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CORK Bibliography: Managed Care

72 citations. 2003 to present

Prepared: June 2011

Alexander JA; Lemak CH; Campbell CI. Changes in managed care activity in outpatient substance abuse treatment organizations, 1995-2000. Journal of Behavioral Health Services & Research 30(4): 369-381, 2003. (21 refs.)

Using nationally representative data from 1995 and 2000, this study examines trends in managed care penetration and activity among outpatient drug treatment organizations in the United States. Further it investigates how managed care activity varies across different types of treatment providers and for public and private managed care programs. Overall, managed care activity has increased, with a greater proportion of units having managed care arrangements and a larger percentage of clients covered by managed care. In general, public managed care activity has increased and private managed care activity has decreased. Treatment providers report that they have fewer managed care arrangements, which may reflect consolidation in the managed behavioral care secto. Finally, growth in managed care among outpatient substance abuse treatment units affiliated with hospitals and mental health centers may signal a preference for providers that can effectively link substance abuse treatment with medical and social service provision, or alternatively, that linkages with such organizations may provide the size necessary to assume the risks associated with managed care contracts.

Alexander JA; Nahra TA; Wheeler JRC. Managed care and access to substance abuse treatment services. Journal of Behavioral Health Services & Research 30(2): 161-175, 2003. (29 refs.)

As managed care organizations promote the use of gatekeepers, specialized utilization review, and outpatient over inpatient care, concerns have been raised about how managed care has altered the quality of and access to behavioral treatment services. This study examined how managed care penetration and other organizational characteristics were related to accessibility to outpatient substance abuse treatment. Nationally representative data from 1995 and 2000 was used in this evaluation. Client access was determined at an organizational level as the percentage of clients unable to pay for services, the percentage of clients receiving a reduced fee, and the percentage of clients with shortened treatment because of their inability to pay. Treatment units with midrange managed care penetration were least likely to support access to care. The complexity of managing in an environment of conflicting incentives may reduce the organization's ability to serve those with limited financial means.

Atkinson JS; Whitsett D. Severity of common personal and substance abuse related problems in low-income women: Implications for treatment. Journal of Addictions Nursing 14(1): 27-33, 2003. (32 refs.)

Many states are now moving toward enrolling Medicaid recipients into managed care programs. This presents both opportunities and challenges to providers treating individuals with personal adjustment and/or substance abuse problems. A comparative research design was used to describe two groups of low-income women in Houston, Texas: 133 chronic drug users and 381 non-drug users. Participants were administered the Multidimensional Addictions and Personality Profile (MAPP) in order to measure personal adjustment and substance abuse problems. The results show that while many of the nonusers in the sample may only require moderate outpatient services, a substantial proportion of drug-using women (31%) required inpatient hospitalization for personal adjustment or substance abuse problems. An additional 12% of drug users had substance abuse problems or personal adjustment problems sufficient for referral to in-hospital treatment with substantial structured aftercare. We endorse a multidimensional approach in providing services to low-income individuals within a managed care setting.

Auller BE; Rieckmann T; McCarty D; Smith KW; Levine H. Adoption of naltrexone to treat alcohol dependence. Journal of Substance Abuse Treatment 28(3): 273-280, 2005. (22 refs.)

Three surveys (1997, 1999, and 2001) of outpatient substance abuse treatment centers in Connecticut, Massachusetts, Rhode Island, Maine, Vermont, and New Hampshire examined organizational characteristics that influenced the adoption of naltrexone. Structural equation modeling with manifest variables assessed predictors related to the use of naltrexone. Use of naltrexone increased over time from 14% in 1997 to 25% in 2001. In 1997, programs funded by managed care were more likely, and clinics that provided only substance abuse services were less likely to use psychiatric medication and naltrexone. In subsequent years, counselor education level and organization size also influenced use of naltrexone.

Bachman SS; Drainoni ML; Tobias C. Medicaid managed care, substance abuse treatment, and people with disabilities: Review of the literature. (review). Health & Social Work 29(3): 189-196, 2004. (52 refs.)

Most states enroll individuals with disabilities who receive Supplemental Security Income (SSI) in Medicaid managed care plans. The impact of managed care on these individuals, especially those with substance abuse disorders, is not well understood. A review of the literature related to substance abuse, disability, and Medicaid managed care suggests that substance abuse is a serious issue for individuals with disabilities. More research is needed to determine how the substance abuse treatment needs of individuals with disabilities can be met through Medicaid managed care. The authors identified topics for a research agenda on the needs of individuals with disabilities who also experience co-occurring substance abuse disorders. Implications for social work policy and practice are discussed.

Bachman SS; Drainoni M-L; Tobias C. State policy and practice regarding substance abuse treatment services for Medicaid recipients with disabilities. American Journal on Addictions 12(2): 166-176, 2003. (31 refs.)

This article presents the results of an exploratory study conducted to identify best practice Medicaid managed care models for people with disabilities who need substance abuse treatment services. These results suggest that there is wide variation in the managed care strategies that states use to provide substance abuse treatment services to the SSI disabled population, that state policymakers are often focused on general program management issues rather than addressing specific issues related to providing substance abuse treatment services to people with disabilities, and that although managed care theoretically offers opportunities for creativity,this practice does not appear to be widespread under current Medicaid managed care arrangements for people with disabilities.

Barglow P. Comparison of VA intentional and unintentional deaths. American Journal on Addictions 13(4): 358-371, 2004. (17 refs.)

This retrospective clinical study contrasts 22 unintentional ('accidental') deaths with 31 intentional (suicide) deaths of patients obtaining psychiatric care in a mid-sized VA Health Care system during 1993 - 1998. Unintended deaths were more frequently associated with addicting agents, particularly opioids. The number of such incidents increased from 1993 - 1998, a phenomenon that appeared to be associated with the implementation of managed care. These findings challenge rapidly changing psychiatric care systems to generate more effective treatment methods for dangerous addiction pathology despite decreasing numbers of substance abuse personnel per patient.

Barry CL; Ridgely MS. Mental health and substance abuse insurance parity for federal employees: How did health plans respond? Journal of Policy Analysis and Management 27(1): 155-170, 2008. (44 refs.)

A fundamental concern with competitive health insurance markets is that they will not supply efficient levels of coverage for treatment of costly, chronic, and predictable illnesses, such as mental illness. Since the inception of employer-based health insurance, coverage for mental health services has been offered on a more limited basis than coverage for general medical services. While mental health advocates 14 view insurance limits as evidence of discrimination, adverse selection and moral hazard can also explain these differences in coverage. The intent of parity regulation is to equalize private insurance coverage for mental and physical illness (an equity concern) and to eliminate wasteful forms of competition due to adverse selection (an efficiency concern). In 2001, a presidential directive requiring comprehensive parity was implemented in the Federal Employees Health Benefits (FEHB) Program. In this study, we examine how health plans responded to the parity directive. Results show that in comparison with a set of unaffected health plans, federal employee plans were significantly more likely to augment managed care through contracts with managed behavioral health "carve-out" firms after parity. This finding helps to explain the absence of an effect of the FEHB Program directive on total spending, and is relevant to the policy debate in Congress over federal parity.

Beattie M; McDaniel P; Bond J. Public sector managed care: A comparative evaluation of substance abuse treatment in three counties. Addiction 101(6): 857-872, 2006. (73 refs.)

Aims: A study of publicly funded substance abuse treatment systems compared MidState, a county that reorganized its treatment system using managed care principles, to two other California counties that took different approaches, NorthState and SouthState. It was hypothesized that MidState would have better outcomes due to its emphasis on quality of care. Design: This natural experiment compared the 'experimental' county, MidState, to two 'control' counties, assessing client outcomes following treatment. Administrative and historical exigencies that may affect system differences were explored in interviews with treatment program managers and staff. Settings Comparison counties were selected using treatment system and county census data, maximizing similarities to enhance internal validity. Participants: Adult clients (n = 681) were interviewed when beginning treatment and 12 months later (81% response rate). In addition, 50 treatment program managers and staff members across the three counties were interviewed during the year of client recruitment. Measurements Client interviews assessed functioning in the seven Addiction Severity Index domains-alcohol, drug, psychiatric, legal, employment, medical and family/social.Outcomes (differences between baseline and 12 month composite scores) did not differ between counties in six of seven domains; in the seventh, psychiatric functioning, SouthState had better outcomes than MidState. Staff interviews indicated generally similar treatment strategies across counties, with MidState supplying greater oversight and performance standards. Conclusions: Managed care in public sector treatment generally did not result in poorer outcomes. Future attention in MidState to the barriers to successful implementation of individualized treatment, and to dual diagnosis treatment, might bring more positive results.

Beattie MC; Hu TW; Li R; Bond JC. Cost-effectiveness of public sector substance abuse treatment: Comparison of a managed care approach to a traditional public sector system. Journal of Behavioral Health Services & Research 32(4): 409-429, 2005. (65 refs.)

Costs and cost-effectiveness of public sector substance abuse treatment in 2 California counties with similar substance abuse treatment system histories are compared, one county (MidState) has adopted managed care principles. As hypothesized, MidState's costs for the index treatment episode were significantly lower than SouthState's, although unexpectedly because of lower outpatient utilization. Treatment benefits in the 7 Addiction Severity Index functional areas were examined through cost-effectiveness analyses. MidState can claim greater cost-effectiveness for its treatment dollars for significant improvement in alcohol and medical functioning (compared to unsuccessful clients and those reporting no problems). When comparing both improved clients and those maintaining no problems to unsuccessful clients, MidState is more cost-effective for improving alcohol, medical, legal, and family/social functioning; and 3 outcomes important to community stakeholders and taxpayers (legal, medical, and psychiatric functioning) are more cost-effective than alcohol, drug, and employment improvement.

Bigelow DA; McFarland BH; McCamant LE; Deck DD; Gabriel RM. Effect of managed care on access to mental health services among Medicaid enrollees receiving substance treatment. Psychiatric Services 55(7): 775-779, 2004. (41 refs.)

Objective: Mental health services are important to treatment retention and positive outcomes for many clients of substance abuse treatment programs. For these clients the implementation of managed care should provide for continued or increased access to mental health treatment, rather than decreased access because of short-term, cost-reduction objectives. This study assessed whether converting Medicaid from a fee-for-service program to a capitated, prepaid managed care program affected access to mental health services among clients who were treated for substance abuse. Methods: Medicaid enrollees who were being treated for substance abuse in Oregon were interviewed before beginning treatment and after six months of service. One cohort (N=53) was interviewed one to six months before the implementation of managed care, a second (N=66) was interviewed two years after the implementation, and a third (N=49) was interviewed three to four years after the implementation. Logistic regression analyses were used to identify whether the implementation of managed care, the psychiatric need of the client, and other client characteristics affected the receipt of mental health services during the first six months of substance abuse treatment. Results: Clients in all three cohorts had similar characteristics. The implementation of managed care did not affect whether clients received mental health services. A baseline interview score that was derived from items in the Addiction Severity Index psychiatric section was the only client characteristic that predicted receipt of mental health services. Conclusions: Although this study was a naturalistic experiment with many methodologic flaws, it provided a unique opportunity to observe whether the introduction of managed care changed access to mental health services among Medicaid enrollees who were being treated for substance abuse.

