Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
{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
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 ~. ~
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
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
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
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
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
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
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.
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
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
THE EVOLUTION OF FINANCING POLICY 417 drinking driver). The SAA has no formal relationship with hospital-based programs that provide treatment for alcohol problems nor with any private program that does not receive governmental funds or drinking driver referrals. The SAA estimates that 60 percent of the specialist programs in the state receive its funding (Butynski and Canova, 1988~. Although the services supported by the California SAA vary, their orientation is primarily nonmedical, reflecting the California model of social recovery. The model stresses an alcohol-free environment and participant responsibility for recovery as described in Chapter 3 (S. Blacksher, California Alcohol Program Division, personal communication, December 30, 1987~. Most staff in programs funded by the state and county authorities are nondegreed counselors, and many are recovering individuals. Costs are lower as a result. The state requires all social model providers of direct alcohol services to have medical backup, which is not paid for by the state and federal block grant categorical funding. In addition, all funded programs must be capable of identifying those persons who need medical attention for physical complications or other comorbid conditions (e.g., mental illness, problems with other drugs, or mental retardation) and of referring them to the appropriate resource. Participants in SAA-funded services tend to be persons with chronic severe alcohol problems who have limited financial, health, vocational or social resources and little in the way of spiritual reserves. Therefore, many of the programs incorporate other goals such as getting off welfare, becoming employed, and sustaining independent living in addition to the goal of eliminating alcohol use (Costello, 1982; Borkman, 1983, 1988; Weisner, 1986; Reynolds and Ryan, 1988) (see Chapter 3~. Minnesota The continuum of care supported by the Minnesota SAA as described in Chapter 4 comprises detoxification, assessment, primary treatment, extended care, halfway houses, and aftercare. Community services block grant funds are used to cover certain services and, in contrast to California, hospital programs can also be reimbursed for providing appropriate services (Minnesota Chemical Dependency Program Division, 1987, 1989a). Minnesota is currently unique in its implementation of a consolidated chemical dependency treatment fund, administered by the Chemical Dependency Program Division organizationally housed within the Department of Human Services (Minnesota Chemical Dependency Program Division, 1987, 1989b). Initiated in 1988, amid concern that hospital and residential primary rehabilitation was being overutilized, the fund covers outpatient and inpatient primary treatment, extended care, and halfway houses; it combined $27 million in state appropriations for treatment of alcohol and drug abuse from six sources or funding areas: (1) general assistance, (2) general assistance medical care, (3) medical assistance (Medicaid), (4) regional treatment centers, (5) the alcohol, drug abuse, and mental health block grant, and (6) state categorical appropriations. The funds are allocated to counties based on population, income, and welfare caseload; they are distributed to Indian reservations based on population. A 15 percent county match is required (i.e., the county must provide 15 percent of the total in matching funds). One of the major advantages of the consolidated fund mechanism is that it removes eligibility restrictions on the types of treatment service providers that are eligible for reimbursement (e.g., freestanding residential facilities and halfway houses for Medicaid recipients). In this way, persons who are eligible to receive state public assistance in paying for treatment for alcohol (or other drug) problems can be treated in the most appropriate and economical manner. The county agency administering the mix of state, federal, and local funds assigns individuals to treatment using legislatively defined, uniform placement criteria and an assessment and referral methodology approved by the SAA Oregon States vary not only in the continuum of care they fund but in the mechanisms and criteria they use to monitor contractor performance. Some states have imposed fairly stringent performance contracting requirements on providers (e.g., Oregon,
418 BROADENING THE BASE OF ltREATMENT FOR ALCOHOL PROBLEMS Indiana, Colorado), even when funding is channeled through counties or regional coordinating agencies; others impose minimal contract obligations. The policies developed by the Oregon SAA for a performance contracting reimbursement mechanism are an example of the attempts by the SAAs to develop both process and outcome objectives which can be used to monitor treatment providers' performance (Oregon State Health Planning and Development Agency, 1986; Oregon Office of Health Policy, 1988; J. Kushner, Oregon Office of Alcohol Programs, personal communication, August 1, 1988~. The Oregon SAA has established specific performance criteria for each service element in the continuum of care under its funding authority. The elements are detoxification, CIRT (community intensive residential treatment), residential care, and outpatient treatment, all of which take place in nonhospital settings. Like the California SAA, the Oregon SAA does not fund or monitor hospital-based detoxification or rehabilitation programs. Oregon's three rehabilitation programs warrant some description because they are representative of the nontraditional, Minnesota model-based mixed social and medical model programs now favored by many of the SAAs after almost 20 years of experience. CIRTs provide rehabilitation services to persons who are severely impaired by their alcohol problems and who have typically been unsuccessful in maintaining sobriety after completing less intensive treatment programs. CIRTs resemble the freestanding primary care facilities in Minnesota, Illinois, Colorado, New York, and other states and are based on the original Minnesota model programs described in Chapter 3. Oregon requires the CIRT to meet certain program standards. The CIRT program is designed to last an average of 28 days. The services the providers must offer to qualify for reimbursement include a minimum of 30 hours of structured therapy per week (a minimum of 6 hours a day for 5 days, 14 hours of structured recreational activities over the full 7-day week, and 2.5 hours of alcohol-and-drug specific education per week (Hubbard and Anderson, 1988~. Oregon's alcohol residential treatment (ART) programs are designed to provide 24-hour care within a structured environment that emphasizes group therapy and minimal individual therapy. Other activities to be made available as part of an individualized treatment plan are educational or vocational counseling or training, referral for job placement, consumer living skills training, creative recreational activities, and family counseling. Unlike the CIRT, the state does not specify the hours required for each activity. Although the CIRT and the ART both are rehabilitation programs in terms of the stage model introduced in Chapter 3, the CIRT can be seen as offering only primary care, while the ART is a combination primary care and extended care facility. The ART program represents the professionalized halfway house, in which staff provide both supportive care and treatment for persons who cannot live independently in the community without relapsing (Rubington, 1974~. Oregon's alcohol outpatient treatment Cram (AOPs) Provide assessment and treatment services for persons who are not in need of 24-hour supervision. The target populations for AOPs are described as persons who are less severely impaired by their alcohol problems. The treatment activities offered by these programs are individual, group, and family therapy or counseling and chemotherapy (e.g., Antabuse); the ancillary, or supportive, services offered are educational and vocational training, consumer living skills training, and recreational therapy. The state does not specify a set number of hours for any of the activities. There are four contractor performance criteria applicable to all four service elements: (1) program participants must take part in a self-help group during treatment; (2) participants must be referred to a self-help group at discharge; (3) participants must be referred to another element in the continuum of care upon discharge; and (4) participants must show benefits from treatment as measured by completion of at least two-thirds of a mutually agreed upon treatment plan. Detoxification programs must meet an additional --I- i-------- r--o-~---- ~-----~ r
THE EVOLUTION OF FINANCING POLICY 419 criterion: the individual in treatment cannot be readmitted to the same treatment center within one year. There are five additional program performance criteria applicable to the three rehabilitation elements (CIRT, residential treatment, and outpatient treatment): (1) participants who are not employable at their admission to the program must be employable at discharge; (2) if employed, their employment status must be maintained or improved while they are participating in treatment; (3) their educational status must be maintained or improved while participating in treatment; (4) they must not be arrested during treatment; and (5) they must be abstinent/drug free during the 30 days prior to discharge. The criteria used by the Oregon SAA to judge the performance of funded programs are representative of those used by other states to monitor outcome and determine funding priorities. The criteria incorporate the broad definition of treatment for alcohol problems combining direct and supportive services (see Chapter 3~. There have been no studies, however, of the impact of these performance contracting strategies on the accessibility of treatment services or on outcome. Little is known about the reasons for the differential utilization of resources among the states and whether differences in organization and financing, including the use of performance contracting, play a role in creating this differential. Many SAAs do have in place a treatment outcome monitoring system for program evaluation, although the use made in program planning and funding varies considerably (Lewind(:F, 1988a,b; Kusserow, 1989~. Federal Government Activities The federal government continues to finance treatment for alcohol problems through a variety of mechanisms. It supports agencies that operate their own networks of treatment programs for alcohol problems (e.g., the Veterans Administration, the military services within the Department of Defense, and the Indian Health Service) (see Chapters 4 and 8~. It also supports treatment through agencies that serve as third-party payers: the Health Care Financing Administration (HCFA), the Department of Defense, and the Office of Personnel Management. Agencies that provide block grant funding used to support treatment and ancillary supportive services for persons with for alcohol problems are the Alcohol, Drug Abuse,and Mental Health Administration and the Office of Human Services (i.e., the social services block grant). Operating within statutorily defined parameters, each agency sets its own policy on the type and level of services to be provided (Macro Systems, Inc., 1980; NIAAA, 1984~. Each agency responds to different congressional oversight committees. Since the repeal of the statutory requirement for the existence of the Interagency Committee on Alcohol Abuse and Alcoholism in 1982, there has been no systematic review of the different approaches; nor does there appear to be an ongoing effort within either the congressional or executive branches to coordinate the methods used by the various programs in deciding which treatments are to be supported financially (Grupenhoff, 1983; Cahalan, 1987~. In addition to the block grant funding, which can now be considered a state-determined activity, the three major sources of federal funding for treatment of alcohol problems are Medicare, Medicaid, and the Federal Employees Health Benefits Program. Medicare As discussed in Chapter 8, Medicare is the federally administered health insurance program that covers most elderly Americans, aged 65 and older, and certain disabled individuals under the age of 65, who meet specific criteria or have chronic kidney disease. Under Medicare, treatment for alcohol problems continues to be included in the general category of psychiatric health services rather than being treated as a discrete benefit
420 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS (as desired by the field). Medicare coverage for inpatient care within a psychiatric hospital is limited to 190 lifetime days; there no limit on inpatient psychiatric care within a general hospital. (This limit was originally included in the Medicare benefit design to ensure that only active treatment under a physician's supervision and evaluation, and not "custodial care," would be covered. This restriction reflected a concern that federal funds would be used to supplant state funds for long term care in state mental hospitals.) Coverage is not available for treatment in the newer freestanding residential facilities supported by the majority of SAAs (Noble et al., 1978; Lawrence Johnson and Associates, Inc., 1983, 1986; Saxe et al., 1983~. Coverage for outpatient treatment is similarly limited. The major policy issues confronted by Medicare are cost containment and ensuring the effectiveness of the treatment that is delivered. In 1983 Medicare introduced its new prospective payment system (PPS) as a cost containment measure (Sloan et al., 1988~. (Prior to late 1983, Medicare paid hospitals on a cost-based retrospective basis; that is,
