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INTRODUCTION

Over 80 individuals were involved either as advisors or participants in the meetings. They represented health insurance plans, managed care companies, chemical dependency providers, advocacy groups, physicians, and county and state government. This report reflects the conclusions of the group, in which there was a high level of consensus throughout A list of participants and description of process is outlined in Appendix A.

The Issues Investigation Group, in developing its recommendations, followed the seven criteria developed by the Health Services Effectiveness Committee: (1) equity, (2) access, (3) personal choice, (4) medical necessity, (5) preventive, (6) cost benefit, and (7) based on services not providers. Encompassing these considerations as well as keeping in mind the language of the Health Services Act and current mandates, the Group set forth the following objectives:

1. Define "case-managed chemical dependency services" and any other critical terms.
   
   
2. Identify which services are currently available through most comprehensive, reasonable, cost-effective benefit plans.
   
   
3. Examine which benefit limits and cost control mechanisms are most efficient and applicable to case managed chemical dependency treatment services.
   
   
4. Identify the elements and clinical criteria are necessary to provide clinically appropriate, effective chemical dependency treatment based on the patient's needs, access, choice and services.
   
   
5. Present a summary of the costs associated with chemical dependency and its treatment as well as the cost-offsets, particularly reducing "inappropriate utilization of more intensive or less efficacious medical services."
   
   
6. Prepare a benefit recommendation and rationale.

1. DEFINITION OF CASE-MANAGED CHEMICAL DEPENDENCY SERVICES AND OTHER TERMS

To meet the challenges of providing universal access to health care at an affordable price, health plans will need flexibility and benefits that can be efficiently administered. Case management should be a tool to assist health plans to accomplish these goals, not add new layers of administration. Because treatment episodes for chemical dependency tend to be relatively short in duration, case management with chemical dependency services is primarily concerned with determining appropriate level of care and ongoing clinical review and does not imply added casework activity:

Case-managed chemical dependency services involves the provision of quality, clinically appropriate and cost-effective chemical dependency treatment for a given patient and/or their family applying professional chemical dependency placement, continuing care, and discharge standards administered by state-approved chemical dependency treatment programs.

It is expected that case-management will take place at the last level of contracted risk. Staff model HMOs and capitated providers will perform case-management at the service level. Preferred provider plans will either employ internal utilization review, contract with third-parties to conduct case management independent of ongoing case management at the service level, or contract with providers on a capitated basis. Regardless of administrative structure, the role of case-management is to apply uniform clinical criteria in making decisions around access and coverage.

A small minority of individuals with severe and persistent alcohol and drug addiction may require more intensive casework in relation to long-term care services. This is different from managed care and case-management and would be an additional service, apart from case management, and most likely performed in conjunction with long-term care benefits.

Chemical dependency, alcoholism, other drug addiction: Research often refers to these diseases as "substance abuse." However, "substance abuse," "alcohol abuse" or "drug abuse," as clinically defined in the American Psychiatric Association Diagnostic and Statistical Manual (DSMIIIR or DSMV), are not intended to be covered under the chemical dependency treatment benefit.

"Nicotine dependence" is a substance use disorder under the DSM but the benefit developed herein has not been designed with specific nicotine services in mind. For purposes of pricing this benefit, nicotine dependence will be excluded. However, it would seem appropriate to include smoking cessation services somewhere in the UBP, and it might best fit under the chemical dependency benefit.

2. CURRENT BENEFIT PLANS AND PUBLIC SERVICES

Mandates and Laws Governing Chemical Dependency Coverage

It was agreed that the Uniform Benefit Package (UBP) should not offer less than the coverage for chemical dependency that has been mandated in Washington law for 20 years. RCW 48.21, originally enacted in 1974, mandates treating chemical dependency with parity:

The legislature recognizes that chemical dependency is a disease and, as such, warrants the same attention from the health care industry as other similarly serious diseases warrant...."

In 1986 the Insurance Commissioner adopted WAC 284-53-010 to clarify that intent by defining the comprehensive continuum of services which health plans in Washington State must cover, within medical necessity. These regulations also established a minimum coverage per person of $5,000 every two years; $10,000 lifetime (1986 dollars that have not been adjusted for inflation).

Among the chemical dependency treatment services WAC 284-53-010 requires be covered are medically necessary treatment and supporting services, including medical evaluations, psychiatric evaluations, room and board (inpatient only), psychotherapy (individual and group), counseling (individual and group), behavior therapy, recreation therapy, family therapy (individual and group), and prescription drugs and supplies prescribed by a treatment facility.

