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Chapter 2 of TAP 16: Purchasing Managed Care Services for Alcohol and Other Drug Treatment: Essential Issues and Policy Issues

Chapter 2–Access to Treatment

Maintaining and improving overall "access" to the treatment system is arguably the most important issue to monitor when first implementing managed care into public treatment systems. Access generally refers to the capacity of a treatment system to facilitate entry into the appropriate treatment, as well as the continuance of that treatment, for all individuals who need it.

The extent of access to appropriate treatment in a managed care system depends on the amount of resources devoted to alcohol and other drug (AOD) treatment services. To understand how much access can be implemented for AOD clients, a key variable will be the resources that are made available.

Most treatment systems have access problems that influence whether or not an individual can obtain and continue to utilize treatment services. Uninsured and publicly insured individuals often lack the resources and the knowledge to negotiate their way through overly bureaucratic systems. Every effort must be made to facilitate their entry into the treatment system. Potential barriers to treatment must be carefully analyzed and steps taken to lessen or eliminate these barriers.

In a managed care environment, access to treatment can be hindered in a variety of overt and covert ways. It is imperative that key measures of access be closely monitored to ensure that access is not intentionally or inadvertently restricted.

Factors Affecting Access

Access in AOD treatment refers to a variety of diverse factors. Some of the most important factors include:

• Understanding of AOD problems by gatekeepers

• Structured outreach activities

• Timeliness of the first face-to-face meeting after an initial contact

• Geographic proximity to appropriate services

• User-friendliness of the intake and referral systems

• Absence of financial barriers

• Cultural, ethnic, and gender-sensitive treatment

• Adequacy of AOD treatment funding and resources

Understanding of AOD Problems by Gatekeepers

All too often, gatekeepers into treatment are not sufficiently trained or experienced to assess needs effectively and to triage individuals into appropriate AOD treatment. It is crucial that such gatekeepers (e.g., clinicians, primary care physicians) be well-trained, sensitive to the bio-psychological aspects of addiction, and monitored regularly.

Structured Outreach Activities

Structured outreach activities maximize access to a treatment system by providing systematic efforts to identify individuals in need of AOD treatment. Such outreach activities might be directed to pregnant addicted women, homeless AOD abusers, injection drug users, or others whose impact on society is high and who are less likely to seek out treatment on their own.

Timeliness of Treatment

Immediate and convenient initial access to qualified providers is a hallmark of any quality treatment system. A key component of high-quality treatment is how efficiently a person in need can obtain appropriate AOD treatment. The motivation to address AOD problems is often fleeting, and a delay in access can easily result in a crucial missed opportunity to initiate treatment. Contracts with managed care organizations (MCOs) should ensure rapid access to all levels of treatment.

Detoxification should be understood as an emergency care service. Individuals should have very easy access (i.e., same day or the next morning) to detoxification evaluation and treatment services 7 days a week.

While screening can occur over the telephone, evaluations should be face to face. Standards should assure 24-hour telephone intake, immediate referral capacity, and rapid access to appropriate treatment. Noncrisis treatment should generally be available in 1 to 3 days (Zwick and Berman 1992). It may be decided that some subpopulations (e.g., pregnant women, injection drug users) should receive higher priority or more immediate access within the system.

Geographic Proximity

Appropriate treatment services must be within reasonable distance for the population served. The maximum distance in time or miles should be determined for each level of care. Since most publicly insured recipients do not have reliable transportation, services should be accessible via public transportation whenever possible. Special plans may be required in rural areas, including the use of volunteers or members of self-help groups to provide transportation. Any outpatient services should be especially easy to access.

"User-Friendliness" of Systems

The "user-friendliness" of a system describes the overall ease with which an individual can negotiate the various steps of a treatment system. To assure access, when policies and procedures are being developed for an MCO plan, it is essential that ease of use should assume the highest priority. Those who utilize the services offered are in an excellent position to rate their access to that service. For example, information regarding the time to first appointment, ease of telephone access, ease of understanding how to use the system, clarity of written materials, and staff attributes can easily be incorporated into standardized client satisfaction surveys, program/MCO records, and ongoing focus groups.