THE EVOLUTION OF FINANCING POLICY 421 hospitals (i.e., hospitals with specialty treatment units and hospitals without such units) for DRGs, lengths of stay, patient characteristics, and other variables. Consistent with other studies, there was a higher percentage of discharges in all four DRGs from hospitals without a specialty unit than from those with a specialty unit (40.1 percent of total discharges versus 18.2 percent, respectively). Organic mental problems" was the predominant discharge diagnosis. Taube and coworkers suggested that the short length of stay found for the majority of the admissions was due to detoxification being the treatment of choice in both unit and nonunit hospitals included in both data bases. Qualifying this conclusion, they noted that the length of stay for DRG 436, alcohol dependence, was three times the usual two- to five-day detoxification period. This finding suggested that some rehabilitation was taking place for persons in this category in both unit and nonunit hospital settings. In 1985 the alcohol-related DRGs were modified to include the distinction between detoxification and rehabilitation as recommended by NIAAA. The exemption for treatment of alcohol and drug problems in hospital settings was ended in 1987 after a joint ADAMHA-HCFA review that generated a second revised set of DRGs more acceptable to both practitioners and payers. Yet concerns are still being voiced (as is the case with DRGs for other physical and psychiatric disorders) that inadequate attention has been paid to variables that contribute significantly to the process of treatment and resource utilization for example, age, physical comorbidities, psychiatric comorbidities, severity of dependence, dependence on multiple substances, and level of social stability or deterioration. The DRGs adopted in 1987 continue to differentiate between detoxification and rehabilitation, although alcohol and drug problems are combined: (1) 433-alcohol/drug abuse or dependence, left against medical advice; (2) 43Lalcohol/drug abuse or dependence, detoxification or other symptomatic treatment with complications or comorbidity; (3) 435-alcohol/drug abuse or dependence, detoxification or other symptomatic treatment without complications or comorbidity; (4) 43~alcohol/drug dependence with rehabilitation; and (5) 437-alcohol/drug dependence with detoxification and rehabilitation. Supporters of prospective payment have predicted that the use of such a system would decrease the average length of stay and the number of admissions to covered settings. There have been no studies published as yet, however, that describe the impact of the shift to prospective payment in regard to the treatment of alcohol problems in covered hospital settings either for detoxification or rehabilitation. Medicaid As previously discussed (see Chapter 8), Medicaid is a jointly financed federal-state entitlement program, the major public insurance mechanism for providing medical assistance to low-income persons in federally supported welfare programs. States can also choose to make Medicaid available to other persons who are not eligible for the federal welfare programs and are unable otherwise to access health care. The states administer Medicaid within broad federal guidelines that establish required and optional services as if it were an insurance program. Each state designs its own unique Medicaid program, and the coverage of treatment for alcohol problems can, and does, vary from state to state (Macro Systems, Inc., 1980; Sharfstein, 1982; Toff, 1984; Howell et al., 1988~. Like Medicare, Medicaid does not have a specific benefit for the treatment of alcohol problems and does not necessarily provide coverage for the educational, vocational, and psychosocial services that are considered by most treatment providers as an essential , part of rehabilitation and relapse prevention, particularly for low-income persons. Medicaid, like Medicare and other health insurance plans, still categorizes the treatment of alcohol problems under the mental disorders rubric. It provides federally mandated coverage for inpatient hospital treatment of alcohol-related diagnoses except in institutions for mental disorders or tuberculosis. (Medicaid does provide coverage for children, adolescents, and young adults under the age of 22 treated as inpatients in psychiatric
422 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS hospitals.) A state can include physician-supervised nonhospital residential services and outpatient care in its package of optional services, and some have done so (Cooper, 1979; Toff, 1984~; however, Medicaid coverage of outpatient treatment for alcohol problems does not appear to be a significant funding resource in most states, although there are exceptions (e.g., New York, in which the state has elected the clinic option to cover eligible individuals being treated in state-aided and state-operated outpatient programs). There have been no recent detailed studies of the benefits currently available among the states for treatment of alcohol problems independent of generic mental health coverage. (The routine reporting of services available state by state does not include this level of description.) In many states, reporting on psychiatric expenditures includes reporting about the treatment of alcohol problems among a limited set of eligible providers. Recent surveys of state practices in funding mental health services, as well as earlier studies specific to the treatment of alcohol problems, suggest that Medicaid reimbursement for the nontraditional forms of treatment supported by SAAs is lacking (Toff, 1984~. Indeed, because Medicaid was originally designed as a decentralized program, there has been little detailed information available at the national level to monitor performance and expenditures (Howell et al., 1988~. He Federal Employees Health Benefits Program The Federal Employees Health Benefits Program (FEHBP), which was established in 1959, offers health insurance to federal government and postal service employees, retirees, and their dependents. FEHBP is the largest employer-sponsored health insurance program in the nation. The Office of Personnel Management (OPM) administers the program and contracts annually with various health plans to provide coverage for different employee groups. Each of these health plan varies in its provisions, covered benefits, and premiums. In 1985, there were about 300 plans participating in the FEHP; the plans collected premiums of approximately $6 billion to cover 10 million enrollees. The cost of the premiums is shared by the federal government and its employees. The government's share of the premiums is anticipated to be approximately $2 billion in fiscal year 1989. (The Office of Personnel Management is also responsible for overseeing the development and operation of appropriate counseling and assistance services for federal civilian employees; however, this employee assistance program is distinct from the F~HP [OPM, 1988~.) In recent years, several of the major plans have cut back on the level of benefits available for treatment for alcohol, drug, and mental problems (Hustead et al., 1985~. The U.S. General Accounting Office (GAO) (1986) compared the Overages offered in 1985 by the F~HBP with that offered by private-sector employers and found that 53 percent of federal employees were covered for alcohol and drug abuse care, whereas 68 percent of private-sector enrollees were covered for alcohol problems treatment and 61 percent were covered for drug abuse treatment. GAO studied the benefits provided in the 18 plans that had a total enrollment more than 20,000 for each of the six years under review and noted that all of the plans covered medical and hospital services for acute care or detoxification; 14 of the 18 had some coverage for rehabilitation. (In 1987, the remaining four plans added the benefit.) GAO did not study the specific coverages offered. In some plans the alcohol problems benefit is distinct; in others it is included in a substance abuse benefit or a mental health benefit. Outpatient care and coverage for treatment by nontraditional social model providers appear to be limited. In general, the level of coverage has declined for all mental health benefits since 1980 and also for coverage of the treatment of alcohol problems. In 1983, at the request of Congress, the Office of Technology Assessment undertook a review of the effectiveness of treatment for alcohol problems specifically to make recommendations about whether to continue support for the system that had evolved (Saxe et al., 1983~. The study found that the research evidence was not conclusive in regard to the effectiveness of specific modalities and could provide little guidance for
THE EVOLUTION OF FINANCING POLICY 423 reimbursement policies. It noted that HCFA and NIAAA were supporting a four year demonstration to test the effectiveness of less costly social model treatment settings (e.g., freestanding inpatient and outpatient facilities, halfway houses) and to assess whether nonmedical personnel could carry out detoxification and rehabilitation effectively (Lawrence Johnson and Associates, Inc., 1983, 1986~. The evaluation of this demonstration was not completed in time for committee review, although preliminary findings do suggest that these facilities and staff can provide equivalent services to those generally offered under the traditional medical model (e.g., Becker and Sanders, 1984; Reutzel et al., 1988~. In fact, the states involved (Michigan, Connecticut, Illinois, Oklahoma, New York, and New Jersey) have attempted to implement the preliminary findings of the demonstration in their treatment policies for alcoholism problems. There are a number of methodological problems with the evaluation, however, and these problems again make it difficult to suggest that Medicare and Medicaid reimbursement policies should be based on its findings. If there are concerns remaining regarding the appropriateness of the mixed medical and social model that has adopted by the states, HCFA and NIAAA should conduct a more adequately designed clinical trial using random assignment. The committee's review of the literature, however, suggests that there is sufficient information regarding the effectiveness of these strategies to propose some general principles for the revision of all benefit structures of federal agencies that fund treatment for alcohol problems (see Chapter 20~. Private Health Insurance Activities It is generally assumed that health insurance coverage makes treatment more accessible to those who need it by lowering the effective price (i.e., the out-of-pocket cost) at the time care is sought (Morissey and Jensen, 1987; American Hospital Association, 1988; Freeborn, 1988~. Private health insurance was originally seen as the major target of efforts to expand coverage for the treatment of alcohol problems to ensure equal access to all who desired such treatment and not just care for the physical consequences of alcohol use (Harlan, 1972; USDHEW, 1978; Regan, 1981; USDHHS, 1981~. Yet early studies of the availability of coverage for the treatment of alcohol problems found that both insurers and providers actively discriminated against persons with alcohol problems through exclusions and limitations (Rosenberg, 1968; Holder and Hallan, 1983~. Initial efforts in the field to overcome resistance to developing a specific nondiscriminatory public and private insurance health benefit for the treatment of alcohol problems focused on obtaining coverage for inpatient hospital treatment of alcohol withdrawal and dependence. These efforts have been fairly successful. Basic coverage now no longer excludes the treatment of alcohol-related physical illnesses and trauma or detoxification in general hospital settings. Rehabilitation, which is defined as the treatment of alcohol abuse and dependence, is most often still an add-on benefit that is included in major medical coverage or as an additional rider with an extra premium cost. Advocates of a specific benefit for treatment for alcohol Problems have used two major strategies to --- ~ O obtain increased private insurance coverage: (1) demonstrations of cost savings through analysis and simulation of claims experience and (2) legislative mandates. NIAAA sponsored the development of model benefit packages and studies on the cost of adding insurance coverage as well as on the health care cost offsets (i.e., savings in other health care expenditures) to be obtained by providing coverage for treatment of alcohol problems (Holder and Hallan, 1983; Holder et al., 1985; Holder, 1987~. The research emphasis has been on demonstrating that the addition of a discrete benefit, even when very liberal, would not lead to a dramatic rise in costs that would lead to a premium increase. (Any premium increases were expected to be offset by the decrease in costs associated with the use of other health services [Holder et al., 1985; Holder, 19873~. An NIAAA-sponsored study
424 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS examined the cost implications of six model insurance benefit plans through simulations of utilization and costs (Holder and Hallan, 1983~. The coverage provided by the six plans ranged from a limit of 14 days of hospitalization only to a combination of up to 30 days of hospital care with up to 30 days of intermediate (transitional) care and up to 45 outpatient sessions. The different models were associated with substantial differences in benefits paid over a f~ve-year period and with sufficient cost offsets to decrease the amount of the monthly premium increase that would be required to add the benefit. The outcomes of these studies and simulations have not been widely accepted, however, because of their design and because of questions about the value of long term offsets to the insurer and employer (Luckey, 1987; IOM, 1989) (see Chapter 19~. A number of studies have found that the largest proportion of direct expenditures for the treatment of alcohol problems is spent on services provided in short-term community general hospitals (Harwood et al., 1985a; Davis, 1987~. Some of the services in community hospitals are provided in specialized units, but the bulk of such services utilize Scatter" beds in hospitals that do not have a designated unit. Treatment activity in general hospitals includes detoxification and rehabilitation, but it still emphasizes treating related health problems and the direct consequences of excessive alcohol use for such illnesses as cancers, and ulcers as well as cirrhosis, pancreatitis, and cardiopathies, and trauma resulting from accidents. Other studies suggest that the primary treatment for alcohol problems that is currently available in community hospitals is still oriented toward detoxification rather than rehabilitation (Harwood et al., 1985a; Blue Cross of Greater Philadelphia, 1987~. Proponents of expanding a discrete benefit for the treatment of alcohol problems interpret the above data on the numbers of persons admitted to hospitals only for detoxification and treatment of alcohol-related physical illnesses as reflecting a continuing failure to recognize the value of such treatment in reducing future health care and social costs (rein, 1984; Davis, 1987~. This practice is seen as related to the current structure of benefit designs, which continue to emphasize acute treatment in inpatient hospital settings (McAullife et al., 1987; Freeborn, 1988; New Jersey Department of Insurance, 1988~. Despite efforts to demonstrate the value of having a specific benefit for the treatment of alcohol problems, there has not been full acceptance by health insurers of the insurability of treatment of alcohol problems. It has been estimated that only a limited number of the persons at risk have private health insurance that also includes coverage of such treatment (rein, 1984; USDHHS, 1986~. Surveys of private health insurance benefit packages reveal that coverage for treatment of alcohol problems varies greatly and is still frequently limited to inpatient medical procedures. Most private insurance and public insurance plans continue to place stringent restrictions and limits on the range of services covered, the providers eligible, and the level of coverage offered for the direct treatment of alcohol problems (the primary rehabilitation and maintenance stages) (Davis, 1987~. Private insurance expenditures continue to appear to be primarily for treatment of related disorders and consequences and for acute intervention and detoxification, although the number of plans which offer a separate benefit for rehabilitation has been greatly expanded (Morissey and Jensen, 1988~. Insurers as a group have not all been opposed to providing insurance benefits for the treatment of alcohol problems. The Kemper Insurance Companies have pioneered providing coverage of treatment for alcohol problems, establishing an employee alcoholism program in 1962 for their own employees (Graham, 1981~. Kemper added coverage to their employee accident and health plan offerings in 1964; the first Blue Cross plans providing coverage appeared in 1969. Yet, as noted by Jensen and Gabel (1988), treatment for alcohol problems is still considered by many private health insurers to be a "fringe service." Although some coverage is provided and is not likely to be dropped totally because of employers' interest,
