|
Managed Care and Substance Abuse Prevention
Annotated Bibliography
July, 1998
Gale A. Held, M.P.A.
Hyperlinks to sections within this text:
Legislation
Cost Benefit
Coverage/Guidelines
Employee Assistance
State Programs
Miscellaneous
Helf, C. (1995, December). Mental health and substance abuse: Health insurance: An overview of 1995 state legislative activity. Washington, DC: Intergovernmental Health Policy Project.
The Intergovernmental Health Policy Project annually publishes this document, which is aimed primarily at state and federal legislators and agencies. In this edition, two state legislative actions focused on substance abuse prevention are listed. First, Iowa mandated a study regarding the inclusion of health care coverage costs for preventive care services and mental health and substance abuse treatment services under basic and standard health plans. It is unclear to what extent the study specifically will include substance abuse prevention. Second, Mississippi expanded its mandated benefits to include reimbursement for certain health care services for female enrollees, including preventive services or treatment related to acute and chronic conditions and psychosocial issues.
Legal Action Center. (1993). Model legislation mandating national health insurance benefit for prevention and treatment for alcoholism and drug addiction. Unpublished position paper.
This document was prepared during the height of the national Health Care Reform debate and was designed to provide the basic specifications for a minimum alcohol and drug abuse and dependence benefit. The primary target audience for this document was Congress and health care providers and consumers who could influence congressional action. The document cites both prevention and intervention. Prevention is defined as "patient education about the risks associated with alcohol and drug use" and includes clinical screening, health promotion, and education. Intervention is defined as including assessment, diagnosis, and referral. The document further calls for family outpatient services, which include prevention services to the families of addicted individuals.
Center for Substance Abuse Prevention. (1996, March). CSAP technical report: Cost savings of substance abuse prevention in managed care (draft). Rockville, MD: U.S. Department of Health and Human Services.
This document examines the research on cost-effectiveness of substance abuse prevention and treatment services. The authors examine primary, secondary, and tertiary prevention to address substance abuse problems and develop cost-benefit estimates for proven secondary and tertiary prevention services. These estimates explicitly identify savings to the managed care provider. The authors also recommend that managed health care include (a) early identification of heavy users of alcohol or other drugs through simple screening questionnaires; (b) brief intervention services designed to reduce drinking and drug use by heavy nondependent users; (c) timely diagnosis and treatment services; and (d) specific training for health care workers in early identification and brief intervention techniques. The primary audience for this document is substance abuse prevention professionals and advocates.
Center for Substance Abuse Prevention. (June, 1994). Cost-benefit issues in programs for prevention of alcohol and other drug abuse. Rockville, MD: U.S. Department of Health and Human Services.
The Center for Substance Abuse Prevention developed this report of the 1993 Forum on Cost-Benefit. Participants included economists, substance abuse specialists, and researchers. The forum was conducted in the context of health care reform and, hence, managed care. It focused on the quality of cost-benefit and cost-effectiveness and how it might be measured when applied to substance abuse prevention programs, as well as what would be necessary to develop cost-effectiveness tools. The forum and the report do not provide conclusive resolution of the issues discussed. Rather, the report represents a discussion of the major issues to be addressed, both short- and long-term. The primary audience for this document is substance abuse prevention professionals and advocates.
Center for Substance Abuse Prevention. (1995). Cost-effectiveness and preventive implications of employee assistance programs. Rockville, MD: U.S. Department of Health and Human Services.
This publication focuses specifically on the cost-effectiveness of employee assistance programs (EAPs), with special emphasis on the implications for prevention. The publication was developed for managers and business owners. A number of industry cost-effectiveness studies that demonstrate the cost-effectiveness of EAPs are cited. The authors discuss the important preventive roles that EAPs can play in identifying problematic life-style, adaptation, and stress-management patterns or family and psychiatric problems that are prodromal to alcohol and other drug (AOD) abuse problems and dependencies. Once identified, these problems can be addressed, and primary prevention of AOD abuse may be achieved.
Contra Costa County Health Services Department. (n.d.). Prevention program: Saving lives and money: A managed care/primary prevention partnership. Unpublished manuscript.
