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– Paul W. Ingram, M.S.W., Executive Director, PBA Inc., The Second Step, Pittsburgh, Pennsylvania*

Community-based substance abuse treatment programs that provide primary, secondary, and tertiary services need not panic because of health care reform and the emergence of managed care systems. Those of us who provide community-based services where the majority of our targeted population is indigent need to think proactively. After all, those of us who have survived have frequently had to move from a reactive position to a proactive one.

Actively Confronting Change

Even though managed care is not yet clearly defined for the majority of us, what we need to know is that change is upon us. This change is no different from the time when some of us were told to switch, without much notice, from program funding to slot matrix to fee-for-service. Those of us who have survived learned quickly how to switch and fight at the same time.

We are being confronted with a health reform system – managed care – that may view treating chronic illnesses as unprofitable. We know that, for many, substance abuse addiction is a chronic, relapsing illness. The taxpayers, legislators, and health care systems are looking for measurable, positive outcomes. Positive results are not easy to achieve, especially when we are given only a short time to treat. If we are not careful, we will be set up for failure.

Questions and Issues for Providers

Through collaboration and the building of powerful coalitions, we treatment providers can have an impact on the new managed care systems. As treatment providers, we must become involved. We need to know what is happening. We need to explore and understand such issues as:

• What is this health care reform that is overtaking the nation?

• What is managed care?

• What is a health maintenance organization (HMO)?

• What is meant by single-payer voucher?

• What comprises primary health care?

• What is the difference between a for-profit HMO and a nonprofit HMO?

• What is the difference between case management and managed care?

These are some of the questions that providers need to be able to answer. We need to learn what is happening in our State, county, city, and local community. We need to speak out for our clients and constituents.

Many community-based programs serve a population of indigent people. Providers need to get these clients involved, so we can speak from a position of numbers. However, let us not belabor war stories. Stories about patients falling through the cracks need to be shared, but they are not the only way of getting attention. We need to talk in terms of resolving issues.

Becoming Grounded for Negotiation

We treatment providers can only negotiate effectively when we understand the other side' s needs. Currently, there are several types of operational and proposed managed care plans. I do not fully understand all of them. I suspect that those who are planning have not thought of all the issues. I suspect that some planners are purposely trying not to address all of the issues. In fact, no one can address all of the issues.

In many States, these issues affecting us and our patients are being discussed, proposed, acted upon, denied, or omitted in the health care planning process. Only if we treatment providers are involved, around, nearby, overhearing what is being said, can we at least raise a flag, ring a bell, or scream " fire " to get attention. Once we have the attention, we should speak from a position of knowledge, understanding, and power. The power comes from our coalition or from the numbers of patients we serve hourly, daily, monthly, or yearly.

Yes, this is really going to be a numbers game, along with quality output. If we have a large client population and/or are located in a community with a large number of indigent residents, it would be wise for us to determine how many clients we can really serve. The larger the number of people we can reach and potentially serve, the stronger our position can be when we are approached or actively seek out a managed care organization.

Some of the major insurance health carriers have developed subsidiary companies to provide managed health care to the indigent population through contracts with State welfare and health departments. Substance abuse treatment is included in many of these contracts. However, the contractual language relating to substance abuse treatment is not openly available to providers. For our State or locality, we need to know what services are being covered. Our legislators can help us get important information. We should use them and their staffs. If needed, these legislators may even join us in our endeavor to change things.

Promoting What Community-Based Programs Offer

Managed care is a hot issue. No one has a complete answer. Many issues are unresolved. It is not too late to get involved. Community-based programs have a lot to offer. If major insurance companies are going to continue to negotiate with State agencies for contracts to provide health care services, particularly to the indigent, then community-based programs can fill a big niche in the process of reaching this indigent population.

HMOs are generally paid a percentage of a dollar or more for each individual in the targeted area they have chosen and negotiated to treat. They receive this percentage whether or not the services are utilized. Therefore, it may seem that the HMOs benefit when their targeted population underutilizes the services. However, the indigent population can cost the HMOs more than other patients. Poor people generally use health services when chronic illness has become acute. The emergency room is used for what should be a physician' s office visit. That excessive cost affects all of us.

Many managed care systems would rather not serve the indigent population. For this reason, community-based AOD treatment programs that have access to large indigent populations, either on their own or through collaboration with other programs, should be able to negotiate with the managed care systems targeted to serve residents in their community. Substance abuse treatment, particularly methadone maintenance, is classified as a specialty service among many of the managed care systems.

Providing primary prevention services. Community-based programs should be able to show that they can reach and serve indigent or specialized populations cost effectively. Such programs can add primary health care to their existing program services, which will eventually lead to preventive health care for these patients. This primary health prevention can occur because we community-based treatment programs have frequent contacts with our clients; these contacts allow for close monitoring of their health needs.

Providing outreach, education, and support. Community-based programs, through their outreach activities, are able to reach a large number of people with information and services. They can pick up and deliver people to appointments, help to educate about preventive health care, encourage the need for pre- and postnatal care, and provide hands-on door-to-door services. These programs are culturally sensitive to the communities they serve. It is important to remember that cultural sensitivity does not pertain only to race and ethnicity; it also involves gender, sexual orientation, and other issues.

Providing a continuum of care. Community-based methadone maintenance programs can initiate a strong proactive position. At a minimum, they are required to have available – either on-site or within close proximity – a physician, nursing staff, hospital emergency room, psychiatric consultation, psychological testing, primary health care, and testing for HIV/AIDS, sexually transmitted diseases, tuberculosis, and hepatitis. These methadone maintenance programs or any prototype should present themselves to the HMOs as being an extended arm of continuum care.

Proving Our Competence to the HMOs

Many HMOs are skeptical of community- based programs. They generally prefer to wait and see what we are capable of doing. The first authorization of services is usually for the short term. However, if we treatment programs perform well and provide a good record-keeping system and professional feedback, extended authorization of services usually will be granted.

Small community-based programs should think about mergers or collaborations with other similar programs as a way of increasing their client population numbers. If a community-based program is chosen to provide services to a targeted population of an HMO group, it should not accept the HMO 's offer if the terms are not adequate. Instead, the program should negotiate costs. For this negotiation, establish a laundry list of services that are to be provided to the same population of both the HMO and the community-based provider. Look at what you do daily, weekly, monthly, and annually. Think in terms of your static and dynamic capacity. Know what your gross and net costs are. The objective should be to get in the door without " losing the store. "

Demonstrate an understanding of managed care and/or HMO needs. When negative situations occur, take a proactive position and use these situations as a way to solve problems. Once accepted by an HMO, we treatment providers need to understand and respond to the HMO 's reporting needs. To do this, we need to:

• Develop internal audits and controls

• Centralize our reviews of client records and progress notes

• Develop treatment plans

• Complete treatment plan updates

• Maintain legible records

The purpose of establishing central control is to avoid having all of your counseling staff reporting to the managed care system. You do not want too many cooks in the kitchen. A centralized information service or single contact person can help to assure that reporting information about clients is consistent with your program' s treatment protocol. As a final word of advice to providers in this new situation, I recommend:

• Be diligent

• Be patient

• Be thorough

• Be smart.

* Editor's note: PBA Inc. is a community-based substance abuse treatment program that contracted 1 1/2 years ago to provide services through a managed care organization. This program serves more than 500 patients per day, a large proportion of whom are indigent.

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