Absence of Financial Barriers

Uninsured and publicly insured individuals are overwhelmingly poor and disenfranchised. Any financial barriers (e.g., copayments) can be a barrier to access and should be avoided.

Cultural/Ethnic/Gender Sensitivities

Treatment that does not meet the cultural, ethnic, and gender needs of clients is poor treatment and will result in poor outcomes. Such non-responsive treatment restricts the access of those with cultural, ethnic, and gender needs.

Adequacy of AOD Treatment Funding and Resources

Quality AOD treatment requires a comprehensive continuum of treatment services. Many State systems do not support such a continuum, because they lack the resources, commitment, and/or understanding of the value of AOD treatment within such a framework. Any managed care initiative should include an analysis of the AOD treatment continuum and the costs associated with needed expansion. Such information is vital to inform the planning process.

Avoiding Obstacles and Promoting Access

Numerous factors can influence– both directly and indirectly– whether or not an individual obtains and continues to utilize necessary AOD treatment services (see table 3). When poorly implemented, managed care can dramatically reduce access to services. When well implemented, it can substantially increase access to care.

Depending on the structure of the contract, MCOs may have strong financial incentives to create obstacles or to otherwise restrict care. All too often, MCOs receive set amounts of dollars which are insufficient to maintain the array of services needed for supporting stability of the patient. When developing contracts with MCOs, it is essential (1) to guard against incentives to undertreat these vulnerable populations, and (2) to build strong incentives to promote access (Frank 1994; Christianson 1989).

Managed Care in Rural Areas

Implementing managed care programs in rural or frontier communities requires careful planning. Such planning needs to address the unique clinical challenges of rural America.

The Challenges

In rural America, mental health and AOD treatment services have been rationed for decades because of poor accessibility and the lack of human and fiscal resources. Access to quality treatment in rural communities and regions is often limited by a range of challenges. These include:

• Geographic distance

• Concerns about confidentiality

• Community prejudice

• Lack of properly trained providers

• Inadequate support services

• Limited benefits

• A conservative values orientation

Often, the public mental health system is the only provider in rural communities.

Several factors contribute to the difficulty of developing an effective managed care system in rural and frontier States. Poverty and unemployment rates are generally higher. Public transportation is lacking. A disproportionate number of populations are at risk for behavioral health disorders.

Additionally, managed care initiatives have primarily happened in more urban centers, which allow a certain economy of scale. The implications of managed care for rural areas are less clear.

Guidelines for Developing Services

It is important to develop and analyze a baseline inventory of practitioners who are providing AOD treatment services. If that inventory identifies shortages, potential MCO providers can be asked to propose strategies to bring in or recruit professionals in a Request for Proposal (RFP) process.

Managed competition models based upon competition among independent provider groups may not be the most effective model for rural areas. It has been suggested by some that a "managed cooperation model might more effectively improve access and quality of care." This model would create a rural "Authority" that would use subsidies and exclusive franchises to achieve goals. The approach would be flexible, fostering cooperation where needed and competition in areas where sufficient diversity exists. Initiatives involving cooperation would facilitate the development of networks. The managed component would improve the interface between urban and rural areas, coordinate access to tertiary care, and assist in recruiting needed professionals.

When managed care is implemented in rural settings, it is likely that the experience of the company and leadership is more urban than rural in its perspective. It is essential that any implementation in rural areas actively utilize local professional and client groups in adapting managed care principles to rural and frontier settings.

