Broadening the Base of Treatment for Alcohol Problems (1990) / Chapter Skim
Currently Skimming:
Chapter 18--The evolution of financing policy
Chapter 18--The evolution of financing policy
Pages 406-454
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 406... ...
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.
|
From page 407... ...
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.
|
From page 408... ...
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.
|
From page 409... ...
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.
|
From page 410... ...
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)
|
From page 411... ...
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)
|
From page 412... ...
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)
|
From page 413... ...
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~.
|
From page 414... ...
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~.
|
From page 415... ...
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~.
|
From page 416... ...
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)
|
From page 417... ...
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)
|
From page 418... ...
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.
|
From page 419... ...
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.
|
From page 420... ...
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.
|
From page 421... ...
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.
|
From page 422... ...
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.
|
From page 423... ...
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)
|
From page 424... ...
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)
|
From page 425... ...
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~.
|
From page 426... ...
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~.
|
From page 427... ...
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]
|
From page 428... ...
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~.
|
From page 429... ...
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~.
|
From page 430... ...
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~.
|
From page 431... ...
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.
|
From page 432... ...
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~.
|
From page 433... ...
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.
|
From page 434... ...
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~.
|
From page 435... ...
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)
|
From page 436... ...
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~.
|
From page 437... ...
, 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~.
|
From page 438... ...
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.
|
From page 439... ...
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~.
|
From page 440... ...
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)
|
From page 441... ...
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.
|
From page 442... ...
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.
|
From page 443... ...
(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.
|
From page 444... ...
1982. How to make block grants work: An intergovernmental perspective.
|
From page 445... ...
1984. Private health insurance: New measures of a complex changing industry.
|
From page 446... ...
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.
|
From page 447... ...
1981. Occupational programs and their relation to health insurance coverage for alcoholism.
|
From page 448... ...
1972. Health Insurance Coverage for Alcoholism.
|
From page 449... ...
1988. The erosion of purchased health insurance.
|
From page 450... ...
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
|
From page 451... ...
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.
|
From page 452... ...
1981. The role of federal, state, local, and voluntary sectors in expanding health insurance coverage for alcoholism.
|
From page 453... ...
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.
|
From page 454... ...
1981. Nature and scope of benefit packages in health insurance coverage for alcoholism.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.