Broadening the Base of Treatment for Alcohol Problems (1990) / Chapter Skim
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Chapter 20--Paying for the treatment system
Chapter 20--Paying for the treatment system
Pages 464-484
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From page 464... ...
In some states, the state passes the funds through to the county to distribute with minimum restrictions; an example is the California Division of Alcohol Programs, which provides a formula allocation of state, county, and federal funds to purchase nonhospital detoxification, residential recovery services, and nonresidential recovery services using a social model to define eligible providers and services. In other states, the block grant is passed through to counties with a very strict legislatively defined method for level of care placement; an example is the Minnesota Chemical Dependency Program Division, which provides a formula allocation to counties to purchase both hospital and nonhospital services for eligible beneficiaries meeting stringent income guidelines.
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From page 465... ...
In that system (as discussed in Chapter 13) access to the appropriate orientation, setting, and modality at each stage would be controlled through assessment, matching, outcome monitoring, and continuity assurance activities.
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From page 466... ...
Criteria for Evaluating Coverage Appropriateness Insurance appropriately covers the cost of uncertain medical care expenses. In an ideal world, the best insurance coverage would be coverage that paid only for appropriate care and nothing else.
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From page 467... ...
These issues are considered in the following discussion of the three broad coverage strategies noted earlier in this chapter. Optimal Conventional Coverage We begin by using these principles to define what might be desirable coverage of the conventional sort, coverage without extensive case management that pays market prices for medical services.
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From page 468... ...
Thus, with regard to the current' available system of identification and treatment, the committee recommends that public and private insurance should provide coverage for the following: (a) assessment, reassessment, and continuity assurance to facilitate matching to the appropriate level and intensity of treatment at each stage; (by brief interventions for alcohol problems, if coverage is needed to facilitate the use of the service; (c)
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From page 469... ...
That such a distribution of alternative treatment is currently not available can be inferred from the uneven distribution of the "types of cares reported in the 1987 NDATUS and described in Chapter 7. The committee anticipates that the availability of such alternatives as brief intervention in community settings, day care programs, residential programs, and intensive primary rehabilitation outpatient programs will result in a significant redistribution of resource utilization.
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From page 470... ...
In each county, assessors use uniform guidelines established by the state's Chemical Dependency Program Division to determine the level of care placement for persons who meet the financial eligibility requirements for coverage (Minnesota Chemical Dependency Program Division, 1987, 1989; Minnesota Department of Human Services, 1987~. Criteria have been developed for placement in either outpatient care, primary residential care in a freestanding facility or in a hospital setting, or extended care in a residential facility or a halfway house.
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From page 471... ...
O Chemically Dependent PLUS C: Now in Outpt or was in Detox, Primary, Extended PLUS THREE OR MORE O Unable to Abstain O Lacks Family Support O Lost Voc/Educ Due to CD 3 Lacks Helpful Social Network O Documented Mental Disorder Under Control O * Exception FIGURE 20-1 Minnesota Chemical Dependence, Program Division Level of Care Placement Form.
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From page 472... ...
Detoxification should be carried out in a medical or psychiatric inpatient hospital setting if, and only if, one or more of the following concomitant health conditions is present: 1. withdrawal symptoms that require close medical monitoring and continuous nursing care; severe comorbid medical conditions; or severe comorbid mental illness.
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From page 473... ...
severe comorbid medical conditions. 473 Although the Minnesota consolidated fund criteria allow for exceptions and some committee members endorsed the continuing use of clinical judgement, other committee members felt that allowing providers to waive coverage restrictions could, in select circumstances, lead to excessive use of the inpatient option.
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From page 474... ...
Encouragement, Subsidization, or Mar~dation of Private Health Insurance There are several ways to affect private group health insurance purchases. One way is simply to provide information to buyers about which coverage makes the most sense, which coverage does not make sense, and why.
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From page 475... ...
Any taxes collected on such payments could be used to enhance the tax subsidy to appropriate coverage, especially for low-wage workers. The mandating of coverage by government is a third method of affecting private health insurance purchases.
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From page 476... ...
with the effort to cut costs by reducing the care provided, rather than by developing a plan for matching a person to the most appropriate treatment regimen at each treatment stage. The committee's stance is that the addition of assessment and reassessment, coupled with the emphasis on outcome monitoring in its proposed system, makes case management a legitimate clinical endeavor, one that has been severely lacking in the treatment of alcohol problems under a unitary model of problems and treatment.
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From page 477... ...
The Minnesota Consolidated Chemical Dependency Treatment Fund is an example of mechanisms for controlling access and cost which should be followed by other state alcoholism authorities and the federal government. The federal government, in particular, needs to consider such consolidation in both its contributions to community-based service provision through the block grant, Medicare, Medicaid, and the federal employees' health insurance program and its direct operations in the Department of Defense, the Department of Veterans Affairs, and the Indian Health Service.
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From page 478... ...
Persons with problems similar to those of Elizabeth are estimated to account for approximately two-thirds of those who enter specialist treatment in hospital settings under the current system in which the full spectrum of intervention responses is not available. Assuming that a significant proportion of these individuals can be identified earlier and can be treated in lower cost residential and outpatient settings or in brief intervention settings involving no additional cost, there should be sufficient savings to pay for the cost of outcome monitoring and continuity assurance and to increase the proportion of persons who can be treated.
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From page 479... ...
In the proposed system, however, Patrick's moderate level of alcohol problems would be picked up through screening; the optimal referral would be to a brief intervention in the general health care system or, if available, in his company's employee assistance program. The additional cost for a brief intervention if done in the general health care system is estimated to be zero or, at most, $280 ($70 per session for 4 sessions)
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From page 480... ...
It is the committee's hope that the creation of alternatives and the ability to match persons to the appropriate treatment will bring additional persons with severe and substantial problems who are not now being seen into both nonspecialist brief interventions and specialist treatment. Prompt early treatment can decrease the need for later, more expensive treatment.
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From page 481... ...
Minnesota's consolidated fund administered by the state alcoholism authority is one approach for fostering integration of the diverse sources of public funds that must be used to pay for the proposed comprehensive system. The committee recommends that, in addition to monitoring the progress of this exhort, demonstrations of other approaches also be undertaken and evaluated.
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From page 482... ...
Specific priority should be set to determine the allocation of funds to free care for the poor versus partially paid programs for the nonpoor who are not covered for specific treatment of alcohol problems. One could well envision the formulation of a federal minimum standard requirement, for both Medicaid and state specialist programs (through the alcohol, drug abuse, and mental health services block grant)
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From page 483... ...
1987. Consolidated Chemical Dependency Treatment Fund: County and Reservation Training Manual.
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From page 484... ...
Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism.
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