the federal role has been a substantial variability in sources and level of funding among the states and within the public and private specialist sectors (Jacob, 1985; Institute for Health and Aging, 1986; USDHHS, 1987). Major questions are now being raised about whether current financing and reimbursement policies provide for access to the most cost-effective treatments (Freeborn, 1988~. These policies have evolved over the last 20 years through a combination of government initiatives, research findings, and advocacy efforts. Recently, they have come into conflict with policies relating to cost containment and have been faced with questions regarding the effectiveness of current strategies (Gordis, 1987; Holden, 1987; Wallace, 1987; Gibson, 1988; Lewis, 1988~. It may be helpful to look briefly at some of the noteworthy points along this evolutionary path for a historical perspective on the current state of funding policy. Development of a National Policy The recommendations of the Joint Commission on Mental Illness and Health (1961) are a good starting point for observing the development of a national policy on funding of treatment for alcohol problems. These recommendations were the driving force behind the shifts from state-dominated operation and financing of institutional services toward an increasing role for, first, the federal government (through categorical grants for community-based services) and, then, for public and private health insurance in financing a continuum of community-based treatment services for all mental disorders, including alcohol problems. Similar efforts of the Cooperative Commission on the Study of Alcoholism were aimed at removing the financial barriers to treatment of problem drinkers in community-based traditional hospital and nontraditional social model residential settings. One of the commission's most far-reaching recommendations was that a national organization be supported which would provide leadership in developing a coordinated approach to research, prevention, manpower development, and treatment throughout the United States (Plaut, 1967; Chafetz, 1976; Lewis, 1982; gurney, 1987~. The major impetus for change in both the financing and organization of treatment for all mental illness came in 1963, with the passage of the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 (P.L. 88-164~. The major impetus for similar change in treating alcohol problems came in 1970 with the passage of the "Hughes Act," the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 (P.L. 91-616~. With this legislation came establishment of the National Institute of Alcohol Abuse and Alcoholism as the focal point for the coordination of federal activities and for the development of national policies ~. ~

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408 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS and priorities (USDHEW, 1971; USGAO, 1977; NIAAA, 1984; Cahalan, 1987; Lewis, 1988a). Important contributions to a national policy were made by the Task Force on Drunkenness of the President's Commission on Law Enforcement (1967b) and by a series of court decisions that supported the disease concept of alcoholism (Hart, 1977; Lewis, 1982~. These efforts focused on the ineffective and inhumane handling of public inebriates within the criminal justice system, recommending that such individuals be treated within a public health model. The President's Commission on Law Enforcement (1967a) recommended that a network of detoxification centers be established to replace local jail facilities for public inebriates. One important factor in bringing about the recommended changes was the efforts of Senator Harold Hughes (as chair of the Special Subcommittee on Alcoholism and Narcotics) Senator Harrison Williams, Congressman Paul Rogers, and a coalition of constituent groups led by the National Council on Alcoholism and the North American Association of Alcohol Problems. As a result of their efforts, the National Center for the Prevention and Control of Alcoholism was established in 1969 within the NIMH Division of Special Mental Health Programs. In 1970 the center was upgraded and renamed the Division on Alcohol Abuse and Alcoholism to give added visibility to the federal effort. . _ _ ,, _ The Establishment of the National Institute on Alcohol Abuse and Alcoholism The advocates of the new "problem drinking approachn embodied in the reports of the commissions noted above were not content with the establishment of the Division on Alcohol Abuse and Alcoholism. They were pushing for an even more visible and independent federal alcohol control agency which would not be dominated by the larger mental health establishment (Lewis, 1982, 1988; Neiberding, 1983; Cahalan, 1987; Weisman, 1988~. Their goal was to redefine alcoholism as a primary illness rather than a symptom of mental illness (its position at that time). Their strategy was to create a network of specialist treatment facilities linked within a continuum of care (D. J. Anderson, 1981~. With the early support of President Johnson and his assistant, Joseph Califano, who was later to become secretary of health, education and welfare, Senator Hughes and the constituent groups sought and ultimately received congressional authorization for a program of direct federal funding of alcohol treatment and prevention programs. This authorization was embodied in the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970. This legislation, known as the Hughes Act (P.L. 91-616), established the National Institute of Alcohol Abuse and Alcoholism (NIAAA) as an independent institute within the National Institute of Mental Health (NIMH). NIAAA's mission was to administer the new programs which were authorized by the Hughes Act as well as those already established through amendments to the Community Mental Health Centers Act (P.L. 90-574 and P.L. 91-211~. The secretary of health, education, and welfare, acting through NIAAA, was required to develop and conduct comprehensive health education, training, research, and planning programs for the prevention and treatment of alcohol abuse and alcoholism. Using Federal Grants to Increase Treatment Resources The Hughes Act also established two major new programs with significance for the development of alcohol treatment services. The first was a program of formula grants (i.e., allotments to states according to a formula involving population, per capita income, and need). States were to use these grants for planning, establishing, and maintaining

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THE EVOLUTION OF FINANCING POLICY 409 prevention and treatment programs. The second program was a two pronged approach comprising project grants to public agencies and nonprofit organizations and contracts with public or private organizations or individuals. The formula grant program required preparation of state plans outlining needs and resources for alcoholism programs and containing a description of the activities for which the federal funds were to be used. The initial plan submitted by a state was to identify a single agency, the state alcoholism authority (SAA) to administer the plan. The plan was required to contain assurances that federal funds would supplement, not replace, state and other nonfederal funds that were already being spent to support alcoholism programs. In 1971, only a few of the states had oversight agencies in place that were similar to the proposed SAA (i.e., that could develop and monitor specialty programs for treatment of alcohol problems). (More than 40 states had separate alcohol programs, but the programs were primarily engaged in public education; only a few states operated a specialty inpatient program or provided funds for community-based outpatient clinics.) Most alcohol treatment services were provided by the state mental health authorities, either directly in state hospitals or through grants and contracts to newly developing community-based programs. The formula grant program provided the means for all of the states and territories to develop a new specialty oversight agency, the SAA, or to strengthen an . , _ existing agency; whichever proved to be the case, fine resulting agency would tnt;n Try provide categorical funds for specialized treatment services and coordinate and monitor funds expended by other state agencies. NTAAA also provided financial support for the development of a national organization, the Council of State and Territorial Alcoholism Authorities, to promote the exchange of programming and financing strategies; this organization later merged with a similar group founded by directors of state drug abuse agencies to become the National Association of State Alcohol and Drug Abuse Program Directors (NASADAD). NASADAD has become the major vehicle by which the states interact with the federal government on policies for federal financing of treatment for alcohol problems (skins and Williams, 1982; Butynski et al., 1987; Butynski and Canova, 1988~. The initial appropriation for the NIAAA formula grants program was made during the federal government's fiscal year 1972 and represented 35 percent of the institute's appropriation for all activities that year. By the end of the fiscal year, all of the states had submitted their required plans and received formula grant awards. The formula grant program ended in 1981. Approximately 80 percent of the formula grant expenditures over the years were for intervention, treatment, and rehabilitation services. The second new program authorized by the Hughes Act consisted of project grants and contracts (awarded and administered by the secretary acting through NIAAA) to conduct demonstration, service, and evaluation projects. The initial focus of the program was on the use of project grants to demonstrate the feasibility of providing community-based intervention and treatment that was oriented toward the integration of services and the provision of comprehensive services. Through these projects, combined with the education and training of personnel, and cooperation with other agencies, NIAAA was to assume the leadership role in developing treatment capacity across the nation. Indeed the new institute's highest priority was the expansion of available treatment for persons with alcohol problems within their home communities (USDHEW, 1971~. The major barriers to accomplishing this goal were the stigma attached to alcoholism, which was still viewed as a moral failing rather than as a disease; general ignorance about the condition; general hospital admission practices that excluded persons with alcohol problems; and the exclusion of alcohol-related disorders from health insurance coverage. The strategy DHEW and NIAAA adopted was to expand treatment resources as rapidly as possible through categorical grants to states, local governments, and local community groups for treatment and rehabilitation services. The primary target population