This unpublished paper is a proposal for the inclusion of primary prevention into Health First, the Contra Costa Health Plan (CCHP) managed care effort. It makes the case for primary prevention related to injury prevention, violence prevention, and poverty-related diseases. Although it does not address substance abuse prevention directly, it does propose to investigate the etiology of injury prevention and violence; injuries and violence frequently have been shown to be directly related to substance abuse. The proposers are basing their program on a capitation of $1 monthly per client. The authors address the cost-benefit of prevention but do not address substance abuse directly. However, in discussing the adequacy of the services, they reference smoking cessation.
(NOTE: This proposal ultimately was implemented)
Harwood, H. J. (1993). Building substance abuse prevention into national health care reform. Fairfax, VA: Lewin-VHI, Inc.
The author prepared this position paper for discussion at the Center for Substance Abuse Prevention (CSAP) sponsored Cost-Benefit Forum held July, 1993 and is directed toward substance abuse professionals and economists, as well as federal government officials. The author is well known for his work on costs and cost-benefit of substance abuse. He suggests that CSAP develop a position paper that would identify the major alternative models for health care reform, develop a typology for preventive services, analyze particular substance abuse prevention services for inclusion under the various alternative models, and estimate the potential economic savings from effective prevention initiatives.
Center for Mental Health Services. (1994, October 5). Key issues facing health systems planners. Managed behavioral healthcare: History, models, key issues, and future course. Rockville, MD: U.S. Department of Health and Human Services.
This paper is a comprehensive discussion of managed behavioral healthcare, which focuses primarily on treatment. However, Chapter III references the movement by employers toward investing in health and suggests the need to provide financial incentives for behavioral health prevention and promotion to facilitate earlier intervention in the course of an illness. This chapter also discusses the access and utilization issues important to successful managed care, including preventive and demand-reduction efforts.
Center for Substance Abuse Prevention. (1996, March). ATOD prevention in an era of managed care (draft) (pp. 10-46). Rockville, MD: U.S. Department of Health and Human Services.
This document investigates the potential impact of managed care on the delivery of alcohol, tobacco, and other drug (ATOD) prevention services and is designed to provide information and guidance to state agencies and others in the substance abuse field. It includes discussion of the current managed care-related activities in nine states and the challenges faced by states that would like to offer ATOD prevention services to Medicaid enrollees through managed care plans. The paper presents issues surrounding states’ efforts to contract with managed care organizations (MCOs) or behavioral health organizations (BHOs) to manage existing ATOD prevention services.
The paper describes the activities in nine states – Illinois, Kansas, Kentucky, Michigan, Ohio, Oregon, Pennsylvania, Tennessee, and Washington. Only Oregon and Kansas are actively pursuing inclusion of prevention in their managed care systems. Telephone interviews were conducted with each state, focusing on the nature of the health care reform initiatives, the motivation behind the states' interest in delivering ATOD prevention within a managed care environment, and the critical issues that have emerged. Initially, the intent had been to examine covered services, eligibility, financing mechanisms, reimbursement, state agency functions, and accountability, but states were largely unable to address these questions because of the very early stages of their internal processes.
Key findings from the state interviews were as follows: States need to determine if managed care is right for their approach to prevention; time is needed for effective planning; communication with other states is important; key prevention stakeholders and MCOs must be involved early; states should consider prevention standards; and states should be prepared to sell prevention. Lastly, the document discusses a number of key challenges that relate to the findings that states will face.
Center for Substance Abuse Prevention Training System. (1995, June 30). Guidelines for alcohol, tobacco, and other drug problem prevention in managed care organizations (Appendix B). Invest in prevention: Prevention works! in health care delivery systems (facilitator guide). Rockville, MD: U.S. Department of Health and Human Services.
This is a training document provided to health care delivery system organizations. The training is focused on the larger system but includes very specific guidelines for managed care organizations and hospitals. The guideline was developed by CSAP with the assistance of expert consultants in the areas of prevention, health promotion, mental health and substance abuse services, and managed care. The guidelines are divided into eleven categories: needs assessment, planning, management, communication/coordination, member access to ATOD prevention services, ATOD prevention practice and programs, personnel, follow-up, hospital liaison, community involvement, and evaluation and documentation. Each guideline includes organization and service delivery guidelines, as well as suggested activities.
Center for Substance Abuse Prevention Training System. (1995, June 30). Action planning resources for alcohol, tobacco, and other drug problem prevention in managed care organizations, guidelines for prevention. Implementation in health care delivery systems (managed care and hospital systems) (facilitator guide). Rockville, MD: U.S. Department of Health and Human Services.
