Annotated Bibliography - Substance Abuse

This special supplementary section of the bibliography provides an independently produced annotated bibliography on managed behavioural healthcare prepared for the US Substance Abuse and Mental Health Services Administration; please see the first page of the supplement for recommended citation information.

Table of Contents

  1. Introduction
  2. Benefit and System Design
  3. Capitation
  4. Community Mental Health Services
  5. Diagnosis-Related Groups (DRGs)
  6. Economics, Forecasting, and Pricing
  7. Employee Assistance Programs (EAPs)
  8. Health Maintenance Organizations (HMOs)
  9. Law and Ethics
  10. Provider Issues
  11. Public Sector
  12. Quality Assurance and Outcomes
  13. Special Populations
    1. Children
    2. Elderly
    3. Ethnic Groups
    4. Women
  14. Substance Abuse
  15. Training and Education
  16. Utilization Management
  17. Author Index
  18. Keyword Index

Substance Abuse

353. Alexander, J. A., & Lemak, C. H. (1997). The effects of managed care on administrative burden in outpatient substance abuse treatment facilities. Medical Care, 35(10), 1060-1068.

This article describes a study of the burden (in hours per week and per client) of administra-tive functions related to managed care on outpatient substance abuse treatment facilities. The authors focus in particular on the effects of four dimensions: managed care oversight proce-dures, organizational experience with managed care (length of time), managed care penetra-tion, and complexity of managed care arrangements. The sample was drawn from the 1994 to 1995 National Frame of Substance Abuse Treatment Programs and prior waves of the National Drug Abuse Treatment System Survey. A telephone survey was conducted of the facilities’ administrative and clinical directors. The authors’ findings support their hypothesis that administrative requirements imposed by managed care create a significantly increased burden on these facilities. They find that managed care penetration and managed care over-sight procedures are most strongly associated with this increased burden.
Keywords: community providers, substance abuse

354. Alexander, J. A., & Lemak, C. H. (1997). Managed care penetration in outpatient substance abuse treatment units. Medical Care Research and Review, 54(4), 490-507.

This article reports the first national data on the impact of managed care at the provider level. The study used data from a 1995 national survey of 618 outpatient substance abuse treatment (OSAT) units. The sample was categorized by treatment modality, ownership status, and organizational affiliation. The study investigated the level of managed care penetration into OSAT units and found that they were not affected by managed care. However, for-profit OSAT units were more involved in managed care than public and private not-for-profit units. OSAT units involved with managed care utilized multiple arrangements and on average are involved with eight separate managed care arrangements that conform to a series of different and even competing requirements. Hospital-affiliated OSAT units are more likely to have multiple managed care arrangements. The study indicates that OSAT units are participating in very few public managed care arrangements, whereas private managed care arrangements occur at a greater frequency and with a constant distribution across types of arrangements.
Keywords: community providers, substance abuse

355. Caplan, R. (1992). Treatment of drug abuse in the managed care setting. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (1st ed., pp. 305-320). Washington, DC: American Psychiatric Press.

In this chapter, the author demonstrates how the philosophy of managed care can be well integrated with a clinically sound approach to drug treatment. He outlines the specific ele-ments that make managed care different from other settings, and describes a treatment model developed for a staff model HMO. In this model, major clinical decisions are made using a clinical algorithm. He explains how a managed care system can handle the four major phases of drug treatmentÑevaluation, stabilization, relapse prevention, and mainte-nanceÑ and addresses additional issues of contracting for services, staffing, the role of the case manager, and employer groups. Alternative approaches to dealing with the small but difficult group who experience chronic relapse are presented.
Keywords: models, substance abuse

356. French, M. T., Dunlap, L. J., Galinis, D. N., Rachai, J. V., & Zarkin, G. A. (1996) Health care reforms and managed care for substance abuse services: Findings from eleven case studies. Journal of Public Health Policy, 17(2), 181-203.

This paper presents data from case studies of 11 drug treatment programs, on their current funding and level of cost, as well as their perceptions about the current or forthcoming impact of behavioral managed care on their delivery of services. The programs included in the study cover a broad geographic, programmatic, and organizational range. They include public and private facilities, inpatient and outpatient models, and a variety of modalities of care. The authors used two instruments developed by the Research Triangle InstituteÑthe Drug Abuse Treatment Cost Analysis Program (DATCAP) and the Drug Abuse Treatment Financing Analysis Program (DATFin)Ñto gather data on cost and financing of the facilities. Perceptions of the impact of managed care varied among the programs depending on the type of site. For example, many of the residential treatment facilities expressed concern that case management strategies would result in more patients being referred to outpatient modalities, even though they may not be the ideal treatment type for some patients, simply because they offer lower intensity and lower cost care.
Keywords: costs, evaluation, substance abuse

357. Gondolf, E., Coleman, K., & Roman, S. (1996). Clinical-based vs. insurance-based recommendations for substance abuse treatment level. Substance Use & Misuse, 31(9), 1101-1116.