HMOs must additionally comply with the federal HMO Act of 1973. Under this law (P.L. 93-222 and its subsequent amendments) HMOs are required to provide medical treatment and referral services for abuse and/or addiction to alcohol and drugs. HMOs typically cover inpatient and outpatient treatment, but virtually all exclude methadone and long-term inpatient chemical dependency treatment.¹

Typical Benefits for Chemical Dependency

A survey of case-managed chemical dependency and mental health benefits conducted by William M. Mercer² revealed plans now typically provide comprehensive coverage for chemical dependency treatment. Table 1 outlines their findings:

Chemical dependency treatment makes up a very small portion of the overall health care premium. Prior to case management, 80% of employees were able to access their inpatient chemical dependency treatment benefit with no limitations.34 In a study of over 3,000,000 lives, MEDSTAT found that chemical dependency payments were under 3.8% of inpatient medical payments, even at its peak of utilization:⁵

In a 1990 study, MEDSTAT⁶ found over a single year a 22.59% reduction in admissions to inpatient chemical dependency treatment and a 20.34% decrease in payments per capita on those treatments. Table 3 shows these changes in relation to other medical benefits.

Public Services

Within the publicly funded sector, services are broader in range of intensity and duration than those common to private treatment. In addition to intensive outpatient and short-term intensive inpatient, public treatment includes transitional care (recovery houses) of 30–60 days, and long-term treatment of 90 days or longer. In addition, hospital stabilization programs for pregnant addicted women provide hospital inpatient care for several weeks, and some residential programs designed to take women with their infant or young children are also available. DSHS also funds a residential facility to provide treatment for persons involuntarily committed. Finally, "ADATSA," a public program utilized by all persons initially needing residential treatment, provides up to three months residential treatment and three months outpatient.

3. BENEFIT LIMITS AND OTHER COST CONTROL MECHANISMS

The National Academy of Sciences' Institute of Medicine has recommended alcoholism and drug addiction be treated as other chronic, relapsing problems such as diabetes and hypertension, with no prespecified day or visit limits. 7 8, 9 Members of the Institute of Medicine, in a subsequent meeting to address health reform, took the position:

A benefit package that prescribes an arbitrary number of inpatient days and/or outpatient visits in order to control costs is most likely to lead to inappropriate utilization in settings and intensity of care, and hinder the flexibility needed to achieve cost effective outcomes¹⁰

Case Management as a Cost Control Mechanism

Case-management has become the preferred method for controlling behavioral health care costs.¹¹ Managed behavioral healthcare companies, generally operating under capitated carve-out contracts, have reported savings to health plans from 23-50% in the first year.¹² One large employer reduced costs for chemical dependency coverage from $85 to $19 per capita per year.¹³ Once established, claims increases have been held to 1% for HMO/PPO coverages and 9.5% for indemnity plans.^{14 15,16}

State health reform is moving to case-management and uniform clinical criteria in place of restrictive limits. Table 4 outlines the chemical dependency benefit structures in five states undergoing reform:

The Washington State Board of Health is among those locally that have recommended against placing limits on chemical dependency treatment under health reform.¹⁷

Minnesota's Experience with Using Case Management for Cost Control

Minnesota's basic health plan for low income, Medicaid and uninsured, Minnesota Care, has a $10,000 a year limit on combined mental health and chemical dependency intensive inpatient treatment. and no limit on outpatient. The actual cost per episode of treatment has been held to $3,000 through use of uniform criteria to make individual case decisions about level of care and duration of treatment. After five years of experience, Minnesota's data provide strong support for using case management in lieu of traditional benefit limits:¹⁸

• Utilization initially increased only 9%, then tapered off.
  
  
• Over the five years, the cost of treatment rose less than 7%, compared to 28% for other medical services.
  
  
• Fewer than half of all patients repeated treatment within 4 years. - Only 3% received 6 or more placements in 5 year period.
  
  
• Treatment costs averaged $3,000 per client for a treatment episode.

Estimates of the Cost of Case-Managed Chemical Dependency Benefits

No studies or research were found that showed limits on benefits to be superior to case management for cost control.

Local chemical dependency case management firms working with the Issues Investigation Group indicated that utilization for inpatient and residential treatment under case management can be kept to a small portion of the total population served.