Blondell RD; Simons RL; Smith SJ; Frydrych LM; Servoss TJ. Initiation of outpatient treatment after inpatient detoxification. Journal of Addiction Medicine 1(1): 21-25, 2007. (12 refs.)

Additional treatment after inpatient detoxification is recommended; however, many patients fail to initiate aftercare. The purpose of this observational study was to determine which patients hospitalized for alcohol or drug withdrawal subsequently fail to initiate recommended outpatient aftercare treatment by using existing data from medical records. Of 406 patients, 180 (44.3%) did not initiate outpatient aftercare treatment after hospitalization for detoxification. Compared with those who did initiate aftercare, those who did not were less likely to have education beyond high school (44% vs. 32%; P = 0.018), to be enrolled in a managed care health insurance plan (46% vs. 34%; P = 0.013), and to have a family history of chemical dependency (81% vs. 72%; P = 0.049). These values were similar with multiple regression analysis. Of the 406 patients, 11 of 56 (20%) without any of these risk factors, 145 of 314 (46%) with 1 or 2 risk factors, and 24 of 36 (67%) with all 3 of these risk factors did not keep scheduled outpatient appointment for aftercare. These findings suggest that some patients admitted for inpatient detoxification, identifiable by certain admission characteristics, are at risk for failure to link with appropriate outpatient aftercare treatment.

Boekeloo BO; Jerry J; Lee-Ougo WI; Worrell KD; Hamburger EK; Russek-Cohen E; Snyder MH. Randomized trial of brief office-based interventions to reduce adolescent alcohol use. Archives of Pediatrics & Adolescent Medicine 158(7): 635-642, 2004. (35 refs.)

Objective: To determine whether office-based interventions change adolescents' alcohol beliefs and alcohol use. Design: Randomized, controlled trial. Setting: Five managed care group practices in Washington, DC. Participants: Consecutive 12- to 17-year-olds (N = 409) seeing primary care providers (N = 26) for general checkups. Most of the adolescents (79%) were African American, 44% were male, and 16% currently drank. Interventions: Usual care (Group I), adolescent priming with alcohol self-assessment just prior to check-up (Group II), adolescent priming and provider prompting with adolescent self-assessment and brochure (Group III). Main Outcome Measures: Adolescent alcohol beliefs at exit interview and self-reported behaviors at 6- and 12-month follow-up. Results: At exit interview, Groups II and III reported that less alcohol was needed for impaired thinking and a greater intent to drink alcohol in the next 3 months than Group I. At 6 months, Group III reported more resistance to peer pressure to drink, and Groups II and III reported more bingeing than Group I. At 1-year follow-up, controlling for baseline levels, Groups II (odds ratio [OR], 3.44; 95% confidence interval [CI], 1.44-6.24) and III (OR, 2.86; CI, 1.13-7.26) reported more bingeing in the last 3 months than Group I. Group II reported more drinking in the last 30 days (OR, 2.31; CI, 1.31-4.07) and in the last 3 months (OR, 1.76; CI, 1.12-2.77) than Group I. Conclusion: Brief office-based interventions were ineffective in reducing adolescent alcohol use but may increase adolescent reporting of alcohol use.

Breton AR; Taira DA; Burns E; O'Leary J; Chung RS. Follow-up services after an emergency department visit for substance abuse. American Journal of Managed Care 13(9): 497-505, 2007. (39 refs.)

Objective: The recent introduction of substance abuse treatment measures to the Health Plan Employer and Data Information Set (HEDIS) highlights the importance of this area for managed care organizations (MCOs). Particularly challenging are members first diagnosed in an emergency department (ED). Study Design: Retrospective claims analysis. Methods: Claims were abstracted for all members who used an ED in 2004 for a diagnosis of substance abuse in a large commercial MCO. General linear models were used to estimate the association between receiving follow-up care within 14 and 60 days and sex, age, type of primary diagnosis, substance abused, and level of use. Results: Of the 1235 patients who visited an ED with a diagnosis of substance abuse, 13% received follow-up substance abuse services within 14 days of their ED visit. An additional 36% of patients had an outpatient service that did not code a substance abuse diagnosis within 2 weeks of an ED visit. The diagnosis breakdown of patients' primary diagnoses was 28% substance use, 13% mental health issues, and 59% noripsychiatric (medical) disorders. The multivariable regression analyses revealed having a nonpsychiatric (medical) primary diagnosis was the strongest predictor of not receiving follow-up care (relative risk = 0,51) at 14 days compared with patients who had a mental health diagnosis. Conclusions: Training ED staff and nonbehavioral health outpatient providers in treatment follow-up for substance abuse may improve the quality of care for patients. Encouraging providers to code for substance abuse when treatment or counseling is delivered would improve health plan HEDIS scores. Interventions may be needed for frequent ED users with substance abuse.

Campbell CI; Chi F; Sterling S; Kohn C; Weisner C. Self-initiated tobacco cessation and substance use outcomes among adolescents entering substance use treatment in a managed care organization. Addictive Behaviors 34(2): 171-179, 2009. (38 refs.)

Purpose: Adolescents with substance use (SU) problems have high rates of tobacco use, yet SU treatment has historically ignored treatment for tobacco use. Barriers to such efforts include the belief that tobacco cessation Could compromise other SU abstinence. This study examines Self-initiated tobacco cessation and 12-month alcohol and drug abstinence in adolescents entering SU treatment in a private, managed care organization. Results: Self-initiated tobacco cessation at 6 months, and at both 6 and 12 months, were related to higher odds of drug abstinence but not alcohol abstinence. Conclusion: Self-initiated tobacco cessation was not related to poor SU outcomes, and may be important to maintaining drug abstinence. Implementing tobacco cessation efforts in SU treatment can be challenging, but Comprised SU Outcomes may not be a barrier. The positive associations for drug abstinence and lack of associations for alcohol abstinence could be due to differences in motivation, medical conditions, or to the illicit nature of drug use. Tobacco use has serious long-term health consequences, and tobacco cessation efforts in adolescent SU treatment programs need further research.

Campbell CI; Wells R; Alexander JA; Lan JA; Nahra TA; Lemak CH. Tailoring of outpatient substance abuse treatment to women, 1995-2005. Medical Care 45(8): 775-780, 2007. (41 refs.)

Background: Tailoring substance abuse treatment to women often leads to better outcomes. Previous evidence, however, suggests limited availability of such options. Objectives: This investigation sought to depict recent changes in outpatient substance abuse treatment (OSAT) tailoring to women and to identify unit and contextual factors associated with these practices. Research Design: Data were from 2 waves of a national OSAT unit survey (N = 618 in 1995, N := 566 in 2005). Comparisons of weighted means between waves indicate which practices changed over time. Multiple logistic regressions with generalized estimating equations test associations between unit and contextual attributes and tailoring to women. Measures: Tailoring to women was measured as availability of prenatal care, child care, single sex therapy, and same sex therapists, and the percentage of staff trained to meet female clients' needs. Results: Two measures of tailoring to women declined significantly between 1995 and 2005: availability of single sex therapy (from 66% to 44% of units) and percent of staff trained to work with women (from 42% to 32% of units). No aspect of tailoring to women became more common. Proportion of female clients, total number of clients, methadone status, and private and government managed care were associated with higher odds of tailoring to women. For-profit facilities, which became more prevalent during the study period, had lower odds than other units of tailoring treatment to women. Conclusions: Some key aspects of OSAT tailoring to women decreased significantly in the last decade. Managed care contracts may offer mechanism for counteracting these trends.

Cavanaugh DA. Substance abuse and mental health services for children and adolescents. Administration and Policy in Mental Health 32(4): 439-456, 2005. (4 refs.)

This study examines the initial effects of the Massachusetts Mental Health and Substance Abuse Program on 24-hour care for children and adolescents. Analysis of Medicaid claims shows that under managed care, access to 24-hour services, the number of service users, and admissions increased, while length of stay and expenditures decreased. The decomposition of the savings indicated that although the increase in admissions would have added an additional $2.7 million to expenditures without managed care, the carve-out saved $9.1 million in the first year through changes in length of stay, service settings, and price per day. The managed care variable was not significant in the regression models examining rapid readmission.

Center for Substance Abuse Treatment; Forman RF; Nagy PD. Substance Abuse: Administrative Issues in Intensive Outpatient Treatment. Treatment Improvement Protocol (TIP) Series 46. Rockville MD: Center for Substance Abuse Treatment, 2006. (137 refs.)

This Treatment Improvement Protocol (TIP) is directed to administrators and speaks to the changing environment in which outpatient treatment programs operate. It provides basic information about running an outpatient treatment program, including strategic planning, working with a board of directors, relationships with strategic partners, hiring and retaining employees, staff supervision, continuing education and training, performance improvement, outcomes monitoring, and promotion of the program to potential clients, funding agencies, and government officials. More specialized sections address challenges that have emerged and gathered importance in the last decade: preparing a program to provide culturally competent treatment to an increasingly diverse client population and succeeding in a managed care-dominated world by diversifying the funding sources a program draws on.

Public Domain

Chi FW; Weisner CM. Nine-year psychiatric trajectories and substance use outcomes - An application of the group-based modeling approach. Evaluation Review 32(1): 39-58, 2008. (48 refs.)

This study identifies longitudinal psychiatric trajectories of 934 adult individuals entering chemical dependency treatment in a private, managed care health plan and examines the relationship of these trajectories with substance use (SU) outcomes. The authors apply a group-based modeling approach to identify trajectory groups based on repeated measures of psychiatric severity for 9 years and identify four distinct groups. Results of multivariate logistic generalized estimating equation models find an association between psychiatric trajectories and long-term SU. Older cohorts and life course measures of marital status and employment status as individuals changed over time are related to drug and some alcohol outcomes.

Chuang E; Wells R; Alexander JA; Friedmann PD; Lee IH. Factors associated with use of ASAM Criteria and service provision in a national sample of outpatient substance abuse treatment units. Journal of Addiction Medicine 3(3): 139-150, 2009. (46 refs.)