The facilitator guide for training systems for health care organizations contains this section, which is focused on managed care organizations. This section lays out the portion of the training focused on assisting the participants in developing an Action Plan for including ATOD prevention as part of the overall program. It ties back to the Guidelines for Alcohol, Tobacco, and Other Drug Problem Prevention in Managed Care Organizations, cited earlier.
Center for Substance Abuse Prevention Training System. (1995, June 30). Suggested activities for alcohol, tobacco, and other drug problem prevention in managed care organizations, guidelines for prevention. Implementation in health care delivery systems (managed care and hospital systems) (facilitator guide). Rockville, MD: U.S. Department of Health and Human Services.
Another section of the facilitator guide for a larger training of health care organizations is focused on managed care organizations. This section addresses several suggested activities for implementing a substance abuse prevention program in managed care organizations. It ties back to the Guidelines for Alcohol, Tobacco, and Other Drug Problem Prevention in Managed Care Organizations, cited earlier.
Center for Substance Abuse Treatment. (1995). Comprehensiveness of treatment. Purchasing managed care services for alcohol and other drug treatment: Essential elements and policy issues. CSAT Technical Assistance Publication Series (Vol. 3 No. 16). Financing Subseries. Rockville, MD: U.S. Department of Health and Human Services.
This document was developed to benefit the state agencies, as well as other substance abuse practitioners, and focuses primarily on treatment issues, including coverage, access, comprehensiveness of treatment, financial considerations, and consumer protection. Chapter 3, Comprehensiveness of Treatment, includes a brief discussion of prevention and argues that increasing the capacity of the system to screen for AOD problems is essential to offering targeted prevention efforts and to earlier intervention in the course of an individual's substance use. The authors further argue that primary care physicians are frequently the source of referrals, and they are often ill-trained to screen for and diagnose substance abuse disorders. The authors, therefore, advocate increased training of physicians in screening technologies. Lastly, the discussion notes a range of prevention technologies that increasingly are being employed, including wellness training, early identification, and brief interventions.
Del Toro, I. M., Larsen, D. A., & Carter, A. P. (1994). A new approach to alcoholism detection in primary care. Journal of Mental Health Administration, 21 (2), 124-135.
The authors of this article describe in detail an approach to alcoholism detection that brings together chemical dependency, mental health, and primary care services. The article mentions alcoholism prevention, but the context is primarily early intervention. They do, however, include identification of patients with emotional/behavioral problems in order to provide crisis-oriented intervention. The project model included a masters level social worker and a designated family physician from the clinic. This team worked with community resources, as well as those within the HMO, to provide the necessary services. The authors conclude that placing this team in the primary care facility is advantageous to both the patient and the medical team.
FHC Systems. Assorted papers describing various components of their prevention and wellness program.
FHC Systems is a large managed care organization that provides managed care services for CHAMPUS. It does not have a specific substance abuse prevention program, but does have a larger prevention and wellness program that addresses many of the risk behaviors that may lead to substance abuse. In addition to the papers on various wellness programs, there is an excerpt from an April 19, 1996 presentation to the Department of Health and Human Services Secretary at a Managed Behavioral Health Care Seminar in which FHC notes the importance of prevention. The papers included are targeted to the health care program beneficiaries.
Jacobi, B. (1996). Setting the stage: Taking prevention into the managed care field. Prevention Forum, 16 (2), 19-20.
This article describes the development of Guidelines for Alcohol, Tobacco and Other Drug Problem Prevention in Managed Care Organizations noted earlier in this paper. A multi-disciplinary group representing expertise in managed care, hospitals, program development, substance abuse prevention, and mental health developed the guidelines. The author notes that these guidelines are consistent with the standards for preventive behavioral health being developed by the National Committee for Quality Assurance (NCQA) – the accreditation body for the managed care industry (these guidelines are expected to be released mid-1996). The article focuses primarily on substance abuse professionals and advocates, and the author recommends that prevention providers (a) review the guidelines or standards ultimately developed; (b) create a menu of possible services they could sell to managed care; (c) develop a marketing brochure for the managed care audience; (d) learn the managed care language; (e) make multiple contacts at each managed care organization; and (f) don't give up.