THE EVOLUTION OF FINANCING POLICY 425 broader coverage is constrained because of concerns over treatment costs and effectiveness. This reluctance of insurers to cover the treatment of alcohol problems at the same level as that for physical illnesses has remained consistent even though the percentage of employers providing some form of coverage has grown from 36 percent in 1981 to 68 percent in 1985 in the medium and large firms covered by the biannual Bureau of Labor (BLS) Statistics Employee Benefits Survey (Morissey and Jensen, 1988~. Preliminary data from the 1988 survey show a continuing increase in plans that offer a specific benefit for alcohol treatment: 86 percent of the plans surveyed provided some form of coverage (Bureau of Labor Statistics, 1989~. A larger proportion of HMO plans (96 percent) versus non-HMO plans (78 percent) included some coverage. The pattern of benefits also differed between HMO and indemnity plans. In addition, HMO plans are more likely to offer coverage for inpatient detoxification and outpatient treatment (more than 90 percent offered such coverage); non-HMO plans, on the other hand, tend to offer these benefits in addition to inpatient rehabilitation, although not in the same proportion-approximately 60 percent (Bureau of Labor Statistics, 1989~. Size is a factor in determining whether a firm will provide a benefit for treating alcohol problems; larger firms tend to offer such a benefit (more than 75 percent of Fortune 500 firms do so) (Davis, 1987~. A major problem with the BLS survey, however, is that it only establishes whether the coverage was in place and not the breadth and depth of that coverage. Studies are needed of the actual coverage that is offered by specific plans and how this coverage varies throughout the country (Morissey and Jensen, 1988~. Given the pattern of interstate variation of such reimbursement to specialist programs as seen in the most recent NDATUS data (see Chapter 8), studies are also needed to determine utilization and costs over a wide range of plans, industries, and geographically dispersed service areas. There have been a number of analyses of the sources of the resistance of third-party payers, whether representing public or private interests, to provide the same level and type of coverage for the treatment of alcohol problems as is provided for physical illnesses (e.g., Boche, 1975; Bu~nski, 1982, 1986; Sieverts, 1983; Fein, 1984; Sharfstein, et al., 1984; Morissey and Jensen, 1988; New Jersey Department of Insurance, 1988~. Proponents of expanded coverage argue that insurers have questioned-and continue to question whether alcohol problems are truly diseases, or rather represent self-inflicted injury and therefore not eligible for coverage. Proponents also contend that insurers remain uncomfortable with the many nontraditional settings and organizational arrangements in which and by which treatment services for alcohol problems are now delivered. The development of freestanding residential facilities and clinics, which have adopted the social model of treatment mixing medical and social support services, have, indeed, created questions and concerns among insurers regarding the appropriateness of health insurance for these services (Booz-Allen and Hamilton, Inc., 1978; Noble et al., 1978; Lawrence Johnson and Associates, Inc., 1983, 1986; Leyland et al., 1983; Sieverts, 1983~. The majority of treatment services outside the traditional hospital facilities and clinic or private practice settings are delivered increasingly by nonphysician case managers and counselors, both with and without physician supervision. As a result, insurers have questioned the professional status of the treatment providers in these settings. Many insurers now provide coverage for rehabilitation and detoxification in such facilities only if they conform to the traditional medical model practices embodied in licensure and accreditation standards. Another source of the resistance of insurers arises from their perception of providers as treatment entrepreneurs. They believe providers create a market for their services by being overinclusive in their definition of who needs treatment and by overtreating those they do identify. The expansion of inpatient services described earlier in the chapter has not necessarily been welcomed, however, and questions are now being
426 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS raised by researchers as well as public and private payer regarding the necessity for inpatient detoxification and rehabilitation and the cost of such services (e.g., Miller and Hester, 1986; Harrison and Hoffmann, 1986; Annis, 1987; Saxe and Goodman, 1988; Yahr, 1988; Klerman, 1989~. Insurers see the model benefit package advocated by treatment providers, with its emphasis on f~xed-length inpatient primary rehabilitation programs as the preferred treatment strategy, as creating demand for unnecessary services. Insurers and employers continue to have concerns about the lack of hard cost data about the cost-effectiveness of contemporary practices. Where once insurers preferred to view Alcoholism as an acute disorder and pay for "short-term" treatment with definite time limits (i.e., 28-day inpatient programs and no-cost aftercare), the cost-effectiveness of this pattern is now being questioned and alternatives are being sought (Walsh and Egdahl, 1984; Hurst, 1987; Lebenluft and Lebenluft, 1988; Shadle and Christiansen, 1988~. In response to insurers' concerns about the lack of quality control and credentialing procedures for treatment facilities, programs, and personnel, efforts were undertaken to develop standards that would be acceptable to them (Gualtieri, 1977; Gunnersen and Feldman, 1978; Birch and Davis, Inc., 1984~. States were encouraged to develop licensing procedures, to be administered either by the SAA or the health facilities regulatory agency. In addition, NIAAA contracted with the Joint Commission on the Accreditation of Hospitals (JCAH) to develop standards acceptable to insurers (JCAH, 1974~. Now known as the Joint Commission on the Accreditation of Health Care Organizations (JCAHO), it accredits approximately 800 specialty residential and outpatient facilities and specialty units in general and psychiatric hospitals (M. McAnnich, JCAHO, personal communication, 1988~. The Commission on Accreditation of Rehabilitation Facilities (CARF) has recently developed accreditation standards that are seen as more compatible with the mixed social and medical model of treatment now offered by the majority of nonhospital programs in both the public and private sectors (CARF, 1988~. The program began in 1986, and CARF now accredits 42 programs. CARF accreditation is recognized by a number of Blue Cross/Blue Shield plans and is accepted by six states as part of their licensure process (J. Schacht, CARF, personal communication, 1988~. Mandated Private Health Insurance The concerns about decreasing the discrimination in the health insurance industry against persons with alcohol problems have led to calls from the field for federal and state legislative mandates requiring insurance carriers to provide coverage for alcohol problems similar to the coverage provided for other diseases (Harlan, 1972; Butynski, 1982, 1986; Holder and Hallan, 1983; Toff, 1984; McAuliffe et al., 1988~. Originally, a joint NIAAA-NCA task force rejected the notion of pushing for mandates, choosing instead to work voluntarily with the insurance industry and employers to implement the model benefit package that they had developed (see the discussion earlier in this chapter) (National Council on Alcoholism Task Force on Health Insurance, 1974~. However, for many in the field, the perception of a lack of progress toward the goal of achieving broader private insurance coverage for alcohol problems led to pressing for mandated coverage at both the state and federal levels with the National Council on Alcoholism assuming a leadership role in 1977 (Seesel, 1988~. Mandates are generally opposed by insurers and employers as adding costs and restricting flexibility in designing a set of benefits tailored to the specific population at risk. Indeed, this ongoing push for mandated coverage from the alcohol treatment community has created a continuing adversarial relationship between the insurers and providers (e.g., Alkire, 1987; Hurst, 1987; New Jersey Department of Insurance, 1988~. As a result, success
THE EVOLUTION OF FINANCING POLICY 427 from the perspective of the field has been achieved only at the state level. Thirty-seven states and the District of Columbia (comprising 85 percent of the nation's population) have now legislatively mandated that private health insurance plans offer some form of coverage for the treatment of alcohol problems. (The number of states is up from the 33 states reported in 1982 [Butynski, 1982] and up from the 19 states having any mandate in 1977 [Booz-Allen and Hamilton, Inc., 19783~. Twenty-five of the 37 states and the District of Columbia have laws in place that mandate the provision of benefits for treatment of alcohol problems; the remaining 12 states have laws that require health insurance companies to offer these treatment benefits for purchase. Mandates vary from state to state: some are very specific and set out a minimum number of days or sessions to be covered or a dollar value to be provided; others simply require that a benefit be offered for sale. The benefit structure elements spelled out in mandates may or may not be related to actual practice (Frank and Lave, 1985~; they may include both requirements and restrictions (e.g., reimbursable days per admission, per year, or per lifetime; modalities covered or excluded; providers, facilities, and personnel eligible to receive reimbursement). In 1981 the National Association of Insurance Commissioners (NAIC) adopted a recommended model act for the coverage of alcohol and drug dependence by group health insurance contracts and policies. The act requires insurers to offer benefits for sale that are not less favorable than those offered for physical illness: dollar limits, treatment duration limits, deductibles, and coinsurance factors are to be the same (NAIC, 1981~. The act also requires insurers to pay for treatment in nonhospital treatment centers if the centers are affiliated with a hospital, licensed by the appropriate governmental agency, or accredited by the JCAHO and there is a treatment plan approved and monitored by a physician. Not included in the act but endorsed nevertheless by the NAIC is a model benefit structure for treatment of alcohol problems that provides for 30 days of inpatient care and 30 outpatient visits. Although the state mandates now in place are seen as an indication of some progress in expanding private insurance coverage, advocates contend that much remains to be done. For one thing, the mandates do not include all third party payers. Medicare and Medicaid are exempted from state mandates, as are employers who are self-insurers under the federal employee retirement act (ERISA) (Shartstein et al., 1984; AHA, 1988; Jensen et al., 1988~. There is concern that, absent mandates, self-insured companies are less likely to provide coverage for treatment of alcohol problems (e.g., New Jersey Department of Insurance, 1988~. Although there is some evidence to support this contention, the presence or absence of a state mandate appears to be less important as a predictor of coverage than are other company characteristics such as the industry, the size of the company, and the makeup of the work force (Morrissey and Jensen, 1988~. In fact, Morrissey and Jensen found that 65 percent of the self-insured companies that participated in the 1985 Bureau of Labor Statistics Survey of Employee Benefits did have some coverage for the treatment of alcohol problems and that coverage grew faster among self-insured employers from 1981 to 1985 than among firms that purchased coverage from insurance carriers. Another difficulty with the state mandates is that they vary widely in their provisions (Butynski, 1986~. Some states cover both group and individual contracts; in other states, only group contracts may be covered. HMOs may or may not be included in the scope of the legislation. The type of treatment setting (hospital, residential and/or outpatient) covered by the mandates varies, as does the type of individual provider (physician, social worker, psychologist, or other professionals). Vermont's mandate now includes certified substance abuse counselors as an eligible individual providers. Statutes also vary in their requirements regarding physician-provided or physician-supervised services. In addition, the mandates may specify benefit minimums or limits, or both, expressed as dollars or units of service. It is commonly accepted that the nature of the coverage
428 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS available shapes the treatment available and used (Cahallan, 1987; Freeborn, 1988; see Chapters 7 and 8~. Although the structure of the mandates vary, most are derived from the model benefit packages developed in the early 1970s. These models did not reflect the continuum of care outlined in the Uniform Act or in the original NCA-NIAAA benefit package but rather the modal treatment approach being implemented at that time: 30 days of inpatient hospital or nonhospital residential detoxification and primary rehabilitation, followed by (minimal) outpatient aftercare. This pattern reflected the spread of the Minnesota model hospital-based programs described in Chapter 3. Typically mandates are structured to promote the treatment form currently seen as necessary for the treatment of all persons with alcohol problems. Thus, earlier mandates emphasized a 30-day stay in a hospital setting; later legislation has added freestanding residential facilities as a lower cost alternative when the facilities are licensed by the state or accredited by the Joint Commission on Accreditation of Hospitals. (CARE is now seeking similar recognition.) This shift to encourage the use of less expensive inpatient detoxification and rehabilitation in nonhospital or freestanding residential facilities is the result of efforts by the SAAs to obtain third-party coverage for persons admitted to the modified medical and social model programs that had been developed (through both federal and state efforts) to implement the continuum of care defined in their state plans (DenHartog, 1982; Diesenhaus, 1982; Saxe et al., 1983; Butynski, 1986~. Private health insurers have also begun to reimburse these facilities (Leyland et al., 1983; McGuire et al., 1986; ICE, Inc., 1987~. Despite these efforts, however, the most recent NDATUS data suggest that the majority of health insurance funds are still expended for inpatient hospital treatment (see Chapter 8~. Initially, in the field of treatment for alcohol problems, insurers were more comfortable with the fed-length primary care program structure that stressed active treatment of a finite duration in hospital settings with familiar operations and quality assurance mechanisms under medical supervision. The feed length of stay program was seen as an important means of developing a reasonable, acceptable model benefit. Insurers preferred to view alcohol dependence as an acute disorder and pay for short-term treatment with definite time limits (i.e., 28-day inpatient programs) rather than accepting the providers' view of dependence: a condition having a high potential for relapse and requiring long-term support and repeated episodes of treatment in some cases. Now, however, concerns about the overutilization of the hospital and increasing distrust of physician practice patterns in all areas of medicine, coupled with controversial evidence on the marginal effectiveness of h~xed-length inpatient programs have led to increased questioning of the need for mandates and for the emphasis on hospital rehabilitation (Walsh and Egdahl, 1984; Alkire, 1987; New Jersey Department of Insurance, 1988~. The primary arguments for and against legislation to require mandatory insurance for the coverage of treatment for alcohol problems have been well reviewed in a 1982 study sponsored by NIAAA (Butynski, 1982~. Mandates are supported by those who believe that health insurers discriminate against the treatment of persons with alcohol problems because of the stigma associated with alcoholism as a self-inflicted condition. Mandates are also supported as a means to provide a broader and more stable financial base for the treatment of alcohol problems (rein, 1984~. They are seen as increasing the accessibility and availability of treatment, especially for employed individuals and their dependents, as promoting resource development by bringing in private-sector providers that offer those services that will be reimbursed (McAuliffe et al., 1988~. Mandates are also supported as a way to cut health care costs over the long run, by decreasing the excessive use of all health care services by persons with chronic, severe alcohol problems. Employers and insurers oppose mandates on the grounds that they need flexibility to purchase a tailored benefit package. They maintain that decisions regarding what is to