Table 3. Factors Influencing Access to Treatment

Obstacles to Access		Factors Promoting Access
Not identifying individuals in need of treatment		Effective screening, assessment, AOD training
Not reaching clients in the locations in which they enter the "system" (i.e., courts, criminal justice system)		Satellite sites, systematic linkage, training
Long waiting periods for appropriate service		Services within 72 hours, depending on severity of clinical need
Multiple steps, places, and people needed to access services		Widely available and simplified intake processes
Arbitrary service limits		Individualized treatment plans
Automatic "fail first" policies (e.g., the client must fail a less intense level of treatment before a more intense level is made available)		Individualized comprehensive assessment used to guide appropriate placement
Geographic inaccessibility		Geographically well distributed sites located on transportation lines
Resource-intensie review and appeal procedures		Highly effecient, publicly known utilization review processes
Excessive and clinically inappropriate exlusionary criteria		Restricted ability to exclude specified types of hours/day of operation
Cultural, gender, and/or ethnic insensitivities		Priority placed on cultural competence development
Restrictive copayments		Elimination of copayments
Unknown, untimely, or non-objective appeals processes		Widely known, timely, objective appeals
Lack of transportation		Transportation available as needed
Patient placement criteria that are nonstandardized, financially driven, and/or subjectively applied		Patient placement criteria that are collaboratively developed, clinically driven, objective, and standardized

Utilization Patterns As Measures of Access

It is imperative that the managed care industry and the AOD treatment field develop standard access measures, so that data and findings can be easily compared. It is impossible to overstate the importance of consistent data and standardized units of analysis for purchasing, monitoring, and improving care. Accurately managing these data is critical to determining the success of any managed care intervention.

The utilization patterns of various treatment services provide a range of quantifiable measures of access within a managed care system. Also influenced by the quality and outcomes of treatment, these utilization data are easily obtained from medical claims encounter data. They allow systematic comparison of different plans and the ongoing monitoring of overall access.

A review of the literature (Shadle and Christianson 1989; Levin 1993; Mercer 1990, pp. 1-13) suggests that certain measures represent the current state of the art and should be standardized across the managed care spectrum. These state-of-the-art measures include the following:

• Potential purchasers should be aware that AOD treatment often cannot be separated from mental health treatment in MCOs.

• Contracts should ensure that AOD treatment can be analyzed as a discrete entity or it will be impossible to accurately measure access, utilization, quality, or other important variables.

• All levels of care should be separately analyzed, with aggregate totals compiled as needed.

• The utilization rates of clinical subpopulations (e.g. pregnant women, ethnic minorities) should be capable of being discretely analyzed as separate entities.

Recommended annual utilization (unduplicated) profile measures (per level of care) are shown in table 4. Exhibit 1 provides sample contract language regarding actions MCOs should take to provide access to treatment.

• Admissions per 1,000 covered lives (unduplicated)

• Total days or units per 1,000 covered lives

• Mean length of stay (LOS) or mean number of treatment units

• Average cost per case

Example: You are a State AOD director and you are comparing the utilization rates of two MCOs that are competing for a contract. In this example, MCO #1 historically has half the admission rate of MCO #2. However, MCO #1 allows its clients to stay in treatment twice as long, resulting in both MCOs averaging the same amount of treatment days per 1,000 clients. MCO #1 pays an average of $125/day, while MCO #2 pays an average of $150/day. Using these data as a starting point, you continue to request outcome data, readmission rates, customer satisfaction results, and continuing care profiles to inform your decisionmaking.

The MCO hall regularly report on specified utilization data for all levels of care, including, but not limited to, the number of enrolled members, unduplicated admissions per 1,000 covered lives, day/units per 1,000 covered lives, mean length of stay/number of treatment units, and mean cost per case.

The MCO shall provide emergency, urgent, and nonurgent care within specified, clinically responsive timeframes. Emergent care should be offered immediately or within 4 to 6 hours, depending on the situation. Urgent care should be available within 24 hours. Noncrisis treatment should generally be available in 1 to 3 days (Zwick and Berman 1992).

The MCO shall develop an outreach plan with specified objectives and regularly report on its success at reaching those goals.

The MCO shall make and report on systematic efforts to identify, or encoruage the identification of, beneficiaries with AOD problems and refer them for evaluation and treatment.

The MCO shall ensure systematic screening for AOD disorders in those settings most likely to deal with individuals at high risk for AOD problems. These may include standard screening tools as part of initial contact with the system, during routine physical exams, at initial prenatal contact, when "trigger conditions" suggest a high possibility of AOD problems, or when there is evidence of serious overutilization of medical, surgical, trauma, or emergency services.

Last Updated 11-7-02