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410 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS for these initial categorical grant programs were uninsured persons with alcohol problems (i.e., public inebriates, poverty area residents, and ethnic minorities). The initial appropriation for the categorical grants program was made in federal fiscal year 1972. In addition to the new grants for treatment services, staffing grants for comprehensive community alcoholism programs had previously been awarded under amendments to the Community Mental Health Centers Act. These grants were now also to be administered by NIAAA Originally, these staffing grants utilized the initial community mental health centers model, which called for five essential services organized within a continuum of care to a delineated catchment or service area; the five services are: (1) inpatient care; (2) outpatient care; (3) intermediate care such as halfway houses and day or night hospitals; (4) emergency care; and (5) consultation and education services (see Chapter 3~. These staffing grants were later redefined and became NIAAA's cross-population demonstration program, keeping the concept of the continuum of care but eliminating the catchment area concept and the concept of five essential services (Booz-Allen and Hamilton, Inc., 1978~. In keeping with its mission as the central federal agency for alcohol-related activities, other programs also moved under NTAAA's control. When the Office of Economic Opportunity was abolished in 1972, NIAAA assumed the administration of almost 200 grants serving residents of low income areas, American Indians, and Alaskan natives. These projects were originally funded under the Economic Opportunity Amendments of 1968 and 1969 and were the first federal grants for services to persons with alcohol problems; they provided primarily outreach and linking services or outpatient care, or both. The largest group of grantee agencies funded under this program comprised community action agencies, whose activities focused on social advocacy and linking poor persons with alcohol problems to treatment providers. The poverty grant program became the largest of NIAAA's special population categorical program areas, constituting approximately 54 percent of all such grants. Problems were encountered when the transfer occurred because the program's social advocacy and social services approach was not consistent with the field's effort to integrate treatment of person's with alcohol problems into more traditional health care financing mechanisms. These poverty grantees were seen as the group least likely to continue to receive funding if categorical grants were discontinued because their approach was not consistent with the treatment approach favored by state or third-party funders (Booz-Allen and Hamilton, Inc., 1978~. During the lifetime of this categorical project grant mechanism, grants for treatment and rehabilitation services to special, or underserved, populations received priority as a way to complement the Generic treatment provided through the community mental health services approach (comprehensive services to a designated catchment area) (USDHEW 1971; see section IV). In addition to the cross-population, poverty, and Indian grants, additional programs were created to fund demonstrations of effective services for Hispanics, blacks, women, youth, the elderly, drinking drivers, criminal justice clients, gays and lesbians, migrant farmworkers, physically handicapped persons, and public inebriates. NIAAA prepared guidelines for grant applications to identify those elements that were thought to be essential components of treatment services for each of the special populations (e.g., child care services to enable women to enter inpatient residential treatment; vocational counseling and job training for low-income ethnic minorities; outpatient counseling for youth). A third treatment oriented grant program was established in 1974. The incentive or uniform act grant program was designed to provide additional financial support for treatment services to those states that decriminalized public intoxication and provided treatment rather than jails for intoxicated persons (Grad et al., 1971; USD HE W. 1971; Finn, 1985; gurney, 1987~. As an additional encouragement to this trend of treatment rather than jail, NIAAA supported the development of the Uniform Alcoholism and Intoxication Treatment Act by the National Conference of Commissioners on Uniform State

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THE EVOLUTION OF FINANCING POLICY 411 Laws (see Chapter 3 and Appendix D). When the NIAAA program ended in 1981, 34 states had passed an acceptable version of the Uniform Act and received incentive grants (Finn, 1985~. Despite NIAAA's effort to strengthen the SAAs through the formula and incentive grant programs, the early years of the NIAAA categorical grant program were marked by a lack of communication and coordination about funding priorities with the SAAs (USGAO, 1977; Booz-Allen and Hamilton, Inc., 1978~. To improve cooperation, the states and NIAAA collaborated in the development of a demonstration program, in which the SAA would become the grantee for all project grants, assume responsibility for monitoring the adequacy of treatment, and provide data on accomplishments (skins and Williams, 1982~. While this project grant mechanism was still in the demonstration phase, however, the alcohol, drug abuse, and mental health services block grant was established by statute. The block grant consolidated the project and formula grant and contract programs administered by NIAAA and transferred responsibility for administration of these services funds to the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). The leadership role in treatment capacity and services development was transferred to each of the states in keeping with the intent of the legislation to allow states the flexibility to set and carry out their own priorities (ADAMHA, 1984~. There was also a cutback in the level of federal funds (Sharfstein, 1982; Robertson, 1988~. The determination of the level and form of treatment services and their financing is fairly well left to each state. The block grant mechanism is still in place today, and states now allocate block grant funds according to the same policies by which they allocate state appropriations (USGAO, 1984; ADAMHA, 1988~. Efforts to Increase Public and Private Health Insurance A second major emphasis in early NIAAA activities was on demonstrating that treatment of the employed individual who was experiencing alcohol problems was beneficial to both the individual and the employer; the primary mechanisms for these efforts were grants for the establishment of occupational alcoholism programs (now known as employee assistance programs) and the creation of an alcoholism counseling service for federal employees (Trice, 1986; Roman, 1988~. In addition, NIAAA offered grants to each SAA to develop its own statewide program of consultation and technical assistance to local businesses and government agencies that were considering the establishment of occupational alcoholism programs. In particular, the state consultation programs highlighted the cost savings to be achieved through the adoption of company policies for identifying, referring, and treating the employee with alcohol problems in concert with the adoption of a specific health insurance benefit that encouraged early intervention for employees whose job performance was impaired by alcohol problems. A significant part of NIAAA's effort in this area was support for research on the development and testing of model health insurance benefit packages (e.g., Berman and Klein, 1977a, Hallan and Holder, 1983; Holder and Those, 1986~. Working with the major voluntary association, the National Council on Alcoholism (NCA), and representatives from the insurance industry, NIAAA sponsored the development and dissemination of a model benefit package in 1973 (USDHEW, 1974; Williams, 1981~. The suggested benefit structure was developed through a review of the existing coverage of treatment services for alcoholism and alcohol-related conditions offered by both private insurers and public insurers (Medicare and Medicaid) and by analyzing the costs and practice patterns of current NIAAA grantees (USDHEW, 1974~. NIAAA offered the model benefit plan to insurers and companies purchasing health insurance as a basis for projecting a reasonable range of possible costs to use in their negotiations. The model

