Managed care and access to substance abuse treatment services

Medicaid coverage in substance use disorder treatment after the affordable care act

The Affordable Care Act (ACA) prompted sweeping changes to Medicaid, including expanding insurance coverage to an estimated 12 million previously uninsured Americans, and imposing new parity requirements on benefits for behavioral health services, including substance use disorder treatment. Yet, limited evidence suggests that these changes have reduced the number of uninsured in substance use disorder treatment, or increased access to substance use disorder treatment overall. This study links data from a nationally-representative study of outpatient substance use disorder treatment programs and a unique national survey of state Medicaid programs to capture changes in insurance coverage among substance use disorder treatment patients after ACA implementation. Medicaid expansion was associated with a 15.7-point increase in the percentage of patients insured by Medicaid in substance use disorder treatment programs and a 13.7-point decrease in the percentage uninsured. Restrictions in state Medicaid benefits and utilization policies were associated with a decreased percentage of Medicaid patients in treatment. Moreover, Medicaid expansion was not associated with a change in the total number of clients served over the study period. Our findings highlight the important role Medicaid has played in increasing insurance coverage for substance use disorder treatment.

Case management in aftercare of involuntarily committed patients with substance abuse. A randomized trial

OBJECTIVE

Case management has since the 1970s been widely used to co-ordinate services for mental health patients. The methodology has expanded to support patients in many different types of conditions. This study is one of very few randomized trials on case management in a European setting. It examined the impact of case management on substance abuse and use of service after discharge from court-ordered institutional care.

METHODS

Court-ordered patients with substance abuse ( n = 36) were randomly assigned to either strengths based case management or treatment-as-usual during 6 months in aftercare. Data was collected at intake, at conclusion of intervention and at 6 month's follow-up with a follow-up rate of 94%.

RESULTS

Case management interventions were well received by the patients with no drop-out during intervention. Patients with the support of a case manager seemed to sustain abstinence in a higher degree compared with treatment-as-usual but no differences were detected in regard to use of care. A subgroup analysis showed that patients with a continuous drug abuse did have access to care from both social welfare and hospital care systems.

CONCLUSIONS

Case management may be useful in order to retain abstinence in aftercare following court-ordered treatment. The social welfare and hospital care systems seem to provide care irrespective of case manager intervention. The study design, interventions and assessments instruments were well received by patients but needs to be replicated with a larger population.

CLINICAL IMPLICATIONS

The 100% retention in the case management support group indicates that patients were satisfied with this type of intervention and the methodology seems to be useful in order to retain abstinence.

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.

A comparison of the efficacy of two interventions to reduce HIV risk behaviors among drug users

Numerous interventions have been developed and implemented to decrease risk behaviors which lead to HIV infection and transmission. These interventions have been differentially successful in reducing high risk behaviors in various populations. Testing and evaluation of the interventions have been subject to various degrees of rigor. The CDC recommends the use of interventions which have been rigorously tested and meet the standards for evidence based intervention rather than the continuation of the development of new interventions. Project RESPECT is an evidence based intervention that proved efficacious in increasing condom use among patients of STD clinics. We tested the efficacy of the RESPECT intervention against the NIDA standard intervention to determine if the RESPECT intervention was more effective in reducing high risk behaviors among drug users. Both interventions showed changes from baseline to follow-up; RESPECT was more effective than the NIDA standard intervention in reducing high risk sex behaviors.

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.

State policies matter: the case of outpatient drug treatment program practices

This study examined relationships between state policy requirements governing outpatient substance abuse treatment services and reported outpatient treatment program practices. State policies effective as of February 1, 2003, and February 1, 2004, were collected and analyzed via primary legal research; data were validated by state officials (88% response rate; >90% validation rate). Treatment practice data were obtained from the National Survey of Substance Abuse Treatment Services for the years 2003 and 2004. Multivariate analyses clustered by state were conducted, controlling for state, program, and state-aggregated client admission characteristics. Results indicated that treatment programs located in states with requirements for comprehensive substance abuse assessment, family counseling, substance abuse and infectious disease/sexually transmitted disease testing services, HIV/AIDS education, and aftercare services had significantly higher odds of offering such services (p values ranging from < .05 to < .001). This study presents new information regarding the potential role that state policy context may play in understanding treatment program practices.