Legal Action Center. (1993, March 24). The need for specific coverage for drug and alcohol treatment in national health care reform (pp. 3-5, 10-13). Special report.
This document is focused almost exclusively on treatment, but the discussion on pages 3-5 includes discussion on prevention. The target audience is Congress, health professionals, and consumers who could influence congressional actions. As with the model legislation discussed above, it defines prevention as patient education about the risks associated with alcohol and drug use. It includes a discussion of services for children and adolescents that recommends coverage for psychological and developmental factors in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program under Medicaid. Lastly, it recommends inclusion of health education programs for families, including parenting skills and other risk-reduction activities.
Pages 10-13 include a detailed discussion of the savings to the health care system resulting from substance abuse treatment. Many of the statistics can be used in a discussion of prevention as well.
National Committee for Quality Assurance. (1996, April 1). Standards for preventive behavioral healthcare services. Draft accreditation standards for managed behavioral healthcare organizations (pp. 49-52). Washington, DC: Author.
The National Committee for Quality Assurance is one of the accreditation agencies for managed care organizations (MCOs). These draft standards cover the full scope of an MCO’s organization and management, utilization control, quality assurance, credentialing, members’ rights, etc. Included is a specific set of standards for prevention. These standards focus on four broad areas: establishment of a program to decrease the incidence, prevalence, and residual effects of behavioral health disorders; distribution of the programs and updating its practitioners; regularly encouraging its members to use preventive behavioral healthcare programs and services; and annually monitoring and evaluating at least 4 of 25 screening and educational interventions. The 25 interventions are organized into 5 groups based on the life cycle from infancy through aging, including a separate group for family and community educational interventions. Alcohol and drug abuse are specifically identified for adolescents, adults, and the elderly (including prescription drug dependence). Many of the other interventions identified are related disorders or risk factors for substance abuse.
Peacock, P. B., Gelman, A. C., & Lutins, T. A. (1975). Special report: Preventive healthcare strategies for health maintenance organizations. Preventive Medicine, 4 (2), 183-203, 210-223.
This article is interesting primarily because of its historical perspective. Written in 1975 for health practitioners and HMO administrators, it is an extensive discussion of possible prevention strategies for HMOs. As is the case with most articles on HMOs and prevention, the majority of the discussion is on physical prevention strategies. However, there is a good general discussion of the benefits to HMOs to engage in disease prevention and the need for health education that references drug and alcohol use and abuse. In the discussion on drug abuse and alcoholism, the authors indicate that primary prevention of drug abuse is primarily a community problem and the target population is youth. However, they see the role of the HMO more in secondary prevention or early detection and intervention, as well as addressing possible drug dependence of prescription drugs. With respect to alcoholism, they again indicate that the primary focus is in the community and especially the schools. However, they see the HMO supplementing those activities with educational services on healthy living habits, focusing on children of alcoholics, secondary prevention, and early detection. The authors end the discussion with a summary of existing HMO preventive benefits and possible HMO organizational structures to include prevention, but substance abuse prevention is not addressed specifically.
Poignand, C. (1996). Forging a relationship with managed care. Prevention Forum, 16 (2), 13-16.
The author describes how two managed care prevention activity areas can be used in substance abuse prevention and aims her discussion toward substance abuse professionals and advocates. The two areas are disease management, giving attention to patient members at risk for disease progression and who are already utilizing a high level of resources, and demand-side management, used for healthy populations and for those who are at general health risk due to lifestyle and stress-related factors. She notes that whereas managed care organizations (MCOs) are looking into the costs of substance abuse among their members and the relationship to prevention activities, substance abuse providers can help MCOs conceptualize substance abuse prevention within the context of the two activity areas cited above. She further notes that the most "sellable" prevention activities are those that relate to secondary prevention or early identification and intervention; cost benefit data on primary prevention are too sparse. Lastly, the author outlines a framework for substance abuse providers in working with managed care that includes keeping current on managed care strategies and programs; becoming knowledgeable about the Medicaid waiver process and state government activities; knowing the MCOs in the area and the nature of the competition among them; knowing the purchasers of managed care plans, the populations they serve, and their priorities; and, finally, engaging in a number of marketing and delivery strategies.
Shifman, N., & Varadian, M. (1989, June 29). The city of Somerville: Analysis and strategy for controlling utilization of behavioral related disorder medical benefits. Unpublished manuscript.