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412 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS was also seen as a guide for future studies of the impact of providing coverage on the cost of insurance coverage. The cost estimates in the model were derived from analyses of 27 treatment programs offering treatment in more than 60 settings. The model was designed to reflect the continuum of care with a projected length of stay for each setting required for treatment: inpatient emergency cared days; inpatient care-14 days; intermediate care, short term 30 days; intermediate care, long term 6()-90 days; and outpatient care-30 visits. When it distributed the package, NIAAA noted that costs varied significantly among the variety of settings in which equivalent care or treatment was provided (e.g., general hospital - inpatient emergency care was tound to cost trom ~ tO 1U umes as mucn as olner em`;rg`;ncy care settings), a factor that continues to require consideration today (Holder and Hallan, 1983; Holder et al., 1988) (see Chapter 8~. This original benefit design attempted to incorporate then current expert opinion on effective treatment regimens and to promote alternatives to inpatient hospital treatment, including treatment in residential or partial care settings. NIAAA continued to encourage the development and adoption of model benefit packages working with the voluntary sector, professional associations, and state agencies; its role shifted in the late 1970s from advocating a specific model benefit to sponsoring research and providing information on which employers, third party payers, and other policymakers can base decisions on the extent and nature of coverage (Luckey, 1987; USDDHS, 1987~. In recent years, however, the leadership role in encouraging the adoption of a model benefit has been shifted to the SAAB, which are working with the voluntary and professional interest groups in the field to obtain voluntary expansions of benefits or to have such coverage mandated by law (Alcohol and Drug Problems Association Task Force on treatment Financing, LYNX; Butynski, 1986; Oregon State Health Planning and Development Agency, 1986; Massachusetts Special Commission, 1988; New Jersey Department of Insurance, 1988~. During the 1970s, the federal role in financing treatment for alcohol problems-as with other physical and mental illnesses-was developmental: using the categorical grant mechanism, federal efforts were directed toward capacity building and resource development, embodied in such activities as basic and clinical research, professional training, and services demonstration. In general, this support was seen as a temporary measure, to be used only until the "more conventional" third-party financing mechanisms (particularly the expected national health insurance) could be brought into play. This view was expressed in a report by a study committee organized by the American Hospital Association (Advisory Panel on Financing Mental Health Care, 1973:59~: ~- ~ ^0~ Personal services for alcohol abuse should be financed through the same mechanisms as treatment for all other illnesses, even though some categorical support for direct services may be necessary in initial states of program development. The establishment of categorical administrative structures and funding structures at the Federal level, while providing a justifiable and necessary focus for the development of resources and the coordination of existing ones, should represent a temporary mode of approach. Fragmentation of authority and financing mechanisms within the mental health field, unquestionably has contributed to increased costs and reduced effectiveness. In the long run, federal programmatic support for the control of alcohol abuse should not be separated from Federal funding for all mental health programs. Thus it was assumed that conventional third-party reimbursers (public insurance for the indigent and private insurance for the employed and their families) would begin to support these federally initiated alcohol treatment projects. Grantees were encouraged to

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THE EVOLUTION OF FINANCING POLICY 413 seek out funding from a variety of third-party payers, ranging from private health insurance, to Medicaid, to Title XX Social Services funds (Morrison, 1978~. The Health Services Funding Regulations and Guidelines [42 CFR. Sec. 50.101-1071 adopted in 1974 specified ~ ~ . , ~ , _ _ or_ _ ~ the steps to be taken to capture these funds. In addition, technical assistance was offered to grantees through workshops, consultants, and manuals (Boche, 1975; Morrison, 1978~. The goal was for projects to become financially self-sufficient, replacing federal categorical grant funds with other third-party sources by the end of the demonstration period. However, concerns began to surface about whether such a goal was realistic, and several studies suggested that many NIAAA-funded categorical projects could not expect to capture third party funds and to survive in the existing funding environment without significant changes to meet the medical model requirements of third-party payers (Boche, 1975; Booz-Allen and Hamilton, Inc., 1978; President's Commission on Mental Health Task Panel on Alcohol-Related Problems, 1978; Creative Socio-Medics Corporation, 1981~. Contemporary NIAAA reports sound the same theme as the American Hospital Association committee report while continuing to seek separate alcohol-specific third-party financing mechanisms. One of the agency's major objectives was to promote changes in the practices of health insurers who were seen to discriminate against persons with alcohol problems. This theme is consistently presented in each of NIAAA's early reports to Congress, which also detail the agency's efforts to demonstrate that effective treatment of alcohol problems is possible, that direct treatment of alcohol problems reduces other health care and productivity costs, and that treatment for alcohol problems can be brought into the "mainstreams-that is, included in existing health and social care systems (USDHEW, 1971; USDHEW, 1974; Chafetz, 1976; USDHHS, 1986~. Despite NIAAA's advocacy, however, there were questions raised as to whether such mainstreaming was possible given the nature of the services needed (supportive social as well as medical services) and the continuing doubts of insurers and policymakers regarding the effectiveness of treatment (Boche, 1975; Booz-Allen and Hamilton, Inc., 1978; Leyland et al., 1983; Saxe et al., 1983; Sievert, 1983; Hurst, 1987~. To aid the survival of its grantees and to further demonstrate the validity of its approach, NIAAA funded a variety of projects aimed at addressing the concerns of Congress, the states, and the insurance industry regarding quality of treatment delivered, the effectiveness of treatment, and the costs of adding treatment of alcohol problems as a covered benefit. For example, NIAAA awarded a contract to the Blue Cross/Blue Shield Association to study the feasibility of offering a comprehensive benefit that would include the new nontraditional settings for treatment as eligible providers, allow counselors as well as physicians, psychologists, and social workers to be included in coverage, and provide coverage for the newer psychosocial modalities (e.g., family treatment) (Berman and Klein, 1977a). Another contract supported the development of accreditation standards for alcoholism treatment facilities by the Joint Commission on the Accreditation of Hospitals (now the Joint Commission on the Accreditation of Health Care Organizations). Such standards could be used to demonstrate that providers of treatment for alcohol problems could meet the traditional quality control measures used by the insurance industry in defining provider eligibility (Joint Commission on the Accreditation of Hospitals, 1979, 1983~. In addition, a combined management information and treatment evaluation system was developed and its use made a requirement for NIAAA funding; these data were . , _ considered by peer review committees in determining whether to continue NIAAA funding of individual projects. Another NIAAA project was aimed at credentialing personnel; here, the agency chose to develop model standards to be used by the states and voluntary organizations in licensing or accrediting counselors (Birch and Davis Associates, Inc., 1984~. While NIAAA was pursuing these avenues, state alcoholism authorities were encouraging the nontraditional agencies they funded to attempt to bring in a mix of patients and funding sources by conducting outreach to employers and by obtaining

