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Chapter 4—Building Support for Adopting UPPC

This chapter describes benefits associated with adopting uniform patient placement criteria (UPPC). Special issues to consider in adopting criteria, such as the need to use them flexibly, are addressed. The remainder of the chapter outlines an approach to build support for UPPC among a variety of stakeholder groups at the State level.

General Benefits

The primary benefit expected from UPPC is the effect they will have on promoting quality, individualized care. Effectively implemented, UPPC can provide a common framework for matching patients to the levels of care that best address their needs. UPPC have the potential to define, in a common language, a range of services and to facilitate patients' access to them. Once established within a continuum of treatment options, uniform placement standards can help balance the sometimes competing needs for quality and cost effectiveness.

The usefulness of UPPC will be seen in both treatment planning and treatment outcomes evaluation. As with assessment, making placement decisions is an ongoing process, not a one-time event. As patients move through the treatment continuum, decisions about continuing services in the current level in which the client is placed can be reexamined. The outcomes of placement can also be periodically reevaluated. Data obtained from evaluation can then be used to further refine placement decisions, creating a feedback process leading to improved care. An additional result will be a more empirically sound database to use in researching and evaluating treatment content, system gaps, treatment needs of special populations, and geographic distribution of services.

Improving Assessments

The use of UPPC will demand a multidimensional approach to alcohol and other drug (AOD) abuse problems that can address the biopsychosocial nature of addictive disease. UPPC can be used to take into account the various dimensions of patient care and to look at the whole person, identifying for each patient the aspects of illness that are universal and those that are unique to the individual. By structuring the assessment process, UPPC can become a positive force that assists providers in looking at the broad range of treatment options. UPPC guarantee that the assessment addresses the components necessary for successful treatment.

Uniform criteria will require the clinician to focus on observable measures of the severity of illness. Therefore, as a UPPC system is adopted, an anticipated benefit is the impetus it will provide for the development of more precise screening and assessment instruments, particularly to measure dimensions such as treatment acceptance or resistance, and relapse potential.

Improving Treatment Plans

Two essential elements of UPPC will improve individual treatment plans. The first, a thorough assessment, identifies the patient's strengths and needs and assists the clinician in focusing on the patient's most severe problems and barriers to recovery. The treatment plan, like the assessment, becomes more multidimensional.

The second element, continued stay criteria, addresses why the patient is staying in treatment and what outcomes are expected. Reassessment of patient needs and responses to treatment strategies based on the continued stay criteria guide adjustment of the plan. The individualized treatment plan is thus an evolving document, changing as patient issues are resolved, when outcomes are met, or when treatment strategies do not achieve the desired effect.

Perhaps most important, patients can be more effective partners in their own treatment when the problems being addressed and the desired outcomes are clearly articulated.

Economic Benefits

Differing costs of treatment are associated with intensity of care. Although less expensive treatment may be desirable, most treatment providers would agree that treatment is not cost effective if it is the wrong treatment. Instead, providing the right treatment at the right intensity is inherently cost effective.

Some managed care systems are finding that patients are placed into a particular level of care for addiction treatment services simply because it is available—even if it provides a more intense level of care than necessary. This is neither cost effective nor benefit effective and creates an obvious financial burden. UPPC can promote more efficient contracting for services because there is a check on specific treatment needs, independent of the availability of treatment slots.

Some rural communities with a scarcity of social services find themselves paying for higher cost residential AOD treatment services that are clinically unnecessary. UPPC can clarify when communities are making inappropriate clinical decisions. They can point to the need for more economical choices in resource allocation. In Alaska, for example, most geographic areas have no available community treatment options for nonresidential AOD abuse care. Thus, patients receive only inpatient AOD treatment, when they could benefit equally from outpatient treatment. Having outpatient treatment resources would reduce the overall cost of AOD services. In other parts of the country, historical or funding policy has led to a reliance on inpatient or residential care and an overuse of these costly services for clients who might benefit just as much from lower cost outpatient treatment.

