Managed care and technical efficiency in outpatient substance abuse treatment units

This article examines (1) the extent to which managed care participation is associated with technical efficiency in outpatient substance abuse treatment (OSAT) organizations and (2) the contributions of specific managed care practices as well as other organizational, financial, and environmental attributes to technical efficiency in these organizations. Data are from a nationally representative sample survey of OSAT organizations conducted in 1995. Technical efficiency is modeled using data envelopment analysis. Overall, there were few significant associations between managed care dimensions and technical efficiency in outpatient treatment organizations. Only one managed care oversight procedure, the imposition of sanctions by managed care firms, was significantly associated with relative efficiency of these provider organizations. However, several organizational factors were associated with the relative level of efficiency including hospital affiliation, mental health center affiliation, JCAHO accreditation, receipt of lump sum revenues, methadone treatment modality, percentage clients unemployed, and percentage clients who abuse multiple drugs.     

Managed care and access to substance abuse treatment services

Using nationally representative data from 1995 and 2000, this study examined how managed care penetration and other organizational characteristics were related to accessibility to outpatient substance abuse treatment. At an organizational level, access was measured as the percentage of clients unable to pay for services; the percentage of clients receiving a reduced fee; and the percentage of clients with shortened treatment because of their inability to pay. Treatment units with both relatively low and relatively high managed care penetration were more likely to support access to care; these units provided care to higher percentages of clients unable to pay and were less likely to shorten treatment because of client inability to pay. Treatment units with midrange managed care penetration were least likely to support access to care. The complexity of managing in an environment of conflicting incentives may reduce the organization's ability to serve those with limited financial means.     

Health services for women in outpatient substance abuse treatment

OBJECTIVE: To evaluate how a sample of outpatient substance abuse treatment units respond to organizational and environmental influences by adopting and implementing treatment services for women. DATA SOURCES: The National Drug Abuse Treatment System Survey from 1995 and 2000, a national survey of outpatient substance abuse treatment units. STUDY DESIGN: Health services for women are the dependent variables. The predictors include organizational and environmental factors that represent resource dependence and institutional pressures for the treatment unit. Logistic regression and Heckman selection models were used to test hypotheses. DATA COLLECTION: Program directors and clinical supervisors at each treatment unit were interviewed by telephone in 1995 and 2000. PRINCIPAL FINDINGS: Units that depended on specific funding for women's programs and that depended on government funds were more likely to adopt, but not necessarily implement, women's services. Methadone units and units that train more staff to work with women were more likely to adopt as well as implement women's services. Private not-for-profit units were more likely to adopt some services, while for-profit units were less so. However, in general, neither for-profit nor not-for-profit units significantly implemented services. There was evidence that the odds of adopting services were greater in 2000 than 1995 for two services, but were otherwise stable. CONCLUSIONS: There is considerable variation in the adoption and implementation of women's services. In addition, not all adopted services were significantly implemented, which could reflect limited organizational resources and/or conflicting expectations. This also suggests that referral mechanisms to these services, and therefore access, may not be adequate. Government funds and specific funds for women's programs are important resources for the provision of these services. Women's services appear more available in methadone units, suggesting that regulation has been influential and that the recent methadone accreditation system should be evaluated. Staff training may be one strategy to encourage implementation of these services. For the most part, the adoption of services for women did not change between 1995 and 2000.     

Program structure and counselor-client contact in outpatient substance abuse treatment

OBJECTIVES: To examine organizational structural attributes associated with counselor-client contact. DATA SOURCES: Data were collected in 2004 and 2005 for a federally funded project, which simultaneously examines organizational structure, functioning, and resources among outpatient substance abuse treatment programs. STUDY DESIGN: The study uses a naturalistic design to investigate organizational structure measures-ownership, accreditation, and supplemental services-as predictors of time in counseling and case management, and caseload size, controlling for geographic differences. DATA COLLECTION: Directors at 116 outpatient drug-free treatment programs located in four regions across the U.S. (Great Lakes, Gulf Coast, Northwest, and Southeast) voluntarily completed a survey about program structure. PRIMARY FINDINGS: Clients received more counseling hours in programs that were "intensive," publicly owned, accredited, and had a lower proportion of recently hired counselors. More case management hours were offered in "intensive," private-for-profit or publicly owned (versus private-nonprofit) programs, serving a lower proportion of dual-diagnosis clients, and providing more on-site supplemental services. Smaller caseloads were found in programs that were accredited and had a smaller average client census and a lower proportion of criminal justice referred clients. CONCLUSIONS: Organizational attributes are related to counselor-client contact and may have implications for staff turnover and service quality.     