THE EVOLUTION OF FINANCING POLICY 429 be covered should be left to the purchasers after evaluating the needs of the persons to be covered and the data on treatment appropriateness. In this way, purchasers are not forced to pay for coverage that they do not want or need or that is not of proven efficacy. Mandates are also opposed on the grounds that they will increase costs and premiums to the extent that benefits for other conditions may be endangered and because of questions about the effectiveness of treatment for alcohol problems and concerns about the mix of services to be provided. Furthermore, current mandated insurance coverage has several structural limitations that may interfere with its ultimate purpose of increasing the availability and accessibility of services. Recent reviews suggest that outpatient benefits tend to be low, and very few states include an intermediate care option. The mandates also tend to be rigid in structure and do not permit trading off between different kinds of benefits as a way to take advantage of alternative treatments and settings. Finally, the typical mandate does not provide for outpatient assessment and diagnostic testing services that are required if placing the individual in the appropriate level of care or setting and matching to the appropriate modalities are to be possible. Recently, McAuliffe and colleagues (1988) conducted a review of the impact of mandated benefits for alcoholism and drug abuse treatment on the availability and utilization of treatment. They concluded that statutory mandates do increase the availability of and access to services for employed persons without adversely affecting the insurance industry. They also concluded that such mandates do not similarly increase access and availability for indigent persons or for persons who have exhausted their private benefits and must therefore be covered by either public insurance (i.e., Medicaid and Medicare) or by state and federal categorical funds. Comparisons of per capita expenditures between those states with mandates and those without suggest that the mandates have played a role in increasing private health insurance expenditures t~utynsx~, HYMN. Median per Capella expenditures for pnvart; insurance were found to be higher in those states that mandated benefits than in those states that only required that they be offered or in those that did not have mandate legislation (Butynski, 1986~. This same pattern is found in the 1987 NDATUS; however, the large interstate variation in all three groups of states makes such an analysis by itself meaningless. There is no way to determine whether the increase in the amount of reimbursement by private health insurance is due to the passage of mandated benefits legislation, to changes in attitudes about the ability to treat alcohol problems successfully, or to the specific industries and companies located in a state (Morrissey and Jensen, 1988~. In addition, Butynski's median analysis does not successfully capture the wide range of variation in per capita expenditures among the states that is found in the most current NDATUS data and described in Chapter 8. More sophisticated studies are required to determine which factors are at work (Morrisey and Jensen, 1987~. Many features of the mandates currently in place in this country are reflected in the recommended model benefit design recently proposed by the National Council on Alcoholism and the Legal Action Center. This design, which is for coverage of both alcohol and drug problems, is based on a survey of the mandated benefit laws in place in states that require coverage be included or offered in all group health plans. The survey revealed that the majority of states (28) mandate coverage in terms of days of treatment per year rather than in terms of dollar limits. The majority of states have also added coverage for treatment in nonhospital freestanding residential facilities (when they are appropriately licensed) to reflect the movement away from hospital services that is favored by the majority of state agencies. The proposed model is based on the median coverage in the states that mandate such coverage in days of active treatment per year. It comprises three elements: (1) inpatient detoxification for up to 7 days per year in a hospital or detoxification facility; (2) inpatient rehabilitation for up to 30 days per year in a hospital or residential facility; and (3) outpatient rehabilitation for up to 60 days per year. The
430 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS benefits are renewable each year. The model has been proposed for inclusion in any federal legislation that sets up minimum standards for health insurance coverage (F-lavin, 1988~. It is designed for the socially stable person with alcohol problems and reflects provider preferences rather than the continuum of care considered necessary for treating heterogeneous subgroups of both socially advantaged and socially disadvantaged persons (see Chapter 3~. McAuliffe and colleagues (1988) studied the effect of mandates on the utilization and cost of treatment for alcohol and drug abuse problems. Following their review, they recommended to the Rhode Island State AlcohoVDrug Authority that it follow the lead of Oregon and play an aggressive role in restructuring its mandated benefit legislation to provide realistic incentives for outpatient and residential treatment and in implementing the legislation through regulation. They recommended using tighter licensing requirements and monitoring of all treatment programs, public and private alike. They also recommended that the state authority actively participate with insurance carriers in efforts to develop utilization review criteria, as was done in Oregon. Oregon has recently adopted mandate legislation that favors outpatient services and that includes provisions for an aggressive utilization review system, including preadmission certification and continuing stay review (Oregon State Health Planning and Development Agency, 1986; Oregon Office of Health Policy, 1988; J. Kushner, Oregon Office of Alcohol Programs, personal communication, August 1, 1988~. The Oregon SAA, the insurance carriers, and the providers are working together to develop and refine the criteria and procedures. Similarly, an ad hoc advisory committee has been exploring the need to revise the 1977 New Jersey law mandating treatment for alcohol problems and recently recommended that any facility that offered only detoxification without an affiliated rehabilitation program or that offered only inpatient rehabilitation without an outpatient equivalent not be eligible to receive reimbursement under the proposed mandate (New Jersey Department of Insurance, 1988~. The committee's report stressed the need to provide the full continuum of care, with three stages identified as detoxification, rehabilitation, and aftercare/relapse prevention. The advisory committee concluded that the structure of the current mandate had unnecessarily increased costs by emphasizing inpatient hospital treatment for all rather than only for those whose clinical status required this level of care. The committee therefore recommended that a revised mandate statute require that rehabilitation be available in all four of the settings discussed in its proposed model benefit (outpatient, day care, residential inpatient, and hospital inpatient). The committee also recommended not licensing facilities that offer only one level of care for rehabilitation; these facilities therefore would not be eligible for reimbursement by third party payers. The ad hoc committee recommended that any inpatient facility, whether hospital or residential, be required to provide day-care and outpatient rehabilitation (primary care) to qualify for licensure and reimbursement by private and public third party payers. Finally, the ad hoc committee also recommended that the revised mandate include provisions for managing treatment in the most appropriate and cost-effective setting. In that regard, it emphasized the need for preadmission and continuing stay authorizations by qualified practitioners experienced in treating alcohol and drug problems. The report indicates that insurance industry and employer representatives on the committee agreed with the need for these provisions but did not agree that the continuation of a mandate was the desired pathway to achieve the objectives of broad and stable coverage in the most cost-effective setting. This report reflected the changes taking place throughout the nation as funders and providers reevaluate current programs in light of continued cost increases (Arnett and Trapnell, 1984~.
THE EVOLUTION OF FINANCING POLICY Changes in Health Care Financing Policy: The Recent Emphasis on Cost Containment 431 In its 1977 study of the feasibility of a comprehensive benefit for the treatment of alcohol problems, the Blue Cross Association stressed the need for concern about the overall environment of rising health care costs: With health care costs in the United States rising about 14 percent a year, third party payors cannot tamper with the structure of their benefits and risk drawing costs still higher unless they know the change will enhance community health within tolerable new costs and/or will generate more efficient use of health resources. (Berman and Klein, 1977b:A2-4) Recent developments in the financing of all health care-an emphasis on cost containment by restricting benefits or changing practice patterns by utilization review, or both; prospective pricing; sharing risk; the encouragement of competition among insurers and providers; and the development of new forms of practice have led to modifications that affect coverage for the treatment for alcohol problems. The growth of HMOs and of managed care arrangements represent modifications in private insurance that illustrate the changing climate in which financing policy is now being determined. Since the early 1980s employers have reacted to increases in insurance premiums with efforts to cut costs: participating in business coalitions that share data in order to bargain for improved rates, shifting to full or partial self-insurance, contracting with managed care administrators who cut down on (inappropriate) utilization through a variety of mechanisms (e.g., concurrent review, case management), increasing employee cost sharing (e.g., increased deductibles, copayments, maximum limits on claims recovery), and excluding payments for procedures whose effectiveness is questionable. Insurers and employers as major purchasers of care are looking for solid answers to questions about which of the treatments available for a particular condition will produce the best results for the least cost (Jensen et al., 1988~. Yet there are few data, especially in the case of treatment for alcohol problems, on which to base such answers. Cost containment has become the dominant theme in the delivery of all health care services. Today, the emphasis is on monitoring the costs of treating patients and on the modification of provider practice patterns to decrease costs by providing fiscal incentives for valued procedures and disincentives for questioned procedures (e.g., Tsai et al., 1988~. In such a climate, the treatment of alcohol problems has become a popular target, with complaints regarding the rise in treatment costs being the most prominent. For example, a large manufacturer was reported to have experienced an 81 percent increase in one year of its benefit costs for mental health and chemical dependence treatment; other firms report similar increases of 10 percent to 40 percent (Walsh and Egdahl, 1984; Rodriguez and Maher, 1986; Hurst, 1987; Muszynski, 1987~. There is continuing uneasiness with the certification of rehabilitation as "medically necessary because the psychosocial and behavioral treatments involved in many current programs do not fit the traditional health insurance definitions of "procedures" (Sieverts, 1983; Wenzel, 1988~. Insurers continue to question whether contemporary treatments can bring about long-term behavioral changes in drinking behavior, and therefore they tend to anticipate unpredictable and uncontrollable costs for repeated rehabilitation episodes (Holder, 1987~. As noted by Goldman (1986) in a discussion of financing long-term psychiatric care, "Financing mechanisms, such as Medicare and most private insurance, favor high skill, medically oriented treatment benefits excluding from coverage maintenance and custodial care services as well as lower intensity treatment alternatives, such as psychosocial rehabilitation." (p. 6) Health insurers typically focus on services offered by traditional
432 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS providers (i.e., hospitals, physicians) and have not become comfortable with the new specialty providers that also treat alcohol withdrawal and excessive alcohol use (e.g., detoxification and rehabilitation in freestanding residential facilities that are not always under physician direction). Those in the field see private and public health insurers as trying to apply acute care treatment models and financing mechanisms to problems which require chronic care or episodic care models and financing strategies. The current troubled relationship between providers of treatment for alcohol problems and representatives of employers and insurers-for example, benefit administrators-stems to a large degree from the benefit administrators' perception that the dramatic increase in the demand for inpatient treatment, whether in a hospital or freestanding residential setting, reflects the providers' marketing efforts rather than the true need for these services. This perception is reenforced by the fact that providers of treatment for alcohol problems have been among the pioneers and leaders in advertising medical services on television and in newspapers; for example, the Television Bureau of Advertising reported that CompCare Corporation, one of the larger firms operating and managing specialty programs, spent $6.3 million on TV advertising in 1985, whereas the Kaiser Health Plans spent just over $1 million and Humana, the fourth largest hospital chain, was reported to have spent $1.5 million (Modern Healthcare, 1987~. In addition, administrators view with a great deal of skepticism any claims by providers regarding the effectiveness of the procedures being marketed (Hurst, 1987; Saxe and Goodman, 1988~. Reflexively, providers (many of whom are themselves recovering persons) believe that the benefit administrators' concerns reflect the stigma borne by persons with alcohol problems who are perceived as untreatable and as undeserving of treatment. Providers see the increase in treatment episodes as merely the expression of a latent need previously ignored by payers who excluded treatment of alcohol problems from their benefit packages; insurers see the increase in treatment episodes as an expression of moral hazard, the tendency to seek treatment because insurance is available to pay for it (T. Doherty, Recovery Centers of America, personal communication, January 21, 1988; Ford, 1988; Shulman, 1988~. The history of efforts to develop a discrete benefit for the treatment of alcohol problems in HMOs can illustrate the effects of such concerns regarding expanded options for treatment and for cost containment. Health Maintenance Organizations HMOs are becoming a significant factor in all health care and an increasingly significant source of funding for treatment of alcohol problems (Shadle and Christianson, 1988~. HMOs are prepaid health insurance plans that use a per capita or Decapitation" approach to provide comprehensive health services to a voluntarily enrolled and defined population (Burton, 1984~. They attempt to combine the delivery and financing of health care services into a single organization. The HMO assumes all or some portion of the financial risk or gain in the delivery of comprehensive care. In contrast to the indemnity or services plan that purchases care from independent providers, HMOs provide health care directly to their subscribers through their own facilities and staff. They may employ their own medical staff (the staff model of organization) or they may contract with a group of practitioners to provide care in the HMO's facilities or in the practitioners' own offices (the individual practice association, or IPA, model). Except under certain conditions (e.g., emergencies, traveling outside the service area, the need for a service the HMO does not offer), treatment provided to enrollees by nonparticipating facilities or practitioners is not covered by the HMO or is covered at a reduced level. HMOs are an alternative to private indemnity health insurance plans which offer a schedule of benefits for the treatment of various illnesses on both an inpatient and
