Managed care and technical efficiency in outpatient substance abuse treatment units

The critical factor: The role of quality in the performance of supported accommodation services for complex mental illness in England

Rehabilitation services have a key role in ensuring integrated and comprehensive mental health (MH) care in the community for people suffering from long-term and severe mental disorders. MH-supported accommodation services aim to promote service users’ autonomy and independence. Given the complexity associated with MH-supported accommodation services in England, a comparative evaluation of critical performance indicators, including service provision and quality of care, seems to be necessary in designing evidence-informed policies. This study aims to explore the influence of service quality indicators on the performance of MH-supported accommodation services in England. The analysed sample includes supported accommodation services from 14 nationally representative local authorities in England from the QuEST study grouped by three main types of care: residential care homes (divided into two subgroups: move-on and non-move-on oriented), supported housing and floating outreach. EDeS-MH (efficient decision support-mental health) was used to assess the performance indicators for the selected services by combining a Monte Carlo simulation engine, data envelopment analysis and a fuzzy inference engine for integrating expert knowledge. Depending on the type of care, six/seven quality domains were sequentially included after a baseline scenario (only technical) was analysed. Relative technical efficiency scores for the baseline scenarios revealed high performance in all the selected supported accommodation services, but the statistical variability was high. Quality domains significantly improved performance in every type of care. The inclusion of quality indicators has a positive impact on the global performance of each type of care. Remaining at the corresponding services more than expected for two years has a negative impact on performance. These findings can be considered from a planning perspective to facilitate the design of pathways of care with more realistic expectations about gaining autonomy in two years.

Application of fuzzy DEA and machine learning algorithms in efficiency estimation of paddy producers of rural Eastern India

Purpose

Data envelopment analysis (DEA) has wide applications in the agricultural sector to evaluate the efficiency with crisp input and output data. However, in agricultural production, impreciseness and uncertainty in data are common. As a result, the data obtained from farmers vary. This impreciseness in crisp data can be represented in fuzzy sets. This paper aims to employ a combination of fuzzy data envelopment analysis (FDEA) approach to yield crisp DEA efficiency values by converting the fuzzy DEA model into a linear programming problem and machine learning algorithms for better evaluation and prediction of the variables affecting the farm efficiency.

Design/methodology/approach

DEA applications are focused on the use of a common two-step approach to find crucial factors that affect efficiency. It is important to identify impactful variables for minimizing production adversities. In this study, first, FDEA was applied for efficiency estimation and ranking of the paddy growers. Second, the support vector machine (SVM) and random forest (RF) were used for identifying the key leading factors in efficiency prediction.

Findings

The proposed research was conducted with 450 paddy growers. In comparison to the general DEA approach, the FDEA model evaluates fuzzy DEA efficiency giving the user the flexibility to measure the performance at different possibility levels.

Originality/value

The use of machine learning applications introduces advanced strategies and important factors influencing agricultural production, which may help future research in farms' performance.

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.

The transition to medication adoption in publicly funded substance use disorder treatment programs: organizational structure, culture, and resources

OBJECTIVE

Medications for the treatment of substance use disorders (SUDs) are not widely available in publicly funded SUD treatment programs. Few studies have drawn on longitudinal data to examine the organizational characteristics associated with programs transitioning from not delivering any pharmacotherapy to adopting at least one SUD medication.

METHOD

Using two waves of panel longitudinal data collected over a 5-year period, we measured the transition to medication adoption in a cohort of 190 publicly funded treatment organizations that offered no SUD medications at baseline. Independent variables included organizational characteristics, medical resources, funding, treatment culture, and detailing activities by pharmaceutical companies.

RESULTS

Of 190 programs not offering SUD pharmacotherapy at baseline, 22.6% transitioned to offering at least one SUD medication at follow-up approximately 5 years later. Multivariate logistic regression results indicated that the employment of at least one physician at baseline, having a greater proportion of Medicaid clients, and pharmaceutical detailing were positively associated with medication adoption.

CONCLUSIONS

Adoption of pharmacotherapy was more likely in programs that had greater medical resources, Medicaid funding, and contact with pharmaceutical companies. Given the potential expansion of Medicaid under the Affordable Care Act, patients served by publicly funded programs may gain greater access to such treatments, but research is needed to document health reform's impact on this sector of the treatment system.