Lewin-VHI, Inc. recently completed a national actuarial study on four different chemical dependency benefits.¹⁹ The estimate for a plan similar to the one conceived by the Issues Investigation Group of limited residential and short-term, was around $2 per person per month, which would be less than 2% of the premium of the Uniform Benefit Package. The highest estimated cost in this study was $3.75 per person per month for a benefit that included long-term residential, unlimited outpatient, higher utilization and longer duration residential/inpatient, and full drug prevention and education activities.

Based on current market contracts in the Puget Sound area, and on existing data, it would appear that the proposed benefit will capitate under $2 per person per month. The Department of Social and Health Services is working with the Health Services Commission to obtain an actuarial analysis of this proposal, and this data will be available after June 10, 1994.

Appendix B provides more information on Minnesota and the executive summary of the Lewin-VHI analysis.

4. ELEMENTS OF AN EFFECTIVE CHEMICAL DEPENDENCY BENEFIT

Such diverse groups as the American Society of Addiction Medicine, President Clinton's Commission on Model State Drug Laws, the Legal Action Center, the American Managed Behavioral Healthcare Association, and the Washington Business Group (190 of the nation's largest employers) have all called for comprehensive coverage for chemical dependency in health reform, managed like any other medical condition.²⁰ The elements common to all proposals for chemical dependency coverage are:

• Providing a full continuum of care, ranging from low to high intensity, so that patients can be matched through the initial diagnostic evaluation to the lowest cost level of care appropriate to the severity of the condition, and taking into consideration social and clinical factors impacting clinical outcomes.
  
  
• Utilizing well established, uniform criteria to standardize placement and length of stay decisions while also providing baseline data for ongoing case management, quality assurance and outcomes monitoring.
  
  
• Habilitative, social and support services are funded outside the health plan but patients are linked to these through case management.

Comprehensive Coverage

A cornerstone of this benefit recommendation is to use less restrictive alternatives as the mainstay of delivery. However, it is essential that those few who need more intense forms of treatment also are able to receive appropriate, effective care.

Chemical dependency benefits must address the needs of a wide range of individuals of all ages, receiving treatment at different points in the progression, and experiencing different levels of physical, mental, or social impairment as a result of the disease.

Severity of addiction plays a great role in placement determinations: 60% of inpatients are at the high end of severity of addiction, and 60% of outpatients are at the low end of severity²¹ (see Appendix C for full research summary from CATOR). A 21-day residential intensive inpatient treatment in Washington State can be obtained for as little as $2520 for adults, and a 28-day residential adolescent program can cost as little as $3920. If unable to receive effective levels of treatment, individuals only end up revolving in an out of detox, emergency rooms, mental health facilities, and physicians' offices at far greater expense than the cost of appropriate chemical dependency treatment.

Some individuals cannot be treated in outpatient settings. For example, a pregnant addicted woman may require medically managed chemical dependency treatment to complete safe withdrawal from drugs for herself and the unborn baby.

Making the coverage available does not imply that patients will utilize each coverage, or have unlimited access to that modality of care. Intensity of care and duration will be determined on a case by case basis, based on clinical indicators and examination of "appropriate" and "effective" in the case management process. Increasingly services are "blending" inpatient and outpatient programs for patients who live in areas where inpatient facilities are available.

Since the Uniform Benefit Package is intended to provide a benefit floor, basic and affordable while meeting the health needs of most citizens of this state, the benefit herein is also a basic one that will effectively treat the disease. The long-term services needed by the minority may either be provided within the scope of long-term care benefits or funded through another service system altogether.

Medical Necessity

For consistency, the Issues Investigation Group required that every included service must be medically necessary and directly linked to treating the disease of chemical dependency. It also treats chemical dependency as a primary disease, consistent with research that has identified that chemically dependent persons have no greater incidence of mental disorder than the population in general.^{22, 23, 24}

In the context of chemical dependency, medical necessity is used in a broader sense, as defined by the Health Services Commission, to mean "clinical necessity" as well. References to "medical necessity" herein include "clinical necessity."

This UBP recommendation deliberately does not attempt to cover all the psycho-socio-economic needs of individuals and their families presenting for treatment. However, this exclusion should not be interpreted as a denial of the value of support services or the role they may play in facilitating access, outcome, or prevention. As is stated throughout this paper, it is possible that some of these services will be covered under other benefits; if not, they will need continuation under supplemental systems. The group simply determined early that this must be a conservative package that does not create concerns for cost that might lead to excluding chemical dependency treatment altogether.