THE EVOLUTION OF FINANCING POLICY 433 outpatient basis. In HMOs, the basic inpatient and outpatient coverages available in private plans are typically included as basic benefits that are generally covered in full; supplemental services are subject to additional controls such as special copayments or limits on volume or frequency. In many instances in which an HMO has not developed a capacity for treating a specific condition (e.g., alcohol problems), it will contract with one or more facilities in the community to provide specified services on direct referral from the person's primary care physician or another HMO employee "gatekeeper" (e.g., a psychologist, social worker, counselor). The payment mechanism is also likely to be a capitation fe~that is, a fixed amount for each enrollee-and the specialty provider is at risk along with the HMO if utilization is greater than anticipated when the fee is negotiated (Korchok, 1988~. Fees are based on estimates of the number of enrollees who will require inpatient care, outpatient treatment, family counseling, and so forth; the fee is calculated by estimating the units of service that will be required for each projected admission (Hunter and Rowe, 1982~. Although prepaid group practices have been in operation for years, interest in HMOs has recently been heightened because of the continuing escalation of health care costs and employer fringe benefit costs (Plotnick et al., 1982; Fein, 1984; Bilker, 1985~. The HMO option was developed as a more cost-eff~cient means of providing medical care, primarily through control of hospitalization rates. Traditionally, HMOs have emphasized outpatient services, utilization review, and conservative practice patterns and have been promoted by both the federal government and by health policy analysts as providing less costly alternatives to conventional indemnity insurance arrangements. It is assumed that there are extra (possibly unnecessary) services performed under the conventional indemnity arrangement in which the fee for each unit of service is paid by a third party (an insurance company; an employer; a federal, state, or local government agency) rather than the patient; the reasons given for the provision of these extra services range from practice patterns based on untested clinical experience, income maximizing on the part of unscrupulous providers, overly cautious practice patterns owing to a fear of malpractice suits, providers' desires to meet patient and family expectations "to do somethingn, and so on. Because HMOs are not paid more for providing these extra services, it is assumed that there is an economic incentive to provide as few services as possible; this position is counterbalanced by an incentive to provide the appropriate number of services which arises from the influence of professional and ethical norms, the threat of malpractice suits, and the threat of loss of patients to competing systems. In past years, HMOs have shown reduced medical care costs, largely because of reduced inpatient use (Manning and Wells, 1986; Lutt, 1988~. The federal government has actively promoted and subsidized the formation of new HMOs since 1973, when legislation was enacted to provide federal grants, loans, and loan guarantees. The legislation also gave HMOs access to the full market for health insurance by requiring certain employers to offer a federally qualified HMO along with any other health insurance. The most well known of the models existing prior to the passage of the federal legislation were the Kaiser Foundation Health Plans, the Group Health Association of Washington, D.C., and the Puget Sound Health Cooperative. HMO membership is distributed unevenly throughout the country with concentrations in such states as Minnesota and California. Most major health insurers, including Blue Cross and Blue Shield, have now introduced their own HMOs as a way to remain competitive and to offer both indemnity and HMO options to employers, associations, and individuals seeking to purchase the best plan for their needs. Although HMOs primarily are seen as serving the private sector, increasing numbers of public sector agencies (e.g., government agencies that purchase HMO coverage for their employees, as well as Medicare and Medicaid) have been testing the feasibility of using private HMOs as the vehicle for treating their beneficiaries (e.g., Temkin-Geser and Clark, 1988~.
434 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS The earlier growth in enrollment, however, has now begun to slow as competition has increased among HMOs and as other forms of health insurance have adopted many of the HMO cost-cutting strategies through such mechanisms as utilization management and preferred provider organizations (in which providers agree to participate at feed rates and to accept more stringent constraints on hospital admissions, expensive procedures, and lengths of stay). To remain competitive, HMOs have had to raise premiums, to cut back on the services they offered, and to institute new controls (Luft, 1988~. IPAs, in which the physician is an independent solo or group practitioner and not an employee, have had the most difficulties in keeping costs down. The federal government's continuing uncertainty over the best means to promote the availability of treatment for alcohol problems can be seen in the debate over whether to include coverage in HMO's as a mandate or as an option; the compromise was to include minimum coverage. From 1973 to 1986, federal legislation, as interpreted by regulation, required only those HMOs that were seeking federal funds or approval for loans to include within their basic benefits provisions for detoxification (either inpatient or outpatient) and for the treatment of alcohol-related medical problems and referral services for alcohol dependence; other benefits for treatment of alcohol dependence (both nonmedical ancillary services such as vocational rehabilitation and counseling as well as rehabilitation in a specialized inpatient or hospital facility) could be offered on an optional or supplemental basis (Hunter and Rowe, 1982~. Only about 60 percent of the new HMOs that were being established sought federal approval and thus came under these requirements; those that did were often encouraged by health insurance analysts to provide only the minimum benefit for alcohol problems, drug abuse and mental disorders that was necessary to remain competitive and in compliance (Sutton, 1981~. Thus the benefits available through HMOs for treating alcohol problems, along with those for treating mental disorders and drug abuse, have tended to be more restricted than the benefits for treating general medical conditions (Burton, 1984), although this situation is now changing. In a 1982 national survey of 205 HMOs in operation for more than one year, treatment for alcohol problems was provided as a limited supplemental benefit by 96 percent of the plans; only detoxification and emergency treatment were covered by almost half the plans offering coverage (Levin et al., 1984~. In a 1985 national survey of 286 HMOs, more than 95 percent of the plans offered at least one benefit package that covered treatment for alcohol problems. All these plans offered a broad range of services and outpatient treatment was stressed. Treatment for alcohol problems constituted 1.2 percent of the reporting HMOs' total costs. The average benefit was 34 days of inpatient treatment and 28 outpatient visits. Approximately 17 percent of those treated received inpatient services (Shadle and Christiansen, 1988~. To encourage HMOs to provide coverage for treatment of alcohol problems, the federal government, through NIAAA, had sponsored a series of studies that many believe are a successful demonstration that HMOs can profit from providing a comprehensive treatment program for alcohol problems as part of their basic benefits (Hunter and Rowe, 1982; Plotnick et al., 1982~. Working with the Group Health Association of America, Inc. (the national HMO organization), NIAAA sponsored studies and developed a handbook for HMOs that wanted to implement a ~realistic" benefit package or treatment component (Hunter and Rowe, 1982~. The package was based on the results from the demonstration of the feasibility of the benefit in five plans that used in-house staff and services; the program is outpatient oriented for both detoxification and rehabilitation, Reemphasizing the utilization of hospital or residential inpatient care in favor of outpatient counseling and follow-up using both alcohol counselors and medical/nursing personnel. Another area that has been stressed in HMO practice is preventative services, routine health checkups, and early case finding. The NIAAA sponsored studies have also
THE EVOLUTION OF FINANCING POLICY 435 demonstrated that routine screening for alcohol problems and early referral to specialty treatment can decrease the utilization of other health services (e.g. Putnam, 1982~. As a relatively new and rapidly growing major segment of the health care system, there is still a relative paucity of data on performance, although a recent case study comparing treatment for alcohol problems in HMOs and through conventional indemnity plan fee-for-service programs suggests that HMOs have cut hospital utilization significantly (Shadle and Christianson, 1988~. The study examined data from Minnesota, one of the states in which HMOs have captured a significant market share and found a differential utilization of hospital days by residents of the Saint Paul-Minneapolis area. Residents enrolled in HMOs used 14 alcohol and other drug abuse inpatient days per 1,000 persons, whereas residents not enrolled in HMOs used 68 inpatient days per 1,000 persons. Preferred Prowder and Managed Care Arrangements Another cost-cutting strategy that has developed in recent years is the preferred provider arrangement, a network of service providers that may be organized in a variety of ways. These networks may be assembled by an insurer to offer services to potential industrial clients at a discounted rate, or they may be assembled directly by a large corporate purchaser. Preferred provider arrangements originally differed from HMOs in that they retained a fee-for-service orientation, offering discounted services and adherence to standards of care, rather than shared risk through capitation. Insurers offered financial incentives to the employees and their families for using members of the preferred provider network; copayments and deductibles were usually lowered when treatment was delivered by a preferred provider. These arrangements have been evolving: groups of providers create their own networks and negotiate with the third party payers for their services and other preferred provider reimbursement methods (e.g., capitation, per case payments) have been introduced. A relatively recent innovation has been the managed care firm, which offers a variety of services that range from serving as an external utilization review agent for an insurer or corporation, to providing case management, to organizing and administering a preferred provider arrangement (Rodriguez and Maher, 1986; Goldstein et al., 1988~. The managed care contractor assumes the responsibility for establishing provider eligibility criteria (that must be met by facilities and practitioners in order to receive referrals of eligible beneficiaries), recruiting participant practitioners and organized programs, and negotiating contracts. Contracts typically include a discounted rate for services, referral policies, and agreement to abide by the firm's standards of performance and its hospital admission and length-of-stay review procedures. Each of the firms has developed its own criteria for admission, length of stay, and treatment procedures (Hoffmann et al., 1987; Weedman, 1987; Goldstein et al., 1988; Korchok, 1988; Tsai et al., 1988~. Managed care plans achieve their cost-cutting objectives by limiting the choices available to patients and providers in charting the course of treatment for a given illness episode. Heretofore, the major limitation imposed by this type of plan has been ,, . curtailment of the use of the most expensive component of treatment: the inpatient hospital stay. Some of the mechanisms used for this purpose have been preadmission screening, continued stay reviews, retrospective claims reviews, discharge planners, and prospective payment systems. Now managed care firms are directing similar attention to an examination and questioning of the appropriateness and cost-effectiveness of specific procedures used in physical medicine (e.g., Rodriguez, 1983, 1984; Lohr et al., 1988; Wennberg, 1988~. Managed care firms in the private sector offer the same types of external control and monitoring services to third party payers (insurance companies, employers) that were
436 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS initially developed by professional standards review organizations for the Medicare program (Rodriguez and Maher, 1986~. The managed care firm usually offers a menu of services, ranging from utilization review, preadmission certification, second opinion programs, and concurrent review to case management and a capitation plan to provide and monitor all inpatient and outpatient treatment. Most managed care firms still include treatment of alcohol problems under their psychiatric program. Recently, a number of companies have been formed which provide only psychiatric managed care; others that had been primarily serving as contract employee assistance program providers now offer specialized substance abuse services. There is considerable debate among employee assistance practitioners about whether they are to become financial case managers or to continue their advocacy of clinically appropriate services for employees in need of treatment (Googins, 1986; Mahoney, 1987~. Such advocacy has often brought employee assistance personnel in conflict with benefit administrators, who view them as in appropriately unconcerned with the overall effect of the cost of the treatment on the costs of health insurance benefits (Walsh and Egdahl, 1984; Tison, 1989~. Managed care firms have gone beyond the quality assurance, peer review and second opinion techniques used by other such entities to introduce "case managements in a form which involves the external reviewer more actively with the primary counselor or physician in the evaluation of the individual's clinical and psychosocial status and treatment needs. More and more, reviewers are active in the formulation of the short- and long-term treatment plans, in the development of a discharge and aftercare plan, and in referrals for additional services. Clinicians and programs have tended to question the experience and training of the case managers as well as the adequacy of the various firms' uniquely developed and applied decision rules about treatment options and lengths of stay (Lewis, 1988b; Shulman, 1988~. Treatment providers see these efforts, which are a prominent feature in the marketing strategies used by managed care firms, as indicative of their emphasis on cost reduction, a less appropriate focus (in the providers' view) than the delivery of adequate, high-quality treatment (Rodriguez and Maher, 1986; Muszynski, 1987; Korchok, 1988; Wenzel, 1988; Altman, 1989~. In the application of managed care to psychiatric services as well as to physical medicine, firms have tended to emphasize outpatient services rather than hospital services; the firms stress that their focus is on obtaining the least intensive level of care that is medically necessary. This principle has led these firms to turn more readily to the lower cost freestanding, medically supervised residential facilities offering detoxification and rehabilitation for persons with alcohol problems and to devise mechanisms for admitting persons to the appropriate Level of cares (i.e., setting). The impact of these recent innovations for the treatment of alcohol problems has not been systematically studied (Shadle and Christianson, 1988~. Much of the information on the impact of these private cost-containment efforts is anecdotal and nonsystematic, although studies are beginning to appear that suggest that costs are being reduced (Feldstein et al., 1988; Goldstein et al., 1988; Tsai et al., 1988~. The concern of providers regarding the actions of case managers in the treatment arena has led them to develop their own mechanisms for treatment management. An example of such a mechanism is a placement system currently being tested, the Cleveland Admission, Discharge, and Transfer Criteria (Hoffmann et al., 1987~. (The appendix to Chapter 11 is a sample of these criteria.) The system was developed under the auspices of an areawide association of treatment providers who sought to provide clear and consistent guidelines for assigning adolescents and adults in need of substance abuse treatment to the appropriate Level of care." The providers were concerned with the lack of a standardized nomenclature and classification for treatment approaches and with the proliferation of idiosyncratic setting and modality definitions (as well as nonempirically supported treatment assignment criteria) being introduced by third party payers: Some third party payers have
