In this era of managed care, health care providers are being asked to carefully reexamine previously held notions that equate quantity and intensity of care with quality. The struggle between the "more is better" philosophy and the realization that we care for people and populations with limited resources is nowhere more apparent than in the addictions treatment field. Some of us still look back with nostalgia to the time when the 28-day inpatient program was the standard treatment approach. Although the abstinence-based "Minnesota Model" did produce better outcomes than previous psychoanalytic and psychiatric models,1 our excessive reliance on this level of care led to overuse of expensive and sometimes unnecessary services and impeded the development of more flexible, less restrictive, and possibly more efficacious models of care.
Recent efforts between the American Society of Addiction Medicine (ASAM) and the American Managed Behavioral Care Association (AMBHCA)2 highlight the need for managed care organizations and treatment providers to arrive at a consensus with regard to the avail ability of high-quality, cost-effective treatment for addictive disorders.3 These efforts led to a joint statement supporting parity for addictions and underscored the importance of matching the treatment plan with the patient's individual needs in the least restrictive setting that is reasonably consistent with safety.
Treatment providers daily face a compelling temptation to put each patient in the most restrictive setting available to hopefully decrease the possibility of treatment failure or relapse. The urge to give in to that temptation must be moderated by an objective appraisal of risk.
AMERICAN SOCIETY OF ADDICTION MEDICINE CRITERIA
ASAM has made significant strides in researching and publishing patient placement criteria for the treatment of substance-related disorders. The second edition, published in 1996, outlines dimensions of risk and assists clinicians in determining appropriate levels of care. ASAM criteria appear to be widely accepted by managed care organizations as well as by clinicians and serve us well as a current consensus document, but will almost certainly need revision as outcome data are collected in a more systematic way.
THE IDEAL TREATMENT SYSTEM
Full Spectrum of Services
An integrated system of care encompasses multiple levels of care and ensures that patients can be moved quickly between various levels of intensity. This full range of options allows a program to be tailored to the needs of the individual (Figure).
Ease of Access
Patients, employee assistance programs (EAPs), and managed care organizations can access all aspects of the treatment system through a single telephone number, 24 hours per day and 7 days per week. Centralized appointments at a convenient location are available the same day for emergencies, within 48 hours for urgent cases, and within 5 days for routine cases. Case managers and customer service representatives are readily available to respond to inquiries from patients and referral sources.
The "Focused Factory"
Borrowing a phrase from Regina Herzlinger,4 the treatment system is a highly efficient enterprise focused solely on the provision of psychiatric and addictions treatment. It excels at meeting the needs of its special patient populations through extensive staff training, customer service, and the use of evidence-based care. Treatment is continuously refined and improved through outcome measurement.
Integration of Psychiatry
Psychiatric services in addiction treatment settings have been suspect because of the long history oí traditional psychiatry conceptualizing the addiction as symptomatology of an underlying psychiatric illness.5 However, there is growing sophistication within the psychiatric community as evidenced by the American Academy of Addiction Psychiatry (AAAP) and the growing role of psychiatry in both the direct treatment of addictions and the treatment of comorbid conditions. In a truly integrated delivery system, psychiatry should play a major role. A good system combines a fully credentialed psychiatrist with experience and training in addictions along with psychiatric social workers and other licensed mental health clinicians. Integrating care avoids splitting between separate programs. Cross-fertilization of ideas and approaches between psychiatry and addiction treatment enhances the skills of the entire team.
Treatment is tailored to the individual patient. There are no fixed-length or fixed-content programs that all patients are expected to complete regardless of relevance or need. Treatment planning is done from a "menu" containing educational elements, group and individual approaches, various levels of spouse/family involvement, psychopharmacology, self-help group participation, and recovery environment enhancement strategies. More restrictive levels of care are used only to manage risk, and patients can quickly move between various levels of care in response to changes in their clinical status and safety.
We applaud ASAM's efforts in attempting to objectify criteria for admission to various levels of care; however, current criteria focus on the setting (placement) and the global intensity of care (hours per day) rather than content. We feel that the ideal system must provide a structure for much more flexible treatment matching, especially in less restrictive levels of care where the majority of care is delivered.