Standardized patient placement criteria such as those developed by the American Society of Addiction Medicine are increasingly common in substance abuse treatment, but it is unclear what factors are associated with their use or with treatment units, provision of related services. This study examined these issues in the context of a national survey of outpatient substance abuse treatment units. Regressions using 2005 data revealed that both public and private managed care were associated with a greater likelihood of using American Society of Addiction Medicine criteria to develop client treatment plans. However, only public managed care was associated with a greater likelihood of offering more resource-intensive services. Associations between client population severity and resource-intensive service provision were sparse but positive.

Clark RE; Weir S; Ouellette RA; Zhang JY; Baxter JD. Beyond health plans behavioral health disorders and quality of diabetes and asthma care for Medicaid beneficiaries. Medical Care 47(5): 545-552, 2009. (34 refs.)

Background: Most health insurance plans monitor ambulatory care quality using the Healthcare Effectiveness Data and Information Set (HEDIS), publicly reporting results at the plan level. Plan-level comparisons obscure the influence of patients served or settings where care is delivered. Mental illness, substance abuse, and other physical comorbidities, particularly prevalent among Medicaid beneficiaries, can impact adherence to recommended care. We analyzed individual-level HEDIS measures for diabetes and asthma from 5 Medicaid managed care plans to understand how these factors contribute to quality. Methods: We used claims and medical records to study HEDIS measures for persistent asthma (n = 9103) and diabetes (n = 1790) among beneficiaries enrolled in Massachusetts' Medicaid program during 2004 and 2005. Logistic regression models included patient-level demographic and health factors, provider type, region, and managed care plan. Results: Alcohol and drug use disorders and emergency department use were associated with lower quality care for most measures. Glycemic control was better for patients with diabetes and severe mental illness. Patients with higher illness burden and with more frequent ambulatory visits received higher quality care for both conditions. Younger adults received recommended care less often than older adults. Quality varied across plans. Conclusions: Additional efforts to improve quality of care for asthma and diabetes for Medicaid beneficiaries are needed for individuals with substance use disorders and young adults. Although evidence of higher quality for patients with multiple conditions is encouraging, improving quality for comparatively healthier individuals might also produce significant long-term benefits.

Conover CJ; Weaver M; Arno P; Ang A; Ettner SL. Insurance coverage among people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders. Journal of Health Care for the Poor and Underserved 21(3): 1006-1030, 2010. (59 refs.)

HIV triply-diagnosed adults (those with chronic mental illness and substance abuse disorders) must rely heavily on public insurance to cover high annual medical costs (similar to $50,000). This study examines the nature and determinants of insurance coverage (including managed care) for this population, along with annual transitions in coverage. Relative to people living with HIV/AIDS in general, fewer triply-diagnosed adults rely on private coverage (3% vs. 30%), but their rate of being uninsured is only slightly lower (16% vs. 20%). More than one third of such adults below poverty are uninsured a matter of significant policy concern since the annual income of this group is less than 10% of the amount needed to cover their expected medical expenses. Those with the lowest mental health status were disproportionately represented in managed care. While coverage appears relatively stable over time, those with low incomes and moderate mental health status may face barriers in securing Medicaid.

Council CL; Bray JW. Conclusions and Implications. Chapter 9. Council CL, ed. IN: Health Services Utilization by Individuals with Substance Abuse and Mental Disorders. Analytic Series A-25. Rockville, MD: Office of Applied Studies, 2004. pp. 173-182. (3 refs.)

Over the past two decades, the behavioral health care delivery system in the United States has experienced rapid change in terms of clients served, as well as organizational and financial structures. New patterns of substance use, the changing demographics of affected populations, the availability of pharmacotherapies, and the growing presence of managed care have challenged the system and its study. These changes are the result of competing demands to contain costs, maintain the quality of care, make care available to all who need treatment, and focus resources on those forms of care that offer the best hope of successful outcomes. The chapters in this compendium extend our knowledge by providing information on factors that may facilitate or inhibit the delivery of behavioral health services for those persons with substance use or mental disorders. Valuable new information is provided on accessibility, utilization, quality, cost, cost-effectiveness, and outcomes. The findings describe the relationship between demographic characteristics and how, when, where, and if a person will seek care, as well as what types of care are chosen and what happens during the delivery of care. Finally, the findings presented in this compendium also reveal potential biases that may occur when using many of the large datasets currently available for conducting research in the behavioral health sciences. This chapter explores the implications of these findings in key areas for policymakers, the treatment community, and researchers and suggests directions for future research.

Daley MC. Race, managed care, and the quality of substance abuse treatment. Administration and Policy in Mental Health 32(4): 457-476, 2005. (46 refs.)

The adoption of managed behavioral health care by state Medicaid agencies has the potential to increase the quality of treatment for racial minorities by promoting access to substance abuse treatment and creating more appropriate utilization patterns. This paper examines three indicators of quality for white, Black, and Hispanic Medicaid clients who received substance abuse treatment in Massachusetts between 1992 and 1996. It evaluates whether a managed behavioral health care carve-out in FY1993 had a positive or negative effect on access, continuity of care, and 30-day re-admissions. Prior to managed care, access and continuity were worse for minorities than for whites. For all clients tinder managed care, access and continuity improved between 1992 and 1996. Access improved more for Hispanic clients relative to other racial groups. Continuity improved more for Black clients relative to other racial groups. Although seven-day and 30-day re admissions also increased following managed care, the rate of increase was not significantly greater for minorities. Although managed care had a beneficial impact on the quality of treatment for minority clients, the percent of minority Medicaid-eligible clients who accessed treatment and the percent who achieved continuity of care remained lower than for whites in every year of the study. Managed care reduced, but did not overcome, racial disparities in behavioral health care.

D'Ambrosio R; Mondeaux F; Gabriel RM; Laws KE. Oregon's transition to a managed care model for Medicaid-funded substance abuse treatment: Steamrolling the glass menagerie. Health & Social Work 28(2): 126-136, 2003. (23 refs.)

The approval of a Health Care Financing Administration (now called Centers for Medicare and Medicaid Services) 1115 Medicaid waiver in Oregon allowed the state to design and implement an expanded publicly funded health care system, the Oregon Health Plan (OHP). Integral to OHP is the administration of physical and behavioral health services, including outpatient substance abuse treatment, through contracted managed care organizations. The two overarching changes to the outpatient substance abuse treatment system were expanded Medicaid eligibility and new operating procedures for the outpatient substance abuse treatment system. The authors used grounded theory to examine the effects of this transition on the treatment system, with an emphasis on the experiences of treatment providers.

Duffy SQ. Substance Use and Mental Disorder Discharges from U.S. Community Hospitals in the Early 1990s, Revisited. Chapter 3. Council CL, ed. IN: Health Services Utilization by Individuals with Substance Abuse and Mental Disorders. Analytic Series A-25. Rockville, MD: Office of Applied Studies, 2004. pp. 41-52. (33 refs.)

Managed care and behavioral health care carve-outs proliferated during the early 1990s, and research suggests these arrangements reduce inpatient mental health services and substance abuse treatment. Based on these findings, one might expect to have seen a coinciding decline in admissions to community hospitals of patients with substance use and/or mental disorders (SU/MD). Such short-term, general, non-Federal hospitals have long been involved in SU/MD treatment and have accounted for a large share of inpatient stays -- approximately 54 percent of all such stays in 1985 and 69 percent of those of Medicare beneficiaries in 1995. However, much of the research on managed care has relied on methods, such as simple pre- and post-comparisons of aggregate claims from privately insured populations, that may fail to capture the experience of many with SU/MD. Other reports suggest that these patients may receive inadequate substitutes for inpatient mental health services, that a treatment gap exists, and that a growing percentage of the U.S. population lacks insurance. We examine these concerns by analyzing trends in discharges of those with SU/MD from community hospitals nationwide during the first half of the 1990s. In this study, we reexamine trends during this time period both by explaining how these different estimates could have been generated by the NHDS data and by providing new estimates using a dataset more appropriate for examining community hospitalizations of those with SU/MD. The findings presented here will contribute to our understanding of the impact of the changes in the health care system in the early 1990s on those with SU/MD diagnoses.

Ettner SL; Denmead G; Dilonardo J; Cao H; Belanger AJ. The impact of managed care on the substance abuse treatment patterns and outcomes of Medicaid beneficiaries: Maryland's HealthChoice program. Journal of Behavioral Health Services & Research 30(1): 41-62, 2003. (32 refs.)

The introduction of Medicaid managed care raises concern that profit motives lead to the undersupply of substance abuse (SA) services. To test effects of the Maryland Medicaid HealthChoice program on SA treatment patterns and outcomes, Medicaid eligibility files were linked to treatment provider records and two study designs were used to estimate program impact: a quasi-experimental design with matched comparison groups and a natural experiment. Patient sociodemographic and clinical characteristics were adjusted using multiple regression. Under managed care, there was a shift from residential, correctional-only, and detoxification-only treatment toward outpatient-only treatment. Among beneficiaries entering treatment, those enrolled in managed care organizations (MCOs) had similar utilization and outcomes to those in Medicaid fee for-service; those enrolling in MCOs during treatment had longer and more intensive episodes and, as a result, better outcomes. Thus, the study disclosed no empirical evidence that health plans respond to capitation by reducing SA services.

Ettner SL; Johnson S. Do adjusted clinical groups eliminate incentives for HMOs to avoid substance abusers? Evidence from the Maryland Medicaid HealthChoice program. Journal of Behavioral Health Services & Research 30(1): 63-77, 2003. (18 refs.)

The adequacy of risk adjustment to eliminate incentives for managed care organizations (MCOs) to avoid enrolling costly patients has been questioned. This study explored systematic differences in expenditures between beneficiaries with and without substance disorders assigned to the same capitation rate group under the Maryland Medicaid HealthChoice program. The investigators used fiscal year (FY) 1995 to 1997 Medicaid data to assign beneficiaries to rate cells based on FY 1995 diagnoses and compared the distribution of expenditures for beneficiaries with and without substance disorders, defined using FY 1997 and FY 1995 diagnoses. Results showed that differences in FY 1997 expenditures between beneficiaries with and without FY 1995 substance disorders were negligible. However, MCOs could expect greater average losses and lower average profits on beneficiaries with FY 1997 substance disorders. Thus, the adjusted clinical groups methodology used to adjust capitation payments in the HealthChoice program attenuated, but did not eliminate, financial incentives for MCOs to avoid substance abusers.

Greenfield SF; Azzone V; Huskamp H; Cuffel B; Croghan T; Goldman W et al. Treatment for substance use disorders in a privately, insured population under managed care: Costs and services use. Journal of Substance Abuse Treatment 27(4): 265-275, 2004. (40 refs.)