This article reports on an exploratory study created to determine the extent of the disagree-ment between clinical-based and insurance-based recommendations for level of care in sub-stance abuse treatment. The study included 250 patients from three treatment facilities in the Western Pennsylvania region, and compared treatment recommendations based on criteria developed by the American Society of Addiction Medicine (ASAM) to those based on criteria developed by managed care organizations. The study showed that 85 percent of the insurance-based and clinical-based recommendations for treatment level were in agreement and that 93 percent of the cases coincided with ASAM recommendations for care. These findings suggested that even when there was disagreement in treatment, clinical-based recommendations were most likely to be followed.
Keywords: standards of care, substance abuse

358. Gragg, D. M. (1991). Managed health care systems: Chemical dependency treatment. In C. S. Austad & W. H. Berman (Eds.), Psychotherapy in managed health care: The optimal use of time and resources (1st ed., pp. 202-219). Washington, DC: American Psychological Association.

This chapter describes the Chemical Dependency Recovery program at Kaiser Permanente Medical Center in Los Angeles. The author discusses treatment philosophy, guidelines, pro-gram design and development, general principles of addictions treatment, psychotherapeutic goals and issues, and specific influences of managed health care on treatment programs such as this one. He describes key elements in an evaluation of this and similar programs to ensure quality of care, and a philosophy of critical "self-study" among staff of an addictions treat-ment program.
Keywords: substance abuse

359. Kushner, J. N., & Moss, S. (1995). Purchasing managed care services for alcohol and other drug treatment: Essential elements and policy issues: Vol. 16. Technical assistance publication series. Rockville, MD: Center for Substance Abuse Treatment.

As States consider or move forward with the decision to redirect public funds for the treatment of substance abuse to private managed care organizations (MCOs), they face certain opportu-nities and challenges. This document serves as a brief technical assistance manual for State AOD (alcohol and other drug) agencies. Chapter 1 provides an overview of current State man-aged care arrangements and urges States to use their contracts with MCOs as a means of enforcing standards of treatment. Chapter 2 discusses access issues that emerge under managed care, ranging from geographic accessibility of services to the cultural, ethnic, and gender sensi-tivities of providers. Chapter 3 discusses the importance of ensuring the provision of wrap-around services, targeted outreach to special populations, and inclusion of publicly funded pro-grams/ essential community providers, especially because private managed care companies may be inexperienced in the treatment of populations receiving publicly funded AOD treatment services. Chapter 4 discusses financial considerations that should be taken into accountÑrisk management strategies, potential benefits restrictions, the elimination of opportunities for cost-shifting the burden of uncompensated care, and the importance of understanding and being able to challenge actuarial analysis. Chapter 5 addresses key consumer protections such as out-of- plan services, disenrollment processes, "consumer-friendly" materials, and appeals. This document also provides examples of model contract language for the establishment of stan-Annotated dards, as well as a Managed Healthcare Organizational Readiness ChecklistÑa resource designed to help States take into account the broad spectrum of policy issues that enter into effectively contracting for services through the private managed care market.
Keywords: contracting, public sector, substance abuse, technical assistance

360. McNeese-Smith, D. K. (1998). Program directors’ views of the effect of managed care on substance abuse programs in Los Angeles County. Psychiatric Services, 49(10), 1323-1329.

Fifty program directors, representing 134 substance abuse treatment centers in Los Angeles County, responded to a survey in early 1997 soliciting their views about the impact of man-aged care on their facilities. The primary topics of the survey were changes in the programs since 1994 resulting from managed care, major concerns about the influence of managed care on substance abuse programs, advantages and disadvantages of managed care, and anticipated future changes to promote success in the managed care environment. Responses indicated that outreach and marketing had increased while length of treatment and staffing levels had decreased. There were concerns that incentives to provide the least costly service posed a threat to quality. Advantages described were an increasing focus on outcomes, the opportunity to contract with managed care providers, and the establishment of consistent program standards. Disadvantages named were contractual restrictions on services, increasing paperwork, restric-tions on length of treatment, and decreasing quality. Directors described a wide array of antici-pated future changes including changes in structure, type of program, sources of referral, staff composition, revenue generation, and increased focus on prevention.
Keywords: community providers, substance abuse

361. Rawson, R. A., Obert, J. L., McCann, M. J., Marinelli-Casey, P., & Suti, E. (1991). Outpatient chemical dependency treatment and the managed care system: An unrealized symbiosis. Journal of Ambulatory Care Management, 14, 48-59.