This paper was written for the city of Somerville, Massachusetts, to provide an analysis of medical utilization specifically to control problems from inappropriate utilization of health care services in substance abuse, psychiatric, or behavioral-related areas. Proposals were made for the city to develop education and control programs and to enhance employees’ ability to respond to health and health-related complaints.
Twenty-one recommendations were made to the city, including the following: Recommendation #3 for a health promotion program; Recommendation #11 for employee-level training in health prevention activities involving drugs and alcohol abuse; Recommendation #12 for a public relations campaign for enhancing utilization of health promotion programs; and Recommendation #21 for building into the health plan coverage certain prevention and wellness incentives.
(NOTE: As a result of this study, one of the larger HMOs in the area negotiated a stronger health promotion/prevention benefit, including substance abuse.)
Substance Abuse and Mental Health Services Administration. (1996, March). Medicaid managed care for mental and addictive disorders. Tracking and monitoring managed behavioral healthcare in the public sector, first quarterly report (pp. 20-57). Rockville, MD: U.S. Department of Health and Human Services.
This report provides preliminary information about state managed behavioral health care programs and is the first report in an expected series. A system has been set up to monitor the impact of managed care on public mental health and substance abuse providers, their clients, customers, and stakeholders. The report includes discussion of current trends, Medicaid managed care for mental health and chemical dependency, and some state case studies.
Chapter 2, "Medicaid Managed Care for Mental and Addictive Disorders," includes a brief discussion on prevention within a larger discussion about covered services. The authors note that the mandatory Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service can include services targeted at developmental delays and many mental health and substance abuse services that are nonclinical in nature. Further, most managed care firms are just beginning to learn how to provide care for high-risk populations and, therefore, think in terms of the medical model and medical necessity, which may not apply to mental health or substance abuse problems. They also note that the plans tend to stress acute services, with inadequate attention to prevention. Lastly, in this chapter, they note that the Oregon has required plans to include primary prevention services under their capitated rate.
Substance Abuse and Mental Health Services Administration. (1996, March). Case studies. Tracking and monitoring managed behavioral healthcare in the public sector, first quarterly report (pp. 58-87). Rockville, MD: U.S. Department of Health and Human Services.
Chapter 3 of the publication cited above is a discussion of three state programs – New York, Tennessee, and Washington. Only the New York discussion includes a reference to substance abuse prevention and notes that the state's Partnership Plan 1115 (Medicaid) waiver includes a goal for AOD services that includes prevention and intervention within the managed care environment in order to recognize and treat addictions early. Action on the waiver was pending at the time of publication of this report.
Thompson, R. S., Taplin, S. H., McAfee, T. A., Mandelson, M. T., & Smith, A. E. (1995). Primary and secondary prevention services in clinical practice: Twenty years' experience in development, implementation, and evaluation. Journal of the American Medical Association, 273, 1130-1135.
This article reviews the 20-year history of the Group Health Cooperative of Puget Sound's development and provision of clinical preventive services. It is often touted as a model of managed care and prevention, including substance abuse prevention, although the only clear connection to substance abuse prevention is smoking cessation programs. The approach used by the Cooperative is population-based, targeting the individual level of primary care and multiple infrastructure levels of care, resulting in a synthesis of clinical medicine and public health approaches. It uses demonstration projects, coalitions, or policy development activities at the community level. The article includes a series of tables listing the critical elements for prevention; criteria to examine primary and secondary prevention issues; and critical intervention strategies aimed at predisposing, enabling, and reinforcing factors. This discussion is focused on health maintenance organizations and other managed care organizations and managers.
(NOTE: The Cooperative also shared a copy of its "Adult Health Questionnaire," which includes a series of questions on tobacco, alcohol, and other drugs.)
Tolnai, E. A. (1996). Navigating health care reform: Prevention in managed care. Prevention Forum, 16(2), 6-13.