The study investigated the relationship of substance use disorders, concurrent psychiatric disorders. and patient demographics to patients of treatment use and spending in behavioral health and medical treatment sectors. We examined claims data for individuals covered by the same organization. Services spending and use were examined for 1899 individuals who received substance use disorder treatment in 1997. Medical and pharmacy spending was assessed for 590 individuals (31.1%). The most prevalent services were outpatient, intensive outpatient, residential, and detoxification. Average mental health/substance abuse (MHSA) care spending conditional on use was highest for those with concurrent alcohol and drug disorders ($5235) compared to those with alcohol ($2507) or drugs ($3360) alone; other psychiatric illness ($4463) compared to those without ($1837); and employees' dependents ($4138) compared to employees ($2875) or their spouses ($2744). A significant minority also sought MHSA services in the medical sector. Understanding services use and associated costs can best be achieved by examining services use across treatment sectors.

Green-Raleigh K; Lawrence JM; Chen HC. Pregnancy planning status and health behaviors among nonpregnant women in a California managed health care organization. Perspectives on Sexual and Reproductive Health 37(4): 179-183, 2005. (29 refs.)

CONTEXT: Women's behaviors before and during pregnancy can affect their infants' health. Particularly because many births in the United States are unintended, it is important to understand women's health behaviors and pregnancy planning status before they become pregnant. METHODS: A telephone survey of nonpregnant women of childbearing age who belonged to a Southern California managed care plan was conducted from 1998 through 2000. Survey data were analyzed in logistic regression models assessing differences in selected behaviors between women planning pregnancy and others. RESULTS. Compared with women not planning pregnancy, those planning pregnancy within the next year ("soon") were less likely to report smoking (odds ratio, 0.6), and more likely to report taking a multivitamin regularly (1.4) and having had a health care visit in the past year (1.6). Women planning a pregnancy more than one year in the future had elevated odds of reporting alcohol use (1.4); they were similar to women not planning pregnancy with respect to multivitamin use and smoking behavior. Women planning pregnancy soon were more likely than women not planning pregnancy to report that a health core professional had talked to them about taking a vitamin or mineral supplement (1.6). CONCLUSIONS: All women of childbearing age need information about the importance of engaging in healthy behaviors. Health care providers who have regular contact with such women should send clear messages about the adverse effects of alcohol and smoking during pregnancy and the importance of taking a multivitamin regularly, regardless of women's pregnancy plans, before they become pregnant.

Harrow BS; Tompkins CP; Mitchell PD; Smith KW; Soldz S; Kasten L et al. The impact of publicly funded managed care on adolescent substance abuse treatment outcomes. American Journal of Drug and Alcohol Abuse 32(3): 379-398, 2006. (37 refs.)

This study compares the 12-month changes in substance use following admission to substance abuse treatment in Massachusetts between adolescents enrolled in Medicaid managed care and other publicly funded adolescents. Two hundred and fifty-five adolescents were interviewed as they entered substance abuse treatment and at 6 and 12 month follow-ups. Medicaid enrollment data were used to determine the managed care enrollment status. One hundred forty two (56%) adolescents were in the managed care group and 113 (44%) comprise the comparison group. Substance use outcomes include a count of negative consequences of substance use, days of alcohol use, days of cannabis use, and days of any substance use in the previous 30 days. Repeated measures analysis of covariance (ANCOVA) was used to assess change with time of measurement and managed care status as main effects and the interaction of time and managed care included to measure differences between the groups over time. Although several changes across time were detected for all four outcomes, we found no evidence of an impact of managed care for any of the outcomes. The results of our study do not support the fears that behavioral managed care, by imposing limits on services provided, would substantially reduce the effectiveness of substance abuse treatment for adolescents. At the same time, the results do not support those who believe that the continuity of care and improved resource utilization claimed for managed care would improve outcomes.

Hodgkin D; Horgan CM; Garnick DW; Merrick EL. Benefit limits for behavioral health care in private health plans. Administration and Policy in Mental Health Services Research 36(1): 15-23, 2009. (36 refs.)

Data from a nationally representative sample of private health plans reveal that special lifetime limits on behavioral health care are rare (used by 16% of products). However, most plans have special annual limits on behavioral health utilization; for example, 90% limit outpatient mental health and 93% limit outpatient substance abuse treatment. As a result, enrollees in the average plan face substantial out-of-pocket costs for long-lasting treatment: a median of $2,710 for 50 mental health visits, or $2,400 for 50 substance abuse visits. Plans' access to new managed care tools has not led them to stop using benefit limits for cost containment purposes.

Hodgkin D; Horgan CM; Garnick DW; Merrick EL. Cost sharing for substance abuse and mental health services in managed care plans. Medical Care Research and Review 60(1): 101-116, 2003. (35 refs.)

Recent initiatives to improve private insurance coverage for substance abuse and mental health in the United States have mostly focused on equalizing coverage limits to those found in general medical care. Federal law does not address cost sharing (copayments and coinsurance), which may also deter needed care or impose significant financial burdens on enrollees. This article reports on cost sharing requirements for outpatient care in a nationally representative sample of managed care plans in 1999. Levels of cost sharing are substantial, with around 40 percent of products requiring copayments of $20 or more and another 15 percent requiring coinsurance of 50 percent. Cost sharing for outpatient substance abuse treatment is very similar to that for mental health. Compared to general medical care, at least 30 percent of products impose higher cost sharing for substance abuse and mental health treatment. Future parity initiatives should be examined for how they address differences in cost sharing as well as limits.

Jan SA. Patient perspective, complexities, and challenges in managed care. Journal of Managed Care Pharmacy 16(1, Supplement B): s22-s25, 2010. (21 refs.)

BACKGROUND Lack of coordination of care is one of the largest obstacles involved, with treating opioid dependence. Physicians also face the challenges of managing comorbidities and dealing with relapse. OBJECTIVE: To examine the clinical, economic, and humanistic factors involved in treating opioid dependence. SUMMARY. Despite the extensive utilization of narcotic analgesics, pain is often uncontrolled. Effective pain management and coordination of care is essential in treating pain patients, as patients who abuse pain medications consume more health care resources than nonabusers. Patients who abuse are 2.3 times more likely to present at the emergency department and 6.7 times more likely to be hospitalized than nonabusers. Managed care organizations are now incorporating integrated approaches to treating pain and substance abuse disorders, realizing that patients must be looked at as a whole, considering alternative and behavioral therapies in addition to pharmacological treatments. They are also able to assess patterns of abuse using pharmacy claims data and alert physicians to potential problems by making use of prescription monitoring programs. Physicians who treat chronic pain must utilize strategies to minimize the risk of developing dependence on opioids, and practitioners treating opioid dependence must employ policies to optimize outcomes. Such strategies include developing pain contracts; performing random urine screenings and pill counts; and setting goals of therapy and re-evaluating patients throughout treatment. Plans must be in place in the event of relapse, as well. CONCLUSION: In order to be successful in managing opioid dependence, physicians, employers, and managed care organizations must work together to provide an integrated approach to treatment.

Jansson LM; Svikis DS; Velez M; Fitzgerald E; Jones HE. The impact of managed care on drug-dependent pregnant and postpartum women and their children. Substance Use & Misuse 42(6): 961-974, 2007. (25 refs.)

In the shift from fee-for-service (FFS) to managed care (MC), many drug user treatment programs have eliminated all but basic services, lessening short-term costs without considering long-term consequences. This study explored maternal and infant outcomes at an urban drug user treatment center for pregnant drug-dependent women under FFS (1995) vs. MC (2000) service periods. The two groups had similar birth parameters, but the MC group had more fetal and infant deaths, decreased immunization rates, and greater incidences of social services intervention. While these data are correlational and need to be interpreted with caution, they suggest poorer outcomes for drug-exposed children under MC and invite further study of short- and long-term consequences of such change.

Karter AJ; Stevens MR; Gregg EW; Brown AF; Tseng CW; Marrero DG et al. Educational disparities in rates of smoking among diabetic adults: The translating research into action for diabetes study. American Journal of Public Health 98(2): 365-370, 2008. (31 refs.)

Objectives. We assessed educational disparities in smoking rates among adults with diabetes in managed care settings. Methods. We used a cross-sectional, survey-based (2002-2003) observational study among 6538 diabetic patients older than 25 years across multiple managed care health plans and states. For smoking at each level of self-reported educational attainment, predicted probabilities were estimated by means of hierarchical logistic regression models with random intercepts for health plan, adjusted for potential confounders. Results. Overall, 15% the participants reported current smoking. An educational gradient in smoking was observed that varied significantly (P<.003) across age groups, with the educational gradient being strong in those aged 25 to 44 years, modest in those aged 45 to 64 years, and nonexistent in those aged 65 years or older. Of particular note, the prevalence of smoking observed in adults aged 25-44 years with less than a high school education was 50% (95% confidence interval: 36% to 63%). Conclusions. Approximately half of poorly educated young adults with diabetes smoke, magnifying the health risk associated with early-onset diabetes. Targeted public health interventions for smoking prevention and cessation among young, poorly educated people with diabetes are needed.

Lapham SC; McMillan G; Gregory C. Impact of an alcohol misuse intervention for health care workers. 2: Employee assistance programme utilization, on-the-job injuries, job loss and health services utilization. Alcohol and Alcoholism 38(2): 183-188, 2003. (15 refs.)

Aims: We evaluated the effects of an enhanced substance misuse (SM) prevention/early intervention programme on referrals to an employee assistance programme, health care utilization rates, on-the-job injury rates and job termination rates among health care professionals employed in a managed care organization. Methods: The intervention was implemented at one site, with the remaining sites serving as the comparison group. Existing data from hospital databases were used to compare events occurring in the periods before and after initiation of the intervention. To account for baseline differences in age, gender and job class, logistic regression models produced adjusted means for events per employee month-at-risk. Results: We found that employee assistance referrals and non-SM-related in-patient hospitalizations increased significantly post-intervention, while rates of total out-patient SM-related visits decreased at both the intervention and comparison sites post-intervention. There was a small, statistically significant decrease in the monthly rate (OR = 0.92) of non-SM out-patient utilization at the intervention site, once the intervention was in place. No differences potentially attributable to the intervention were detected in job turnover or injury rates. Conclusions: We conclude that, while the intervention did not appear to affect health care utilization for SM-related problems, it was associated with increased referrals for employee assistance.

Larson MJ; Zhang A; Smith K; Kasten L. Access to services: Multiple perspectives from adults with substance abuse disorders in Massachusetts. Administration and Policy in Mental Health 32(4): 357-371, 2005. (22 refs.)

