treatment converted into weighted hours by a special formula), significant differences among the four groups emerged. The state-funded group had the shortest length of stay, followed by the intensive managed care group and then the traditional managed care group. This suggested to the authors that the state-funded and intensive managed care patients could be treated at lower cost than the traditional managed care patients without compromising treatment effectiveness, although they noted that other outcome measures should be studied besides recidivism.

One of the greatest problems in using client records is the lack of measures of treatment effectiveness. Relapse is a common measure used in research because it is one of the few objective outcome measures for which data are readily available. The Addiction Severity Index, which is one of the most comprehensive and commonly used research instruments for measuring effectiveness, takes about 45-60 minutes to administer at baseline and about 20 minutes at follow-up. It requires administration by a trained technician. Due to the length of time and cost, this type of research instrument would not be feasible in routine clinical use for a variety of reasons. One new outcome instrument, which is being developed to assess the effectiveness of alcoholism treatment, requires only 5 minutes for the average clinician to complete and 20 minutes for the average patient (Rost et al., 1996). There is a critical need for similar, easy to-administer instruments that measure the effectiveness of drug abuse treatment in clinical settings.

One outcome study that did use the Addiction Severity Index, but has not yet been published, compared the effectiveness of FFS drug abuse treatment with that of HMOs. In 1991, when the study began, 75 percent of the study population—Philadelphia Medicaid patients treated by 11 separate programs-were FFS patients; by 1995, 70 percent were treated by HMOs. Each year randomly selected samples of patients were followed through treatment and for six months postdischarge. Since the dramatic shift to managed care was not foreseen at the start of this study, comparisons between FFS and HMO treatment were considered to be inadvertent findings. Patients treated in 1995 received fewer services and experienced worse outcomes relative to those treated in the first year of the study, which suggests superior treatment under FFS (T. McLellan, University of Pennsylvania, personal communication, 1996).

Cost-Effectiveness

The cost-effectiveness outcome measure provides an economic evaluation by comparing alternative treatments to determine which produces a desired outcome for the lowest cost (Center of Alcohol Studies, 1993). There have been only two studies of cost-effectiveness of managed drug



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