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414 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS accreditation from the Joint Commission on Accreditation of Hospitals. A number of states also strengthened their own licensing requirements. Their efforts brought some progress. Insurers began to recognize state licensure of certain nonhospital programs as a substitute for accreditation (Leyland et al., 1983~. However, efforts to obtain similar recognition by Medicare and Medicaid were unsuccessful (Noble et al., 1978; Saxe et al., 1983; Lawrence Johnson and Associates, Inc., 1983, 1986~. The Current Situation The Shifting Leadership Role In 1982 the alcohol, drug abuse, and mental health services block grant established by the 1981 Omnibus Budget Reconciliation Act (P.L. 97-35) replaced the NIAAA formula, incentive, and project services grant programs. The action was taken as a result of general congressional and administration concerns about the proliferation of categorical programs that served many of the same client populations and the often duplicative and burdensome federal reporting requirements (Agranoff and Robins, 1982; USGAO, 1982; Grupenhof, 1983~. Still in place today, the block grant is administered by the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), the umbrella agency established in 1974 to oversee NIMH, NIAAA, and NIDA; the grant provides funds to the states for redistribution to local governments or agencies to carry out the general aims of the legislation but with minimal federally directed requirements. The initial award was based on the amount of funds which a state was receiving under the NIAAA categorical grant programs, less 25 percent. Since the initial award, however, there have been several adjustments in the level of the funding and in the formula because of concerns about inequities in the distribution of funds among the states (W. J. Anderson, 1984; USGAO, 1985, 1987b; Institute for Health and Aging, 1987~. The block grant was designed to be more flexible than NIAAA's categorical and formula grants program in its application, administration, and reporting requirements. There are relatively few restrictions placed on any of the block grants, although in some cases monies have been "set asides for specific purposes (ADAMHA, 1984, 1988; USGAO, 1987a). The alcohol, drug abuse and mental health services block grant provides set asides for primary prevention and increased treatment availability for women (NCA, 1987~. There is also a restriction on the amount of the block grant that can be used to support state administrative costs and a prohibition against using block grant funds to pay for hospital treatment of alcohol and drug problems. With the shift to block grant funding for treatment services, the leadership previously exercised by NIAAA in the development of the network of specialist programs and enhanced financing for treatment devolved upon the states (Lewis, 1982, 1988; Cahalan, 1987~. NLAAA's role has become primarily to fund and conduct research; to disseminate research findings to improve the prevention and treatment of alcohol-related problems; and to provide technical assistance in the development of effective alcohol abuse prevention and treatment programs and activities (USDHHS, 1986; Butynski and Canova, 1988; NASADAD, 1988~. The momentum for continued resource development and capacity building has been shifted to the states and local communities, to advocacy groups, and to professional associations.

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THE EVOLUTION OF FINANCING POLICY State and Local Government Activities 415 Today, each state has an identifiable unit charged with overseeing the development, funding, and regulating of specialist treatment for alcohol problems and of monitoring the quality of such treatment (USDHHS, 1986; NASADAD, 1988~. As noted earlier in this chapter, the concept of a state alcoholism authority with specific functions was introduced as part of the requirements to obtain federal formula grants under the Hughes Act; these requirements were reduced with the passage of the block grant. Yet the SAAs have remained in place, carrying out most of the same functions and continuing to provide funding for treatment of low-income persons and other special populations. The organizational placement, statutory structure, and functioning of the SAAs vary from state to state (NASADAD, 1988~. In some states the SAA is part of an independent agency that also serves as the single state authority for drug abuse (e.g., Connecticut); in others it may be a component of a state mental health agency (e.g., Virginia, Alabama, Illinois), of a health department (e.g., Ohio, Pennsylvania), or of a human resources superagency (e.g., California, Minnesota). In fiscal year 1986, there were 14 states in which the state health agency served as the SAA to receive the alcohol portion of the federal block grant; all but one of these agencies were also the designated recipients of the drug abuse portion of the block grant. In only 6 states were the state alcoholism, state drug abuse, and state mental health authorities placed within the public health department (Public Health Foundation, 1988~. Funding practices and program administration vary considerably among the states and territories (Butler and Littleffeld, 1985~. Although each state and territory has an agency designated as responsible for funding and monitoring alcohol problem treatment activities, this agency may not be the only state entity to expend such funds. In three states (the District of Columbia, Indiana, and Montana), other state agencies are reported to provide more funding to publicly supported specialty programs than does the SAA (Butynski et al., 1987~. As discussed in Chapter 8, funding varies among the states in terms of per capita levels and the relative proportion of funds available from state and local government appropriations as well as from public and private health insurance. The determinants of this variation are not clear. Additional empirical studies of the complex funding environments that exist are required to understand the sources of variation. The SAA usually provides categorical funds to specialty providers but generally does not directly manage other funds for treatment in hospitals, correctional facilities, and social services agencies. Some states contract directly with provider agencies (e.g., Colorado, Connecticut, Missouri); other states provide funds to counties or regional coordinating agencies to use for provider contracting (e.g., Michigan, New York, California, Pennsylvania, Virginia). In addition, some states that contract with counties also have programs for contracting directly with providers on demonstration and other special projects (e.g., New York, California). Most state governments are the largest single purchaser in their state of treatment services for alcohol problems through the categorical programs administered by the SAA The NDATUS and SADAP survey data reported in Chapter 8 suggest that states provide more than 50 percent of the funds available to nonprofit specialty programs, which primarily serve the indigent and uninsured. The continuum of care supported by the benefit package in each state program differs from that of other states; within states, benefit plans of the Medicaid agency, the state employee health insurance program, and the SAA programs also differ. For example, Medicaid continues primarily to support a medical model of hospital-based detoxification and rehabilitation, whereas the SAA more often supports a mixed medical and social model that also includes social services, relapse prevention, and extended care in nontraditional, nonhospital settings (Lawrence Johnson and Associates, Inc., 1986; Butynski and Canova, 1988~. Both public- and private-sector