This paper describes how 267 Massachusetts adult substance abuse consumers rated the substance abuse counseling they have received, their access to behavioral health care, and their overall experiences with their health plan or free care. This perspective is supplemented with information from administrative data on type of care received immediately after the baseline interview, including use of wraparound services while in treatment. We hypothesized that consumers in a carve-out behavioral health plan would view their care more favorably because they had a payment source for both substance abuse and mental health care. This hypothesis was confirmed. However, it is access to Medicaid insurance, not involvement of managed care, that is associated with greater access and higher consumer ratings of care.

Leff HS; Wieman DA; McFarland BH; Morrissey JP; Rothbard A; Shern DL et al. Assessment of Medicaid managed behavioral health care for persons with serious mental illness. Psychiatric Services 56(10): 1245-1253, 2005. (48 refs.)

Objectives: This five-site study compared Medicaid managed behavioral health programs and fee-for-service programs on use and quality of services, satisfaction, and symptoms and functioning of adults with serious mental illness. Methods: Adults with serious mental illness in managed care programs (N=958) and fee-for-service programs (N=1,011) in five states were interviewed after the implementation of managed care and six months later. After a multiple regression to standardize the groups for case mix differences, a meta-analysis using a random-effects model was conducted, and bioequivalence methods were used to determine whether differences were significant for clinical or policy purposes. Results: A significantly smaller proportion of the managed care group received inpatient care (5.7 percent compared with 11.5 percent). The managed care group received significantly more hours of primary care (4.9 compared with 4.5 hours) and was significantly less healthy. However, none of these differences exceed the bioequivalence criterion of 5 percent. Managed care and fee for service were "not different but not equivalent" on 20 of 34 dependent variables. Cochrane's Q statistic, which measured intersite consistency, was significant for 20 variables. Conclusions: Managed care and fee-for-service Medicaid programs did not differ on most measures; however, a lack of sufficient power was evident for many measures. Full endorsement of managed care for vulnerable populations will require further research that assumes low penetration rates and intersite variability.

Lemak CH; Alexander JA. Factors that influence staffing of outpatient substance abuse treatment programs. Psychiatric Services 56(8): 934-939, 2005. (32 refs.)

Objective: This study examined whether and how various organizational and environmental forces influence staffing in outpatient substance abuse treatment programs. Methods: The authors used data from the 1995 and 2000 waves of the National Drug Abuse Treatment System Survey (NDATSS), a telephone survey of unit directors and clinical supervisors. Multivariate analyses with generalized estimating equations were conducted. Two measures of staffing were modeled: the number of weekly treatment hours per client, and active caseload. Results: Managed care activity influenced active caseloads but not the number of treatment hours per client. Significant differences were noted in staffing levels among private for-profit, private nonprofit, and public treatment programs, with public units offering fewer hours per client and having larger caseloads. Units accredited by the Joint Commission on Accreditation of Healthcare Organizations offered more treatment hours per client. Conclusions: The results of this study contribute to the understanding of various influences on treatment staff time and caseloads. Understanding these relationships is critical for policy makers, managed care companies, and managers, because staffing levels have the potential to affect both the cost and the quality of treatment.

Leslie LK; Kelleher KJ; Burns BJ; Landsverk J; Rolls JA. Foster care and Medicaid managed care. Child Welfare 82(3): 367-392, 2003. (69 refs.)

Children in the foster care system are often dependent on Medicaid for health care. These children, however, have more complex health care needs than the typical child receiving Medicaid. States are implementing Medicaid managed care programs as a way to control escalating costs while providing necessary services. This article reviews the issues surrounding delivery of managed health care services to children in foster care and describes several solutions.

Maglione M; Ridgely MS. Is conventional wisdom wrong? Coverage for substance abuse treatment under Medicaid managed care. Journal of Substance Abuse Treatment 30(4): 285-290, 2006. (16 refs.)

Conventional wisdom suggests that coverage for substance abuse treatment under Medicaid is generally poor, and that access to care may be reduced when control over behavioral health set-vices is given to private health plans, such as those under Medicaid managed care. To examine this premise, this study reports on a cross-sectional comparative Survey of state Medicaid managed care programs conducted in the year 2000. Although not all states provided substance abuse benefits under their Medicaid programs, our findings suggest that a majority of states used managed care arrangements to provide substance abuse treatment, with most providing an array of covered services. Most Medicaid behavioral health plans were fully capitated. The number of comprehensive health plans providing substance abuse services was slightly higher than the number of behavioral health carveouts. About half of the waiver programs that covered substance abuse treatment covered methadone maintenance, but waiver programs employing comprehensive health plans were more likely to provide coverage for methadone maintenance.

Marcy TW; Thabault P; Olson J; Tooze JA; Liberty B; Nolan S. Smoking status identification: Two managed care organizations' experiences with a pilot project to implement identification systems in independent practice associations. American Journal of Managed Care 9(10): 672-676, 2003. (14 refs.)

Objective: To determine whether managed care organizations (MCOs) can effectively promote the sustained use of smoking status identification systems among independent practice associations. Study Design: Quasi-experimental design measuring smoking status documentation before and after an intervention. Methods: A chart review of the MCOs' patients at 4 participating primary care clinics determined the baseline for smoking status documentation before intervention. Baseline data were unavailable from a fifth participating clinic. Two quality improvement personnel were sent by the MCOs to help the clinics chose and implement a system for identifying smoking status. All of the clinics chose a sticker system. The change in smoking status documentation was assessed by chart reviews of patients enrolled in the MCOs who were seen during the period between 3 and 16 months after implementation of the system. Results: Following the intervention, a significant increase in smoking status documentation was noted among participating clinics. The proportion of patients whose smoking status was identified and documented by any method increased from 50% to 87% (P < .01) at the 4 clinics with baseline data. By clinic, the increase varied from 6% to 60%. The sticker system was the method by which most patients' smoking status was documented (77%). There were no controls, so the influence of outside factors, including a regional smoking cessation campaign that coincided with this study, cannot be quantified. Conclusions: Managed care organizations may be an effective change agent for implementing the guidelines for tobacco use and dependence treatment.

McCarty D; Argeriou M. The Iowa Managed Substance Abuse Care Plan: Access, utilization, and expenditures for Medicaid recipients. Journal of Behavioral Health Services & Research 30(1): 18-25, 2003. (16 refs.)

The Iowa Managed Substance Abuse Care Plan (IMSACP) used a behavioral health care organization to manage expenditures for treatment of alcohol and drug dependence financed through Medicaid, block grants, and state appropriations but maintained relatively distinct eligibility and benefit structures for Medicaid-eligible individuals. Medicaid claims, encounters, and eligibility files were reviewed for 2 years before and 3 years after implementation of IMSACP to evaluate changes in access, utilization, and expenditures. The rate of substance abuse treatment doubled, use of inpatient hospital services decreased, and residential and outpatient services increased. Direct care costs decreased, while total expenditures held steady. The Iowa experience suggests that a well-planned initiative can control costs and improve access and utilization.

McCarty D; Dilonardo J; Argeriou M. State substance abuse and mental health managed care evaluation program. Journal of Behavioral Health Services & Research 30(1): 7-17, 2003. (18 refs.)

The articles in this special section of the Journal of Behavioral Health Services & Research present results from evaluations of publicly funded managed care initiatives for substance abuse and mental health treatment in Arizona, Iowa, Maryland, and Nebraska. This overview outlines the four managed care programs and summarizes the results from the studies. The evaluations used administrative data and suggest a continuing challenge to structure plans so that undesired deleterious effects associated with adverse selection are minimized. Successful plans balanced risk with limited revenues so that they permitted greater access to less intensive services. Shifts from inpatient services to outpatient care were noted in most states. Future evaluations might conduct patient interviews to examine the effectiveness and quality of services for mental health and substance abuse problems more closely.

McFarland BH; Deck DD; McCamant LE; Gabriel RM; Bigelow DA. Outcomes for Medicaid clients with substance abuse problems before and after managed care. Journal of Behavioral Health Services & Research 32(4): 351-367, 2005. (50 refs.)

Medicaid conversion from fee for service to managed care raised numerous questions about outcomes for substance abuse treatment clients. For example, managed care criticisms include concerns that clients will be undertreated (with too short and/or insufficiently intense services). Also of interest are potential variations in outcome for clients served by organizations with assorted financial arrangements such as for-profit status versus not-for-profit status. In addition, little information is available about the impact of state Medicaid managed care policies (including client eligibility) on treatment outcomes. Subjects of this project were Medicaid clients aged 18-64 years enrolled in the Oregon Health Plan during 1994 (before substance abuse treatment managed care, N = 1751) or 1996-1997 (after managed care, N = 14,813), who were admitted to outpatient non-methadone chemical dependency treatment services. Outcome measures were retention in treatment for 90 days or more, completion of a treatment program, abstinence at discharge, and readmission to treatment. With the exception of readmission, there were no notable differences in outcomes between the fee for service era clients versus those in capitated chemical dependency treatment. There were at most minor differences among various managed care systems (such as for-profit vs not-for-profit). However, duration of Medicaid eligibility was a powerful predictor of positive outcomes. Medicaid managed care does not appear to have had an adverse impact on outcomes for clients with substance abuse problems. On the other hand, state policies influencing Medicaid enrollment may have substantial impact on chemical dependency treatment outcomes.

McFarland BH; McCamant LE; Barron NM. Outcomes for clients of public substance abuse treatment programs before and after Medicaid managed care. Journal of Substance Abuse Treatment 28(2): 149-157, 2005. (36 refs.)

Following conversion of Medicaid substance abuse treatment programs in Oregon from fee-for-service to managed care, there were suggestions of poorer outcomes. This project interviewed cohorts of Medicaid and non-Medicaid substance abuse treatment clients before and after the 1995 implementation of Oregon's Medicaid capitated payment system. Subjects were 553 adults (59% male, average age 35, 64% white). Forty-three percent were Medicaid clients and 60% were treated during the fee-for-service era. All clients were interviewed with the Addiction Severity Index at baseline and at 6 and 12 months thereafter. Multilevel, multivariate analyses examined baseline and outcome differences between the Medicaid and Non-Medicaid groups; between the fee-for-service and managed care conditions; and their interactions. After adjustment for covariates, most analyses were not statistically significant. It does not appear that Medicaid managed care had an adverse impact on outcomes for clients with substance abuse problems.

McMillan GP; Lapham SC. Does moderate alcohol use affect health-care costs? A propensity analysis of female health-care workers. Addiction 99(5): 612-620, 2004. (32 refs.)