Treatment Matching for High-Accountability Professionals
Risk assessment to determine degree of restrictiveness and general treatment planning should include consideration of special factors inherent in high-accountabüity professions such as health care, transportation, the clergy, the legal profession, and law enforcement. Addicted individuals in these professions are responsible not only for their own safety and the safety of their families, but also for the safety and wellbeing of the public they serve. There is increasing evidence that programs that are specifically geared to special professional needs produce a better outcome.6 These special occupational factors have implications for the treatment milieu, content of programming, value of a residential component, risk from relapse, and need for longer-term monitoring. Treatment of these individuals is also suboptimal without careful coordination with licensing agencies, professional organizations, and other professional support services, such as state medical society assistance programs.7
Data Management System
All treatment sites and providers in the "ideal system" will be linked together with a centralized data repository. Immediate access to financial, clinical, and outcome data is essential to manage use and productivity, and to continuously improve the quality of care.
Each member of the treatment team and support staff enjoys his or her work environment and describes his or her day as "fun." There are ample opportunities for continuing education and recognition of excellence, and there is opportunity for advancement.
A BEHAVIORAL HEALTH TREATMENT SYSTEM
An example of the application of these principles is the development of a behavioral health treatment system in the Chicago metropolitan area. Although this system provides a full spectrum of mental health services in multiple sites, its history and specialty is addiction treatment.
During the 1970s and 1980s, a wide spectrum of addiction treatment centers and programs were available in the Chicago area. A number of hospitals provided inpatient detoxification and treatment, along with a variety of outpatient services. There were two large (more than 100 beds each), free-standing residential (subacute) treatment centers focusing on thirdparty payment patients, along with a number of large, public-funded residential centers. Treatment admissions were not restricted by managed care precertification requirements. Inpatient lengths of stay for adults were typically 3 to 6 weeks, and adolescents typically stayed 6 to 12 weeks. Most programs were more or less set in a particular model that resulted in a predictable and uniform length of stay for most patients.
Although structured intensive outpatient programs (IOPs) that typically called for 15 hours or more per week as an alternative to inpatient/residential treatment had begun as early as 1979, the 1980s witnessed a virtual explosion of treatment programs as franchise models became popular. Unused hospital beds could be and were converted to chemical-dependency treatment programs. There was a similar expansion of psychiatric programs, both hospital and specialty hospital based.
In part because of the abuse of this system by aggressive treatment providers, the managed care industry grew rapidly. Fueled by widespread concern by employers about the rapid escalation of overall medical costs, the managed behavioral health care industry began a sharp, focused effort to eliminate the abuses in the field. Mental health and chemical dependency treatments were seen as areas of health care that were rampant with overuse of costly treatment, both through overzealous diagnosis and unnecessary use of expensive inpatient/residential treatment. Although it was in the interest of this new industry to heighten this concern, there was a growing consensus by employers, insurers, and responsible providers that costs could be curtailed without compromising quality of care and desired outcomes.
Most responsible providers had begun modification of this model even before external pressure from managed care organizations (MCOs) forced the issue. These changes included the adoption of criteria for patient placement in an appropriate level of care, and for length of stay. Outpatient modalities, including both partial hospitalization (6-8 hours per day) and IOP programs, were added.
Although there was conceptual agreement among providers, insurers, and researchers that these developments were necessary, intensive debate continues as to what intensity and length of treatment is optimal for which individuals. Somewhat predictably, providers tend to emphasize the need for more time and intensity, whereas the behavioral health care MCOs stress the lack of evidence that more treatment results in better outcomes.
In 1994, Rush-Presbyterian-St. Luke's Medical Center decided to expand its behavioral health treatment system by the addition of community-based outpatient centers (Rush Behavioral Health) that would provide a full spectrum of addiction treatment and include a "partnership" approach to MCOs (Rush Behavioral Health Systems) This system also included a specialized, nationally known program for the treatment of impaired health care professionals. All programs are outpatient only, with the exception of a small inpatient stabilization unit at the medical center. Because of geographic access needs, one other system hospital has an inpatient unit, which is also used to provide detoxification/stabilization services.
This arrangement of services provides the availability of highly specialized and intensive services (inpatient medical and inpatient psychiatric) in centralized locations with outpatient services in geographically accessible locations throughout the metropolitan area. In addition to the structured intensive programs, each site offers a wide array of assessment and intervention services, educational groups, and lower intensity groups for individuals and families.
The impaired professionals program deals primarily with physicians and other health care professionals, along with other high-accountability individuals. This program pioneered in the Chicago area the use of an independent living community in neighborhood apartments as an adjunct to treatment. This model intensifies the treatment provided in a day hospital or IOP program through the experience of living with peers in various stages of treatment. Although most third-party payers will not cover the expense of the apartments, they recognize the value of this model as providing more accountability for the patient to assume responsibility for the tasks of daily living as well as the natural integration of new learning.