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416 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS programs reflect the dominance of the Minnesota model discussed in Chapter 3 (inpatient primary rehabilitation followed by extended care or aftercare of decreasing intensity and frequency and using a blend of AA and professional services). The trends toward decentralization in funding decisions that were noted in the last comprehensive study of the sources of and barriers to financing of treatment for persons with alcohol problems have continued (Booz-Allen and Hamilton, Inc., 1978~; consequently, the current environment is extremely complex, with large interstate and intrastate variation in both funding levels and funding policies (Weisner and Room, 1984; Weisner, 1986~. The role of substate units (e.g., counties, regional coordinating agencies) has continued to grow in importance as more states require local matching funds as a condition of receiving state-appropriated funds or federal "pass-through" monies (i.e., block grant or Medicaid funds). This shift is reflected in the SADAP annual reports of state alcohol and drug abuse agencies: there are six states in which the county or other local government share is 20 percent or more of the total expenditures for treatment of alcohol problems (Butynski et al., 1987~. Another factor in the development of coverage and reimbursement policies is the trend toward combined alcohol and drug treatment programs and state and county authorities. Reflecting both a desire for administrative simplicity and the perception that more and more of the persons being seen in treatment have problems related to both alcohol and other drugs, all but four of the states now have combined alcohol and drug abuse state agencies (NASADAD, 1988~. Some states with combined agencies still have separate funding mechanisms and policies for alcohol problems treatment (e.g., California, Colorado, New York); others have the same mechanisms (an addictions, chemical dependency, or substance abuse orientation as in Connecticut, Minnesota, and Michigan). Still others administer their funds for treatment of alcohol problem as part of a combined alcohol, drug, and mental health funding mechanism (e.g., Virginia's Community Services Boards; Alabama's integrated community services). The diversity in funding policies and organization that exists among the states can be best communicated by describing several of the current state programs. California represents the administrative combination of distinct drug and alcohol programs into a single department within a large human resources agency. The California SAA has adopted a social model in its funding of specialist treatment for alcohol problems. Minnesota and Oregon represent combined alcohol and drug programs which have adopted mixed medical and social model concepts and administrative requirements. The three SAAs are attempting to deal with the issues of improving provider accountability and increasing the availability of appropriate treatment using different mechanisms. Californuz The California SAA, the Alcohol Program Division within the Department of Alcohol and Drug Programs, represents an increasingly common administrative pattern (California Department of Alcohol and Drug Programs, 1988~. The California SAA has an annual budget of approximately $64 million for treatment. Funds are primarily distributed through county agencies that serve as county alcohol authorities _ and purchase specific services from local providers. The state's Alcohol Program Division assists counties in the planning, development, implementation, coordination, and funding of local prevention, treatment, and rehabilitation programs. The state agency identifies statewide objectives and priorities that serve as guidelines to the counties in the preparation of their county alcohol plans. The county plans are then used as the basis for receiving state funding. The continuum of services for treatment of persons with alcohol problems administered by the California State Department of Alcohol and Drug Programs includes three categories of residential programs (detoxification, short term and extended-term residential treatment, and short term and extended-term recovery homes) and three categories of nonresidential services (treatment/recovery, vocational rehabilitation, and

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444 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS appropriate level of care (settirlg) and the appropriate treatment orier~on, and midday for an individual at each stage of Comment. Bringing together researchers, practitioners, funders, and regulators in an expert committee for a systematic review of the various methods currently in use and of the experiences of both payers and providers in applying those methods could lead to the adoption of a common framework and a reduction in the confusing array of criteria systems that now confronts purchasers and providers of services alike. Although additional research is required on the effectiveness of specific treatment matches, the committee believes that there is now sufficient data and experience for the development of a common framework. What has been lacking is a neutral and ongoing forum for such an endeavor. The consensus activity the committee recommends could provide such a forum and could continue on a regular basis (perhaps in the form of an expert committee, as described in Chapter 11) offering an opportunity for researchers, payers, and providers to review and consider matching approaches based on the results of outcome monitoring activities and experimental studies. Such an endeavor could also clarify the conditions under which the medical model and the social model are most appropriate for use. In addition to a surveillance program, there should be expanded support of health services research programs that are current' investigating f Lancing policy issues. There are a renumber of such programs that are funded at a minimal level, with appropriate m~difeations these research programs could provide the necessary data for planners arid polipymakers to use in making decisions regarding the allocation of resources and choices among competing modalities and settings. The following research is needed: studies on the impact of the structure of insurance benefits and of alternate cost-containment strategies on the availability and outcome of treatment for alcohol problems; in-depth studies of the differences among payers in policies and experiences in funding treatment of alcohol problems; in-depth investigations of the variation among the states in the sources of funding available to different types of providers; research on the impact of the availability of insurance benefits on the level of treatment utilization in distinct populations; and effectiveness studies that routinely include the mode of payment and cost data in their data collection and analyses. Currently, the research funded by the federal government on the financing of treatment for alcohol problems is minimal. NIAAA's (1988) recently issued program announcement soliciting investigator-initiated research on economic and socioeconomic issues in prevention, treatment, and epidemiology is a step in the right direction, but as currently structured the program is too small to stimulate sufficient attention and produce the volume of data that is needed. The committee strongly endorses the establishment of visibility and priority for research on financing policy in the appropriate federal agencies. The committee also recommends that NIAAA take the lead in these efforts, just as it has led in the establishment and evolution of financing policy in previous years. Now, however, the agency is positioned to play a key role in the refinement of that policy by sponsoring more rigorous research and a broader program of studies to capture the data required for sound decision making. REFERENCES ~ r--~- Advisory Panel on Financing Mental Health Care. 1973. Financing Mental Health Care in the United States. Rockville, Md.: National Institute on Mental Health Agranoff, R., and L. Robins. 1982. How to make block grants work: An intergovernmental perspective. New England Journal of Human Services 2:3646. Akins, C., and D. Williams. State and local programs on alcoholism. Pp. 325-352 in Prevention, Intervention, and Treatment: Concerns and Models, J. de Luca, ed. Washington, D.C.: U.S. Government Printing Office.