A multi-level analysis of counselor attitudes toward the use of buprenorphine in substance abuse treatment

Despite evidence that buprenorphine is effective and safe and offers greater access as compared with methadone, implementation for treatment of opiate dependence continues to be weak. Research indicates that legal and regulatory factors, state policies, and organizational and provider variables affect adoption of buprenorphine. This study uses hierarchical linear modeling to examine National Treatment Center Study data to identify counselor characteristics (attitudes, training, and beliefs) and organizational factors (accreditation, caseload, access to buprenorphine, and other evidence-based practices) that influence implementation of buprenorphine for treatment of opiate dependence. Analyses showed that provider training about buprenorphine, higher prevalence of opiate-dependent clients, and less treatment program emphasis on a 12-step model predicted greater counselor acceptance and perceived effectiveness of buprenorphine. Results also indicate that program use of buprenorphine for any treatment purpose (detoxification, maintenance, and/or pain management) and time (calendar year in data collection) was associated with increased diffusion of knowledge about buprenorphine among counselors and with more favorable counselor attitudes toward buprenorphine.

Managerial performance and cost efficiency of Japanese local public hospitals: a latent class stochastic frontier model

The paper explores the link between managerial performance and cost efficiency of 617 Japanese general local public hospitals in 1999-2007. Treating managerial performance as unobservable heterogeneity, the paper employs a panel data stochastic cost frontier model with latent classes. Financial parameters associated with better managerial performance are found to be positively significant in explaining the probability of belonging to the more efficient latent class. The analysis of latent class membership was consistent with the conjecture that unobservable technological heterogeneity reflected in the existence of the latent classes is related to managerial performance. The findings may support the cause for raising efficiency of Japanese local public hospitals by enhancing the quality of management.

Assessing the Service Linkages of Substance Abuse Agencies with Mental Health and Primary Care Organizations

Fragmentation of substance abuse treatment represents a major barrier to effective treatment for individuals with cooccurring substance abuse and mental and physical health disorders. Linkages of substance abuse treatment organizations with primary care and mental health agencies are widely considered to be a feasible way to integrate services. In this study, we analyzed information collected from a national sample of 62 outpatient substance abuse treatment units (OSATs) to understand the extent of services linkages in these organizations and to identify facilitators and barriers to service linkages. Results showed that OSATs had limited service linkages with primary care and mental health providers. The cited barriers to linkages included clients' financial problems, managed care restrictions, and limited organizational capacity. Onsite service provision was implemented in some OSATs. The pattern of service linkages in OSATs appeared to reflect the health needs of substance abuse clients.

Smoking Cessation Services in Adolescent Substance Abuse Treatment: Opportunities Missed?

The majority of adolescents receiving substance abuse treatment also use tobacco, yet there are few data regarding the adoption of tobacco use assessment and smoking cessation services by adolescent treatment programs. Using data from a national sample of adolescent-only treatment programs (n = 154), this research measures the adoption of aspects of assessment and treatment from the Public Health Service's (2000) guideline, Treating Tobacco Use and Dependence. When adoption of four intake/assessment practices was measured, adoption appeared high, but only 45% of programs had adopted all four practices. About 43% of programs offered some type of smoking cessation services. However, there was no association between adoption of intake procedures and the odds of availability of smoking cessation services, suggesting a lack of connection between the identification of treatment needs and the availability of services. The lack of smoking cessation services may represent a missed opportunity for early intervention with this population.

Influence of ownership on access in outpatient substance abuse treatment

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.

A profile of the substance abuse treatment industry: organization, costs, and treatment completion

Nationally representative data from the Alcohol and Drug Services Study, conducted between 1996 and 1999, are used to explore the structure and operation of the substance user treatment industry in the United States. The empirical relationship among client (N=4945) retention and completion, types and use of counseling and medical personnel, diagnostic mix, client demographics, the level of services used, and the cost of treatment in different treatment settings is discussed using tabular presentation and tests of significance. Limitations of the analysis are outlined. This information and analysis are expected to help the research community understand the potential of the ADSS data in addressing many important questions about substance user treatment.

Organizational- and individual-level correlates of posttreatment substance use: a multilevel analysis

In addressing the need to study the effects of organizational factors on individual-level treatment outcomes, this study used hierarchical models to examine the organizational- and individual-level correlates of posttreatment substance use. Risk for posttreatment use varied significantly across organizations. Factors in the external institutional environment of facilities significantly influenced risk for use: managed care regulation increased the risk, whereas Joint Commission on the Accreditation of Healthcare Organizations accreditation decreased it (p < .01 for both). On the individual level, longer treatment episodes and treatment completion reduced the risk (p < .01 for both) after controlling for client characteristics. The benefits of length of stay in treatment were modified by elements of the external institutional environment and organizational treatment technology. The ameliorative effects of prolonged treatment were reduced by higher levels of managed care regulation, organizational monitoring, caseload size (p < .01 for all), and proportion of degreed staff (p < .05). The results highlight the influence of organizational factors on posttreatment use.