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.     

Factors related to Medicaid payment acceptance at outpatient substance abuse treatment programs

Objective. To examine factors associated with Medicaid acceptance for substance abuse (SA) services by outpatient SA treatment programs. Data Sources. Secondary analysis of 2003–2006 National Survey of Substance Abuse Treatment Services data combined with state Medicaid policy and usage measures and other publicly available data. Study Design. We used cross‐sectional analyses, including state fixed effects, to assess relationships between SA treatment program Medicaid acceptance and (1) program‐level factors, (2) county‐level sociodemographics and treatment program density, and (3) state‐level population characteristics, SA treatment‐related factors, and Medicaid policy and usage. Data Extraction Methods. State Medicaid policy data were compiled based on reviews of state Medicaid‐related statutes/regulations and Medicaid plans. Other data were publicly available. Principal Findings. Medicaid acceptance was significantly higher for programs: (a) that were publicly funded and in states with Medicaid policy allowing SA treatment coverage; (b) with accreditation/licensure and nonprofit/government ownership, as well as mental‐ and general‐health focused programs; and (c) in counties with lower household income. Conclusions. SA treatment program Medicaid acceptance related to program‐, county, and state‐level factors. The data suggest the importance of state policy and licensure/accreditation requirements in increasing SA program Medicaid access.     

Organizational determinants of boundary spanning activity in outpatient substance abuse treatment programmes.

OBJECTIVES: Substance abuse treatment programmes depend on boundary spanning to identify opportunities and threats, and represent their interests to stakeholders such as licensing entities and regulators. This study sought to identify director, client, unit and market factors associated with active director boundary spanning. METHODS: Using data from the 1995, 1999-2000 and 2005 waves of a national survey of outpatient substance abuse treatment units, generalized estimating equation regression models tested associations between predictors and five aspects of directors' self-reported boundary spanning. RESULTS: Directors licensed as substance abuse treatment counsellors spent more time than average consulting with other treatment providers and making presentations in the community. Older directors spent less time consulting with other treatment providers, making community presentations and liaisoning with monitoring organizations. The few associations between client unemployment and director boundary spanning were positive; the two associations between the percentage of clients who were African-American and boundary spanning were negative. Private ownership and being based in larger organizations were negatively associated with some types of boundary spanning. Perceived competition for public support was positively associated with all measures of boundary spanning. CONCLUSION: Directors of treatment organizations may improve treatment practices and political leverage by directly, but selectively, interacting with key external stakeholders.     

The impact of managed care on substance abuse treatment services

OBJECTIVE: To examine the impact of managed care on the number and types of services offered by substance abuse treatment (SAT) facilities. Both the number and types of services offered are important factors to analyze, as research shows that a broad range of services increases treatment effectiveness. DATA SOURCES: The 2000 National Survey of Substance Abuse Treatment Services (NSSATS), which is designed to collect data on service offerings and other characteristics of SAT facilities in the United States. These data are merged with data from the 2002 Area Resource File (ARF), a county-specific database containing information on population and managed care activity. We use data on 10,513 facilities, virtually a census of all SAT facilities. STUDY DESIGN: We estimate the impact of managed care (MC) on the number and types of services offered by SAT facilities using instrumental variables (IV) techniques that account for possible endogeneity between facilities' involvement in MC and service offerings. Due to limitations of the NSSATS data, MC and specific services are modeled as binary variables. PRINCIPAL FINDINGS: We find that managed care causes SAT facilities to offer, on average, approximately two fewer services. This effect is concentrated primarily in medical testing services (i.e., tests for TB, HIV/AIDs, and STDs). We also find that MC increases the likelihood of offering substance abuse assessment and relapse prevention groups, but decreases the likelihood of offering outcome follow-up. CONCLUSION: Our findings raise policy concerns that managed care may reduce treatment effectiveness by limiting the range of services offered to meet patient needs. Further, reduced onsite medical testing may contribute to the spread of infectious diseases that pose important public health concerns.     