Aims: To determine differences in health-care costs associated with moderate alcohol consumption among female health-care workers while controlling for other risk factors that may be correlated with alcohol use. Design and setting: Non-randomized, prospective, observational study of health-care costs by female health-care workers in a large managed care organization recruited between 1 January 1998 and 1 July 2000. Participants: Six hundred and eighty-five female employees, continuously and stably employed by the managed care organization, who received health-care through the affiliated managed care organization. All women completed a health risk appraisal as part of the company's Employee Wellness Plan; 218 women were categorized as moderate drinkers and 467 as abstainers/light drinkers. Measurements: Total costs of in-plan and out-of-plan health-care utilization, by type of service, during the 6 month period after completing the health risk survey were calculated. Findings: Using 218 one-to-one matched pairs of moderate drinkers and abstainers/light drinkers, no significant differences in total, outpatient or inpatient costs were observed during the 6 month observation period. Pharmacy costs were significantly lower for moderate drinkers (-$43, 95% CI = -$88.82 to -$2.41), primarily due to differences in costs from anxiolytic (including barbiturates and benzodiazepines), hypnotic and sedative drug fills. Conclusions: Findings demonstrate the value of risk factor matching when studying the relationship between alcohol use and health-care utilization. The discovery of differential pharmacy utilization raises the possibility that alcohol consumption may reduce the use of prescribed central nervous system depressants.

McNeese-Smith D; Nyamathi A; Longshore D; Wickman M; Robertson S; Obert J et al. Processes and outcomes of substance abuse treatment between two programs for clients insured under managed care. American Journal of Drug and Alcohol Abuse 33(3): 439-446, 2007. (11 refs.)

The purpose of this research (N = 160) was to describe and compare substance abuse treatment in two programs under managed care: one residential (RT) and one outpatient (OP). Clients in both settings improved significantly from before to after treatment in relation to substance use and quality of life. However, intensity of treatment (hours of care/week) was much greater in RT and days of sobriety were significantly higher after treatment in RT than in OP (p = .04). Intensity was negatively related to incidents of substance use during treatment (SUdT), which predicted substance use after treatment; SUdT averaged 2 for RT, and 1.6 for OP (p = .0001). Importantly, treatment was completed by 74 patients (over 90%) from RT, with 8 dropping out, and 53 (almost 70%) of those in OP completed treatment while 25 dropped out. Intensity, as seen in the RT program, rather than duration, was more effective in substance use reduction and treatment completion.

McNeese-Smith DK; Crook MW; Marinelli-Casey P; Rawson R. Processes and outcomes of substance abuse treatment within managed care: A preliminary report. Journal of Addictions Nursing 14(2): 65-73, 2003. (41 refs.)

While managed care is changing substance abuse treatment (SAT), little is known about the relationship between managed care structures and SAT processes and outcomes. The purposes of this study are to describe: (1) client characteristics, (2) SAT processes provided by outpatient treatment under managed care, and (3) client outcomes in an insured and primarily employed population. Twenty SAT clients including equal numbers of males and females, in two Los Angeles settings were interviewed at three points before and after treatment. Instruments with established reliability and validity in SAT research, including the TCU Drug History Form and the Treatment Outcome Profile, were administered. Descriptive statistics were used to describe SAT clients, as well as processes and outcomes of treatment. Drug use scores before treatment averaged 5.95 (on a scale of one to eight). Processes of treatment showed a mean of 17.4 weeks of treatment, for an average intensity of 4.66 hours/week. Abstinence (n = 12) was accompanied by an increase in the quality of life for clients and satisfaction with treatment services. The severity of drug use by this insured, well-educated, and employed sample indicates that managed care must deal with serious drug and alcohol abuse.

McNeese-Smith DK; Wickman ME; Earvolino-Ramirez M; Moncrieff M; Robertson S. Program directors' views of the effect of managed care on substance abuse programs in southern California. Journal of Addictions Nursing 17(2): 105-113, 2006. (14 refs.)

This article reports the results of semi-structured interviews with substance abuse treatment (SAT) program directors (PDs) regarding the ways SAT is being influenced by managed care (MC), plans for future SAT, and strategies for decreasing costs of care. It compares findings to an earlier survey of 50 SAT PDs. Interviews were conducted in 20 SAT programs to gather information about treatment delivery since the advent of MC, including PD responsibilities, funding source, treatment intensity, location, duration, and methods of treatment. Open-ended responses were used to gather information about current and future plans in providing SAT, and awareness of new types of treatment being planned by organizations impacted by MC. PDs reported changes in SAT secondary to MC such as decreased treatment length, limiting of inpatient and outpatient services, and delayed treatment secondary to benefit determination. Political and economic constraints were seen as barriers to providing adequate and effective services. SAT being subsumed by mental health was viewed as problematic along with an emerging split between alcohol abuse and drug treatment. A positive emerging treatment trend was the development of targeted programs for special need groups. PDs revealed a variety of strategies that have promoted necessary adaptations to economic and political influences within the structure of managed behavioral care. Strategies such as varying treatment length, modality, and subspecialty care reflected necessary adaptations to diverse market needs. Managed care continues to have a tremendous impact on the delivery of SAT services. While MC has helped to contain costs, negative outcomes are decreased availability of appropriate care and overtaxing of units that have survived MC cut backs. However, special need programs have allowed SAT programs to specialize, expand, and even flourish in today's competitive SAT market. Interviews with PDs reinforced the need for maintaining quality and diversified SAT services in today's MC environment.

Nahra TA; Alexander J; Pollack H. Influence of ownership on access in outpatient substance abuse treatment. Journal of Substance Abuse Treatment 36(4): 355-365, 2009

Marked changes in ownership and control in substance abuse treatment delivery have garnered the attention of providers and policymakers alike. The proliferation of private for-profit providers and the shift to a delivery system that may be more explicitly influenced by financial incentives are of particular concern for this vulnerable population. This work empirically addresses how treatment unit ownership affected access and retention between 1995 and 2005 in the United States. Regressions show statistically significant associations between unit ownership and both restricted treatment access and shortening of treatment duration for financial reasons. In comparison to private nonprofit and public units, private for-profit units were less likely to provide initial treatment access and reported shortened treatment for a greater percentage of clients unable to pay. Other organization characteristics, such as methadone-maintenance programs and managed care participation, also were associated with limiting treatment accessibility. While this work does not determine the underlying motivation behind access limitations, continued shifts in ownership structure should heighten the attention of policymakers.

Normand S-LT; Belanger AJ; Frank RG. Evaluating selection out of health plans for Medicaid beneficiaries with substance abuse. Journal of Behavioral Health Services & Research 30(1): 78-92, 2003. (15 refs.)

In the absence of adequate risk adjustment, capitation for enrollees creates incentives for health plans to enroll and retain good risks and to avoid bad risks. This article examines whether Maryland Medicaid beneficiaries with histories of substance abuse disenroll from health plans more frequently than those without such histories. The findings indicate that enrollees with a history of substance abuse were more likely to switch plans than other enrollees, regardless of whether they chose the health plan or were randomly assigned to the plan. These results suggest that current risk-adjustment systems may fail to offset selection incentives in modern capitated health plans.

Olmstead T; White WD; Sindelar J. The impact of managed care on substance abuse treatment services. Health Services Research 39(2): 319-343, 2004. (38 refs.)

Objective. To examine the impact of managed care on the number and types of services offered by substance abuse treatment (SAT) facilities. Both the number and types of services offered are important factors to analyze, as research shows that a broad range of services increases treatment effectiveness. Data Sources. The 2000 National Survey of Substance Abuse Treatment Services (NSSATS), which is designed to collect data on service offerings and other characteristics of SAT facilities in the United States. These data are merged with data from the 2002 Area Resource File (ARF), a county-specific database containing information on population and managed care activity. We use data on 10,513 facilities, virtually a census of all SAT facilities. Study Design. We estimate the impact of managed care (MC) on the number and types of services offered by SAT facilities using instrumental variables (IV) techniques that account for possible endogeneity between facilities' involvement in MC and service offerings. Due to limitations of the NSSATS data, MC and specific services are modeled as binary variables. Principal Findings. We find that managed care causes SAT facilities to offer, on average, approximately two fewer services. This effect is concentrated primarily in medical testing services (i.e., tests for TB, HIV/AIDs, and STDs). We also find that MC increases the likelihood of offering substance abuse assessment and relapse prevention groups, but decreases the likelihood of offering outcome follow-up. Conclusion. Our findings raise policy concerns that managed care may reduce treatment effectiveness by limiting the range of services offered to meet patient needs. Further, reduced onsite medical testing may contribute to the spread of infectious diseases that pose important public health concerns.

O'Toole TP; Freyder PJ; Gibbon JL; Hanusa BJ; Seltzer D; Fine MJ. ASAM patient placement criteria treatment levels: Do they correspond to care actually received by homeless substance abusing adults? Journal of Addictive Diseases 23(1): 1-15, 2004. (19 refs.)

We report findings from a community-based two-city survey of homeless adults comparing the level of substance abuse treatment assigned to them using the ASAM Patient Placement Criteria with care actually received during the previous 12 months. Overall 531 adults were surveyed with 382 meeting DSM-IIIR criteria of being in need of treatment or having a demand for treatment. Of those with a treatment need, 1.5% met criteria for outpatient care, 40.3% intensive outpatient/partial hospitalization care, 29.8% medically monitored care and 28.8% managed care levels. In contrast, of those receiving treatment (50.5%, 162 persons), almost all care received by this cohort was either inpatient or residential based (83.6%). Unsheltered homeless persons and those without insurance were significantly more likely to report not receiving needed treatment. Lack of treatment availability or capacity, expense, and changing one's mind while on a wait list were the most commonly cited reasons for no treatment.

Ray GT; Weisner CM; Mertens JR. Relationship between use of psychiatric services and five-year alcohol and drug treatment outcomes. Psychiatric Services 56(2): 164-171, 2005. (47 refs.)

Objective: The objective of this study was to examine the relationship between use of psychiatric services and alcohol and drug treatment outcomes five years after such treatment. It was anticipated that receipt of psychiatric services would predict long-term abstinence. Methods: A sample of 604 outpatients from a managed care organization's chemical dependency program was interviewed about substance use and severity of psychiatric symptoms at baseline and at five years. Patients were required to have at least three years of membership in the health plan during the five years after intake. Severity of psychiatric symptoms was categorized as zero, low, middle, or high. Use of psychiatric services was ascertained on the basis of administrative data from the health plan. Logistic regression analysis was used to assess the relationship between receipt of psychiatric services during the five years after intake and abstinence at five years. Results were adjusted for individual, treatment, and extra-treatment characteristics; severity of psychiatric symptoms at baseline; and other contacts with the health system. Results: Patients who received a threshold level of psychiatric services (an average of at least 2.1 hours a year) were significantly more likely to be abstinent at five years than patients who received less than 2.1 hours a year. Conclusions: The use of psychiatric services among patients with chemical dependency is associated with enhanced long-term outcomes.