Likewise, the Issues Investigation Group conceded that it was not realistic to expect that health plans to cover the cost of a full two-year court-ordered chemical dependency treatment program, regardless of the initial medical need of the patient. Therefore, the Uniform Benefit Package would not cover monitoring or treatment required after the person no longer meets clinical criteria for medical necessity. The reverse of this is also important: Individuals should not be denied access to treatment by virtue of court involvement. Medical necessity determinations should be based on clinical criteria, regardless of legal involvements, as regulations now require.

Uniform Placement, Continuing Stay and Discharge Criteria

As case management has become the preferred mode for administering chemical dependency benefits, health policy experts are moving toward national adoption of uniform criteria to guide the medical necessity decisions of case managers.^{25, 26, 27, 28, 29}

President Clinton's Commission on Drug Laws has prepared the Model Managed Care Consumer Protection Act, based on adoption of uniform clinical criteria, to provide reasonable protections to policyholders that they can access the benefits they have paid for. Oregon, Minnesota, Texas, Colorado, New Mexico, Vermont, Iowa, and Massachusetts are among those that have adopted, or are in the process of adopting, standard practice guidelines for chemical dependency.

The American Society of Addiction Medicine, a national group of physicians with specialized education and experience in chemical dependency, over the past decade developed, tested and refined placement and discharge criteria for chemical dependency treatment services, referred to as "ASAM Criteria."³⁰ These criteria are employed across Washington State and the nation, and are a component of the Model Managed Care Consumer Protection Act.

ASAM Criteria identify six primary problem areas for evaluation when making placement decisions: acute intoxication and/or withdrawal potential; biomedical conditions and complications (such as psychiatric conditions, psychological or emotional/behavioral complications of known or unknown origin, transient neuropsychiatric conditions); emotional/behavioral conditions or complications; treatment acceptance or resistance; relapse potential; and recovery environment.

Assessment of the individual's medical status and functioning in each of these areas will determine the appropriate level of care and length of time needed in treatment. Appendix D contains an overview of the ASAM placement criteria for adults and adolescents as well as their glossary of terms, including "medical necessity."

5. RESEARCH ON COST BENEFITS OF TREATMENT

Alcohol and drug problems in 1990 cost Washington State $1.81 billion--$215.8 million in medical care and over $500 million from accidents and deaths related to alcohol and drug abuse.³¹

Prevalence and Cost of Alcohol and Drug Dependence

At least 13.5% of all adults will experience alcohol abuse or dependence in their lifetimes and 6.1% will experience a drug problem, exclusive of nicotine.³² Over 72 illnesses and health conditions have been directly linked to alcohol and other drug abuse (see Appendix E).³³

Between 20% and 40% of all hospital admissions are for conditions related to alcoholism.^{34, 35, 36, 37} As many as 40% of all patients seen by physicians have alcohol problems.³⁸ Alcohol-related hospitalizations among elderly are as common as myocardial infarction.³⁹ Table 5 shows the use of hospitals for medical, psychiatric, and for detoxification before and after treatment for chemical dependency:⁴⁰

Twenty percent of Medicaid admissions in 1990 were for conditions caused by substance abuse,⁴¹ and 38% of all Medicare admissions were alcohol-related.⁴² Substance abusers required twice the length of stay in hospitals when admitted for other conditions.⁴³

Research Findings on Medical Costs for Alcohol/Drug-Related Conditions

• Alcoholics' medical costs were 300% higher than comparable nonalcoholics before treatment for chemical dependency.⁴⁴
  
  
• Children with prenatal drug exposure problems had twice the Medicaid expenditures after birth as children not exposed to drugs.⁴⁵
  
  
• Chemically dependent families used inpatient medical services at four times the rate of families with no chemical dependency.⁴⁶
  
  
• Children of alcoholics incurred medical costs 32% greater than other children. Compared to other children, children of alcoholics:
  • were admitted to hospitals at a rate 24% higher
  • stayed in the hospital an average of 29% longer
  • use nearly two-thirds more hospital days
  • incurred 36% higher inpatient hospital costs.⁴⁷

Cost Offsets of Chemical Dependency Treatment

Over two decades of data consistently show that the cost of chemical dependency treatment is recouped within two to three years of treatment through reductions in other health care services.^{48 49, 50}

