Pathways of Addiction Opportunities in Drug Abuse Research (1996) / Chapter Skim
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9. Managed Care
9. Managed Care
Pages 222-249
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From page 222... ...
Due to the proprietary nature of data collected by private managed care organizations and the competitive managed care market, most of the studies conducted to date are from Medicaid or other publicly subsidized programs. Further, research has not addressed concerns about patients being denied treatment or being undertreated; the quality of care being reduced; or the cost of care being shifted to families, public health and welfare agencies, and the criminal justice system (Mechanic et al., 1995)
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From page 223... ...
It also examines the formidable barriers to research and the need to ensure the rapid translation of research results into clinical practice. This chapter uses the term "managed drug abuse care" to refer to the drug abuse component of managed behavioral health care, the branch of managed care that administratively combines the traditionally separate areas of drug abuse and mental health.
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From page 224... ...
Staff model HMOs (those HMOs with salaried staff on-site) have traditionally provided managed behavioral health care through their own staff.
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From page 225... ...
. Despite the diversity of managed behavioral health care models, they share four common elements that derive from broader managed care principles (Shueman and Troy, 1994)
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From page 226... ...
. They also offer a cost-saving alternative for employers who want to retain traditional indemnity medical insurance for employees but feel they cannot afford the expense of unmanaged behavioral health care.
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From page 227... ...
. By the mid-1980s, managed behavioral health care began to take hold, particularly due to employer pressures for cost containment and the availability of venture capital financing for new carve-out providers (Freeman and Trabin, 1994)
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From page 228... ...
Patient placements were dictated by placement criteria that typically were developed internally but were not made available publicly. One important means of referral into managed drug abuse care has been through employee assistance programs (EAPs)
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From page 229... ...
It will be important to monitor the outcome of treatment provided to both public and private clients if these sectors are integrated under managed care. The major stakeholders in managed drug abuse treatment are regulators, payers, managed care organizations, providers, advocates, and clients (Figure 9.1)
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From page 230... ...
These medical centers operate somewhat like HMOs, but without many of the managed care elements described earlier. Until there is a solid body of independent research evaluating managed drug abuse care, both the putative benefits and the risks remain unsubstantiated.
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From page 231... ...
Even less is known about the impact on patient care of financial incentives to curtail costs. Finally, although managed behavioral health care organizations appear to be increasingly willing to publish their patient placement criteria, little is known about whether these criteria are actually adhered to by those responsible for making placements.
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From page 232... ...
TABLE 9.2 Access, Cost, and Utilization Comparisons Between Managed Substance Abuse Treatment and Fee-for 232 Service Treatment Comparison Client Number Cost per Study Groups Types of Clients Access Enrollee Utilization Callahan et Before vs. Public 375,000 5% –48% IP –69% al., 1994 a after OPc –4% MMc 20% Ellis, 1992a Before vs.
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From page 233... ...
For drug abuse treatment, the study found that access -- as measured by the number of patients per 1,000 enrollees -- declined by 43 percent. This dramatic decline was most likely the result of an increase in the average charge per inpatient episode of treatment, leading fewer to seek treatment, rather than to patients' being denied treatment.
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From page 234... ...
Clearly, the paramount finding of the study was the significant decline in drug abuse treatment costs per enrollee. A third study examined the Minnesota Consolidated Chemical Dependency Treatment Fund, which pooled different funding streams for publicly subsidized drug abuse clients who had previously been treated in a patchwork of programs with varying requirements for eligibility and service delivery.
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From page 235... ...
The four studies described in this section allow some tentative conclusions. All of the studies reported lower costs in managed drug abuse care relative to traditional FFS plans.
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From page 236... ...
and private organizations support research on the impact of drug abuse treatment in the managed care setting, including studies on: client access, costs, and utilization; effectiveness and cost-effectiveness of drug abuse treatment under managed care; quality of drug abuse treatment in the managed care setting and its impact on treatment outcomes; development of uni formly accepted patient placement criteria that have predictive va lidity; and denial of treatment, undertreatment, and cost-shifting practices by providers of managed care (including comparisons be tween carve-in and carve-out vendors)
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From page 237... ...
The first evidence of the effectiveness of managed behavioral health care came from the mental health field. The Medical Outcome Study, a large two-year observational study, compared prepaid care with FFS care for a variety of chronic medical illnesses, including depression.7 The depression component of the study, which evaluated treatment outcomes for 617 depressed patients, found no differences in treatment effectiveness between the two payment systems when patients were treated by 7There were no baseline differences in psychological and physical sicknesses between patients in prepaid care and FFS care.
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From page 238... ...
was the least effective modality, whereas 24-hour longterm residential treatment -- a combination of case management techniques and FFS reimbursement -- was the most effective modality. Another study examined the relative effectiveness of managed care and unmanaged care models provided at a single facility for drug abuse treatment, the Castle Medical Center in Hawaii (Renz et al., 1995)
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From page 239... ...
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.
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From page 240... ...
. VA medical centers operate somewhat like HMOs insofar as they have a fixed annual budget, but they do not incorporate many of the other features of managed care presented earlier.
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From page 241... ...
. This telephone survey of 31 managed behavioral health care firms found a broad range of professionals to be responsible for case management.
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From page 242... ...
Accrediting organizations and the managed behavioral health care industry itself are becoming more active in quality assurance. Initiatives are under way by the National Committee on Quality Assurance and by the Joint Commission on Accreditation of Health Care Organizations.
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From page 243... ...
. Drug abuse treatment is associated with lower subsequent medical costs, but there are fewer studies and they often do not separate the impact of alcohol versus illicit drug dependence and treatment.
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From page 244... ...
It is for this reason that most of the studies cited in this chapter are from Medicaid or other publicly subsidized programs. Managed care organizations offering private coverage are reluctant to grant researchers access to their data, given the highly competitive market in which they operate and their concerns about protecting patient confidentiality.
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From page 245... ...
This compromises the ability to carry out large-scale studies. There is some cause for optimism, however, as managed behavioral health care organizations become more receptive to uniform patient placement criteria (SAMHSA, 1995)
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From page 246... ...
Additionally, there is no research on what could potentially be inadequacies in managed drug abuse care: denial of treatment; undertreatment; and cost shifting to other providers, public health and welfare agencies, and the criminal justice system. The committee urges appropriate federal and private agencies to undertake the studies recommended throughout this chapter.
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From page 247... ...
1994. The impact of managed behavioral healthcare on the costs of psychiatric and chemical dependency treatment.
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From page 248... ...
1994. Managed behavioral health programs widespread among insured Ameri cans.
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From page 249... ...
1994. Managed Behavioral Health Care: An Industry Perspective.
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