Accessibility of addiction treatment: results from a national survey of outpatient substance abuse treatment organizations

OBJECTIVES: This study examined organization-level characteristics associated with the accessibility of outpatient addiction treatment. METHODS: Program directors and clinical supervisors from a nationally representative panel of outpatient substance abuse treatment units in the United States were surveyed in 1990, 1995, and 2000. Accessibility was measured from clinical supervisors' reports of whether the treatment organization provided "treatment on demand" (an average wait time of 48 hours or less for treatment entry), and of whether the program turned away any patients. RESULTS: In multivariable logistic models, provision of "treatment on demand" increased two-fold from 1990 to 2000 (OR, 1.95; 95 percent CI, 1.5 to 2.6), while reports of turning patients away decreased nonsignificantly. Private for-profit units were twice as likely to provide "treatment on demand" (OR, 2.2; 95 percent CI, 1.3 to 3.6), but seven times more likely to turn patients away (OR, 7.4; 95 percent CI, 3.2 to 17.5) than public programs. Conversely, units that served more indigent populations were less likely to provide "treatment on demand" or to turn patients away. Methadone maintenance programs were also less likely to offer "treatment on demand" (OR, .65; 95 percent CI, .42 to .99), but more likely to turn patients away (OR, 2.4; 95 percent CI, 1.4 to 4.3). CONCLUSIONS: Although the provision of timely addiction treatment appears to have increased throughout the 1990s, accessibility problems persist in programs that care for indigent patients and in methadone maintenance programs.     

Organizational factors related to AIDS/HIV education in outpatient substance abuse treatment units

The association of HIV and AIDS with intravenous drug use is well documented. Given this, substance abuse treatment providers must figure prominently in any effective national response to HIV/AIDS. The strategies employed by human service managers to address AIDS may be important in explaining how substance abuse treatment units implement policies and programs concerning AIDS-related prevention services. This paper utilizes data from the National Drug Abuse Treatment System Survey to examine how strategic activities concerning AIDS/HIV undertaken by outpatient substance abuse treatment unit managers impacted the provision of preventive AIDS-related services to clients. Results of multiple regression analysis indicate collaboration with other human service organizations and environmental scanning activities are important variables in explaining variation among substance abuse treatment units in the provision of AIDS prevention education to clients. Based on these findings, implications for future research and policy concerning AIDS prevention within the context of substance abuse treatment are made.     

On-site primary care and mental health services in outpatient drug abuse treatment units

Providing health services to drug abuse treatment clients improves their outcomes. Using data from a 1995 national survey of 597 outpatient drug abuse treatment units, this article examines the relationship between these units' organizational features and the degree to which they provided onsite primary care and mental health services. In two-stage models, Joint Commission on Accreditation of Healthcare Organizations-certified and methadone programs delivered more on-site primary care services. Units affiliated with mental health centers provided more on-site mental health services but less direct medical care. Units with more dual-diagnosis clients provided more on-site mental health but fewer on-site HIV/AIDS treatment services. Organizational features appear to influence the degree to which health services are incorporated into drug abuse treatment. Fully integrated care might be an unattainable ideal for many such organizations, but quality improvement across the treatment system might increase the reliability of clients' access to health services.     

Residential adolescent substance abuse treatment: recommendations for collaboration between school health and substance abuse treatment personnel

Thousands of youth participate in residential substance abuse treatment each year. After completing treatment, many of these youth return to school. This study analyzed the process of substance abuse treatment at the Generations Youth Program, and identified opportunities for collaboration with school health personnel. A qualitative case study design was employed. Analysis of the treatment process revealed the primary goal of treatment was to assist youth in developing a belief in their ability to remain sober. This goal was achieved through a peer support network, development of self-control, and acquisition of treatment knowledge. Youth who develop these skills are successfully discharged from treatment and return to home and school. Opportunities exist for collaboration between school health and substance abuse treatment personnel to enable discharged youth to remain drug free.     