The use of antidepressant medications in substance abuse treatment: the public-private distinction, organizational compatibility, and the environment

Many studies of innovation adoption in health care organizations focus either on organizational characteristics or the institutional environment, but not both. Furthermore, these perspectives are rarely employed simultaneously in both public and private health care organizations. This research considers the public-private distinction, organizational compatibility, and interorganizational referral relationships in the use of selective serotonin reuptake inhibitors (SSRIs) by substance abuse treatment organizations. Using data from nationally representative samples of 363 publicly funded and 403 privately funded substance abuse treatment centers, a four-category typology of public and private organizations initially predicted variation in SSRI use. However some differences were no longer significant once organizational and environmental characteristics were added to the statistical model. These data support hypotheses about the associations between organizational characteristics and SSRI use as well as hypotheses regarding the external environment. Future research should continue to integrate both internal and external factors in theoretical explanations of innovation adoption.

The adoption of medications in substance abuse treatment: associations with organizational characteristics and technology clusters

Despite growing interest in closing the "research to practice gap", there are few data on the availability of medications in American substance abuse treatment settings. Recent research suggests that organizational characteristics may be associated with medication availability. It is unclear if the availability of medications can be conceptualized in terms of "technology clusters", where the availability of a medication is positively associated with the likelihood that other medications are also offered. Using data from 403 privately funded and 363 publicly funded specialty substance abuse treatment centers in the US, this research models the availability of agonist medications, naltrexone, disulfiram, and SSRIs. Bivariate logistic regression models indicated considerable variation in adoption across publicly funded non-profit, government-owned, privately funded non-profit, and for-profit treatment centers. Some of these differences were attenuated by organizational characteristics, such as accreditation, the presence of staff physicians, and the availability of detoxification services. There was some evidence that naltrexone, disulfiram, and SSRIs represent a group of less intensely regulated medications that is distinct from more intensely regulated medications. These types of medications were associated with somewhat different correlates. Future research should continue to investigate the similarities and differences in the predictors of medication availability across national contexts.

An exploratory analysis of treatment completion and client and organizational factors using hierarchical linear modeling

Data from the Alcohol and Drug Services Study (ADSS) are used to analyze the structure and operation of the substance abuse treatment industry in the United States. Published literature contains little systematic empirical analysis of the interaction between organizational characteristics and treatment outcomes. This paper addresses that deficit. It develops and tests a hierarchical linear model (HLM) to address questions about the empirical relationship between treatment inputs (industry costs, types and use of counseling and medical personnel, diagnosis mix, patient demographics, and the nature and level of services used in substance abuse treatment), and patient outcomes (retention and treatment completion rates). The paper adds to the literature by demonstrating a direct and statistically significant link between treatment completion and the organizational and staffing structure of the treatment setting. Related reimbursement issues, questions for future analysis, and limitations of the ADSS for this analysis are discussed.

Organization and financing of alcohol and substance abuse programs for American Indians and Alaska Natives

OBJECTIVES

Although American Indians and Alaska Natives have high rates of substance abuse, few data about treatment services for this population are available. We used national data from 1997-2002 to describe recent trends in organizational and financial arrangements.

METHODS

Using data from the Indian Health Service (IHS), the Substance Abuse and Mental Health Services Administration, the National Institute on Alcohol Abuse and Alcoholism, the Henry J. Kaiser Family Foundation, and the Census Bureau, we estimated the number of American Indians served by substance abuse treatment programs that apparently are unaffiliated with either the IHS or tribal governments. We compared expected and observed IHS expenditures.

RESULTS

Half of the American Indians and Alaska Natives treated for substance abuse were served by programs (chiefly in urban areas) apparently unaffiliated with the IHS or tribal governments. IHS substance abuse expenditures were roughly what we expected. Medicaid participation by tribal programs was not universal.

CONCLUSIONS

Many Native people with substance abuse problems are served by programs unaffiliated with the IHS. Medicaid may be key to expanding needed resources.

The administrative control system of substance abuse managed care

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.