THE EVOLUTION OF FINANCING POLICY 437 specific criteria for determining appropriate utilization of services, but because no single uniform set of criteria have been adopted by the insurance industry, treatment providers are confronted by an array of confusing and conflicting treatment placement guidelines (Hoffmann et al., 1987:1~. The criteria the providers developed reflect their review of available programs nationally and of clinically developed assignment criteria currently in use. The criteria make use of empirical work in process to develop an assessment tool, the Recovery Attitude and Treatment Evaluator, that can be used for making placements to the appropriate level and intensity of care at each stage of treatment (Mee-Lee, 1988; White and Mee-Lee, 1988~. From their review, the providers developed six levels of care ranging from mutual self-help to intensive inpatient programs. Placement decisions were to be made using seven common dimensions for evaluating an individuals clinical status: (1) acute alcohol and/or drug intoxication and/or potential withdrawal; (2) physical condition or complications; (3) psychiatric condition or complications; (4) life area impairments (behavioral, social, academic, legal); (5) treatment acceptance or rejection; (6) loss of control and extent of relapse crisis; and (7) nature of the recovery environment (supportive, remedial vs. pathogenic, destructive). The status of an individual on these dimensions is determined either through a 3 to 6 hour assessment (for applicants who are socially and behaviorally stable and compliant) or an inpatient assessment lasting approximately one week (for noncompliant, socially unstable applicants). The six levels of care to which an individual may be assigned are: (1) mutual/self help; (2) low intensity outpatient treatment; (3) intensive outpatient treatment; (4) structured all-day treatment; (5) medically supervised intensive inpatient treatment; and (6) medically managed, intensive inpatient evaluation unit. As is evident in these six levels of care, a major concern for the providers is the organization and setting in which the treatment takes place. The outpatient, intermediate (day care), and inpatient settings are included as potential levels of care for each stage of treatment (see Chapter 3~. The Cleveland criteria are designed to address recent concerns about overreliance on the inpatient setting as a result of the dramatic increase in the number of hospital units and freestanding residential facilities for treating alcohol problems (Saxe et al., 1983; Annis, 1986, 1987; Miller and Hester, 1987; Alto et al., 1988; Mintzes, 1988; Saxe and Goodman, 1988; Yahr, 1988~. Clinicians, however, continue to press for the use of 24-hour care programs with various lengths of stay to remove individuals from pathogenic, nonsupportive environments. What is needed is an empirically tested set of criteria which payers, managed care firms, providers, and clinicians can agree upon. State Agencies Private insurers and managed care firms are not the only bodies seeking to control access to inpatient primary care. The Minnesota, Oregon, and New Jersey SAAs have also prepared initiatives as described in the discussion of mandated benefits earlier in this chapter. Confronted with the same evidence-and lack of evidence-regarding the effectiveness of various treatment modalities, the Michigan SAA has recommended that a common set of guiding principles should be adopted by all Prudent purchasers of cost-effective treatment for alcohol problems (Nischan et al., 1986; Alto et al., 1988; Mintzes, 1988~. Its proposal is an outline of a clinical management system similar to the comprehensive treatment system recommended by the committee in Chapter 13 of this report: I. Every client, where possible, should receive a thorough assessment (using standardized assessment techniques).
438 BROADENING TEIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS II. Program services provided to sustain substance abuse clients should be carefully defined with specific goals against which they should be measured. III. Service planning for each client should be based on that client's goals, resources, diagnosis and prognosis at that time as derived from the thorough assessment of that client. IV. Clients should be impartially assigned to services in response to individual goals, resources, diagnoses and prognoses and the specific capabilities of each particular service. Whenever possible and appropriate, the substance abuse network of care should help clients draw upon resources in other human service organizations. Aftercare, planned and matched with the same care and deliberation as the initial service should be a standard part of treatment planning and assignment. Purchasers of service should give careful attention to outcomes so that programs can be improved based on what is learned from those outcomes (Mintzes et al., 1987/1988:1 12~. The Michigan SAA implements these principles by purchasing a continuum of care that includes assessment and screening services as well as residential detoxification, residential primary rehabilitation, and outpatient counseling services (Nischan et al., 1986; Mintzes, 1988~. The continuum of care described by the SAA is a multidimensional concept that actually comprises a number of continua: (1) the sequential continuum, which begins with assessment and matching and continues through aftercare and follow up; (2) the continuum of range across the kinds of services provided in each step of the sequential continuum; and (3) a continuum of intensity for each kind of service. To construct the necessary outcome monitoring mechanism, the Michigan SAA has contracted with a group of investigators at Michigan State University to develop an integrated client outcome evaluation system. This study, which is currently in process, is the seen as the first step in the development of a statewide client-treatment matching study (Stoffelmayer, 1988~. Both person characteristics and agency characteristics (including treatment ideology) have been incorporated into the evaluation design because of the research findings regarding their importance in predicting outcome. Results from this and several other studies currently in progress (Walsh et al., 1986; T. ~ McClellan, Philadelphia VA Medical Center, personal communication, May 25, 1989) will be useful in developing a common framework that could be used by payers and providers for level of care and treatment modality assignment strategies. Conclusions and Recommendations The past twenty years has seen the development of a national network of over 5,000 specialty programs for the treatment of alcohol problems. These programs have been established in the form of freestanding units and as components of general health, mental health, and social services agencies. This growth from the 300 or so specialty programs identified by the Cooperative Commission in 1967 (Plaut, 1967) has been made possible primarily through the formula and categorical grant programs introduced by the federal government which have been complemented by matching funds from state and local
THE EVOLUTION OF FINANCING POLICY 439 governments. These efforts have been supplemented with those of the state alcoholism authorities which provide categorical funding to serve mainly indigent persons who lack other resources (e.g., public or private health insurance). Some of the progress made in establishing this network of specialty programs is a result of the success that has been achieved in removing the barriers formerly found in coverage for treatment of alcohol problems in private and public health insurance. Yet the field's hopes for a nondiscriminatory policy of financing treatment for alcohol problems have not yet been fully realized. Concerns continue to be expressed that the level of services which is still considered to be inadequate to meet the identified need and that the benefit cutbacks of public and private third-party payers for such treatment. It is difficult to respond to these concerns because there has been no ongoing program to monitor the development of the service delivery system-neither from the standpoint of capacity and utilization nor of financing. As outlined in several earlier chapters, there are insufficient data on the current level of services, on the characteristics of the treatment organizations, and on how these characteristics influence the delivery and outcome of O , ~ treatment; thus, the committee is constrained from agreeing or disagreeing with these concerns. Similarly, there has been insufficient study of the public and private insurance mechanisms by which these services are funded and of the impact of alternative financing and reimbursement strategies on the availability and effectiveness of services. What data exist suggest uneven development of financing for treatment, together with continued uncertainty on the part of all funders about which treatments to support. The recent report to Congress from the Advisory Board to the Alcohol, Drug Abuse, and Mental Health Administration (1987) also identified the lack of adequate information on the cost of treatment services as a serious problem. Without such data, it is not even possible to identify the sources of funds available to groups of potential treatment seekers and providers; it is also impossible to develop estimates of the cost-effectiveness of alternative treatment models, settings, and modalities. The Current Funding Environment In the past, the overall pattern of funding for specialty programs that provide treatment for alcohol problems has varied from that found for all health care settings: for alcohol treatment, state and local governments were the most prominent source of funds, and private and public health insurance did not contribute an equivalent share (Harwood et al., 1984, 1985b; Davis, 1987~. Today, the most recent NDATUS findings suggest that, nationally, the proportion of funds contributed by private insurance varies only slightly from that found for overall health care expenditures (see Chapter 8~. Nevertheless, there is wide interstate variation in the availability of third party funds. In many states, the dominant source of support for the treatment of alcohol problems is state and local categorical funding, which incorporates federal block grants. Nationally, there is still a lower proportion of direct patient payments and federal public insurance funds available for alcohol problems treatment when compared to expenditures for all health services. There has been a steady increase of additional private insurance coverage in selected states but little success overall in obtaining increased public insurance coverage. These differences are not explained by the presence or absence of mandated benefit legislation, and additional research on the effect of mandating benefits is needed. Although the model benefit packages that have been tested have included both inpatient and outpatient services, state mandates have tended to be more oriented toward support for fed-length inpatient rehabilitation programs. Recent efforts aim to develop revised mandates emphasizing outpatient treatment and the matching of persons to the appropriate level of care. These efforts parallel the implementation of cost-containment A
440 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS strategies by all third party payers, whether public or private, and exemplified most strongly by HMOs and managed care firms. As discussed in Chapters 4 and 7, there has been a dramatic increase in the number of specialty, nontraditional community-based treatment facilities for alcohol problems as well as an increase in the availability of treatment in more traditional hospital alcohol detoxification and rehabilitation units. The 1987 NDATUS data (reviewed in Chapter 8), suggest that these hospital-based units are receiving the majority of the available private and public health insurance funding; state and local categorical funds (including the federal alcohol, drug abuse and mental health block grant) are going primarily to residential and outpatient treatment facilities. These differences reflect the variations in the policies adopted by these third party payers: a classical medical model for the public and private insurers and a mixed medical-social model for the state and local funding agencies. Legislation to mandate private health insurance coverage for treatment, which encouraged development of inpatient facilities, also played a role in the development of this pattern of funding. The increase in the availability of specialized treatment for alcohol problems has been marked by the proliferation of uncoordinated, inconsistent, and increasingly complex sets of public and private financing strategies, reimbursement mechanisms. and cost-containment schemes. The committee received materials and heard presentations about the impact of these variations. There appears to be no general agreement about which mechanisms are effective, little consistency among payment sources across states, ownership categories, and settings. There is also a clear lack of well-designed studies to guide policymaking (regarding the structure of benefits) and individual decision making (regarding placement in an appropriate level of care or matching to a cost-effective treatment regimen). The end result is that a coherent financing policy has not emerged, even though this has been one of the major aims of the federal and state agencies charged with the development of the treatment resources. The one note of consistency among all payers has been in the effort to introduce cost-containment mechanisms; the strategies used, however, vary widely and are not yet based on sound empirical tests of the effectiveness of alternative treatments. There is no consensually developed framework for matching persons in need of treatment to a given setting, orientation, stage, or modality. The current situation in paying for the treatment of alcohol problems parallels that of persons whose health care needs are covered by Medicaid: similar people in similar circumstances but in different states have access to different types of care because of the sources of payment and treatment network options available to them. A major issue is whether coverage will be provided in alternative settings which do not adhere to the classical medical model. The limited data available reflect the shift of SAAs away from paying for hospital-based and medically directed services for alcohol problems treatment to the use of social model services that provide for medical involvement and backup. A number of state alcoholism authorities (SAAB) have moved to purchase only nonhospital detoxification and rehabilitation (e.g., Oregon, California) or to require preadmission screening (e.g., Minnesota), whereas the private insurance and public insurance payers, including Medicare and Medicaid, continue to emphasize treatment in hospital settings. Several states (e.g., Minnesota, Oregon, Nevada, Michigan, New Jersey) are actively involved in efforts to persuade all payers to follow their lead in developing cost-containment strategies that would decrease the use of hospital-based units for detoxification and rehabilitation. Taken together, the NDATUS and SADAP findings (see Chapter 8) suggest that state and local categorical funding administered by SAAs appears to have replaced the more traditional sources of public insurance (Medicaid and Medicare) in the majority of states as the primary source of public funds for low-income persons with alcohol problems. At the same time a segment of the private sector, involving both for-profit and -