Parity for mental health and substance abuse care under managed care

BACKGROUND: Parity in insurance coverage for mental health and substance abuse has been a key goal of mental health and substance abuse care advocates in the United States during most of the past 20 years. The push for parity began during the era of indemnity insurance and fee for service payment when benefit design was the main rationing device in health care. The central economic argument for enacting legislation aimed at regulating the insurance benefit was to address market failure stemming from adverse selection. The case against parity was based on inefficiency related to moral hazard. Empirical analyses provided evidence that ambulatory mental health services were considerably more responsive to the terms of insurance than were ambulatory medical services. AIMS: Our goal in this research is to reexamine the economics of parity in the light of recent changes in the delivery of health care in the United States. Specifically managed care has fundamentally altered the way in which health services are rationed. Benefit design is now only one mechanism among many that are used to allocate health care resources and control costs. We examine the implication of these changes for policies aimed at achieving parity in insurance coverage. METHOD: We develop a theoretical approach to characterizing rationing under managed care. We then analyze the traditional efficiency concerns in insurance, adverse selection and moral hazard in the context of policy aimed at regulating health and mental health benefits under private insurance. RESULTS: We show that since managed care controls costs and utilization in new ways parity in benefit design no longer implies equal access to and quality of mental health and substance abuse care. Because costs are controlled by management under managed care and not primarily by out of pocket prices paid by consumers, demand response recedes as an efficiency argument against parity. At the same time parity in benefit design may accomplish less with respect to providing a remedy to problems related to adverse selection.     

Client satisfaction with substance abuse treatment

A survey of 15 publicly-funded treatment agencies in Iowa was conducted to identify correlates of satisfaction with substance abuse treatment for voluntary clients. We used stratified least-squares regression analysis to identify program characteristics that were associated with greater satisfaction levels. In order to investigate satisfaction among voluntary clients, we stratified the data using three measures of client choice. These were self-reports of the extent to which the respondent felt pressured by the threat of jail, legal action, or family demands. Women tended to be more satisfied than men. Satisfaction scores for clients who indicated they were in treatment by choice were correlated with judgements about program characteristics. Phone availability, time with counselor, counselor skill, and sensitivity were associated with greater levels of satisfaction in all three models. Parking, privacy and cleanliness were significant in two out of three models.     

Trends in acute mental health care: Comparing psychiatric and substance abuse treatment programs

This study compared psychiatric and substance abuse acute care programs, within both inpatient and residential modalities of care, on organization and staffing, clinical management practices and policies, and services and activities. A total of 412 (95% of those eligible) Department of Veterans Affairs' programs were surveyed nationwide. Some 40% to 50% of patients in psychiatric and substance abuse programs, in both inpatient and residential venues of care, had dual diagnoses. Even though psychiatric programs had a sicker patient population, they provided fewer services, including basic components of integrated programs, than substance abuse programs did. Findings also showed that there is a strong emphasis on the use of clinical practice guidelines, performance monitoring, and obtaining client satisfaction and outcome data in mental health programs. The author's suggest how psychiatric programs might better meet the needs of acutely ill and dually diagnosed patients (eg, by incorporating former patients as role models and mutual help groups, as substance abuse programs do; and by having policies that balance patient choice with program demand).     

Pathways to care: narratives of American Indian adolescents entering substance abuse treatment

Using data from 89 American Indian adolescents and guided by the Network Episode Model, this paper analyses pathways to residential substance abuse treatment and their correlates. These adolescents were recruited at admission to a tribally-operated substance abuse treatment program in the southern United States from October 1998 to May 2001. Results from the qualitative analyses of these adolescent's pathways to care narratives indicated that 35% ultimately agreed with the decision for their entry into treatment; 41% were Compelled to enter treatment by others, usually by their parents, parole officers, and judges; and 24% did not describe a clear pathway to care. In the multinomial logistic regression model examining correlates of these pathways to care classifications, adolescents who described pathways indicative of agreement also reported greater readiness for treatment than the adolescents who described compelled or no clear pathways to care. Adolescents who described a Compelled pathway were less likely to meet diagnostic criteria for Conduct Disorder and described fewer social network ties. We were unable to find a relationship between pathways classifications and referral source, suggesting these narratives were subjective constructions of pathways to care rather than a factual representation of this process. In the final logistic regression model examining correlates of treatment completion, articulating a pathway to care, whether it was one of agreement or of being compelled into treatment, predicted a greater likelihood of completing treatment. Overall, these narratives and their correlates are highly consistent with the Network-Episode Model's emphasis on the interaction of self, situation, and social network in shaping the treatment seeking process, demonstrating the applicability of this model to understanding the treatment seeking process in this special population and suggests important considerations for understanding the dynamics of service utilization across diverse communities.