The other clinic sites do not specialize in impaired professionals, but have also incorporated this apartment option into their treatment menus. These sites also have a much more flexible approach to level of care and length of stay based on MCO criteria. A typical menu includes brief (1-2 day) inpatient detoxification or ambulatory detoxification as necessary, followed by some days in IOP or partial hospitalization. IOP is used in a flexible manner to spread the sessions over a longer period of time as soon as the patient can maintain stability and return to work.
A key ingrethent in this system of care was the addition of an internal managed care component that provided centralized access, centralized data management, outcome measurement, and overall case management according to agreed on internal criteria. This capability allows a true partnership with MCOs that choose to contract with an integrated system. The integrated provider system is able to collect and analyze data about clinical use, and generate management reports that eliminate duplication and redundancy. Large employers or groups can contract for behavioral health care directly if they choose. This provider system has incorporated these functions in a way that improves the functioning of both parties.
This overall system of care has received positive responses from both the EAP community and the MCOs. The partnership approach results in more creative dialogue over treatment approaches and less adversarial posturing on both sides. The payer welcomes the almost exclusive use of outpatient modalities for intensive treatment as more cost effective. The provider realizes the clinical advantage of outpatient treatment for the majority of patients who do not need the external structure of the residential setting. There still is considerable disagreement on individual cases, as to both the level of intensity and the length of treatment, especially when the individual is an impaired health professional. But this discussion is within the context of respect and professionalism on both sides.
What is missing in this system of addiction treatment? One thing is the unavailability of residential care for the person who is unable to handle the stress and the freedom of either the independent living community or living at home. Extended care for those who need a protected environment to build up the internal resources for successful independent living is another. Affordable halfway houses and recovery homes in the Chicago area have begun to increase in number and quality.
All things considered, this treatment model has demonstrated a way to maintain a high quality of care, provide good outcomes, and maintain a moderate cost. Refinements will continue to develop out of data-based review of cases and outcomes in partnership with the MCOs.
GOAL OF TREATMENT
Despite increasing fiscal constraints, providers in a managed care system are expected to provide high-quality, comprehensive care with attention to all of the following elements of treatment.
Detoxification must be provided in the least restrictive setting that is consistent with reasonable patient safety and meets criteria for medical necessity. Inpatient detoxification simply for convenience or "to make sure the patient doesn't use" is no longer justifiable. Inpatient care can be justified only to manage complicated withdrawal in a patient with medical or psychiatric comorbidity that places him or her at high risk. Ambulatory detoxification with daily physician/nurse contact and assistance from family members can safely and efficiently manage many patients who may have been automatically admitted in years past.
Improving the health of an individual or a population requires skill in dealing with highly variable levels of motivation. Although some patients will inevitably remain inaccessible to help, we can no longer afford to dismiss noncompliance with a simple shrug of the shoulders and an invocation of, "They haven't hit bottom yet." Evidence-based techniques are available to assess and enhance motivation. Every physician and counselor in our treatment system should be skilled in the appropriate application of these techniques.8
Health Status Enhancement and Risk Reduction
Federal and state regulations now require that AIDS and tuberculosis education be an integral part of chemical dependency treatment programs. Although education alone does not predictably produce change, it is an essential component of treatment. Additional opportunities for health education include stress management, mood regulation, and nutrition.
Identifying and Treating Psychiatric Comorbidity
Given the prevalence of depression and other psychiatric illnesses in addicted populations, it is imperative that efficient and effective delivery systems provide integrated psychiatric assessment and treatment. Psychiatric participation in the initial assessment, ongoing treatment review staffings, and aftercare planning is essential.
Family and friends must be actively involved in the treatment process to improve chances of successful outcome. One of the foremost goals of treatment and recovery in the addictions is replacing substances with healthy relationships. The therapeutic community and group process are critical elements in this effort.
Spiritual Issues and Questions of Meaning and Purpose
Insurance benefits typically cover only "medically necessary" treatment. The questions and issues that attracted most of the helping professions are now considered outside the realm of third-party reimbursement, especially in managed care settings. Those of us who accept that certain important aspects of healing are simply not going to be "covered" are left with four alternatives:
1. Don't do anything that you won't be reimbursed for.
2. Do it anyway, and hope for the best.
3. Accept that such treatment elements are important to your care, even if they are not reimbursed, and integrate them into your treatment program as "value added" components.
