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–Mark W. Parrino, M.P.A., President of the American Methadone Treatment Association

Most methadone treatment providers throughout the United States are anxious about the impact that managed care will have on methadone treatment practices. Treatment representatives have been equally concerned about the elements of national health care reform. It is not now clear when, or if, a comprehensive health care reform package will be enacted by Congress. However, even without a national reform plan, the issues of managed care and its effect on methadone treatment are important issues to explore and understand. Ultimately, methadone treatment providers must be clear in understanding the elements of managed care and how to work within the system; only then will we be able to protect the interests of good quality patient care and maintain the stability of the treatment environment.

Managed care has been described as being a system of health care delivery that controls cost, quality, and increased access to health care. Managed care companies typically use contracted providers to restrict the uncontrolled use of medical services through a system of centralized authorizations.¹

Most methadone treatment providers view such restrictive systems of centralized authorization as being intrusive and oppressive. Most treatment practitioners also believe that managed care is more appropriately termed " managed costs. " The questions that methadone providers raise most frequently concern the long-term impact on patient care and the freedom to provide the patient with access to essential services.

Experience in States with AOD Managed Care

Fortunately, government agencies at the Federal and State levels, in addition to treatment provider organizations, have developed position papers and guides in response to managed care initiatives. And in several States, successful arrangements have been worked out between methadone providers and the State managed care system for Medicaid clients.

For example, appropriate criteria for methadone treatment program services were developed by the Massachusetts Methadone Treatment Provider Association and the Department of Public Health-Bureau of Substance Abuse Services, working with Mental Health Management of America (MHMA), which is the managed care entity for Medicaid recipients for mental health and substance abuse in the State of Massachusetts. In effect, MHMA admitted all of the State 's methadone treatment programs into their managed care network.

In New York State, the Committee of Methadone Program Administrators has also worked closely with regulatory officials in the New York Office of Alcoholism and Substance Abuse Services to flesh out the most critical elements of patient care that must be included in any managed care network. At present, methadone treatment is a " carved out " service in New York 's managed care benefit package. The New York State Office of Alcoholism and Substance Abuse Services executed a Memorandum of Agreement with other State agencies that are responsible for the implementation of Chapter 165 of the Laws of 1991, establishing standards for the expansion of Medicaid Managed Care throughout New York State.

The presently " carved out " methadone treatment services will be billed to Medicaid in accordance with the existing weekly capitation payment formula and will not require the prior approval of the managed care entity. In spite of this, when a methadone-maintained patient is enrolled in a managed care network, New York methadone treatment programs find they must work with managed care entities when ordering bloodwork or making specialized referrals. A model protocol used for linking New York State managed care providers and methadone treatment programs is available from the author of this article.²

Other States have also been working with treatment practitioners in " carving out " substance abuse services by allowing patients in methadone treatment programs to have their care funded through the Single State Agency budget. The Illinois Department of Alcoholism and Substance Abuse (DASA) has " moved closer to the development of a managed care system for the entire alcoholism and other substance abuse treatment field in Illinois. " According to the June 1994 DASA Bulletin, the Department has been approved to develop its own managed care system, which will be " carved out " from the Department of Public Aid 's HMO model.

Difficult Experiences in Some States

Unfortunately, some States have had extremely difficult experiences as managed care entities have organized treatment networks. The Pennsylvania experience provides such an illustration. The Drug and Alcohol Service Providers of Pennsylvania and the Pennsylvania Association of Methadone Providers presented their concerns for minimum requirements in managed care settings to protect consumers. They indicated that a fundamental principle of managed care " should [be to] maximize treatment availability."

The policy statement also expresses concern regarding the delay of admitting patients to substance abuse treatment. Ten fundamental principles were discussed, including:

• Giving patients reasonable freedom of choice for treatment

• Providing patient access to the full provider continuum of services

• Integrating the existing community treatment provider network into any managed care system

• Developing a managed care network that eliminates all fiscal incentives for denial, delaying, or withholding of needed treatment to consumers.