Frontier efficiency measurement in health care: a review of empirical techniques and selected applications

Health care institutions worldwide are increasingly the subject of analyses aimed at defining, measuring, and improving organizational efficiency. However, despite the importance of efficiency measurement in health care services, it is only relatively recently that the more advanced econometric and mathematical programming frontier techniques have been applied to hospitals, nursing homes, health management organizations, and physician practices, among others. This article provides a synoptic survey of the comparatively few empirical analyses of frontier efficiency measurement in health care services. Both the measurement of efficiency in a range of health care services and the posited determinants of health care efficiency are examined.

The sensitivity of substance abuse treatment intensity to co-payment levels

This study exploits variation in co-payment levels among different contractual arrangements within a regional managed behavioral health care organization to estimate the relationship between co-payment levels for substance use treatment services and the intensity of substance use treatment. The substance use treatment benefits involved a range of co-payment levels across nearly 400 employers during the years 1993 through 1998. Multiple regression techniques were used to estimate the effect of co-payment levels on treatment intensity. The results indicate that co-payment levels had a significant negative effect on outpatient and inpatient substance use treatment. For outpatient treatment the effect on intensity implied a co-payment elasticity of -0.18, implying that moving from a $10 co-payment to a $20 co-payment would result in, for example, a reduction from 5 to 4 outpatient visits per episode. However, the effect was larger for persons with combined alcohol and drug use disorders, as they exhibited a co-payment elasticity of -0.27. For inpatient days, the co-payment elasticity was considerably smaller at -0.017. Given the benefits of maintaining persons with substance use disorders in treatment, employers may have an incentive to take steps to minimize the barriers to treatment.

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

Concerns about access under managed care have been raised for vulnerable populations such as publicly funded patients with substance abuse problems. To estimate the effects of the Iowa Managed Substance Abuse Care Plan (IMSACP) on substance abuse service use by publicly funded patients, service use before and after IMSACP was compared; adjustments were made for changes in population sociodemographic and clinical characteristics. Between fiscal years 1994 and 1997, patient case mix was marked by a higher burden of illness and the use of inpatient, residential nondetox, outpatient counseling, and assessment services declined, while use of intensive outpatient and residential detox services increased. Findings were similar among women, children, and homeless persons. Thus, care moved away from high-cost inpatient settings to less costly venues. Without knowing the impact on treatment outcomes, these changes cannot be interpreted as improved provider efficiency versus simply cost containment and profit maximization.

Using cost and financing instruments for economic evaluation of substance abuse treatment services

Standardized economic evaluation instruments are an important tool in the analysis of change and performance of addiction treatment. Nevertheless, compared to other health care sectors, economic evaluation of addiction treatment is still rare. The present paper proposes two comprehensive economic evaluation instruments that are methodologically sound and that meet the objectives of comprehensiveness, standardization, and comparability. The Drug Abuse Treatment Cost Analysis Program (DATCAP) can be used to estimate the economic cost of treatment services; the Drug Abuse Treatment Financing Analysis Program (DATFin) is a companion instrument and analyzes the complexity and change of treatment financing. This paper outlines the contents of each instrument and, for illustrative purposes, presents results from several case studies. Suggestions for updates and enhancements for each instrument are also discussed.

Managed care and outpatient substance abuse treatment intensity

This study examines the extent to which managed care behavioral controls are associated with treatment intensity in outpatient substance abuse treatment facilities. Data are from the 1995 National Drug Abuse Treatment System Survey, a nationally representative survey that includes over 600 provider organizations with a response rate of 86%. Treatment intensity is measured in three ways: (1) the number of months clients spend in outpatient drug treatment, (2) the number of individual treatment sessions clients receive over the course of treatment, and (3) the number of group treatment sessions clients receive over the course of treatment. After accounting for selection bias and controlling for market, organization, and client characteristics, there is no significant relationship between the scope of managed care oversight and treatment intensity. However, the stringency of managed care oversight activities is negatively associated with the number of individual and group treatment sessions received over the course of treatment.

Conceptualizing and assessing treatment structure and process in community-based drug dependency treatment programs

Having established the effectiveness of drug dependency treatment, the next generation of research will necessitate a focus on treatment structure and process and the systems within which programs operate. As a foundation for a process conceptualization, we constructed a grounded theory definition of treatment consisting of core elements and related comprehensive services. We then presented the multilevel conceptual framework that guided the Drug Abuse Treatment Outcome Study (DATOS) treatment structure and process study design and instrumentation, anchored by supporting empirical literature. The framework emphasizes seven critical levels of process measurement that future research should consider in order to avoid potential spurious findings.