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THE EVOLUTION OF FINANCING POLICY 445 Alcohol and Drug Problems Association Task Force on Treatment Financing. 1983. A Position Paper on Public and Private Insurance Financing of Treatment Services for those Addicted to Alcohol and/or Drugs. Washington, D.C.: Alcohol and Drug Problems Association. Alcohol, Drug Abuse, and Mental Health Advisory Board (ADAMHA). 1987. First Report to Congress. April, 1987. Rockville, Md.: Alcohol, Drug Abuse, and Mental Health Administration. Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). 1984. Alcohol and Drug Abuse and Mental Health Services Data: Report to Congress, January, 1984. Rockville, Md.: Alcohol, Drug Abuse, and Mental Health Administration. Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). 1988. Alcohol and Drug Abuse Treatment and Rehabilitation Block Grant: Report to Congress, May, 1988. Rockville, Md.: Alcohol, Drug Abuse, and Mental Health Administration. Alkire, A. 1987. A research based approach to curbing mandates. Business and Health 3~4):7-9. Allo, C. D., B. Mintzes, J. A. Nischan, and R. A. Brook. 1988. Purchasing Substance Abuse Treatment: Toward a System for Enhancing Positive Outcomes. Lansing, Mich.: Michigan Office of Substance Abuse Services. Altman, L. S. 1989. Preferred provider organization: A historical perspective, legal considerations, and special issues. The ALMACAN 19(3):22-27. American Hospital Association (AHA). 1988. Promoting Health Insurance in the Workplace: State and Local Initiatives to Increase Private Coverage. Chicago: AHA. American Hospital Association (AHA). 1987. Hospital Statistics. Chicago: AHA. Anderson, W. J. 1984. Improvements in the alcohol, drug abuse, and mental health services block grant distribution formula can be made now and in the future (letter report). U. S. General Accounting Office, Washington, D.C., June. Anderson, D. J. 1981. Perspectives on Treatment: The Minnesota Experience. Center City, Minn.: Hazelden Foundation. Annis, H. M. 1987. Effective treatment for drug and alcohol problems: What do we know? Presented at the Annual Meeting of the Institute of Medicine, Washington, D.C., October 21. Annis, H. M. 1986. Is inpatient rehabilitation of the alcoholic cost effective? Con position. Advances in Alcohol and Substance Abuse 5:175-190. Arnett, R. H., and G. R. Trapnell. 1984. Private health insurance: New measures of a complex changing industry. Health Care Financing Review 6(2~:31-42. Becker, F. W., and B. K Sanders. 1984. The Illinois Medicare/Medicaid Alcoholism Services Demonstration: Medicaid Cost Trends and Utilization Patterns. Prepared for the Illinois Department of Alcohol and Substance Abuse. Springfield Ill.: Center for Policy Studies and Program Evaluation, Sangamon State University. Berman, H., and D. Klein. 1977a. Project to Develop a Comprehensive Alcoholism Benefit through Blue Cross: Final Report of Phase I. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Chicago: Blue Cross Association. Berman, H., and D. Klein. 1977b. Project to Develop a Comprehensive Alcoholism Benefit through Blue Cross: Final Report of Phase I. Appendices. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Chicago: Blue Cross Association. Birch and Davis Associates, Inc. 1984. Development of Model Professional Standards for Counselor Credentialing. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. (Reprinted 1986, Dubuque, Iowa: Kendall/Hunt Publishing.) Bilker, T. E. 1985. Health maintenance organizations and prepaid psychiatry. Pp. 119-129 in The New Economics and Psychiatric Care, S. S. Sharfstein and A. Beigel, eds. Washington, D.C.: American Psychiatric Press. Blue Cross of Greater Philadelphia. 1987. Community Data Report: Extending the Influence Beyond the Source. Philadelphia: Blue Cross of Greater Philadelphia.

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446 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Boche, H. L., ed. 1975. Funding of Alcohol and Drug Programs: A Report of the Funding Task Force. Washington, D.C.: Alcohol and Drug Problems Association of North America. Booz-Allen and Hamilton, Inc. 1978. The Alcoholism Funding Study: Evaluations of the Sources of Funds and Barriers to Funding Alcoholism Treatment Programs. Prepared for the U.S. Department of Health Education and Welfare. Washington, D. C.: Booz-Allen and Hamilton, Inc. Borkman, T. 1983. A Social-Experiential Model in Programs for Alcoholism Recovery: A Research Report on A New Treatment Design. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Borkman, T. 1988. Executive summary: Social model recovery programs. Prepared for the Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, May. Brown University Center for Alcohol Studies. 1984. Care for the Chronic Inebriate: Analysis and Recommendations. Prepared for the Rhode Island Department of Mental Health, Retardation, and Hospitals, Division of Substance Abuse. Providence, R.I.: Brown University Center for Alcohol Studies. Bureau of Labor Statistics (BLS). 1989. Prepublished data from the Employee Benefits Survey for the National Institute on Alcohol Abuse and Alcoholism: Health insurance plan counts. Bureau of Labor Statistics, Washington, D.C., January. gurney, G. L. 1987. NLAAA Remembers: Milestones in the History of the Alcoholism Field. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Burton, J. L. 1984. Coverage Policies for Alcohol, Drug Abuse, and Mental Health Care under Major Health Care Financing Programs. Prepared for the ADAMHA Reimbursement Task Force. Rockville, Md.: Alcohol, Drug Abuse, and Mental Health Administration. Butler, P., and C. Littlefield. 1985. Health Care Cost Containment in the Alcohol and Drug Abuse Division. Prepared for the Alcohol and Drug Abuse Division, Colorado Department of Health, Denver, Col., December. Butynski, W. 1982. Status of State Legislation and Research on Health Insurance Coverage for Alcoholism Treatment. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Washington, D.C.: Scientific Management Corporation. Butynski, W. 1986. Private health insurance coverage for alcoholism and drug dependency treatment services: State legislation that mandates benefits or requires insurers to offer such benefits for purchase. NASADAD Alcohol and Drug Abuse Report Special Report: January/February:1-28. Butynski, W., N. Record, P. Bruhn, and D. Canova. 1987. State Resources and Services for Alcohol and Drug Abuse Problems: Fiscal Year 198~An Analysis of State Alcohol and Drug Abuse Profile Data. Prepared for the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. Washington, D.C.: National Association of State Alcohol and Drug Abuse Directors. Butynski, W., and D. Canova. 1988. Alcohol problem resources and services in state supported programs, FY 1987. Public Health Reports 103:611~20. Cahalan, D. 1987. Understanding America's Drinking Problem: How to Combat the Hazards of Alcohol. San Francisco: Jossey-Bass. California Department of Alcohol and Drug Programs (CAPD). 1988. California Alcohol Program State Plan: Fiscal Year 1987-1988. Sacramento: California Department of Alcohol and Drug Programs. Chafetz, M. E. 1976. Alcoholism. Psychiatric Annals 6:107-141. Commission on Accreditation of Rehabilitation Facilities (CARF) 1988. Program Evaluation in Alcoholism and Drug Abuse Treatment Programs. Tucson, Arizona: CARF. Cooper, M. L. 1979. Private Health Insurance Benefits for Alcoholism, Drug Abuse, and Mental Illness. Washington, D.C.: Intergovernmental Health Policy Project, George Washington University. Costello, R. M. 1982. Evaluation of alcoholism treatment programs. Pp. 1197-1210 in Encyclopedic Handbook of Alcoholism, E. M. Pattison and E. Kaufman, eds. New York: Gardner Press.