This article is largely a discussion of the managed care industry as a whole and the historical and organizational relationship to prevention services overall, including behavioral health prevention services. The author’s discussion is aimed at prevention providers and notes that a move into the managed health care field by the prevention field represents an opportunity to expand the geographical area exposed to prevention programs and to increase the knowledge base of physicians regarding ATOD prevention. She comments, however, that although managed care and prevention services seem to have a similar interest in health, there are several challenges. First, the business philosophies of prevention professionals differ fundamentally from those of managed care entities. Managed care organizations (MCOs) are profit-making entities, whereas profit has not been an emphasis for prevention professionals. Second, managed care is a medical system, expecting concrete methods and outcomes; preventionists must expand documentation and evaluation of prevention activities to give credence to including those programs in MCOs. Third, prevention providers may find it difficult to be accepted as experts without the same credentials that medical personnel hold. Lastly, prevention providers must consider how to serve non-Medicaid customers who have no other form of insurance.
Lee, R. (1994). Risk contracting: Making prevention a viable growth area for EAP and managed care firms. EAP Digest, 15 (4), 28-30.
Lee makes the case for "incenting" prevention in employee assistance programs (EAPs) and managed care programs, and the author specifically references substance abuse prevention as an area for focus. The author argues that prevention can and should be a key objective of a purchaser and that there are funding mechanisms that can maximize an investment in disease prevention. He asserts that full capitation is the most successful funding tool for "incenting" the managed care vendor to embrace prevention strategies and that capitation can be used to "incent" drug and alcohol relapse prevention. He notes that the current financing system, which restricts the MCO’s ability to shift risk in capitation payments, makes population-based care management foreign to the majority of behavioral health providers. Therefore, they have not shared the prevention objectives of the customer and the managed care company. The author argues that prevention is an important part of the employer's program because the employees are more likely to be productive if they are not distracted by personal or family issues. The article focuses on a variety of financial incentives and mechanisms for promoting prevention as part of the total benefit package and is targeted toward EAP and managed care professionals.
Penzer, W. N. (1993). Empowerment Centers: Prevention education to balance shrinking resources. EAP Digest, 13 (4), 29-33, 41.
The author presents the concept of Empowerment Centers that would provide a mechanism for developing a solid prevention component in EAPs of the future. The discussion is focused primarily on mental health and prevention; however, the discussion lends itself to substance abuse prevention as well. The Empowerment Center's goals would be to create an atmosphere of self-development toward a more balanced, goal-oriented, healthy-living model. Centers would take participants through several steps such as: self-assessment, coping-skills building, and addressing physical goals such as nutrition and alcohol control, while ensuring linkages with the total community resources. The author argues that the Centers must increase attention to our youth, identify problems early, and provide the coping-skills training needed.
Stokols, D., Pelletier, K. R., & Fielding, J. E. (1995). Integration of medical care and worksite health promotion. Journal of the American Medical Association, 273 (14), 1136-1142.
This article is an extensive discussion of the merits of worksite health promotion in the context of health reform and the rapid changes in the health care system. Although the article is in JAMA and, therefore, focused on physicians, it also focuses very much on employers and employee assistance plan administrators. The article only occasionally references substance abuse directly, but instead focuses the discussion on smoking cessation, health risk appraisal, and stress management. Substance abuse is referred to within this context. The authors have reviewed the history of work site health promotion programs and their limitations. They outline a large number of programmatic challenges to integrating such programs with the medical care system, but do not view those challenges as insurmountable. Some of the challenges they note are: access to hard-to-reach populations, integration of health promotion into corporate benefit plans, protecting employee privacy and job security, developing more comprehensive approaches to work site wellness, addressing the health consequences of the current environment of downsizing, and improving methods for evaluating the health outcomes and cost-effectiveness of these programs.
Yandrick, R. M. (1994, June). Behavior risk management: The EAP's grail. EAPA Exchange, 24 (6), 30-31, 19.
The role of the employee assistance program (EAP) in the context of health care reform is the focus of this article. The author notes that the most substantial change in EAP practice within the context of health care reform and managed care has been the movement toward prevention activities – identification and intervention with employees at risk of heavy health benefit utilization, accidents, absenteeism, and low productivity. He notes that EAPs have focused on secondary prevention in the substance abuse disease process, but because secondary prevention does not stop the onset of illness, more EAPs have become involved in primary prevention and are moving toward behavior risk management, which has as its core the prevention of behavioral "risk exposures" that cost companies in terms of money, productivity, and competitiveness. Lastly, he suggests that the health care reform discussion may cause EAPs to expand their focus beyond managed care to such areas as risk management, wellness issues, and human resource policy development.