• Aetna Federal Employees Health Benefit Plan showed overall health care costs of alcoholics rose from $130 per month to $1370 per month prior to treatment. Three years after treatment they were only $190 a month.⁵¹
  
  
• A 14-year longitudinal study of 3,000 employed alcoholics found that after treatment had a 24% lower health care utilization than non-alcoholics.⁵²
  
  
• A follow-up of 3,572 successfully treated chemically dependents showed a 61% decrease in hospital utilization one year after treatment and a 57% decrease the second year. Even treatment completers who did not remain abstinent decreased hospital use by 35% the first year and 19% the second.⁵³
  
  
• In Washington, ADATSA clients receiving public treatment had half the hospital costs after treatment of non-treated clients.⁵⁴ Infants of pregnant women in public treatment had lower medical costs than babies of untreated women.⁵⁵
  
  
• A study from UCLA calculated for every $1 spent for drug treatment, $11 .54 is saved in medical and social costs.⁵⁶

Families' use of health care has been found to drop by more than 50% after treatment,^{57, 58} with one Blue Cross/Blue Shield plan showing a reduction from S100 a month in the two years prior to treatment to $13.34 in the fifth year post-treatment.⁵⁹

Employer and Societal Cost Benefits of Treatment

When savings from reduction in workplace absenteeism and accidents and increases in productivity are factored in, as well as reductions in crime and violence, dollars spent on treatment are offset even more rapidly.⁶⁰

Appendix F contains more information on cost offsets, including the executive summary of the review of all the research on treatment effectiveness and cost offsets conducted by Rutgers University for President Clinton's Commission on Drugs.

Preventive Services with Chemically Dependent Persons

Courts are the primary intervention agent with chemically dependent persons, and social service agencies the next. Although chemical dependency has been recognized as a medical health problem since the 1 960's, the health care system has not confronted chemical dependency as a primary problem. Washington State health reform provides an opportunity to integrate preventive efforts with health care to identify and treat persons with chemical dependency and "reduce inappropriate utilization of more intensive or less efficacious medical services" (HSA of 1993).

Primary Care Provider Screening and Assessment: Only 32% of primary care physicians in a University of Washington study could effectively diagnose patients with alcoholism; one-third erroneously made psychiatric diagnoses, chiefly anxiety or depression⁶¹ (full article is in Appendix G). In order to reduce the inappropriate use of medical services by chemically dependent persons, it is essential that greater attention be given by health plans to screening and referral to case management.

Screening can be as simple as the four-question CAGE questionnaire⁶², which takes 30 seconds to administer. Group Health of Puget Sound has implemented full protocols for primary care providers to screen and refer patients with chemical dependency. The Chemical Dependency Issues Investigation Group recommends the Health Services Commission, perhaps through the Quality Improvement Committee, recommend systems to improve screening for chemical dependency by primary care providers and other gatekeepers.

6. SUMMARY OF BENEFIT RECOMMENDATIONS

The examination of the previous areas, led to the following conclusions:

1. Chemical dependency treatment, by virtue of its cost-effectiveness, should be the preferred health intervention for alcoholics and addicts.
   
   
2. No single modality has been shown to be effective for all individuals, so a mix of treatment modalities must be available, utilized on the basis of clinical need.
   
   
3. Case management allows cost control while not penalizing those with the highest clinical severity, needing more intensive and longer treatment.
4. Before case management, chemical dependency treatment costs were under 4% of total inpatient claim.
   
   
5. Based on national and local experience, the cost of providing a comprehensive chemical dependency benefit in the Uniform Benefit Package, using case management and uniform placement, continuing stay and discharge criteria, can be expected to be under 2% of the total premium cost, extending current utilization levels.

Benefit Recommendation:

In addition to the specific case-managed chemical dependency benefit, other sections of the UBP appear to cover necessary services for persons with alcohol and other drug problems, and the group makes the following recommendations in this regard:

Detoxification Services

Both clinicians and health plans wish to see detox case-managed, but it must also be immediately accessible, apart from case management, on an emergency basis. The group has recommended that:

1. The UBP should cover not only hospital detoxification but also clinically appropriate alternatives, including residential, medically-monitored detox and outpatient detox, with coverage at the least restrictive level of care in accordance with the uniform placement criteria.
   
   
2. Detoxification facilities should commence case-management upon admission to facilitate referral to treatment, but case-management should not be a prerequisite to accessing detox.
   
