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Defining Treatment Success: Issues for States

— Janet Zwick, Director, Division of Substance Abuse and Health Promotion, Iowa Department of Public Health

Treatment success can be defined in many different ways. When the measurement of success is related to managed care, it is essential to evaluate both cost savings and the effectiveness of treatment. The managed care organizations themselves often look primarily at client and consumer satisfaction as outcome indicators and to plan their quality management. Such indicators are not sufficient for a State substance abuse agency. A State agency must look far beyond client and consumer satisfaction, because the agency is responsible for assuring that the entire treatment system under managed care is functioning at an optimum level. This responsibility entails evaluation of the treatment system as well as changes in client functioning.

The Database and Baseline Data

The State needs to have available an adequate client and program database in order to evaluate the impact of managed care on the treatment system and, most importantly, on the changes in client functioning. Client information needs to be collected at admission, discharge, and follow-up. The information needed includes client demographics and information on the clients' functioning, along with the type of treatment provided. It is desirable that this client database be in existence for several years before managed care is implemented. Historical data provide a solid base of information on the level of treatment and client outcomes under existing publicly funded systems. This baseline can then be used to evaluate changes that may be caused by managed care. Success can be measured using at least five different components:

Accessibility of treatment

Types of treatment services provided

Changes in client functioning

Cost-offset data

Consumer satisfaction (at both the client and treatment program levels)

Accessibility of Treatment

The accessibility of AOD treatment for all groups of clients across the State will be a central — and critical — question as AOD funding streams change and managed care or other new financial arrangements are implemented. It is important to monitor accessibility. How accessible is treatment for the State's individual ethnic, racial, and special populations? And does accessibility vary across different regions of the State? To determine accessibility of treatment, the following areas should be examined:

Waiting time for treatment. The State must have the ability to compare waiting times among indigent clients, Medicaid clients, private-pay clients, and insured clients. In addition, waiting time should be computed for the pregnant client, for those referred by the criminal justice system, and according to gender and race.

Overall admission rates. Overall admissions need to be evaluated to assure that they have not declined since managed care began. If admission rates have declined, then it is important to assess carefully the types of clients affected.

Level of treatment received. The level of care that clients are receiving should be analyzed. If there has been a decline in admission rates for a particular level of care, all levels should be evaluated separately.

Rural vs. urban treatment services . The level of treatment services provided in rural versus urban areas is another important access issue. If a decline in admission rates is seen, then the data should be further evaluated to see whether admission rates are related in any way to rural areas. States may want to conduct a needs assessment prevalence study to identify geographic areas that have a high prevalence of need. These results compared to admission rates allow the State to evaluate an appropriate distribution of services.

Denial of admission or denial to a particular level of care. If denials concerning levels of care have occurred, then the State should evaluate those treatment settings and the risk levels of the client.

In a new managed care or other financial arrangement, it is also necessary to address the change in the provider system. What changes have happened in the provider system since managed care was implemented? Mergers, closings, and acquisitions can all impact the provider system and affect accessibility to treatment. Therefore, exploring these changes must be part of any evaluation effort.

Types of Services Provided

Managed care stresses the need to individualize treatment planning and to place the client in the least restrictive environment necessary for the symptoms. Research shows that the longer a client remains in AOD treatment, the more likely that treatment will be a success.¹ The dichotomy in these two statements raises obvious questions about the impact that managed care principles may have on AOD clients. States need to compare before and after managed care data to see whether the length of time in treatment has been significantly affected.

In addition, States should analyze the number of treatment sessions provided to each client. If length of time in treatment and the number of sessions have significantly changed, then data on client characteristics should be cross-analyzed. Characteristics to be analyzed include gender, age, criminal justice referral, employment status, race, and number of treatment attempts, along with rural versus urban issues.

Changes in Client Functioning

Client data from admission, discharge, and follow-up reporting can be used to measure client functioning before and after treatment. Useful indicators of client functioning include arrests, employment, school level of functioning scales, relationships, involvement in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), and hospitalizations.

Cost Off-Sets

Federal and State officials are beginning to ask whether State funding for substance abuse treatment is cost effective. One of the best ways to show that treatment can be cost effective is to identify the costs associated with substance abuse (the cost-offsets) in such areas as health, crime, and social welfare. In looking at cost off-sets, the key components to identify are associated with client arrests, hospitalizations, and the use of welfare benefits before and after treatment.

In addition, changes in the clients' unemployment and their earned income can show a significant improvement in the tax rolls. A recent Oregon study appears to be a cost-effective way of identifying these cost offsets² (see Societal Outcomes and Cost Savings Resulting from AOD Treatment, in this issue).

Client and Provider Satisfaction

How satisfied are the clients with the managed care or substance abuse treatment program? To adequately address this area, clients need to complete a consumer survey, preferably after they have been discharged from the treatment program. This survey could examine such issues as waiting time, satisfaction with the program, and services perceived by the client as the most beneficial.

What is being proposed here is that States undertake an objective evaluation of the cost savings and the effectiveness of treatment under their new managed care or other financial arrangements. Based on these objective findings, it is imperative that decision makers be open to an ongoing adjustment of the treatment system. This process of evaluation and adjustments can lead to achieving the ultimate treatment goal — reducing the overall effect that alcohol and other drugs have on individuals, families, and the community.

1. Gottheil, E.; McLellan, A.T.; and Druley, K.A. Length of stay, patient severity and treatment outcome: Sample data from the field of alcoholism. Journal of Studies on Alcohol 53(1): 69-75, 1992.

2. Finigan, M. Societal Outcomes and Cost Savings of Drug and Alcohol Treatment in the State of Oregon. Office of Alcohol and Drug Abuse Programs, Oregon Department of Human Resources and Governor's Council on Alcohol and Drug Abuse Programs. February 1996.

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