The assumption that "inpatient treatment is best" is being challenged by some outcomes studies. One study of the determinants of treatment placement found that persons with drug-related problems (other than alcohol) who received outpatient treatment had superior outcomes to those who received inpatient treatment. Patients with alcohol problems had similar outcomes in inpatient and outpatient settings (Harrison et al., 1988).

It is important to recognize that the more expensive option of residential treatment is essential for some patients. Offering more than just a stable living environment, residential care provides a therapeutic milieu that may be a critical factor in the successful treatment outcome of some patients. For example, residential care is indicated for many patients who are dually diagnosed or who have functional deterioration in life skills.

Other patients who do not have a clinical need for residential care may have no other option that will provide the intensity of services required. For such patients, placement in residential care will be the most cost-effective treatment: multiple unsuccessful placements will be avoided and healthcare costs associated with continued alcohol and drug use will be reduced. A distinction should be made between hospital-based residential care and community-based residential care, as the cost differential between the two types of care is significant.

An additional clinical and economic benefit of establishing uniform criteria is that UPPC will alter less effective treatment paths that can result from established referral relationships or other nonclinically based referrals.

Implementation of UPPC will provide research opportunities that could furnish a firm scientific basis for treatment choices. UPPC, regularly updated by research findings, may help clinicians identify the clients who will benefit most from each level of care. Placement decisions made in this manner will ensure true cost and benefit effectiveness.

Program personnel must realize that reimbursement changes following the establishment of UPPC may not automatically result in initial direct benefits for the program itself. Rather than resulting immediately, financial payoffs for implementing UPPC are more likely to occur over time, as the continuum of care becomes more cost effective and patient care and outcomes improve.

Because many public and private funding sources now use different criteria, treatment providers must use valuable staff time to describe their clients and programs in the language of each funder's criteria. Uniform criteria will allow treatment providers to focus on a single set of criteria that is clinically relevant. Staff time and paper work related to admission, continued stay, and payment arrangements will decrease in proportion to the number of funders relying on the established criteria.

UPPC will help prepare public providers who currently receive their funding from State allotments to receive third-party reimbursements and become more competitive with private programs. Uniform criteria can help many programs and systems prepare for managed care and healthcare reform, because inherent in both is the expectation that programs consistently use established assessment, continued stay, and discharge criteria.

The most clear-cut economic necessity for programs to adopt PPC occurs in States where licensing regulations include such requirements, as in Montana. Massachusetts has included PPC in its contracts for treatment of public-sector clients. Minnesota more directly links funding to the use of PPC. Treatment providers are not reimbursed for treating public-sector clients if those clients were not assessed and placed according to the State's PPC.

Establishing a Common Language

Uniform criteria can bring stability and consistency to the field of AOD treatment, allowing diverse disciplines and organizations to work together. Once implemented, they can provide a common agenda, a common language, and shared expectations about treatment across different groups of multidisciplinary service providers, payers, policymakers, and others. For example, when employee assistance programs (EAPs) and case managers use the same criteria, fewer problems will occur when EAPs refer managed care patients into the treatment system. Good communication in this area assures employers that their employees are getting cost-effective care.

Some commonly used terms have different meanings to different providers. For example, the term "outpatient treatment" can mean: very low intensity early interventions, a structured program meeting several times a week, or daily partial hospitalization. Similarly, "non-hospital-based residential facilities" are, in some areas, sober houses with no professional staff, and in others, highly structured programs with multidisciplinary treatment teams and 24-hour nursing.

In addition to standardizing terminology, UPPC can provide a common basis for understanding the immediate and long-range needs of patients in treatment. They constitute a framework for a variety of groups to use as they engage in a collaborative planning process, especially when more than one system is involved, such as the criminal justice system or human services.