Individual and system influences on waiting time for substance abuse treatment

Waiting time is a contemporary reality of many drug abuse treatment programs, resulting in substantial problems for substance users and society. Individual and system factors that influence waiting time are diverse and may vary at different points in the treatment continuum. This study assessed waiting time preceding clinical assessment at a centralized intake unit and during the period after the assessment but before treatment entry. The present study included 577 substance abusers who were enrolled in a large clinical trial of two brief treatment interventions in a midsize metropolitan area in Ohio. Bivariate analyses identified individual and system factors that influenced preassessment and postassessment waiting time, as well as total wait to treatment services. Multivariate analyses demonstrated that longer wait time for an assessment is influenced by being court referred, less belief in having a substance abuse problem, and less desire for change. A shorter wait to actually enter treatment is predicted by having a case manager, being more ready for treatment, and having less severe employment and alcohol problems. The different influences present during the two waiting periods suggest that assessment and treatment programs need to implement system changes and entry enhancement interventions that are specific to the needs of substance abusers at each waiting period.

The role of organization and management in substance abuse treatment: Review and roadmap

To develop an understanding as to why there exists a seemingly wide gap between research and practice in the field of substance abuse treatment and, more important, to understand how this gap can be closed, researchers have focused their attention on the role of organizational and management factors in the delivery of treatment services. This article's overarching goal is to stimulate research and interventions that focus on these factors so as to improve the standards and outcomes of care in substance abuse treatment. Part 1 introduces the key assumptions and perspectives that guide organization and management research. Part 2 selectively reviews empirical studies that examine relationships between treatment programs' use of research-based treatment practices and organization and management factors. The article concludes with a discussion of the next important steps for research and policy.

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.

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.

Retention in publicly funded methadone maintenance treatment in two Western States

This study examined individual and system characteristics associated with retention in methadone maintenance treatment among Medicaid-eligible adults in treatment for opiate use in Oregon and Washington. Logistic regression was used to examine the contributions of predisposing, need, and enabling characteristics on 365 day retention in methadone maintenance treatment. Older patients, patients with a history of methadone maintenance treatment, and persons with stable Medicaid eligibility had higher rates of retention than did patients with disabilities, polysubstance users, and those with an arrest record. In Oregon, which delivers methadone maintenance treatment through managed care, retention rose sharply from 28% to 51% between 1994 and 1998 and then leveled off. During the same time period, retention in Washington State grew from 28% to 34%. The higher rates of retention in Oregon, in part, can be explained by differences in service delivery influenced by financing. Faced with long waiting lists, Washington providers were more than twice as likely to administratively discharge patients for rule violations as their Oregon counterparts. Given the importance of retention, policies and practices that influence retention should be carefully considered. Because Medicaid eligibility has a dramatic impact on retention, policies that help extend eligibility or stabilize eligibility among individuals actively engaged in treatment should be carefully considered.

A conceptual framework for drug treatment process and outcomes

Evidence from specialized treatment evaluations and large-scale natural studies of treatment effectiveness is organized conceptually into a "treatment model" for summarizing how drug treatment works. Sequential relationships between patient and treatment program attributes, early patient engagement, recovery stages, retention, and favorable outcomes are discussed--along with behavioral, cognitive, and skills training interventions that have been shown to be effective for enhancing specific stages of the patient recovery process. Applications of the treatment model for incorporating science-based innovations into clinical practice for improving early engagement and retention, performance measurements of patient progress, program monitoring and management using aggregated patient records, and organizational functioning and systems change also are addressed.

Changes in managed care activity in outpatient substance abuse treatment organizations, 1995-2000

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 sector. 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.