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Managed Care and Dual Diagnosis

Who, What, Where, Why, and How Much Care?

— Richard Ries, M.D., Director of Outpatient Psychiatry and Dual Disorder Programs, Harborview Medical Center, University of Washington, Seattle, Washington. Dr. Ries was consensus panel chair for the CSAT Treatment Improvement Protocol (TIP 9), Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse.

How will managed care approach the treatment and management of persons with co-morbid mental illness and alcohol and other drug (AOD) disorders? What are the key issues that clinical professionals or consumers would want addressed? Jeffrey N. Kushner⁽¹⁾ has raised a series of critical questions for States to consider in setting up managed care contracts for AOD treatment in the following major areas: access to treatment, comprehensiveness of treatment, cost effectiveness, quality of care, client outcomes, and the managing of managed care.

Access to Services

Who will be screened and who will qualify for services? A high prevalence of dual disorders is found in either addiction or mental health populations. This fact suggests that all persons who present at either doorstep should receive an adequate screening for the other problem. This immediately raises two important issues discussed later in this article — the issue of the database to be used and the training of the screener.

Currently, most integrated dual disorder treatment programs focus on the most severely mentally ill clients; that is, persons with severe and persistent mental illness and co-occurring drug/alcohol disorder. However, what type of client is appropriate for treatment in a "dual disorder program"? Should a person in recovery from severe alcoholism who then develops an episode of major depression be treated in this type of program? Or can this person be treated in a primary addiction-oriented program that also provides episodic psychiatric consultation? On the other hand, does someone with severe, chronic, disabling mental illness, who has infrequent alcohol abuse (not dependence), qualify as dually disordered? Does this person require dual disorder treatment in the same way as a person with severe mental illness who has daily, dependent alcohol and cocaine intoxication?

Even this brief discussion makes clear that access to "dual disorder treatment" involves various levels of severity on at least two axes — relative severity of the psychiatric disorder and relative severity of the substance use condition. Managed care review and treatment planning will need to focus on matching different types of treatment intensity to each of the types of problem. No single entity "dual diagnosis" treatment will be appropriate or meet the needs of all the different types and combinations of dual disorders.

What instruments and criteria will be used? The mental health and addictions fields each has a variety of screening instruments, which creates a problem in the case of dual disorders. If there are 10 commonly used instruments for chemical dependency assessment, and 10 for psychiatric condition, there would be 100 combinations possible. Which one of these combinations should be used for dual diagnosis assessments?

It is likely that many dually disordered individuals will be referred to dual disorder treatment from primary addictions or primary mental health treatment. This means that the managed care organization must communicate its assessment criteria for one or the other disorders, and must also agree internally (between addictions and mental health divisions) as to what standardized instruments will be used. Currently, it is rare to find addiction and mental health programs that share a mutual database at any level — from private carriers to city, county, State, or even Federal-level systems. Without a common database accepted by both mental health and addictions, managing care by either provider or insurer will be very difficult.

The national institutes on drug abuse, alcohol abuse and alcoholism, and mental health, as well as the programs operated by the Substance Abuse and Mental Health Services Administration, need to provide a model of such a cooperative database. Such a database should have both research and clinical management versions.

Who will certify treatment? Training personnel to act as managed care reviewers has been a common problem for both the AOD and mental health fields. Dual disorder review will require co-trained personnel who have either certification or some sort of documented training in both areas. Since even finding co-trained staff who can operate dual disorder treatment programs is a problem, where will these extra co-trained staff come from? The field of psychiatry has been increasing its requirements regarding addiction and now has available a national board subcertification in addiction psychiatry. Each field must persistently move toward better training, at all levels, in the other field.

Comprehensiveness

What are comprehensive dual disorder treatment services? A seamless set of services is needed, ranging from prevention to highly secure locked units capable of dealing with clients who have violent psychoses accompanied by alcohol withdrawal. But how comprehensive can such a system afford to be? For example, will inten sive case management, sober residential placement, and integrated vocational rehabilitation be considered as core services for persistently mentally ill, dually disordered persons? Currently, many such individuals in HMO-type systems rapidly use up their limited AOD and mental health benefits, then devolve to the public system. How comprehensive will private and HMO-type services be, and who will bear the costs if such services are inadequate for complex conditions?

Cost Effectiveness

A high cost is involved in using a non-integrated approach to treat individuals with dual disorders. Most research indicates that dually diagnosed persons are over-represented among the homeless, are heavy users of acute inpatient services, and are over-represented in the criminal justice system. This high cost creates a major motivating factor for developing improved dual disorder treatment.