UPPC as an Element in Outcome Evaluation

UPPC, when implemented in conjunction with an outcomes monitoring system, provide several avenues for the improvement of treatment, as they:

• Allow for valid comparisons between programs because common language is used to describe each level of care
• Provide feedback on whether the UPPC are being uniformly applied
• Provide feedback on criteria validity based on the outcomes of clients with certain characteristics who are placed in a specified level of care.

The Center for Substance Abuse Treatment is developing another TIP in this series that will provide detailed information on outcome evaluation, Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment.

Some States are already using patient placement criteria as a starting point to generate outcomes data. This is part of a strategy to demonstrate to legislatures that different levels of care are necessary to address the needs of diverse patients.

UPPC as a Needs Assessment Tool

Use of UPPC can help States identify gaps in the continuum of care, and thus they can be a valuable tool in needs assessment. In rural and other areas where there are limited treatment options, use of UPPC can help document the number of clients who would be referred to a specific option if it were available. Such documentation, used in conjunction with information from the Federal minimum data requirements and waiting lists, can stimulate reallocation and development of needed resources. For example, such data can give added weight to arguments to State legislatures and other funding bodies. In this way, UPPC can influence the development of treatment options in a dynamic, empirically based manner, providing a conceptual framework that will make it possible to identify needs and develop services to meet them.

UPPC and Managed Care

The growth of managed care has already had a significant impact on the U.S. healthcare system by:

• Increasing the emphasis on a continuum of care
• Increasing the importance of assessment
• Creating more focused treatment plans.

There remains a concern that care is being rationed as a result of managed care, to the extent that some persons are denied the services they need. (Rationing is discussed in detail in Chapter 6.) The establishment of UPPC will result in better communication between managed care organizations and treatment providers, as both entities will be using the same criteria for placement, continued stay, and discharge decisions. Consumers and purchasers of services can make comparisons between plans, evaluate levels of care, and monitor outcomes. Health plans will then compete on the basis of quality, cost, and outcomes. It is hoped that the establishment of UPPC can bring a greater degree of consistency and stability to the patient placement process.

Most third-party health insurance plans limit coverage to services and supplies that are "medically necessary." While plans may define the term differently, the intent is to exclude from coverage unnecessary treatment services, equipment, and supplies. Most plans' definition of medically necessary services include, at a minimum, the following elements:

• The service must be ordered by a professional whose license qualifies him or her to diagnose and deliver treatment
• It must be of the proper quantity, frequency, and duration for the condition being treated
• It must not be experimental or investigative.

Failure to satisfy the second element is generally the issue in disputes between AOD treatment providers and third-party payers. The argument often centers on whether the course of treatment is consistent with generally recognized medical standards. The ultimate resolution of many such disputes is in a court of law. The courts take into consideration the contractual terms of the plan or policy, as well as the differing opinions or testimony of medical experts. The outcomes of disputes that are settled prior to litigation are, of course, influenced by how the courts have settled similar cases in the past.

Uniform patient placement criteria, if they are developed according to the consensus-building process outlined in this document, will represent the opinions of AOD abuse treatment providers from many disciplines. The criteria may be viewed by courts as reflecting generally accepted medical practice, especially as the criteria become widespread. In situations in which an insurer or payer has applied its own criteria or standard of medical practice rather than UPPC, the issue in court will in all probability focus on whether the insurer's criteria are significantly different from those of the medical and AOD treatment community.

As UPPC gain acceptance, the standard they provide will help resolve disputes before litigation is necessary (see Chapter 7, Ethical and Legal Issues).

Development and implementation of patient placement criteria must address the unique characteristics of populations being served and of the treatment delivery system. The establishment of UPPC will help improve the system and help define what services are needed, but UPPC will not solve all cultural, political, and financial problems. While it is clear that uniform patient placement criteria can be valuable both locally and nationally, the benefits described in this chapter must be considered in light of several considerations.