Rieckmann T; Fuller BE; Saedi GA; McCarty D. Adoption of practice guidelines and assessment tools in substance abuse treatment. Substance Abuse Treatment, Prevention and Policy 5(e-journal 4), 2010. (38 refs.)

Background: The gap between research and practice limits utilization of relevant, progressive and empirically validated strategies in substance abuse treatment. Methods: Participants included substance abuse treatment programs from the Northeastern United States. Structural equation models were constructed with agency level data to explore two outcome variables: adoption of practice guidelines and assessment tools at two points in time; models also included organizational, staffing and service variables. Results: In 1997, managed care involvement and provision of primary care services had the strongest association with increased use of assessment tools, which, along with provision of counseling services, were associated with a greater use of practice guidelines. In 2001, managed care involvement, counseling services and being a stand-alone drug treatment agency were associated with a greater use of assessment tools, which was in turn related to an increase in the use of practice guidelines. Conclusions: This study provides managers, clinicians and policy-makers with a framework for understanding factors related to the adoption of new technologies in substance abuse treatment.

Rieckmann TR; Kovas AE; Cassidy EF; McCarty D. Employing policy and purchasing levers to increase the use of evidence-based practices in community-based substance abuse treatment settings: Reports from single state authorities. Evaluation and Program Planning 34(4): 366-374, 2011. (53 refs.)

State public health authorities are critical to the successful implementation of science based addiction treatment practices by community-based providers. The literature to date, however, lacks examples of state level policy strategies that promote evidence-based practices (EBPs). This mixed-methods study documents changes in two critical state-to-provider strategies aimed at accelerating use of evidence-based practices: purchasing levers (financial incentives and mechanisms) and policy or regulatory levers. A sample of 51 state representatives was interviewed. Single State Authorities for substance abuse treatment (SSAs) that fund providers directly or through managed care were significantly more likely to have contracts that required or encouraged evidence-based interventions, as compared to SSAs that fund providers indirectly through sub-state entities. Policy levers included EBP-related legislation, language in rules and regulations, and evidence-based criteria in state plans and standards. These differences in state policy are likely to result in significant state level variations regarding both the extent to which EBPs are implemented by community-based treatment providers and the quality of implementation.

Rothbard AB; Kuno E. Comparison of alcohol treatment and costs after implementation of Medicaid managed care. American Journal of Managed Care 12(5): 285-296, 2006. (28 refs.)

Objective: To examine the impact of a mandatory managed care behavioral health program on utilization and cost of alcohol treatment services for high-risk Medicaid patients. Study Design: Pre-post nonequivalent comparison group design to compare managed care clients with fee-for-service (FFS) clients in terms of behavioral treatment costs and use. Methods: Study subjects were adult Medicaid enrollees diagnosed with alcohol abuse or alcohol dependence. Chi-square tests and analysis of variance were used to determine significant differences between managed care and FFS programs in characteristics of the subjects, service use rates, and intensity of care. A regression model was used to examine predisposing, enabling, and need factors that might explain cost differences between programs. Results: The managed care site had reduced behavioral healthcare costs compared with the FFS site. However, the regression analysis, which explained 35% of the variance in behavioral health service cost per user, showed that treatment cost was not significantly lowered by the managed care intervention once predisposing and need factors were controlled for. Nineteen percent of the variance in cost was explained by increased mental health comorbidity and 12% by drug comorbidity. Conclusion: Consistent with other studies, the results show lower behavioral healthcare costs after the managed care intervention because of changes in management practices, service substitution, and negotiation of lower hospital fees. However, the managed care influence was insignificant in explaining cost variation between sites due to higher morbidity in the FSS site post managed care.

Satre DD; Mertens J; Arean PA; Weisner C. Contrasting outcomes of older versus middle-aged and younger adult chemical dependency patients in a managed care program. Journal of Studies on Alcohol 64(4): 520-530, 2003. (39 refs.)

Objective: This study examined how well older chemical dependency patients succeed in treatment relative to middle-aged and younger patients in a mixed-age private HMO outpatient program. To predict successful outcome, we tested a model incorporating age group differences in individual, treatment and extra-treatment factors. Method: The sample included 89 patients aged 55 and over, 379 patients aged 40 to 54, and 736 patients aged 18-39 (N = 1,204). Baseline measures included DSM-IV substance misuse diagnoses, Addiction Severity Index (ASI), psychiatric symptom checklist, sources of suggestion to enter treatment, treatment history and motivation. Outcome measures were abstinence rates and ASI score 6 months posttreatment. Results: At baseline, older adults showed higher levels of alcohol dependence, lower rates of drug dependence and lower psychiatric symptoms relative to younger individuals. Source of suggestions to enter treatment differed by age. Older and middle-aged patients were more likely to have an abstinence goal and to stay in treatment longer than younger adults. At 6 months posttreatment, 55% of older adults reported abstinence in the preceding 30 days, versus 59% of middle-aged adults and 50% of younger adults (p =.035). Conclusions: Lower rates of dependence and hostility and greater abstinence motivation and length of stay in treatment--all of which were associated with greater age-positively affect prognosis of older adults in treatment.

Scheid TL. Managed care and the rationalization of mental health services. Journal of Health and Social Behavior 44(2): 142-161, 2003. (67 refs.)

Managed care represents a response to the wider institutional demand for technical rationality and efficiency, and it may be in conflict with professionally generated logics of mental health care which emphasize the delivery of quality care, as well as providing services to all who need care. The organizational and policy conundrum is to balance conflicting institutional demands for efficiency (cost savings) and effectiveness (access and quality). This paper examines managed care in one public sector mental health care system that has attempted to incorporate the principles of managed care into a community based system of care and to overcome the potential contradictions between demands for efficiency and professional logics of care. Both qualitative and quantitative data are used to examine changes in organizational structure and service offerings; providers' experience of managed care, and the effect of managed care on working conditions and work experiences, and changes in the goals of the organization as measured by the specification of client outcomes. I find that, while increased performance accountability and outcome assessment (in keeping with demands for efficiency) have the potential to improve mental health care services, in fact, providers report that the primary effect of managed care has been an emphasis on cost containment, and there has been a corresponding de-emphasis on the provision of community based services for clients with long term care needs. However there is potential for professional logics to be maintained by larger institutional forces demanding quality care.

Schmidt LA; Weisner CM. Private insurance and the utilization of chemical dependency treatment. Journal of Substance Abuse Treatment 28(1): 67-76, 2005. (50 refs.)

This study examines how different types of health coverage influence the likelihood of entering treatment for an alcohol problem, and the extent that people in treatment are able to use their insurance to help cover the costs of care. Survey data are analyzed from a sample of problem drinkers drawn from the general population and chemical dependency treatment programs in the same community. We find that, in comparison to being on Medicaid and being uninsured, having private coverage does not significantly alter the odds of treatment entry. Being in a private managed care plan, as compared to traditional indemnity coverage, also does not appear to impact the chances of treatment entry. However, having private coverage, as compared to being on Medicare, doubles the odds of treatment entry. For problem drinkers who obtain treatment, those with private coverage are as or more likely than other insured groups to report that insurance helped to pay treatment expenses. Even so, 10% of those privately insured report having paid for all of their treatment costs out of pocket. We conclude that, while prior studies have rarely found that having insurance significantly impacts alcohol treatment entry, the type of coverage one possesses may matter in some cases. Our results concerning Medicare coverage may point to potential problems with making treatment affordable to some problem drinkers outside the private insurance system.

Shepard DS; Strickler GK; McAuliffe WE; Beaston-Blaakman A; Rahman M; Anderson TE. Unmet need for substance abuse treatment of adults in Massachusetts. Administration and Policy in Mental Health 32(4): 403-426, 2005. (80 refs.)

This article presents a methodology to estimate the size and cost of eliminating unmet need for substance abuse treatment services among adults who have clinically significant substance use disorders, and applies the approach to Massachusetts' information. Unmet treatment needs were derived using a statewide household telephone survey of 7,251 Massachusetts residents aged 19 and older conducted in 1996-1997, and an index of treatment mix and cost information from state and Medicaid financial data. The study estimates that 39,450 adult state residents (0.81% of the total sample) had a clinically significant past-year substance use disorder, but had not received treatment in the past year. Providing substance abuse treatment and outreach services to them would have required an additional cost of approximately $109 million (S17 per capita), of which the state's payer of last resort, the Massachusetts Department of Public Health Bureau of Substance Abuse Services (BSAS), would need to fund $31 million ($5 per capita). The share paid by BSAS (28%) would represent an increase of 42% over its current spending. This paper quantifies an important but sometimes overlooked objective of managed care: to improve access for substance abusers who need but do not seek treatment.

Sindelar JL; Olmstead TA. Managed care's dual impact on outpatient substance abuse treatment: Methadone maintenance vs. drug free. Journal of Drug Issues 35(3): 507-528, 2005. (38 refs.)

The number and type of services offered at substance abuse treatment (SAT) facilities are important aspects of the quality of care. Managed care is a growing presence in substance abuse treatment and has been shown to affect the provision of treatment. We expand on earlier work and examine the impact of managed care on the number and type of services offered by methadone maintenance and drug-free outpatient treatment facilities. We use the econometric technique of instrumental variables to address the issue of endogeneity of managed care and service offerings, thereby allowing a causal interpretation of results. Using data from the 2000 National Survey of Substance Abuse Treatment Services, we find that managed care significantly increases the total number of services offered in methadone maintenance outpatient facilities by four, yet decreases the number by two in drug free outpatient facilities. We also show how the impact on specific services differs by modality and provide explanations for our findings.

Sosin MR. The administrative control system of substance abuse managed care. Health Services Research 40(1): 157-176, 2005. (34 refs.)