One method for treating severely mentally ill clients is through programs for assertive community treatment (PACTs), a model that involves intensive case management and outreach. The PACT model usually results in about an 80 percent decrease in acute hospitalizations and incarcerations over traditional treatment. However, the costs of assertive community treatment programs nearly counterbalance the cost savings, since they include 24-hour outpatient coverage and intensive case management. Although the cost saving may be marginal, clients/patients are much more satisfied with assertive community treatment than with acute hospitalization or incarceration, because their quality of life is much better with community treatment. How do we analyze this cost?

Continuous cost offset data are not available for specific dually diagnosed populations over a significant number of years, nor is such data likely to be available soon. Cost offsets for dually diagnosed populations must also calculate legal and jail expenses, crime, individual and family suffering, quality of life, and medical utilization. Unfortunately, these cost effects may not be included. Who makes these choices?

Capitation

If the financing system uses capitation, will dually diagnosed persons be risk-adjusted for payment at a higher level, and if so, how much more? Should increased risk adjustment hold for all the dually diagnosed, however defined, or only for certain of the more severe subgroups? Research data indicates that dually diagnosed persons have worse outcomes and poorer participation than those without a dual diagnosis in either primary mental health or addictions treatment. This finding would tend to support providing an increased capitated rate for these clients. An increased capitated rate could be used to support expensive integrated services, increased salaries for dually trained staff, and increased intensity of treatment. Despite the common sense of this approach, I have yet to find a public or private financing system in which this has occurred.

Quality of Care

o confirmed treatment guidelines exist for dual disorder clients, although a number of texts and manuals have been developed for the treatment of various dual disorder subpopulations. The American Society of Addiction Medicine (ASAM) is currently reviewing its patient placement criteria for addiction for the dual disorder population. To date, this ASAM initiative has just begun to match subtypes of dually disordered persons with potential treatment guidelines. The 1997 summary from the Center for Mental Health Services provides an extensive qualitative literature review on dual disorders.⁽²⁾

Quality-of-care markers for the dually diagnosed population could certainly be taken from separate mental health and addiction treatment guidelines. However, can these be imported fully for integrated treatment? Say, for example, that a quality-of-care guideline for intensive outpatient chemical dependency treatment requires a minimum of 12 hourly groups per week to occur around topics x, y, and z. For intensive outpatient mental health treatment, the guideline requires roughly the same number of hours per week to include issues a, b, and c. Does this mean that, for intensive outpatient dual disorder treatment, 24 hours of group per week including topics a, b, c and x, y, and z need to occur?

A more realistic approach might be the following:

12 or 15 hours per week would qualify for intensive outpatient dual disorder services.

Topics a, b, c and x, y, z would be covered in an integrated fashion over a time period lasting approximately twice as long as either intensive mental health or chemical dependency outpatient treatment alone would normally last.

While this is the way many clinicians have approached these problems, who makes such quality-of-care decisions for the managed care company?

Client Outcomes

For those in straight addiction treatment, multiple relapse episodes may lead to their treatment coverage being limited or canceled. For more severe dually diagnosed persons, multiple relapse episodes during the engagement phase of treatment are probably the norm.

When treating acute or episodic conditions, managed care often identifies decreased utilization of services as being a positive outcome. However, this may not be the goal for many dually disordered persons. In fact, for more severely ill individuals, low participation in outpatient treatment often leads to their use of expensive acute emergency room, inpatient, and jail services. A drop-off in participation may lead to the client's stopping of medications or loss of sobriety. For many dually disordered persons, whose conditions will be chronic and relapsing, the first positive outcome might be higher utilization of outpatient treatment. After participation, the problem of finding a common measure for symptoms and functions emerges. (See above, What instruments and criteria will be used?)

Dually Disordered Clients in Managed Care Environments

Who will actively manage the care of dual disorder clients? If an entity is developed that will manage dual disorder treatment, where will this fit? Will the individual divisions of addiction treatment and mental health treatment oversee such an entity? If so, it is likely that this entity will be so burdened with double and often conflicting bureaucratic requirements that it will not function. If neither mental health nor addictions supervises this new dual disorder entity, who will?

Clearly, the current division of addictions and mental health is inefficient and problematic in terms of information, funding, legal issues, training, and clinical structures. Would it be too radical to propose that the primary entity must be dually competent and that current divisions of mental health and addiction become subdivisions?

1. Kushner, J. N. Managing State Managed Care Contracts, TIE Communiqué, Spring 1995, pp. 20-21. See also Mr. Kushner's articles in this issue.

2. Center for Mental Health Services Managed Care Initiative: Clinical Standards and Workforce Competencies Project, Co-occurring Mental and Substance Disorders (Dual Diagnosis) Panel. Kenneth Minkorr, M.D., Panel Chair. July 1997.

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