Brenna, D., Sloma, D., Byers. J., & Hagens, B. (1994). Developing political support for a substance abuse benefit: Washington State as a case study. Paper presented at the Legislative Leaders' Conference on Substance Abuse and Health Care Reform, Washington, DC.
The authors of this paper describe the events leading up to the development of a health care reform package in the State of Washington that included a proposal for a substance abuse treatment benefit. In developing the benefit, there were strong recommendations for the inclusion of prevention in any health care reform initiative. A stakeholder group was convened to examine the issues of health care reform. Included in the 12 consensus points was the statement, "the provision of adequately funded community-based prevention and education concerning addictions should be assured for all citizens." The Department of Alcohol and Substance Abuse (DASA) also created an internal health care reform team that was charged with defining the role of DASA under the proposed reform. The team supported the relinquishment of all publicly funded treatment services while retaining core functions that assure patient care and population-based services, including prevention. Lastly, DASA has developed and is implementing an extensive health care system based on risk factor prevention strategies using a public health approach to prevention services. When the document was presented, the 1994 legislative session had not yet begun, therefore the status of substance abuse services in health care reform was unknown.
(NOTE: Subsequent information notes that Washington State's health care reform hinged on acquiring an exemption from the Early Retirement Income Security Act [ERISA], which prohibits states from regulating the health care services provided by private employers. They did not receive that waiver and subsequently have been revising its approach. The process appears to be addressing prevention to a greater degree. It is discussed briefly in the Center for Substance Abuse Prevention paper, ATOD Prevention in an Era of Managed Care.)
Henry J. Kaiser Family Foundation and the Commonwealth Fund. (1995, July). Managed care and low-income populations: A case study of managed care in Oregon (pp. xi, xiii, 9, 27, 32). Washington, DC: Author.
This case study provides a full description of the Oregon Health Plan's (OHP) Medicaid component, first implemented in February, 1994, following approval of the state's Federal 1115 demonstration waiver. The study is of Phase I, which was well underway. Phase II was just beginning, and it is in Phase II that the mental health and substance abuse service components are implemented. The study provides a clear discussion of the early implementation and the environment in which the mental health and substance abuse services are being implemented. It also raises some of the key implementation issues that will be faced in Phase II. Since Oregon is currently the state having done the most to integrate substance abuse prevention into managed care, this study is useful in providing a larger context for that implementation. This study was developed primarily for those interested in Medicaid and the impact of managed care on those served by Medicaid.
Kansas Alcohol and Drug Abuse Services. (1996, May 10). Management organization: Request for proposal (pp. 3, 7-11). Topeka, KS: Department of Social and Rehabilitation Services.
This document is a Request for Proposal (RFP) for a contract that will be let to a nonprofit entity to develop and monitor approximately $15 million in contractual arrangements for a statewide continuum of prevention centers and treatment providers. The purpose of this effort is to facilitate the "union of substance abuse prevention and managed care" (p. 1) – the Kansas Alcohol and Drug Managed Care Model. This model consists of seven management processes, including designing and pricing the prevention and treatment system, developing performance-based outcomes and review systems, implementing a state-of-the-art management rinformation system, and other management efficiencies. The Kansas system is based upon the Hawkins-Catalano risk and protective factors model. In addition, the project requires the following three priority outcomes: "a reduction in alcohol, tobacco and other drug abuse by youth, a delay in first alcohol, tobacco and other drug abuse by youth, and an increase in attitudes opposed to alcohol, tobacco and other drug abuse." (p. 10)
Ohio Department of Alcohol and Drug Addiction Services, Wellness/Health Promotion Work Group. (1995, November). Prevention: A cornerstone of managed care. Unpublished manuscript.
During the development of the Ohio State Medicaid 1115 waiver preparation, this paper was developed for the consideration of those designing the state’s managed care program. It discusses the costs associated with substance abuse and argues that the inclusion of prevention services in a managed care benefit package will reduce the number of persons in need of access to more costly treatment services. The report addresses the prevention/early intervention needs of pregnant women as a clear example of the value of prevention services. Finally, it concludes with a variety of recommendations, the first of which is to incorporate prevention services in a managed care model, beginning with a model designed for pregnant women.
(NOTE: Ohio received approval for its 1115 waiver in January 1995; prevention was not considered in the design stage of OhioCare. Because of the Congressional debate over Medicaid, the plan is now on hold.)
