How did the introduction of managed care for the uninsured in Iowa affect the use of substance abuse services?

A conceptual schema for government purchasing arrangements for Australian alcohol and other drug treatment

AIM

The aim of this study was to establish a conceptual schema for government purchasing of alcohol and other drug treatment in Australia which could encompass the diversity and variety in purchasing arrangements, and facilitate better decision-maker by purchasers. There is a limited evidence base on purchasing arrangements in alcohol and drug treatment despite the clear impact of purchasing arrangements on both treatment processes and treatment outcomes.

METHODS

The relevant health and social welfare literature on purchasing arrangements was reviewed; data were collected from Australian purchasers and providers of treatment giving detailed descriptions of the array of purchasing arrangements. Combined analysis of the literature and the Australian purchasing data resulted in a draft schema which was then reviewed by an expert committee and subsequently finalised.

RESULTS

The conceptual schema presented here was purpose-built for alcohol and other drug treatment, with its overlap between health and social welfare services. It has three dimensions: 1. The ways in which providers are chosen; 2. The ways in which services are paid for; and 3. How price is managed. Distinguishing between the methods for choosing providers (such as competitive or individually negotiated processes) from the way in which organisations are paid for their provision of treatment (such as via a block grant or payment for activity) provides conceptual clarity and enables closer analysis of each mechanism.

CONCLUSIONS

Governments can improve health and wellbeing by making informed decisions about the way they purchase and fund alcohol and other drug treatment. Research comparing different purchasing arrangements can provide a vital evidence-base to inform funders; however a first step is to accurately and consistently categorise current approaches against a typology or conceptual schema.

Public managed care and service access in outpatient substance abuse treatment units

The continued growth of public managed behavioral health care has raised concerns about possible effects on services provided. This study uses a national sample of outpatient substance abuse treatment units surveyed in 2005 to examine associations between public managed care and service access, measured as both the types of services provided and the amount of treatment received by clients. The percentage of clients funded through public managed care versus other types of public funding was positively associated with treatment units' odds of providing some types of resource-intensive services and with the odds of providing transportation to clients, but was negatively associated with the average number of individual therapy sessions clients received over the course of treatment. In general, public managed care does not appear to restrict access to outpatient substance abuse treatment, although states should monitor these contracts to ensure clients receive adequate courses of individual treatment.

Outcomes for rural Medicaid clients with severe mental illness in fee for service versus managed care

This study compared outcomes for rural Medicaid clients with severe mental illness in fee for service versus managed care programs. Interviews were conducted with 305 Medicaid clients in rural Oregon (166 in fee for service and 139 in managed care). Logistic and multivariate regression analyses were used to examine client satisfaction, safety, symptoms, functioning, and family satisfaction in the fee for service versus managed care groups. There was no evidence that conversion of the Medicaid mental health system from fee for service to managed care led to changes in outcomes for rural clients with severe mental illness.

Does the impact of managed care on substance abuse treatment services vary by provider profit status?

OBJECTIVE

To extend our previous research by determining whether, and how, the impact of managed care (MC) on substance abuse treatment (SAT) services differs by facility ownership.

DATA SOURCES

The 2000 National Survey of Substance Abuse Treatment Services, which is designed to collect data on service offerings and other characteristics of SAT facilities in the U.S. These data are merged with data from the 2002 Area Resource File, a county-specific database containing information on population and MC activity. We use data on 10,513 facilities, virtually a census of all SAT facilities.

STUDY DESIGN

For each facility ownership type (for-profit [FP], not-for-profit [NFP], public), we estimate the impact of MC on the number and types of SAT services offered. We use instrumental variables techniques that account for possible endogeneity between facilities' involvement in MC and service offerings.

PRINCIPAL FINDINGS

We find that the impact of MC on SAT service offerings differs in magnitude and direction by facility ownership. On average, MC causes FPs to offer approximately four additional services, causes publics to offer approximately four fewer services, and has no impact on the number of services offered by NFPs. The differential impact of MC on FPs and publics appears to be concentrated in therapy/counseling, medical testing, and transitional services.

CONCLUSION

Our findings raise policy concerns that MC may reduce the quality of care provided by public SAT facilities by limiting the range of services offered. On the other hand, we find that FP clinics increase their range of services. One explanation is that MC results in standardization of service offerings across facilities of different ownership type. Further research is needed to better understand both the specific mechanisms of MC on SAT and the net impact on society.

Outcomes for clients of public substance abuse treatment programs before and after Medicaid managed care

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.

Outcomes for medicaid clients with substance abuse problems before and after managed care

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.

Cost-effectiveness of public sector substance abuse treatment

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.

Effects of alcohol and drug use on inpatient and residential treatment among youth with severe emotional disturbance in Medicaid-funded behavioral health care plans

This study examined the use of alcohol and recreational drugs among 875 youth with severe emotional disturbance (SED) enrolled in Medicaid-funded behavioral health care plans, and whether co-occurring SED and substance use affected the subsequent likelihood of receiving inpatient and/or residential treatment. Youth at five sites nationwide were interviewed about their use of drugs and alcohol, while interviews with their caregivers elicited information about youths' service utilization, degree of functional impairment, and a series of demographic and environmental variables. Results indicated that half of the youth (52%) reported lifetime use of alcohol, street drugs, or over-the-counter medications for recreational purposes, while 18% reported use in the past 30 days. Among those reporting recent use, 32% reported using drugs only, 34% alcohol only, and 33% reported use of both drugs and alcohol. In multivariate logistic regression analyses, the effect of recent use was stronger than that of lifetime use; however, the largest effect occurred for those reporting recent use of both drugs and alcohol, versus either alone, or none. Differences remained significant when controlling for managed care versus fee for service enrollment as well as child, family, and environmental characteristics including study site. These results mirror those of prior studies that found an association between substance use and greater likelihood of inpatient services, even in managed care settings.

Reforming managed care certification of mental health services

This article examines the issues associated with the current managed care delivery system for certification of mental health services, including pain management. Inconsistencies in dispositions having impacts upon patient care appear to be inherent in the current peer review certification system. Issues related to public assistance clients will be given particular attention. After introducing the issues, this article reviews the literature to survey what facets have been the subjects of academic research and reflection. It then presents case examples of inconsistencies, followed by recommendations for a model with checks and balances. In conclusion, creation of an independent monitor group is recommended.

State substance abuse and mental health managed care evaluation program

The articles in this special section of the Journal of Behavioral Health Services & Research (30:1) 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.

The Iowa Managed Substance Abuse Care Plan: access, utilization, and expenditures for Medicaid recipients

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 year 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.