Array of Resources

One immediate concern about the use of any set of patient placement criteria in a given geographical area is the availability of treatment resources. Not all areas will have the array of levels of care described in the criteria. In some cases, criteria can be adapted to fit the available resources. For example, in its outpatient criteria, Minnesota included an exception that allows the use of inpatient treatment when outpatient treatment is not within reasonable driving distance.

When the array of resources is adequate for most patients, there may still be gaps for patients who have unique characteristics or needs. Programs addressing the needs of members of special populations may be limited to offering one level of care because that is all the population can support. In the future, unbundling may alleviate some of the problem (see the discussion of unbundling in Chapter 3), but in the current environment, either the criteria must address these situations directly or the implementation must be flexible enough to allow for special circumstances.

While UPPC will help define the continuum of care, identify gaps, and facilitate filling those gaps, it is important that any lack of resources be identified and taken into account as UPPC are implemented.

Clinical Judgment

No set of criteria is likely to address the needs of every client. Rigid adherence to a set of criteria with, for example, four levels, could result in a "four sizes fit all" approach. This result would be only a marginal improvement over the "one size fits all" approach, predominant in the 1970s. The implementation of criteria must allow for flexibility on the part of clinicians to deviate from the levels of care to address the needs of the individual client.

A rigid or bureaucratic use of the criteria could result in placements made according to the criteria only, rather than on the treatment provider's knowledge of the client. For example, a clinician might place the patient in a higher level of care than the clinician believes is necessary, to avoid malpractice suits that might result if he or she deviates from the criteria. In other instances, a clinician might recommend placement in a lower level of care than is necessary due to the client's financial constraints, or because the clinician has difficulty describing the client's needs to fit the guidelines for a higher level.

While the panel recommends that scales and instruments be developed to assist in conducting multidimensional assessments, these tools are an aid to—not a replacement for—trained clinical judgment based on the clinician-patient relationship.

Program Development

Care must be taken to ensure that creativity in program development is not stifled by PPC. The criteria can describe the continuum of care only as it exists, or as sound research indicates it should change. However, the AOD treatment field is continually seeking ways to improve programs, and criteria should not force providers to fit molds or adhere to rigid descriptions of programs.

One benefit of UPPC will be the contribution they make to research findings, especially in regard to identifying elements of effective programs. Treatment providers can then incorporate these findings in their treatment services. While this is a benefit, it also creates a problem. The criteria must be revised regularly to incorporate new findings or they will become outdated. Outdated criteria would prevent, rather than promote, sound care.

Financial Incentives

The usefulness of UPPC will be severely limited in a payment and treatment delivery system that has financial incentives supporting over- or underutilization of specific levels of care. In Minnesota, at the time PPC were implemented, free or sliding fee treatment was available at residential units at State hospitals; however, no free or sliding fee outpatient treatment was available. PPC for outpatient programs were thus of little consequence for many clients until the funding system was changed.

Underutilization is a concern when funders are not held responsible for the outcomes of treatment, or are not at financial risk for repeat placements. Again using Minnesota as an example, there is concern that incentives are not encouraging managed care organizations to take long-term cost offsets into consideration in their provision of short-term care. As Minnesota moves to the use of managed care organizations to cover primary outpatient and inpatient AOD treatment for Medical Assistance clients, funds for extended residential treatment and halfway house services are provided by a separate, publicly paid system. This split responsibility for AOD treatment may have created the incentive for managed care organizations to divert clients to the public system.

Uniform patient placement criteria can be proposed as a positive, proactive approach to improving AOD treatment services. They can be part of the organizational system of healthcare reform occurring in many States and may eventually be mandated for all States, counties, and regions. They imply a structured system of care with linkages to other systems and seamless movement among AOD abuse treatment and other medical and social services.

Before benefits can be realized, however, support is necessary from the many people involved in planning and providing AOD treatment. Support must come from the State, from public and private providers, from practitioners, from policymakers and legislators, from provider associations, from consumers, from managed care representatives, and from other third-party payers. Not only must all these stakeholders commit to the concept of UPPC, the reasons for their commitment must be clear and well articulated.