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THE EVOLUTION OF FINANCING POLICY 447 Costello, R. M., and J. E. Hodde. 1981. Costs of comprehensive alcoholism care for 100 patients over 4 years. Journal of Studies on Alcohol 42:87-93. Creative Socio-Medics Corporation. 1981. An Analysis of Third Party Funding in the Alcoholism Treatment Delivery System in the United States. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Vienna, Va.: Creative Socio-Medics Corp. Davis, K 1987. The organization and financing of alcohol and drug abuse services. Presented at the annual meeting of the Institute of Medicine, Washington, D.C., October 21. DenHartog, G. L. 1982. "A Decade of Detox:" Development of Non-hospital Approaches to Alcohol Detoxification A Review of the Literature. Substance Abuse Monograph Series. Jefferson City, Mo: Division of Alcohol and Drug Abuse. Diesenhaus, H. I. 1982. Current trends in treatment programming for problem drinkers and alcoholics. Pp. 219-90 in Prevention, Intervention, and Treatment: Concerns and Models, J. de Luca, ed. Washington, D.C.: Government Printing Office. Fein, R. 1984. Alcohol in America: The Price We Pay. Newport Beach, Cal.: CareInstitute. Feldstein, P. J., T. M. Wickizer, and R. C. Wheeler. 1988. Private cost containment: the effects of utilization review programs on health care use and expenditures. New England Journal of Medicine 318:1310-1314. Finn, P. 1985. Decriminalization of public drunkenness: Response of the health care system. Journal of Studies on Alcohol 46:7-22. Flavin, D. 1988. Health insurance coverage for alcoholism and other drug dependencies. Testimony presented before the U.S. House of Representatives Committee on Energy and Commerce, Subcommittee on Commerce, Consumer Protection, and Competitiveness hearing regarding insurance coverage of drug and alcohol abuse treatment, National Council on Alcoholism, Washington, D.C., September 8. Ford, M. 1988. Statement presented to the open meeting of the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, Washington, D.C., January 25. Frank, R. G. and J. R. Lave. 1985. The impact of Medicaid design on length of hospital stay and patient transfers. Hospital and Community Psychiatry 36:749-753. Freeborn, D. K Executive summary: Insurance coverage and the treatment of alcoholism. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse. Gibson, R. W. 1988. The influence of external forces on the quality assurance process. Pp. 247-264 in Handbook of Quality Assurance in Mental Health, G. Stricker and ~ Rodriguez, eds. New York: Plenum. Glasscote, R. M., T. F. ~ Plaut, D. W. Hammersley, F. J. O'Neil, M. E. Chafetz, and E. Cumming. 1967. The Treatment of Alcohol Problems: A Study of Programs and Problems. Washington, D.C.: Joint Information Service of the American Psychiatric Association and the National Association of Mental Health. Goldman, H. H. 1986. Financing long term psychiatric care. Business and Health 3(3):5-7. Goldstein, J. M., E. L. Bassuk, S. K Holland, and D. Zimmer. 1988. Identifying catastrophic psychiatric cases: Targeting managed care strategies. Medical Care 26:790-799. Googins, B. 1986. EAPs and cost containment. The ALMACAN 16(11~:18-19. Gordis, E. 1987. Accessible and affordable health care for alcoholism and related problems: Strategy for cost containment. Journal of Studies on Alcohol 48:579-585. Grad, F. P., ~ L. Goldberg and B. A. Shapiro. 1971. Alcoholism and the Law. Dobbs Ferry, N. Y.: Oceana Publications. Graham, G. 1981. Occupational programs and their relation to health insurance coverage for alcoholism. Alcohol Health and Research World 5(4):31-34. Grupenhoff, J. T. 1983. Congressional support for alcohol and substance abuse programs. Advances in Alcohol and Substance Abuse 2:5-13.

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448 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Gualatieri, P. K 1977. State Issues in Drug and Alcohol Abuse: A Sourcebook. Washington, D.C.: Georgetown University Health Policy Center. Gunnersen, U., and M. L. Feldman. 1978. Alcohol and Alcoholism Programs: A Technical Assistance Manual for Health Systems Agencies. San Leandro, Cali: Human Services, Inc.. Hallan, J. B. 1972. Health Insurance Coverage for Alcoholism. Prepared for the National Institute on Alcohol abuse and Alcoholism. Rockville, Md: National Institute on Alcohol abuse and Alcoholism. Harrison, P. A., and N. G. Hoffmann. 1986. Chemical Dependency Inpatients and Outpatients: Intake Characteristics and Treatment Outcome. Prepared for the Chemical Dependency Program Division, Minnesota Department of Human Services. St. Paul, Minn.: St Paul-Ramspy Foundation. Hart, L. 1977. A review of treatment and rehabilitation legislation regarding alcohol abusers and alcoholics in the United States: 1920-1971. International Journal of the Addictions 12:677~78. Harwood, H. J., J. V. Rachal, and E. Cavanaugh. 1985a. Length of stay in treatment for short term hospitals. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Research Triangle Institute, Research Triangle Park, N.C. Harwood, H. J., P. Kristiansen, and J. V. Rachal. 1985b. Social and Economic Costs of Alcohol Abuse and Alcoholism. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Research Triangle Park, N.C.: Research Triangle Institute. Harwood, H. J., D. M. Napolitano, P. L. Kristiansen, and J. J. Collins. 1984. Economic Costs to Society of Alcohol and Drug Abuse and Mental Illness: 1980. Prepared for the Alcohol, Drug Abuse, and Mental Health Administration. Research Triangle Park, N.C.: Research Triangle Institute. Hoffmann, N. G., J. A. Halikas, and D. Mee-Lee, 1987. The Cleveland Admission, Discharge, and Transfer Criteria: Model for Chemical Dependency Treatment Programs. Cleveland, Ohio: The Greater Cleveland Hospital Association. Holden, C. 1987. Alcoholism and the medical cost crunch. Science 235:1132-1133. Holder, H. D., and J. B. Hallan. 1983. Development of Cost Simulation Study of Alcoholism Insurance Benefit Packages. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Holder, H. D., R. Longabaugh, and W. R. Miller. 1988. Cost and effectiveness of alcoholism treatment using best available information. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse. Holder, H. H. 1987. Alcoholism treatment and potential health care cost saving. Medical Care 25:52-71. Holder, H. D., J. O. Those, and M. J. Gasiorowski. 1985. Alcoholism Treatment Impact on Total Health Care Utilization and Costs: A Four Year Longitudinal Analysis of the Federal Employees Health Benefit Program with Aetna Life Insurance Program. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Chapel Hill, N.C.: H-2, Inc. Howell, E. M., M. Rymer, D. K Baugh, M. Ruther, and W. Buczko. 1988. Medicaid tape-to-tape findings: California, New York, and Michigan, 1981. Health Care Financing Review 9(4~:1-29. Hubbard, R. L., and J. Anderson. 1988. Final Report: A Followup Study of Individuals Receiving Alcoholism Treatment. Prepared for the Oregon Office of Alcohol and Drug Programs. Research Triangle Park, N.C.: Research Triangle Institute. Hunter, H. R., and J. C. Rowe. 1982. Alcoholism Services Handbook for Prepaid Group Plans. Washington, D.C.: Group Health Association of America, Inc. Hurst, R. A. 1987. Alternative delivery systems perspective. Presented at the National Association of Addiction Treatment Programs Workshop on Trends and Issues in the Reimbursement of Chemical Dependency Treatment Programs, Houston, Texas, September 15.