4. Write your senator and congressman.
BARRIERS TO EFFECTIVE TREATMENT
Issues of Quality, Cost, and Value
Quality addictions treatment was traditionally defined by the programmatic structure of care rather than treatment outcomes. Rigid inpatient programs were once considered necessary to provide the care that all patients required for recovery. Research conducted through the 1970s and 1980s began to suggest that outpatient care was as effective or even more effective than inpatient care.911 Research has evolved during the past decade and has shifted the focus from the "inpatient vs. outpatient" debate to identifying the most appropriate setting of care and the most effective treatment approaches for each individual patient. The growing emphasis on continuous quality improvement defines quality through individualizing patient care and measuring treatment outcomes/costs, and is achieved by matching patient needs to the most appropriate level of care.
Quality care that is affordable is considered to be of value. Value can be described as the relationship between quality and cost. Quality care must be affordable if it is to be accessible to those who need it. Likewise, affordable care must be of acceptable quality, or it is of no benefit to those who use it. Value is achieved by maintaining a balance between quality and cost.
The very mechanisms that managed care has employed to control cost and decrease unnecessary use have also provided undesirable disincentives to innovation. Concurrent treatment reviews, medical necessity criteria, and benefit exclusions are routinely applied to feefor-service reimbursement to control use. Innovative treatments such as ambulatory detoxification, home-based care, and flexibleintensity programming, which may be safe and appropriate for large numbers of patients, are discouraged through lack of reimbursement. Managed care organizations seem to have little interest in or control over benefit design or billings and claims procedures. Care managers are given minimal flexibility in working out a treatment plan that makes clinical and financial sense but falls outside of rigid guidelines. Case rates and capitation can conceivably encourage innovation if the treatment providers want to stay financially viable but feel truly responsible for the health and well-being of their patients. Without that sense of responsibility, capitation provides a strong financial incentive to simply deny care.
Referral Sources' Expectations
Referral sources such as unions, EAPs' professional organizations, and the courts often request and expect treatment services that are not reimbursed by managed care contracts. Requests for long-term or residential treatment services may not meet medical necessity criteria or are simply services that are not covered. This places the provider in the uncomfortable position of trying to "educate" a valuable referral source about the realities of recent-day addictions treatment and the availability of effective treatment approaches that may not require the expected level of intensity or restrictiveness.
Lack of Provider "Buy In"
Many front-line treatment providers feel that they have been betrayed by their health care system's leaders in taking on managed care agreements that seem to require the delivery of shoddy services. Many of these providers have relied on the unchallenged use of intensity of care as the main treatment variable and resent the attack that managed care seems to make on their cherished notions of what constitutes quality care. At the same time, many of these same providers can be creative in designing successful treatment plans for individual patients who have limited resources, and take justifiable pride in doing so. Drawing on this talent and creativity by involving all providers in the design and implementation of a cost-effective treatment system is crucial to its success.
A patient who was participating in her third treatment program was asked why the previous attempts were not fully successful. She responded, "To find a handsome prince, you must kiss a few frogs." The same can be said of attempts by providers and payers to provide high-quality, cost-effective addictions treatment.
The growth and success of some managed care systems support the notion that value can be obtained through individualizing care and matching patients' needs to the most effective treatment resources. The combination of rational placement guidelines, integrated systems of care, and appropriately motivated and trained providers give us our best chance of success in providing cost-effective treatment. It is a fact that many managed care organizations have adopted practice guidelines that focus on delivering care that is only necessary and essential. Typical guidelines that reflect this philosophy are12:
1. Use the least restrictive level of care that is reasonably likely to initiate abstinence.
2. Assess the likelihood of treatment failure at the level of care chosen and the risks to the patient (and society) if treatment fails.
3. Identify treatment failures quickly and move the patient to a more intensive level of care if significant risks are present.
Increasing numbers of payers are demanding that providers adopt this treatment philosophy and demonstrate treatment quality at lower cost. Patients potentially benefit from a clearer focus on outcomes and individualized care. Providers are incentivized to enhance their clinical skills while embracing accountability and cost-effectiveness. HMOs and other payers that can demonstrate that they deliver high quality can share in the opportunity to promote true value in health care delivery.
Although the healing power of professional caring, abstinence, a strong recovering community, and involvement in self-help groups is undeniable to those of us in the field, we are increasingly expected to "prove it" to purchasers of care. We are also expected to deh ver our best care in flexible settings without sacrificing quality and professional satisfaction. In so doing, we must balance our responsibilities as advocates for our individual patients, as healers, and as scientists, and our fiscal obligations to the populations we serve. This is not a task for the faint of heart. We may indeed find that intensity of care correlates directly with positive outcome, or we may find many of our cherished notions shattered by data. The path inevitably leads us through significant amounts of soul-searching, responsible programmatic innovation, and improvements in measuring the impact of what we do on our patients' lives- a process that has been greatly accelerated by the emergence of managed care.
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