THE EVOLUTION OF FINANCING POLICY 441 not-for-prohlt hospitals, appear to have been developing more traditional hospital-based programs to serve insured persons and those with sufficient financial resources to pay fees. The data also suggest the continuing lack of adequate reimbursement, by all funding sources, for ambulatory or nonhospital residential detoxification and rehabilitation, a trend that has resulted in a markedly uneven distribution in availability of treatment options across the nation. These interpretations, based on preliminary data from the NDATUS, the few available health services research studies, and a review of the evolution of financing policies, must be considered tentative until the necessary follow-up studies are carried out. There are currently no adequate studies available, for example, on which to base a recommendation that a financing and reimbursement mechanism follow either the medical model of rehabilitation favored by insurance carriers or the social model of recovery favored by some of the state and county alcoholism authorities, or the mixed medical and social model favored by most SAAB. Any such recommendation must await the conduct of well-designed studies that will provide a clearer view of the cost-effectiveness of these models in treating persons with alcohol problems. The Need for Better Data on Funding and the Costs of Treatment As noted in Chapter 8, there is no adequate data base and few reported studies that can be used to establish the total level of expenditures for the treatment of alcohol problems and to describe who is paying for which treatment services. The two major national surveys, the NDATUS and SADAP, do not provide sufficiently detailed information to establish the specific sources of payment available for each stage of treatment and in each of the multiple settings available, either on a national or state-by-state basis. Additional surveys and studies are needed to provide information not on) on who Is paying for the treatment of alcohol problems but also which types of treatment are being covered in which settings. NIAAA's recent request for applications for grants which has been issued to stimulate investigator interest in such surveys is a minimal initial step in the direction of obtaining such data (NMAA, 1988~. It is difficult to answer questions about who pays for treatment and about the financing and reimbursement policies followed by different payers when there has been no regular monitoring program to follow the development of the service delivery system. As outlined in several earlier chapters, there are few data in hand on the level of treatment services available, funding levels and patterns, and the characteristics of provider organizations and how these characteristics influence the delivery and outcome of treatment. Without adequate data on these and other topics, formulating financing policy is an exercise in fantasy. What is required to bring policymaking back to the "reals world is the reestablishment of comprehensive national data collection efforts of relevance to the treatment of alcohol problems. One element of such efforts should be a comprehensive, ongoing description of the treatment delivery system that captures all of its variability and complexity, the characteristics of the individuals being seen, the alcohol problems they bring to treatment, and the costs being expended on their treatment in each component of the system. Rather than constructing a separate data collection system de novo, existing survey mechanisms could be used, provided they could be adapted to obtain alcohol treatment-specific data in the relevant domains. The reintroduction of financial and other policy-oriented questions in the 1987 NDATUS is a limited beginning toward achieving the data collection objectives noted above; however, a client-based data collection system like National Medical Care Expenditures Survey may be more valuable. Other possible vehicles
442 BROADENING IlIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS include the National Hospital Discharge Survey, and the National Nursing Home Survey, all of which are conducted by the National Center for Health Statistics. The Anti-Drug Abuse Act of 1988 (P.L. 100-690, Sec. 2052) named the Department of Health and Human Services as responsible for the annual collection of data to monitor the incidence and prevalence of alcohol problems and provide information on the service delivery system for the treatment of alcohol problems. The funding mechanism it chose for this purpose was a variable percentage of the block grant. However, some SAAs have criticized this use of block grant funding as counter to the block grant's purpose of supporting service delivery. Some have even suggested that the use of such a mechanism places the data collection activity in competition with service delivery in the public sector. Giver' this history, the committee recommends that critical data on the provision and fnar~cin~g of seances for perspires with alcohol problems be obtained through the modification of ex~stir~g service sur~eillar~ce mechanisms or, I ex~sti~zg mechanisms prove inadequate, through the creation of a new mechanism. The ongoing services and financing surveillance programs now being carried out should be expanded. The NDATUS should be supplemented with sample surveys which monitor service delivery in more detail within the specialty alcohol treatment sector and which monitor services in related health care, social services, criminal justice, and educational sectors. These surveys should include both facility censuses (e.g., NDATUS) and discharge and episode surveys modeled after the National Hospital Discharge Survey and the National Nursing Home Survey. There should be ongoing monitoring of the activities in each setting and sector, and intervention as well as treatment activities should be covered. Samples should be drawn from specialty treatment units reporting on the NDATUS as well as from those facilities in nonspecialist sectors in which a significant number of persons with alcohol problems are treated (e.g., general hospitals without designated specialty units, employee assistance programs that offer diagnostic and treatment services, correctional facilities). The samples should be stratified by size, geographic location, and other relevant variables (e.g., treatment stage, ideology, setting, ownership). For a detailed review of financing sources, data should be collected from a sample of facilities (using a client-based system complementary to that for service provision) rather than conducting a census of all facilities. The effort to develop and implement such a comprehensive surveillance system should begin. first. bY convening services researchers, evaluation and management ~ _~ ~ ~ ~ ~ ~ 1 _ Al A ~ A ~ ~ ~ A ~ ~ A ~ h ~ Cal ~ rue t ~ the ~ to He to At m ~ t ~ ~ ~ information system administrators, and ep~aem~o~og~s~s ~o In; End My; pa~a~l~ and its data elements. Representatives of the public and private insurance carriers should also be included, as well as the state and federal government agencies involved in categorical funding. Remand the federal government. through ADAMHA, and working with the SAAs ~ ~ a ~ ~ . ~ ~ ~ through NASADAD, should establish a format for standardized reporting for data on treatment services supported through the alcohol, drug abuse, and mental health block grant funds and appearing on the SADAP. Introducing a requirement for reporting on senr~ces within a standard format will provide accountability for the expenditure of block grant funds that does not now exist. The NDATUS, the block grant application and report of activities, and the SADAP currently do not use the same data elements, which leads to inconsistent findings that are difficult to interpret. In addition, the format should be consistent with that used in the surveys that are part of the national surveillance program. All surveys in the national surveillance programs should use common definitions and ~ .. ~ ~ ~ ~..~1:~ ~ ~t~..1A 1~ ^~11^,--t^A in response categories. ~-urlnermore, data on court o~ Up ~tJU1U I me sufficient detail that the relevant sources can be independently tracked. Another potential source of data is data collection systems of the various states. The data gathered by these systems are not now being aggregated through the existing reporting requirements. There has been some discussion about developing a methodology
ITIE EVOLUTION OF FINANCING POLICY 443 to accept the data from the state's own system and translate the records into a common metric; further exploration of this proposal is needed. Utility would be limited in the same manner that the SADAP is limited (i.e., cover only programs funded by the SAA), so this method would not negate the need for other surveys. The SAAs in conjunction with ADAMHA can gather this data as part of the annual block grant application process and provide some of the data needed for ongoing policy review. As important as discovering the current level of services and the funding that supports them is the need to determine the level of resources that are actually needed--that is, the prevalence of alcohol problems. The states presently employ a variety of methods, as do federal agencies and other third-party payers, to develop need estimates for treatment planning and budgeting. Each payer system has its own methodology for projecting how many beds are needed for detoxification or rehabilitation, how many outpatient slots are needed, and how many personnel are required. State and county alcoholism authorities are also concerned with how many maintenance stage beds must be provided for supportive living for use by persons with chronic, severe alcohol problems (e.g., halfway houses, recovery homes, custodial-domiciliary facilities) (Costello and Hodde, 1981; Brown University Center for Alcohol Studies, 1984; Manov and Beshai, 1986; Reynolds and Ryan, 1988; Wittman and Madden, 1988; New York Division of Alcoholism and Alcohol Abuse, 1989~. These estimates have cost implications that must be considered in developing financing policies-the greater the number of persons needing inpatient detoxification or rehabilitation, or both, the higher the costs; the more persons who are appropriately matched to brief interventions, the lower the costs. Such estimates are critical in developing capitation rates and insurance premiums. What is needed is a common framework to describe prevalence and the number of persons who will need and want treatment during a year. There has been some communication among the states on this issue and backup support available from NIAAA's Alcohol Epidemiology Data System (AEDS). A new effort is needed, however, and thus the committee recommends that a consensus activity be carried out to gain adoption of a common set of prevalence indicators and consequent treatment needs and costs. Currently available state or individual insurer estimates, although useful, cannot now be aggregated to provide a comprehensive national picture because of the incompatibility of definitions and data sets. Bringing the states and other payers together to review the various methods now used for prevalence, resource allocation, utilization, and cost estimation as a first step in developing a common methodology is a much needed endeavor. A consensually developed prevalence, utilization, and cost estimating method would be useful for national evaluations of the adequacy of the level of treatment availability for persons with alcohol problems. Another area in which consensus and commonality is needed is in the development of criteria for assigning individuals in treatment to the appropriate level of care (see Chapter 20~. These efforts have has proceeded on a fragmented basis without guidance from a comprehensive model for describing the treatment delivery system that captures all of the existing variations in orientations and settings in each of the states. Each managed care firm, third-party payer, and provider has developed its own system for justifying or denying admission to a given level of care based on Medical necessity. Each has developed unique criteria by interpreting the literature on treatment effectiveness and cost as best it can. Several of the existing approaches were described earlier in this chapter (e.g., the Cleveland Criteria, the Minnesota consolidated fund, the Oregon SAA approach). Although each approach addresses the same issues, definitions of the various treatment settings differ as do the matching variables. As discussed in Chapters 10 and 11, there are now procedures and variables that can be used to create matches between persons seeking treatment and the appropriate treatment regimens. The committee thus recommends that a consensus activity be conducted to develop a common set of criteria for determining the
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.
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.
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.
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.
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.
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.
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.
THE EVOLUTION OF FINANCING POLICY 451 Morrison, L. 1978. Title XX Handbook for Alcohol, Drug Abuse, and Mental Health Treatment Programs. Prepared for the Alcohol, Drug Abuse, and Mental Health Administration. Washington, D.C.: U.S. Government Printing Office. Muszynski, I. L. 1987. Trends in health care financing and reimbursement of chemical dependency programs. 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. National Association of Addiction Treatment Providers, Inc. 1987. NAATP will oppose DRGs for the fourth time. NAATP News 8~4):1, 6. National Association of Insurance Commissioners (NAIC). 1981. Report of the National Association of Insurance Commissioners' Task Force on Alcoholism, Drug Addiction, and Insurance. Washington, D.C.: NAIC. National Association State Alcohol and Drug Abuse Program Directors (NASADAD). 1988. Summary of Alcohol and Drug Agency Locations Within the State Systems. Washington, D.C.: NASADAD. National Council on Alcoholism Task Force on Health Insurance. 1974. Recommendations for Health Insurance Coverage for Alcoholism (memorandum). National Council on Alcoholism, Washington, D.C., January. National Council on Alcoholism (NCA). 1987. A Federal Response to a Hidden Epidemic: Alcohol and Other Drug Problems Among Women. New York: National Council on Alcoholism. National Institute on Alcohol Abuse and Alcoholism (NIAAA). 1984. Report to the U.S. Congress on Federal Activities on Alcohol Abuse and Alcoholism: FY 1981 and FY 1982. Rockville, Md.: NLAAA National Institute on Alcohol Abuse and Alcoholism (NIAAA). 1988. Program Announcement: Research on Economic and Socioeconomic Issues in the Prevention, Treatment, and Epidemiology of Alcohol Abuse and Alcoholism. Rockville, Md.: NIAAA. National Institute on Drug Abuse/National Institute on Alcohol Abuse and Alcoholism (NIDAINIAAA). 1989. Highlights from the 1987 National Drug and Alcoholism Treatment Unit Survey (NDATUS). Rockville, Md.: NIDAINLAAA. Neiberding, S. 1983. The evolution of the National Institute on Alcohol Abuse and Alcoholism. Advances in Alcohol and Substance Abuse 2:15-21. New Jersey Department of Insurance. 1988. Report of Governor's Cabinet Working Group's Ad Hoc Advisoty Committee on Funding Sources for Treatment for Alcoholism and Drug Abuse. Trenton, NJ.: New Jersey Department of Insurance. New York State Interagency Task Force on Insurance. 1988. Mandating Health Insurance Coverage of Inpatient Treatment of Alcoholism and Substance Abuse: A Report to the Legislature as Required by Chapter 444 of the Laws of 1987. Albany, N.Y.: New York State Interagency Task Force on Insurance. New York Division of Alcoholism and Alcohol Abuse (NYDAAA) 1989. Five Year Comprehensive Plan for Alcoholism Services in New York State: 1989-1994. Albany, N.Y.: NYDAAA. Nischan, J. A., C. D. Allo, and R. C. Brook. 1986. Continued evolution in the substance abuse services network of care. Michigan Office of Substance Abuse Services, Lansing, Mich., February. Noble, J. A., P. Widem, H. Malin, and J. R. Coakley. 1978. Medicare Coverage for the Treatment of Alcoholism: Excerpts from DHEW's 1978 Report to Congress on the Advantages and Disadvantages of Extending Medicare Coverage to Mental Health, Alcohol, and Drug Abuse Centers. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Off~ce of Personnel Management (OPM). 1988. Report on Title V of Public Law 99-570: The Federal Employee Substance Abuse Education and Treatment Act of 1986. Washington, D.C.: Office of Personnel Management. Oregon State Health Planning and Development Agency. 1986. Second Report on Oregon's Experience with Remodeling Insurance Benefits for Mental Health and Chemical Dependency. Report to the 64th Oregon Legislative Assembly on Implementation of Chapter 601, Oregon Laws, 1983. Salem, Oregon: Oregon State Health Planning and Development Agency.
