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- Susan Galbraith, M.S.W., Co-Director of National Policy, Legal Action Center, Washington, D.C.

Managed care has changed the alcohol and drug treatment field. Many consumers now have reduced access to treatment services, programs have closed, and many States have either reorganized their alcohol and drug treatment systems or have plans underway to do so. There is no doubt that managed care is here to stay. The challenge for the alcohol and drug field is to find a way to work in this new context, while maintaining the integrity of the services necessary so that individuals can begin the process of recovery and rebuilding their lives.

In its purest and most positive form, managed care is a systematic attempt to match individuals with the appropriate level of health care services necessary to prevent and treat illness. Managed care is also a method used to rein in escalating health care costs by tightly controlling health care decisions.

Ideally, managed care relies on " objective criteria " to make decisions about the health care services an individual needs and will receive. The goal of an objective assessment can be achieved in any number of ways – by using a third party, by relying on treatment programs, or by using trained health care professionals who are primary health care providers.

The Institute of Medicine report, Treating Drug Problems, defines managed care strategies to " include prospective certification or readmission review (PAR) of hospital stay, utilization review during and after discharge, the use of preferred providers, and specialized case management. " ¹ Today, all these managed care approaches are being applied in drug and alcohol treatment systems, whether publicly funded programs or those supported through third-party insurers.

Advocacy for Appropriate AOD Treatment

A cookie-cutter approach will not work for individuals with drug and alcohol problems. Individuals enter treatment at various stages of their addictions. The key to effective intervention and treatment is matching an individual to the most appropriate treatment program, tailoring treatment to the person 's individual needs, and ensuring that he or she remains in treatment and participates in continuing care to prevent relapse. Treatment outcome research indicates that length of treatment is the strongest predictor of positive treatment outcome.

In advocating for appropriate care for individuals with drug and alcohol problems, it is important for providers to point out that it makes no sense to cut corners in providing these services. They must emphasize that treatment services are cost-effective and they work.

As an example, untreated drug and alcohol problems cost our Nation approximately $166 billion, or $700 for each American, each year, in health care, criminal justice, social, and lost productivity costs. In contrast, it costs about $45 per person to provide a comprehensive drug and alcohol treatment benefit that includes a full continuum of services from detoxification to long-term residential care.

Community-based drug and alcohol programs must also argue that they are an essential part of any new delivery systems. They provide treatment efficiently and at low cost. For example, it costs an average of $60 per day to provide treatment in a therapeutic community (TC) or a halfway house program. These programs provide:

• Treatment by trained drug and alcohol professionals

• Primary health care services or links with such services

• Essential support services such as housing, transportation, child care, vocational rehabilitation, and education

• Outreach and follow-up care

TC and halfway house programs treat people with the most severe drug and alcohol problems, people without private insurance, and people who have exhausted their private insurance or have been denied access to appropriate care.

Promotion of Innovative, Positive Models

Significant work is already underway in our field to respond to the reorganization of health care delivery systems and integrate our services into managed care models. Minnesota and Massachusetts are two States that have developed innovative models that do not compro- mise the quality of treatment for the bottom line. Whatever model or models a State adopts, there must be a commitment to providing the level of services that people need in order to get better.

Shortcuts, such as relying too heavily on short-term interventions when individuals need long-term care, will only come back to haunt us later in more expensive health care, social welfare, and criminal justice costs. Schemes that only allow outpatient services or limited residential services for all people, independent of the severity of their addiction, will be dismal failures.

At the heart of this work must be basic principles about organizing services so that individuals have timely access to appropriate levels of care that provide the full range of services described above. Numerous experts have identified the principles that are fundamental to making managed care work for addictions treatment.² These principles must guide our work as we restructure our health care delivery system. Certain protections must be built into any managed care system designed to handle clients with substance abuse problems; these critical protections are listed in the box.

Positive Steps To Protect Providers and Clients

Providers are searching for ways to respond to a changing health care financing and delivery system that could threaten their survival and, ultimately, their ability to provide critical services for individuals who have not been able to get care in the traditional health care system. Our field has a clear choice today. We can rise to the challenge of " managed care " by fighting for the approaches we know are most effective for delivering care to individuals with drug and alcohol problems. Or, we can lose control of the debate. If we do so, we will see changes imposed on us, and we will risk losing the tremendous gains we have made in developing appropriate and effective treatment that is responsive to the needs of people with drug and alcohol problems.

There are steps that community-based alcohol and drug programs can take to position themselves for working effectively with managed care companies and with State agencies that are moving toward managing the care of individuals treated in publicly funded programs. Many programs have initiated relationships and developed contracts with managed care companies. They have also implemented outcomes monitoring efforts, so that treatment effectiveness can be measured over time. In the area of outcomes monitoring, programs must be careful to define the client population they are serving and set goals for outcome that are realistic. Finally, managed care readiness check lists have been developed. Programs would be wise to consult these lists as part of their internal review process and the assessment of their ability to adapt to the changing health care system.

These are all steps that we must take to protect the integrity of the addictions treatment and prevention systems while responding to the challenge of managed care. These steps will require working with consumers, policy makers, insurers, businesses, and government. It is possible to maintain the integrity of alcohol and drug treatment in a managed care system, but it will require our leadership, creativity, and persistence.

Critical Protections In Providing AOD Treatment Services

Simply put, a number of protections must be included in any plan to manage the provision of alcohol and other drug treatment services. These protections must include:

• A process for licensing or certifying managed care entities

• A guarantee that qualified personnel are making and monitoring treatment placement decisions

• Public disclosure of the specific patient placement criteria that are being used to make treatment placement decisions

• A description of a procedure that includes a smooth admission process for assessment and detoxification

• A requirement that treatment be provided by licensed programs and practitioners

• Involvement of a full range of community-based, licensed drug and alcohol treatment programs

• A plan for evaluating patient outcomes over time

• Policies and procedures to ensure that all applicable State and Federal laws that protect confidentiality of records are followed

• A written description of an independent appeals process for an individual who wants to challenge the patient placement decision

• Procedures to ensure that the managed care entity responds to a request for services in a timely manner

• Policies to ensure that professionals making treatment placement decisions and reviewing care are basing their decisions on the best clinical practice rather than on financial pressures and incentives

• Penalties for failing to comply with State and Federal legislative and regulatory requirements

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