Objective. This article searches for the dimensions of the administrative structures in outpatient substance abuse managed care that control the behavior of agency providers. It also ascertains how these dimensions, and several financial mechanisms, affect key aspects of the providers services: the average number of sessions of care that are delivered, the rate of completion of care, and the (estimated) rate at which clients control their substance use. Data Sources. The data were collected in 1999 for this investigation. Study Design. These data come from a nationally representative, cross-sectional sample of individual contracts between outpatient drug treatment providers and the Behavioral Health Managed Care Organizations (BHMCOs) that are empowered to regulate the delivery of services. Provider responses are analyzed here. Data Collection Methods. Factor analyses at a contract level examine the structural dimensions of the control system. Multivariate analyses at the same level rely on generalized linear models to predict the dependent variables by the structural dimensions and financial mechanisms. Findings. The factor analyses suggest that there are six multiple variable structural dimensions. The multivariate analyses suggest that the dimension that mandates follow-up of discharged clients tends to relate to more sessions of care and perhaps a higher rate of service completion. Most other dimensions are found to relate to fewer sessions of care, lower rates of service completion, or lower rates of control of substance abuse. No structural dimension relates to all dependent variables. Financial mechanisms evince varying relations to the sessions of care. They rarely relate to the other dependent variables. Conclusion. The results generally suggest that providers, payers, or policymakers might affect service provision by selecting BHMCOs that stress particular structural dimensions and financial mechanisms. However, managed care contracts most heavily rely on structural dimensions that restrict treatment sessions and fail to predict superior client outcomes.

Sterling S; Weisner C. Translating research findings into practice - Example of treatment services for adolescents in managed care. Alcohol Research & Health 29(1): 11-18, 2006. (34 refs.)

An important question in the alcoholism treatment field is how research findings can be translated into real-world clinical practice. Researchers have developed a new research-practice integration (RPI) model that can both drive the formulation of studies and new research questions and promote improvements in treatment quality. The hallmark of this model is a collaborative relationship between the key stakeholders in both alcohol and other drug (AOD) treatment and research, including health plan administrators and clinicians, treatment program administrators, psychiatry and primary care departments, patients and their families, purchasers, and researchers. The issue of technology transfer is especially relevant in the realm of adolescent AOD treatment. The implementation and feasibility of the RPI model are illustrated by a case study of a managed health care plan's treatment services for adolescents with AOD dependence. In this setting, key research findings are being used to shape the plan's adolescent health services.

Public Domain

Taylor CB; Curry SJ. Implementation of evidence-based tobacco use cessation guidelines in managed care organizations. Annals of Behavioral Medicine 27(1): 13-21, 2004. (39 refs.)

Background: Although managed care organizations (MCOs) may be optimal settings for implementing tobacco use cessation clinical guidelines, such guidelines remain poorly implemented in many MCO settings. Purpose: We examined issues related to the implementation of guidelines in MCOs, to provide examples of studies that have addressed issues related to guideline implementation and to suggest ways behavioral medicine researchers can play a role in examining issues of how guidelines can be better implemented. Methods: Surveys of clinical guideline implementation, studies from the Robert Wood Johnson Foundation addressing tobacco use cessation in a managed care database, selected to illustrate issues related to system-wide implementation. Results: Surveys show that effective tobacco use cessation interventions remain underutilized in MCOs. A few studies have evaluated and shown the benefit of insurance coverage for tobacco use and dependence treatments, clinician reimbursement and leadership incentives, practice feedback, and leveraging administrative data to create tobacco use tracking systems. The studies also point to the need for large-scale, multidisciplinary, methodologically rigorous studies that allow one to isolate the effects of promising strategies as well as to explore synergistic effects as different system changes are combined. Conclusions: Tobacco use cessation guidelines need to be better implemented in MCOs. Behavioral medicine research needs to move beyond treatment efficacy and effectiveness studies to focus on rigorous evaluations of these and other strategies to enhance guideline implementation and dissemination.

Thornton C; Gottheil E; Patkar A; Weinstein S. Coping styles and response to high versus low-structure individual counseling for substance abuse. American Journal on Addictions 12(1): 29-42, 2003. (31 refs.)

We compared outcomes during and after treatment for mixed substance dependent patients (N = 143) randomly assigned to a high-structure, behaviorally-oriented (HSB) or a low-structure, facilitative (LSF) individual counseling style. We hypothesized that patients with different coping characteristics would respond differently to the two styles of counseling. Patients were treated in once-weekly individual HSB or LSF counseling for up to 12 weeks. Outcome measures included patient and counselor ratings of benefit, retention, symptom reduction and negative urines; follow-up assessments included control of substance use and psychosocial adjustment. While no differences in outcomes during or after treatment were found for the HSB and LSF patients, both groups did improve equally. Contrary to our hypothesis, our coping measures did not predict different outcomes for patients treated in the LSF and HSB soles. Post-hoc analyses, however, revealed that outcomes could be predicted in each sole from patterns of pretreatment characteristics, which included measures of coping strategies, psychological characteristics, and treatment readiness. Moreover, the patterns associated with positive outcomes were different for the HSB and LSF patients: high treatment readiness was most important for success in HSB counseling, while low psychiatric severity and positive coping styles were important for the LSF clients. The finding of no HSB-LSF outcome differences calls into question the exclusive emphasis on behavioral treatment approaches by the present-day managed care industry. Also, the traditional approach to matching studies, ie, employing one patient characteristic at a time to predict differential outcomes for particular treatments, may be simplistic. An alternative approach employing multivariate statistical procedures to predict outcomes from several patient characteristics may hold more promise.

Warner KE; Mendez D; Smith DG. The financial implications of coverage of smoking cessation treatment by managed care organizations. Inquiry 41(1): 57-69, 2004. (51 refs.)

This paper presents results from a simulation of the financial impact and cost effectiveness of smoking cessation in a hypothetical managed care organization (MCO), using data from three large managed care organizations and from existing literature. With base-case assumptions and a market cost of capital, at five years, coverage of cessation services costs an MCO $.61 per member per month (PMPM). In a steady-state situation, net cost is $.41 PMPM. Both values include altered medical expenditures and MCO revenue patterns attributable to coverage-induced cessation. Quitters gain an average of 7.1 years of life, with a direct coverage cost of $3,417 for each life-year saved. Coverage of cost-effective programs by MCOs should be strongly encouraged.

Weisner C; Lu Y; Hinman A; Monahan J; Bonnie RJ; Moore CD et al. Substance use, symptom, and employment outcomes of persons with a workplace mandate for chemical dependency treatment. Psychiatric Services 60(5): 646-654, 2009. (42 refs.)

Objective: This study examined the role of workplace mandates to chemical dependency treatment in treatment adherence, alcohol and drug abstinence, severity of employment problems, and severity of psychiatric problems. Methods: The sample included 448 employed members of a private, nonprofit U. S. managed care health plan who entered chemical dependency treatment with a workplace mandate (N=75) or without one (N=373); 405 of these individuals were followed up at one year (N=70 and N=335, respectively), and 362 participated in a five-year follow up (N=60 and N=302, respectively). Propensity scores predicting receipt of a workplace mandate were calculated. Logistic regression and ordinary least-squares regression were used to predict length of stay in chemical dependency treatment, alcohol and drug abstinence, and psychiatric and employment problem severity at one and five years. Results: Overall, participants with a workplace mandate had one- and five-year outcomes similar to those without such a mandate. Having a workplace mandate also predicted longer treatment stays and improvement in employment problems. When other factors related to outcomes were controlled for, having a workplace mandate predicted abstinence at one year, with length of stay as a mediating variable. Conclusions: Workplace mandates can be an effective mechanism for improving work performance and other outcomes. Study participants who had a workplace mandate were more likely than those who did not have a workplace mandate to be abstinent at follow-up, and they did as well in treatment, both short and long term. Pressure from the workplace likely gets people to treatment earlier and provides incentives for treatment adherence.

Weisner CG; Ray T; Mertens JR; Satre DD; Moore C. Short-term alcohol and drug treatment outcomes predict long-term outcome. Drug and Alcohol Dependence 71(3): 281-294, 2003. (78 refs.)

Introduction: Although addiction is recognized as a chronic, relapsing condition, few treatment studies, and none in a commercially insured managed care population, have measured long-term outcomes. We examined the relationship of 6-month treatment outcomes to abstinence 5 years post-treatment, and whether the predictors of abstinence at 5 years were different for those who were, and were not, abstinent at 6 months. Methods: The sample (N=784) is from an outpatient (day hospital and traditional outpatient) managed care chemical dependency program. Subjects were interviewed at baseline, 6 months, and 5 years. Logistic regression analysis was used to assess which individual, treatment and extra-treatment characteristics predicted alcohol and drug abstinence at 5 years. Results: Abstinence at 6 months was an important predictor of abstinence at 5 years. Among those abstinent at 6 months, predictors of abstinence at 5 years were older age, being female, 12-step meeting attendance, and recovery-oriented social networks. Among those not abstinent at 6 months, being alcohol dependent rather than drug dependent, 12-step meeting attendance, treatment readmission, and recovery-oriented social networks predicted abstinence at 5 years. Conclusion: Our findings demonstrate a clear association between short-term and long-term treatment success. In addition, these results strongly support the importance of recovery-oriented social networks for those with good short-term outcomes, and the beneficial impact of readmission for those not initially successful in treatment.

Wells R; Lemak CH; D'Aunno TA. Insights from a national survey into why substance abuse treatment units add prevention and outreach services. Substance Abuse Treatment, Prevention, and Policy 1(e-article 21), 2006. (20 refs.)

Background: Previous studies have found that even limited prevention-related interventions can affect health behaviors such as substance use and risky sex. Substance abuse treatment providers are ideal candidates to provide these services, but typically have little or no financial incentive to do so. The purpose of this study was therefore to explore why some substance abuse treatment units have added new prevention and outreach services. Based on an ecological framework of organizational strategy, three categories of predictors were tested: (1) environmental, (2) unit-level, and (3) unit leadership. Results: A lagged cross-sectional logistic model of 450 outpatient substance abuse treatment units revealed that local per capita income, mental health center affiliation, and clinical supervisors' graduate degrees were positively associated with likelihood of adding prevention-related education and outreach services. Managed care contracts and methadone treatment were negatively associated with addition of these services. No hospital-affiliated agencies added prevention and outreach services during the study period. Conclusion: Findings supported the study's ecological perspective on organizational strategy, with factors at environmental, unit, and unit leadership levels associated with additions of prevention and outreach services. Among the significant predictors, ties to managed care payers and unit leadership graduate education emerge as potential leverage points for public policy. In the current sample, units with managed care contracts were less likely to add prevention and outreach services. This is not surprising, given managed care's emphasis on cost control. However, the association with this payment source suggests that public managed care programs might affect prevention and outreach differently through revised incentives. Specifically, government payers could explicitly compensate substance abuse treatment units in managed care contracts for prevention and outreach. The effects of supervisor graduate education on likelihood of adding new prevention and outreach programs suggests that leaders' education can affect organizational strategy. Foundation and government officials may encourage prevention and outreach by funding curricular enhancements to graduate degree programs demonstrating the importance of public goods. Overall, these findings suggest that both money and professional education affect substance abuse treatment unit additions of prevention and outreach services, as well as other factors less amenable to policy intervention.