   
3. Detox be covered under medical/surgical coverage unless it is provided as part of a full case-managed chemical dependency treatment plan.

Collateral Services

Collateral services under the case-managed chemical dependency benefit of the UBP should be covered only when provided as part of an intensive treatment program, and as medically necessary. Among services needed by some patients are urinalysis and other laboratory tests, medical consultation, medications prescribed by the physician of the chemical dependency treatment facility, psychological evaluation/consultation, and acupuncture.

Preventive Services

Preventive Counseling and Intervention: It is far less costly to provide limited counseling to chemically dependent persons feeling at risk of using drugs or alcohol than to serve them after they have relapsed. To encourage preventive intervention the Preventive Services section of the UBP should specifically identify relapse prevention counseling.

Brief Intervention: One of major tools for families to deal with a chemically dependent relative is "chemical dependency intervention." This consists of a several structured sessions designed to assist families in designing a strategy to confront the dependent person and break the cycle of denial. It often results in treatment for the dependent person and usually provides strong support for the family in crisis. The Issues Investigation Group presumes this fits under "Preventive Services" and raises the issue for clarification and perhaps specification.

Services Not Included in Chemical Dependency Treatment Benefit

Inclusion into the "Case-managed chemical dependency services" benefit was based on direct relationship to treating the person with the addictive disease, and direct relation to the addiction itself. It was also narrowed to exclude some publicly funded social, rehabilitative, and support services. This is not to say these services are not essential and do not need continued funding. It is simply an attempt by the Issues Investigation Group to provide the Health Services Commission with a clinically-based, consistent approach to drawing the boundaries around a service that in the public sector has become quite blurred.

Long Term Care: These recommendations have not attempted to incorporate the full range of individual and community-wide services required by a small group of chemically dependent persons who repeatedly access detoxification centers as well as emergency rooms, hospitals, and primary care physician's offices. It is important, however, to note that special long-term services must continue to be funded, whether through long-term care benefits or through supplemental delivery systems.

Support Services: Publicly funded services have encompassed an array of supportive services, such as housing, living assistance, child care, transportation, and vocational rehabilitation, which enhance the total rehabilitation of individuals with needs beyond primary chemical dependency treatment. These support and habilitative services would be funded independent of the health care system. Therapeutic child care, provided in conjunction with a parent in treatment, would also be a separately funded activity.

Chemical Dependency Family Counseling: When the chemically dependent person enters treatment, family members and other significant persons (including employers) are given ancillary education and counseling, and this is included in the UBP recommendation. However, family members often seek out counseling prior to the dependent person entering treatment. As pointed out earlier, family members are as great a source of health care utilization as the alcoholic/addict, but in order to keep a minimal service package, this was not incorporated into the "Case-Managed Chemical Dependency Services" benefit. It is possible that these services might be covered under mental health benefits and, to a limited extent, under Preventive Services.

Child Care: Neither therapeutic child care nor day care are included in this benefit recommendation. When therapy is provided to children of chemically dependent persons as an adjunct to that treatment, it is assumed that the child will have mental health benefits to cover their services. Other forms of child care would be funded by the Department of Social and Health Services or other supplemental systems.

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²Anderson D.F., and Berlant, J.L. Managed mental health and substance abuse services. In Kongstvedt, P.R. (Ed), The Managed Health Care Handbook, 2nd Edition. Aspen Publishers: Gaithersburg, MD, 1993, pp 130-141.

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⁹Lewis, D.C. The rationale for including a substance abuse benefit in health care reform: Medical, research, economic and community perspectives. George Washington 10 University, Intergovernmental Health Policy Project, 1994, pp. 3-5.

¹⁰Lewis, D.C. Ibid.

¹¹McArdle, FB and Mahoney, JJ. Report prepared by Hewitt Associates, employee benefits consulting firm, for the Subcommittee on Health and the Environment, Committee on Energy and Commerce, United States House of Representatives on Mental Illness and Substance Abuse Benefits, December 3, 1993.

¹²Geraty, R., Bartlett, J., Hill, E., Lee, F., Shusterman, A., and Waxman, A. The impact of managed behavioral healthcare on chemical dependency treatment. Behavioral Healthcare Tomorrow, 1994: Mar/Apr, 18-30.

¹³Larson, M.J., and Horgan, C.M. Issues in calculating the cost of a substance abuse benefit under health care reform. Intergovernmental Health Policy Project, The George Washington University, Washington, DC 1994.

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Last Updated 11-7-02