Prevention Network (of Michigan). (1995, September 20). Prevention and health care reform project: Interim report (Part Four). Unpublished manuscript.
The Prevention Network prepared this interim report under contract with the Michigan Department of Public Health/Center for Substance Abuse Services. The project was to provide a "forum series" to address the role of substance abuse prevention services in the health care system, models in a reconfigured system, problems, and potential solutions and to obtain public input from a variety of sources on the topic. Although an interim report, it describes the process, input, and conclusions of the project up to the final forum.
The conclusion of the forum series was that the prevention field should remain separate from managed care. The forum participants claim comprehensive community-based ATOD prevention efforts would be poorly served overall if administered within a managed care ATOD/health care structure; differences in approach and philosophy likely would result in a reduction in the full range of prevention activities related to ATOD. The participants make a variety of suggestions for a separate prevention system and suggest alternative sources for funding. They also make a case for stronger advocacy for prevention, especially as it relates to the future plans for prevention services. Lastly, they include some data regarding the merits of prevention in reducing ATOD use and costs.
(NOTE: Michigan now does not include prevention services in its managed care program for Medicaid recipients. It is, through this forum series and other means, investigating the possibility of future integration.)
Centers for Disease Control. (1995). Prevention and managed care: Opportunities for managed care organizations, purchasers of health care, and public health agencies. Morbidity and Mortality Weekly Report 44 (RR-14). Atlanta, GA: U.S. Department of Health and Human Services.
This document is part of an ongoing series of reports issued by the Centers for Disease Control (CDC) directed to health care professionals. This issue focuses on the larger prevention arena and provides recommendations for the CDC to foster the incorporation of prevention practices into managed care. Although not focusing on substance abuse specifically, it does include tobacco. The document provides a good discussion of the relationship between managed care and prevention, including discussion of some successful programs. It also provides a good list of assumptions, opportunities, and barriers, most of which are quite applicable to the substance abuse prevention field.
Center for Substance Abuse Prevention. (1996, June). Managed care activities. Unpublished manuscript.
The Managed Care Office in CSAP developed this document for use by CSAP staff and others to inform them about internal managed care activities. These include knowledge dissemination and knowledge application activities (e.g., publications, training, conferences, software). In addition, two demonstration grants are noted. A brief description of each includes the products or results for each activity.
Goplerud, E. (1996). Managed care in the public sector: The federal role. Behavioral Healthcare Tomorrow, 5 (2), 71-73.
In this article, Goplerud describes the federal role as defined by the Substance Abuse and Mental Health Services Administration (SAMSHA) for managed care relative to behavioral health. SAMHSA will track the development and impact of managed care and support projects nationwide to develop quality standards, create training modules, evaluate costs and outcomes, and analyze utilization and cost data.
Jacobi, B. (1996). Prevention in managed care: A look at the national picture. Prevention Forum, 16 (2), 8, 11-13.
The author summarizes the current national status of managed care and ATOD prevention and is designed to provide an overview to substance abuse prevention professionals. The author notes that currently there is no predominant way to include ATOD prevention services in managed care. However, with health care systems beginning to develop "demand-side management," reducing the need for treatment services through early and effective intervention, the managed care industry is more receptive to ATOD prevention than before. The author maintains that ATOD prevention belongs in both the health promotion and the clinical service areas of managed care organizations (MCOs). She recommends that the Single State Authority take the lead in determining a minimum set of ATOD prevention services to be provided through MCOs. She suggests that financing of prevention services will be through multiple sources in the future—through multiple MCOs, state, federal and local government sources. MCOs are beginning to move toward capitation for prevention services through contracts with prevention providers. The author closes with a brief overview of three state or local efforts to integrate substance abuse prevention in MCOs—Oregon; Pima Health System in Tucson, Arizona; and the Group Health Cooperative of Puget Sound in Seattle.
Preventionists Looking for Their Place in Managed Care. (1995). Alcoholism and Drug Abuse Weekly, 7 (43), 3.
This weekly newsletter provides a brief summary of some of the efforts underway to integrate substance abuse prevention into managed care. The article notes that the lack of concrete data continues to be a problem. It briefly mentions efforts in Massachusetts, Ohio, and California (Kaiser). Of the three examples, only Kaiser in California is operating programs to educate family members of patients with substance abuse problems to help prevent those problems from expanding to family and friends.
|
|
|