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THE EVOLUTION OF FINANCING POLICY 449 Hustead, E., S. Sharfstein, S. Muszynski, J. Brady, and J. Cahill. 1985. Reductions in coverage for mental and nervous illness in the federal employees health benefits program, 1980-1984. American Journal of Psychiatry 142:181-186. ICE, Inc. 1987. Analysis of Treatment for Alcoholism and Chemical Dependency. Irvine, Cal: National Association of Addiction Treatment Providers. Institute of Medicine. 1989. Research Opportunities in the Prevention and Treatment of Alcohol-Related Problems. Washington, D. C.: National Academy Press. Institute for Health and Aging (IHA). 1986. Review and Evaluation of Alcohol, Drug Abuse and Mental Health Services Block Grant Allotment Formulas: Final Report. Prepared for the Alcohol, Drug Abuse, and Mental Health Administration. San Francisco, Cali Jacob, O. 1985. Public and Private Sector Issues on Alcohol and Other Drug Abuse: A Special Report with Recommendations. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Rockville, Md.: Alcohol, Drug Abuse, and Mental Health Administration. Jensen, G. A., and J. R. Gable. 1988. The erosion of purchased health insurance. Inquiry 25:328-343. Jensen, G. A., M. A. Morrisey, and J. W. Marcus. 1988. Cost-sharing and the changing pattern of employee-sponsored benefits. The Milbank Quarterly 65(4) 521-550. Joint Commission on the Accreditation of Hospitals (JCAH). 1974. Accreditation Manual for Alcoholism Programs. Chicago: JCAH. Joint Commission on the Accreditation of Hospitals (JCAH). 1983. Consolidated Standards Manual for Child. Adolescent and Adult Psychiatric, Alcoholism, and Drug Abuse Facilities. Chicago: JCAH. Joint Commission on Mental Illness and Health. 1961. Action for Mental Health. New York: Basic Books. Klerman, G. L. 1989. Treatment of alcoholism. New England Journal of Medicine 320:394-395. Korchok, M. 1988. Managed Care and Chemical Dependency: A Troubled Relationship. Providence, R.I.: Manisses Communications Group, Inc. Kusserow, R. P. 1989. An Assessment of Data Collection for Alcohol, Drug Abuse, and Mental Health Services. Office of the Inspector General, U.S. Department of Health and Human Services, Washington, D.C. Lawrence Johnson and Associates, Inc. 1983. Evaluation of the HCFA Alcoholism Services Demonstration: Final Evaluation Design. Prepared for the Office of Research and Demonstrations, Health Care Financing Administration. Washington, D.C. Lawrence Johnson and Associates, Inc. 1986. Evaluation of the HCFA Alcoholism Services Demonstration: Final Second Analytic Report. Prepared for the Health Care Financing Administration. Washington, D.C. Lebenlutt, E., and R. F. Lebenlutt. 1988. Reimbursement for partial hospitalization: A survey and policy implications. American Journal of Psychiatry 145:1514-1520. Levin, B. L., J. H. Glaser, and R. E. Roberts. 1984. Changing patterns in mental health service coverage within health maintenance organizations. American Journal of Public Health 74:453-458. Lewin/ICF. 1989a. Analysis of State Alcohol and Drug Data Collection Instruments, Volumes I through VI. Prepared for the Office of Finance and Coverage Policy, National Institute in Drug Abuse. Washington D.C. Lewin/ICF. 1989b. Feasibility and Design of a Study of the Delivery and Financing of Drug and Alcohol Services. Prepared for the National Institute on Drug Abuse, Alcohol, Drug Abuse, and Mental Health Administration. Washington, D. C. Lewis, J. S. 1982. The federal role in alcoholism research, treatment and prevention. Pp. 385401 in Alcohol. Science and Society Revisited, E. Gomberg, H. White, and J. Carpenter, eds. Ann Arbor, Mich. and New Brunswick, NJ.: University of Michigan Press and Center of Alcohol Studies, Rutgers University. Lewis, J. S. 1988a. Congressional rites of passage for the rights of alcoholics. Alcohol Health and Research World 12:241-251.

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450 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Lewis, J. S. 1988b. Growth in managed care forcing providers to adjust. Alcoholism Report 16~24):1. Leyland, A. Jr., V. Paukstys, and T. Raichel. Substance Abuse Treatment Benefits: A Guide for Plans. Chicago: Blue Cross and Blue Shield Association, 1983. Lohr, K N., K D. Yordy, and S. O. Thier. 1988. Current issues in the quality of care. Health Affairs 7(1):5-18. Luckey, J. W. 1987. Justifying alcohol treatment on the basis of cost savings: The offset literature. Alcohol Health and Research World 12:8-15. Loft, H. S. 1988. HMOs and the quality of care. Inquiry 25:147-156. Macro Systems, Inc. 1980. Final Report: Federal Activities on Alcohol Abuse and Alcoholism: FY 1978. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Silver Spring, Md.: Macro Systems, Inc. Mahoney, J. J. 1987. EAPs and Medical Cost Containment. The ALMACAN 17(5):16-20. Manning, W. G., and K B. Wells. 1986. Preliminary results of a controlled trial of the effect of a prepaid group practice on the outpatient use of mental health services. Journal of Human Resources 21:293-320 Manov, W. F., and N. N. Beshai. 1986. Alcohol-free living centers: Long term, low cost, alcohol recovery housing. Presented at the 114th Annual Meeting of the American Public Health Association, September 28-October 2. Massachusetts Special Commission Relative to the Admission and Denial of Drug and Alcohol Patients in Hospitals and Other Facilities. 1986. First Interim Report of the Special Commission Relative to the Procedures of Admitting Certain Drug-Alcohol Patients for Detoxification and Rehabilitation by Insurance Companies. Submitted to the Legislature, Commonwealth of Massachusetts under Chapter 2 of the Resolves of 1985. Boston: The Commission. McAuliffe, W. E., P. Breer, N. White, C. Spino., L. Goldsmith, S. Robel, and L. Byam. 1988. ~ Drug Abuse Treatment and Intervention Plan for Rhode Island. Cranston, R.I.: Rhode Island Department of Mental Health, Retardation, and Hospitals. McGuire, T. G., B. Dickey, G. E. Shively, and I. Strumwasser. 1987. Differences in resource use and cost among facilities treating alcohol, drug abuse, and mental disorders: Implications for design of a prospective payment system. American Journal of Psychiatry 144:616-620. Mee-Lee, D. 1988. An instrument for treatment progress and matching: The Recovery Attitude and Treatment Evaluator (RAATE). Journal of Substance Abuse Treatment 5:183-186. Miller, W. R., and R. K Hester. 1986. Inpatient alcoholism treatment: Who benefits? American Psychologist 41:794-805. Minnesota Chemical Dependency Program Division. 1987. Biennial Report to the Governor and the Minnesota Legislature. St. Paul: Minnesota Department of Human Services. Minnesota Chemical Dependency Program Division. 1989a. Directory of Chemical Dependency Programs in Minnesota. St. Paul: Minnesota Department of Human Services. Minnesota Chemical Dependency Program Division. 1989b. Report to the State Legislature on the Status of the Consolidated Chemical Dependency Treatment Fund. St. Paul: Minnesota Department of Human Services. Mintzes, B. 1988. Statement on behalf of the Michigan Office of Substance Abuse Services and the National Association of State Alcohol and Drug Abuse Directors. Presented to the open meeting of the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, Washington, D.C., January 25. Mintzes, B., C. Allo, and R. C. Brook. 1987/1988. Cost containment in the purchasing of substance abuse services. Drugs and Society. 2(2):110-123. Modern Healthcare. 1987. Healthcare marketing. Modern Healthcare 17(7):27. Morrisey, M. A., and G. A. Jensen. 1988. Employer-sponsored insurance coverage for alcoholism and drug-abuse treatments. Journal of Studies on Alcohol. 49: 456-461.

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