452 BROADENING ME BASE OF TREATMENT FOR ALCOHOL PROBLEMS Oregon Office of Health Policy. 1988. Model admission and continued stay criteria for chemical dependency treatment of adults (memorandum). Department of Human Resources, Salem, Oregon, June. Plaut, T. F. A., ed. 1967. Alcohol Problems: A Report to the Nation. New York: Oxford University Press. Plotnick, D. E., K M. Adams, H. R. Hunter, and J. C. Rowe. 1982. Alcoholism Treatment Programs within Prepaid Group Practices: A Final Report. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. President's Commission on Law Enforcement and Administration of Justice. 1967a. The Challenge of Crime in a Free Society. Washington, D.C.: U.S. Government Printing Office. President's Commission on Law Enforcement and Administration of Justice. 1967b. The Challenge of Crime in a Free Society, Task Force Report: Drunkenness. Washington, D.C.: U.S. Government Printing Office. President's Commission on Mental Health Task Panel on Alcohol Related Problems. 1978. Report of the Liaison Panel on Alcohol Related Problems. Pp. 2078-2092 in Appendix: Task Panel Reports. Vol. 4 of the Report to the President from the President's Commission On Mental Health, Washington, D. C.: U.S. Government Printing Office. Public Health Foundation. 1988. Public Health Agencies 1988: An Inventory of Programs and Block Grant Expenditures. Washington D. C.: Public Health Foundation. Putnam, S. 1982. Short-term effects of treating alcoholics for alcoholism: Utilization of medical care services in a health maintenance organization. Group Health Journal 3~1~:19-30. Regan, R. 1981. The role of federal, state, local, and voluntary sectors in expanding health insurance coverage for alcoholism. Alcohol Health and Research World 5~4):22-26. Reutzel, T. J., F. W. Becker, and B. K Sanders. 1988. Expenditure effects of changes in Medicaid benefit coverage: An alcohol and substance abuse example. American Journal of Public Health 77:503-504. Reynolds, R. I., and B. E. Ryan. 1988. Executive summary: Policy implications of social model alcohol recovery services. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, July. Robertson, A. D. 1988. Federal and state support for alcohol and drug abuse services. Testimony on behalf of the National Association of State Alcohol and Drug Abuse Directors. Presented to the U.S. Senate Committee on Governmental Affairs hearing regarding overview of federal activities on alcohol abuse and alcoholism, National Association of State Alcohol and Drug Abuse Directors, Washington, D.C., May 25. Rodriguez, A. R. 1983. Psychological and psychiatric peer review at CHAMPUS. American Psychologist 38:941-947. Rodriguez, A. R., and J. J. Maher. 1986. Psychiatric case management offers cost, quality control. Business and Health 3~5~:14-17. Rodriguez, A. R. 1984. Peer review program sets trends in claims processing. Business and Health 1~10~:21-25. Roman, P. 19~. Growth and transformation in workplace alcoholism programming. Pp.131-158 in Recent Developments in Alcoholism, vol. 6, M. Galanter, ed. New York: Plenum Press. Rosenberg, N. 1968. Survey of Health Insurance for Alcoholism. Prepared for the National Center for Prevention and Control of Alcoholism. Bethesda, Md.: National Institute of Mental Health. Rubington, E.. 1974. The role of the halfway house in the rehabilitation of alcoholics. Pp. 351-383 in Treatment and Rehabilitation of the Chronic Alcoholic. Vol. 5 of The Biology of Alcoholism, B. Kissin and H. Begleiter, eds. New York: Plenum Press. Saxe, L., D. Dougherty, K Esty, and M. Fine. 1983. The Effectiveness and Costs of Alcoholism Treatment. Washington, D.C.: U.S. Congress, Office of Technology Assessment. Saxe, L., and L. Goodman. 1988. The effectiveness of outpatient vs. inpatient treatment: Updating the OTA report. Center for Applied Social Science, Boston University, Boston, Mass., June.
TEIE EVOLUTION OF FINANCING POLI(::Y 453 Seesel, T. 1988. Statement presented on behalf of the National Council on Alcoholism 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. Shadle, M., and J. B. Christianson. 1988. The Organization and Delivery of Mental Health, Alcohol, and Other Drug Abuse Services within Health Maintenance Organizations. Final Report. Prepared for the Alcohol, Drug Abuse, and Mental Health Administration. Minneapolis: Interstudy. Sharfstein, S. S. 1982. Medicaid cutbacks and block grants: Crisis or opportunity for community mental health? American Journal of Psychiatry 139:466470. Sharfstein, S. S., S. Muszynski, and G. M. Arnett. 1984. Dispelling myths about mental health benefits. Business and Health 1(10):7-11. Shulman, J. 1988. Statement presented on behalf of the National Association of Addiction Treatment Providers to the open meeting of the IOM Committee for the Study of Treatment and Rehabilitation of Alcoholism and Alcohol Abuse, Washington, D. C., January 25. Sieverts, S. 1983. Third party reimbursement for alcoholism services. Bulletin of the New York Academy of Sciences 59(2)211-215. Sloan, F. A., M. A. Morrisey, and J. Valona. 1988. Effects of the Medicare prospective payment system on hospital cost containment: An early appraisal. The Milbank Quarterly 66(2):191-220. Stoffelmayer, B. 1988. The treatment environment lessons from the field. 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. Sutton, H. L. 1981. Estimating the costs of alcoholism treatment services in HMO programs. Presented to the Conference on Financing of Alcoholism Services in HMOs, Washington, D.C., June. Taube, C. A., H. H. Goldman, and E. S. Lee. 1988. Use of specialty psychiatric settings in constructing DRGs. Archives of General Psychiatry 45:1037-1040 Taube, C. A., J. W. Thompson, B. J. Burns, P. Widem, and C. Prevost. 1985. Prospective payment and psychiatric discharges from general hospitals with and without psychiatric units. Hospital and Community Psychiatry 36:754-760. Temkin-Geser, H., and K T. Clark. 1988. Ethnicity, gender, and utilization of mental health services in a medicaid population. Social Sciences in Medicine 26:989-996. Tison, T. 1989. Defining the relationship between EAPs and benefit departments. The ALMACAN 19(4):19-25. Toff, G. E. 1984. Mental Health Benefits under Medicaid: A Survey of the States. Washington, D.C.: Intergovernmental Health Project, George Washington University. Toff, G. E. 1984. States concerned about cost, impact of mandated mental health benefits. Business and Health 1(10):50-51. Tsai, S. P., S. M. Reedy, E. J. Bernacki, and E. S. Lee. 1988. Effect of curtailed insurance benefits on the use of mental health care: The Tenneco Plan. Medical Care 26:430~40. U.S. Department of Health and Human Services (USDHHS). 1981. Fourth Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute--on Alcohol Abuse and Alcoholism. U.S. Department of Health and Human Senrices (USDHHS). 1987. Sixth Special Report to the U.S. Congress on Alcohol and Health. Rockville, D.C.: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health and Human Se~vices (USDHHS). 1986. Toward a National Plan to Combat Alcohol Abuse and Alcoholism. Report submitted to the United States Congress. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health, Education, and Welfare (USDHEW). 1971. First Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism.
454 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS U.S. Department of Health, Education, and Welfare (USDHEW). 1974. Second Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health, Education, and Welfare (USDHEW). 1978. Third Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. U.S. General Accounting Office (USGAO). 1977. Progress in Treating Alcohol Abusers. Washington, D.C.: USGAO. U.S. General Accounting Office (USGAO). 1982. A Summary and Comparison of the Legislative Provisions of the Block Grants Created by the 1981 Omnibus Reconciliation Budget Reconciliation Act. Washington, D.C.: USGAO. U.S. General Accounting Office (USGAO). 1984. States Have Made Few Changes in Implementing the Alcohol, Drug Abuse, and Mental Health Services Block Grant. Washington, D.C.: USGAO. U.S. General Accounting Office (USGAO). 1985. Block Grants: Overview of Experiences to Date and Emerging Issues. Washington, D.C.: USGAO. U.S. General Accounting Office (USGAO). 1986. Health Insurance: Comparison of Coverage for Federal and Private Sector Employees. Washington, D.C.: USGAO. U.S. General Accounting Office (USGAO). 1987a. Block Grants: Federal Set-Asides for Substance Abuse and Mental Health Services. Rockville, Md.: USGAO. U.S. General Accounting Office (USGAO). 1987b. Block Grants: Proposed Formulas for Substance Abuse, Mental Health Provide More Equity. Washington, D.C.: USGAO. Wallace, C. 1987. Employers turning to managed care to control their psychiatric care costs. Modern Healthcare 9(7) 82. Walsh, D. C., and R. H. Egdahl. 1984. Treatment for chemical dependency and mental illness: Can this utilization be managed? Health Affairs 3(3):130-135. Walsh, D. C., R. W. Hingson, and D. M. Merrigan. 1986. A randomized trial comparing inpatient and outpatient alcoholism treatments in industry A first report. Presented at the Annual Meeting of the Alcohol Epidemiology Section of the International Council on Alcohol and Addictions, Dubrovnik, Yugoslavia, June 9-13. Weedman, R. D. 1987. Admission, Continued Stay, and Discharge Criteria for Alcoholism and Drug Dependence Treatment Services. Irvine, Calif.: National Association of Addiction Treatment Providers. Weisman, M. N. 1988. Musings on the art of treatment. Alcohol Health and Research World 12:282-87. Weisner, C., and R. Room. 1984. Financing and ideology in alcohol treatment. Social Problems 32:167-184. Weisner, C. 1986. The social ecology of alcohol treatment in the United States. Pp. 203-243 in Recent Developments in Alcoholism, vol. 5, M. Galanter, ed. New York: Plenum Press. Wennberg, J. E. 1988. The medical care outcome problem. Health Affairs 7~10~:5-18. Wenzel, L. 1988. Mental health options under HMOs. Business and Health 5(4~:30-33. White, W. T., and D. Mee-Lee. 1988. Substance use disorder and college students: Inpatient treatment issuer model of practice. Journal of College Student Psychotherapy 2(3/4):177-203. Williams, W. G. 1981. Nature and scope of benefit packages in health insurance coverage for alcoholism. Alcohol Health and Research World 5~4~:5-11. Wittman, F. D., and P. A. Madden. 1988. Alcohol Recovery Programs for Homeless People: A Survey of Current Programs in the U.S. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Yahr, H. T. 1988. A national comparison of public- and private-sector alcoholism treatment delivery system characteristics. Journal of Studies on Alcohol 49:233-239.