Although the most compelling reason for implementing UPPC is the enhancement of patient care, this conclusion is often reached "through a back door." It is frequently the cost-effectiveness argument that most persuasively convinces stakeholders of the value of UPPC, while improved patient care is viewed almost as a byproduct. For this reason, it is important to establish universal standards of care that serve to balance quality and cost effectiveness.

An early step in building support for uniform criteria is to adopt a biopsychosocial view of the concept of medical necessity. This panel recommends adopting a definition of medical necessity similar to that used by the American Society of Addiction Medicine in its PPC (Hoffmann et al., 1991). That definition reads, in part:

Medical necessity pertains to necessary care for biopsychosocial severity and is defined by the extent and severity of problems in all six biopsychosocial assessment areas of the patient. Because psychoactive substance use disorders are biopsychosocial in etiology and expression, assessment and treatment are most effective if they, too, are biopsychosocial.

This inclusion of patients' psychological and social as well as medical needs is a critical prerequisite for the inclusion of AOD treatment services under healthcare reform. Without such a broad and explicitly stated definition, the term "medical necessity" may be overly restrictive and may imply an incomplete understanding of addictive illness. In the current context of healthcare reform, the importance of defining healthcare broadly enough to include addictive illness cannot be overemphasized. A narrow view will not address the interests of many stakeholders.

Conflicts about adopting UPPC can pinpoint differences that may ultimately lead to constructive resolutions. All stakeholders should be included in the planning discussions, as they are a critical part of developing any policy or set of criteria. They are motivated by a variety of reasons, some political, some financial. Other stakeholders are concerned with shifting State priorities. It is important that State agencies and providers understand and consider each other's points of view. While one group of stakeholders may be looking at improved patient care and outcomes, another may be focused on cost savings. The more inclusive the process of developing UPPC, the more beneficial the process will be for all parties.

Concerned Stakeholders

The following groups of stakeholders should be considered in the support-building process:

• State AOD agencies and policymakers involved with healthcare reform have a unique responsibility in that they have a leadership role in balancing funding limitations with concerns for access to high-quality appropriate care.
• Consumers and their families have perhaps the greatest stake in the thoroughness of assessment and the appropriateness of placement.
• Managed care companies and other public and private funders require assurance that funds are being used wisely and that decisions about services are made objectively rather than in the self-interest of the provider. Improvements in the quality of treatment reduce incidences of relapse and the long-term need for other medical and social services.
• Other healthcare providers, mental health professionals, benefits administrators and consultants, criminal and juvenile justice personnel, social service providers, and community advocates have a major interest in ensuring easy access to appropriate care and in knowing when and where to refer. Improvements in the quality of treatment will reduce the human costs of AOD problems and the financial cost to other service delivery systems.
• Professional societies in the AOD treatment field will be more responsive to change and can help garner support if they are included in the dialogue.
• State legislators have complicated interests in that they are, in a sense, both policymakers and the general public. Legislators are often asked: What are you doing to solve the drug problem? The consistency and accountability that UPPC can provide for the AOD treatment field can furnish a valid response to the constituents' question.
• Employers that pay for employee healthcare coverage and their EAPs have a significant financial interest in the approach to treatment services.
• Labor leaders and union representatives have the responsibility of negotiating contracts that set care requirements for large employee groups and of protecting workers from unfair practices.
• Utilization reviewers have the responsibility to ensure that patient care is based on clinical necessity and severity of illness. UPPC will have an impact on the criteria used by managed care providers, who depend on utilization reviewers to monitor patient treatment records for adherence to the principles of appropriate care.
• Medical ethicists struggle with the uncertainty of the "right" answers to questions concerning medical policies or care. They are responsible for weighing facts and values to recommend ethically permissible options for a particular case. Their support is necessary to help providers deal with ethical issues relevant to UPPC.
• Individuals and groups who conduct treatment research have an interest in UPPC because they can use the criteria to help identify and prioritize areas of research that will help advance AOD treatment services and policy.
• Native American leaders have sovereign authority over regulating practices on their lands. Their AOD providers are treating a population that is unique in this respect, and they are usually working with minimal resources.
• The general public is concerned that little is being done to solve the far-reaching social and criminal problems that are caused by alcohol and other drugs. UPPC can provide confidence that appropriate and coordinated treatment services are in place and that tax dollars are not being wasted.