The Pennsylvania Methadone Treatment Providers were not admitted into the managed care network, which created considerable confusion and protracted delays in admitting patients to methadone treatment programs. Methadone treatment providers have also faced cash flow crises due to delayed payments for rendered services.

Some States have a significant number of private, nonfunded treatment programs, where patients make out-of-pocket payments for their care. Such proprietary methadone treatment providers have speculated that they may be in the better position. This is because they are not involved in managed care clearance procedures and are not subject to the cash flow difficulties of their funded counterparts, who have become progressively dependent on third party revenues. Policymakers must be careful when advocating for managed care models to take all of these experiences into account.

Recommendations of the American Methadone Treatment Association

The American Methadone Treatment Association encourages its member States and their respective methadone treatment programs to educate managed care entities in understanding the cost-effective nature of methadone maintenance treatment. Methadone programs have the following advantages in working with managed care networks:

1. Methadone maintenance is a highly regulated form of medical care at the Federal and State levels of government. In most States, regulatory authorities have strict requirements concerning patient-staff ratios, licensed patient treatment capacities, and a compre- hensive listing of required patient services. Single State Methadone Authorities can work in conjunction with the network of methadone treatment providers, educating managed care entities in understanding mandated staffing requirements and in providing proper levels of care to methadone- maintained patients. This model certainly proved helpful in Massachusetts.

2. Methadone maintenance employs the use of a medication that is prescribed by medical practitioners and dispensed by licensed nursing personnel. This dispensing occurs in a treatment environment that draws upon the expertise of counseling personnel and related caregivers. The treatment environment includes a rich mix of personnel who represent a broad base of educational experiences. It is likely that a greater number of methadone treatment personnel will be credentialed in their respective disciplines as a further means of preserving the autonomy of the decision making process.

3. Methadone maintenance treatment has been exhaustively researched from its inception. The treatment system can rely on three decades of clinical experience coupled with this extensive research. CSAT's recently published State Methadone Treatment Guidelines also provide guidance to treatment providers and policymakers concerning the best elements of patient care.

The Methadone Association has worked with managed care entities in drafting their respective criteria for patient admission and length of treatment in the methadone treatment setting. We have had a favorable experience in assisting such entities to develop balanced admission and continued care criteria, drawing upon the principles contained in CSAT's State Methadone Treatment Guidelines.

A Call to Work Together

Methadone treatment providers will need to work together in identifying managed care entities and in working with them to protect the interests of good quality patient care. This principle of working together is especially important in order to avoid bidding wars. In some States, managed care entities have created dangerous conflicts within the provider community. These conflicts resulted from the threat of closing certain providers out of the managed care network unless they agreed to lower treatment costs. In some cases, methadone treatment providers within the same city are agreeing to provide services at unrealistically low costs to avoid being shut out of a managed care network. This approach will undermine the long-term integrity of patient care and will damage an already overburdened, fragile treatment system.

Methadone providers will also need to keep informed about new materials and information concerning managed care. CSAT has published a number of valuable publications, which are listed on the Resource List insert in this Communiqu J . One document particularly important for treatment providers, released by CSAT in July 1994, is the " Managed Health Care Organizational Readiness Guide and Checklist. " This document is designed to help treatment providers prepare for integration into managed care organizations.

The Future for Methadone Treatment Providers

The introduction of managed care into the health care system will clearly have an evolving impact on methadone treatment and on substance abuse treatment in general. Methadone treatment providers will fare best if they work together through the aegis of statewide provider organizations. The uncertain status of national health care reform provides some temporary respite as treatment providers work in conjunction with managed care organizations. However, this may be a short-lived " breather. " The American Methadone Treatment Association will continue to work with State methadone provider chapters, Single State Agencies, and Federal agencies in preparing treatment providers for current and future managed care initiatives.

The long-term future of managed care may be uncertain as it relates to the health care system and methadone treatment programs. At present, managed care organizations are an entity that must be dealt with in a clearly defined way, to protect the interests of patients and sustain an effective methadone treatment system. A number of issues add further complexity to provider concerns about managed care. These issues involve making new medications available, providing different levels of care to patients as they remain in the treatment program, and dealing with additional regulatory oversight.

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