Support From the AOD Treatment Field

Clinical providers are an important part of the necessary "buy-in" to UPPC, and the States that have implemented uniform criteria have included providers in their planning process. Treatment providers have knowledge and experience necessary to the development of UPPC. In many cases, they are ahead of public policymakers in considering the important issues in implementation of UPPC.

Even as the value of sharper definitions within the AOD abuse treatment delivery system becomes apparent, these definitions can also be intimidating to the treatment community. By calling attention to the need for a complete array of treatment services, UPPC will set standards that individual programs must attempt to meet. Research on the efficacy of certain types of AOD treatment is sparse, and standards of care are not always well defined. The establishment of UPPC may have the effect of bringing a different set of policymakers to the table with new expectations about outcomes. These additional demands can result in new challenges and difficulties.

For these reasons, additional attention must be given to the interests of AOD treatment providers as the move toward UPPC evolves. Understandably, not all providers will react the same way to a proposal to implement uniform criteria. Those providers who have initiated the use of patient placement criteria in their programs will be valuable resources in a systemwide effort. However, other providers have not yet considered the use of PPC, and have not had the opportunity to examine the possible benefits of systemwide implementation.

In seeking support for UPPC, policymakers can rely on the interest of all providers in improving treatment for their clients. The most compelling reason for providers to support UPPC will be providers' enhanced ability to consistently provide thorough assessments, make appropriate placement determinations, and monitor clients' progress through the course of treatment.

Public programs often view patient placement from a different perspective than private programs. In many public programs burdened by long waiting lists, overextended resources, and the needs of a complex population, time-consuming discussions about patient placement are a lower priority than the need to provide immediate services. It is important that personnel in public programs appreciate that UPPC may eventually reduce the time required for proper placement decisions by providing an easily accessible framework for moving patients into and through a continuum of AOD treatment.

Treatment providers will also support the implementation of UPPC in the interest of protecting revenues and market share for their programs. Survival in the changing world of healthcare reform and managed care may require the use of UPPC. Managed care organizations have expressed a preference for contracting with providers that place clients in the least restrictive, appropriate level of care, and which use specific stay and discharge criteria. If, as in some States, patient placement criteria are required for licensing, the very existence of a program can depend on implementation of UPPC.

Use of UPPC can enhance services and facilitate resource reallocation throughout the continuum of care. Their use can also reveal where new services are needed. However, treatment providers and other professionals who fear that reallocation of resources will result in decreased funding for their own programs may see this as a drawback rather than a benefit. To gain their support, the likelihood of improved outcomes and long-term economic benefits should be emphasized.

As uniform criteria are adopted, providers may need help to restructure their services. Reallocation of resources does not necessarily mean that current providers will cease to exist and new ones will take their place. Providers that traditionally provided intensive services in highly restrictive settings may initially see a reduction in census. At the same time, there may be an increase in demand for a variety of outpatient resources. The experience of trained and committed treatment providers will continue to be needed and their services can be adapted to meet emerging needs.

At the time of implementation, some treatment providers may not be ready to support UPPC. They may simply be required to participate, through methods such as funding or licensing requirements.

To realize the benefits of implementing UPPC, it is crucial to garner support from a wide variety of stakeholders. The interests of each must be considered. A spectrum of reactions can be anticipated, ranging from advocacy to resistance, and a variety of strategies will be needed to obtain support.

Last Updated 11-7-02