This paper traces the rise of outpatient treatment models for chemical dependency as it relates to the managed care movement. The authors draw on their own clinical experience to argue that there are serious problems in the coordination of outpatient drug and alcohol abuse pro-grams by the managed care industry. They point to poor communication with providers, tech-nical "sloppiness," and idiosyncratic, unscientific treatment programs as just some of the pit-falls of managed chemical dependency services. Suggestions are offered for how managed care organizations and chemical dependency treatment providers can work together.
Keywords: models, substance abuse

362. Renz, E. A., Chung, R., Fillman, O., Mee-Lee, D., & Sayama, M. (1995).

The effect of managed care on the treatment outcome of substance use disorders. General Hospital Psychiatry, 17, 287-292. This article examines the effect of managed care and other reimbursement mechanisms on the outcome of substance abuse treatment at a single treatment facility. Data were collected from 1,594 patient records at the Castle Medical Center of Hawaii. Patients in the study were adults admitted for treatment of substance use disorders. The study looked at the incidence of recidi-vism in each patient over a 2-year period. The sample was divided into four groups: intensive managed care, traditional managed care, private pay, and State-funded. The study concluded that managed care patients are not more likely to return to treatment because of truncated treatment episodes. Also, no difference was found between managed and nonmanaged patient populations on relapse rates. The authors discuss the need for future research to include other outcome measures besides recidivism rate.
Keywords: outcomes, performance measurement, substance abuse

363. Schneider, R. J., & Herbert, M. (1992). Substance abuse day treatment and managed health care. Journal of Mental Health Administration, 19, 119-124.

For a variety of reasons, not the least being availability of reimbursement, inpatient care has been viewed as the treatment of choice for substance abuse over the past three decades. However, with the rise of managed health care, prospects for greater acceptance of day treatment programs have improved. This article describes the day treatment program at the Harvard Community Health Plan, a 2-week program that uses a variety of approaches including group work, family meetings, and individual treatment sessions. The authors dis-cuss ways of marketing day treatment and overcoming patient resistance to day treatment.
Keywords: substance abuse

364. Shwartz, M., Mulvey, K. P., Woods, D., Brannigan, P., & Plough, A. (1997). Length of stay as an outcome in an era of managed care. Journal of Substance Abuse Treatment, 14(1), 11-18.

With their emphasis on cost reduction, managed care systems reimburse only for "appropri-ate" lengths of stay. Yet there is no research base for determining what is an appropriate length of stay for a client in substance abuse treatment, and previous studies have found lengths of stay to be important predictors of client outcomes. In this paper, the authors identify length of stay categories within four treatment modalities such that program completion rates are consis-tent within category and differ among categories. The four treatment modalities are short-term residential, long-term residential, outpatient, and detox. The authors demonstrate that future utilization over a 2-year period differs between categories, with those clients in short-length-of-stay categories being admitted more frequently and spending more days in treatment over the followup period than the long-length-of-stay clients. The researchers conclude that length of stay is an easily measured proxy for treatment success and should be considered by managed care companies in constructing length-of-stay cutoffs.
Keywords: outcomes, performance measurement, substance abuse

365. Sturm, R., Zhang, W., & Schoenbaum, M. (1999). How expensive are unlimited substance abuse benefits under managed care? The Journal of Behavioral Health Services and Research, 26(2), 203-210.

With the Federal Mental Health Parity of 1996, legislators prohibited dollar limits on mental health benefits, but not on substance abuse benefits because of the high cost associated with substance abuse treatment. In response, many employers have begun to decouple the two types of services in their behavioral health contracts, which could lead to less efficient care and diffi-culties in coordinating treatment. In this paper, the researchers examine how many patients are affected by substance abuse coverage limits and the implications of limits on insurance pay-ments. They find that removing an annual limit of $10,000 per year on substance abuse treat-ment would increase insurance payments by only 6 cents per member per year while affecting a large percentage of patients needing the care. The authors conclude that "parity" for sub-stance abuse in employer-sponsored health plans is not very costly.
Keywords: parity, substance abuse

366. Wilson, C. V. (1993). Substance abuse and managed care. New Directions for Mental Health Services, 59, 99-105.

This chapter discusses the problems that exist in the coverage of substance abuse. Dissatisfied with high costs and ineffective treatment for substance abuse, employers are turning to man-aged care. A case example illustrates the benefits of this approach. The author suggests that case managers and payers use a standardized intake, assessment, and outcome method devel-oped by the American Society of Addiction Management in order to address concerns about cost and quality.
Keywords: substance abuse

367. Woodward, A. (1992). Managed care and case management of substance abuse treatment. In R. S. Ashery (Ed.), Progress and issues in case management (DHHS Publication number ADM 92-1946). Rockville, MD: National Institute on Drug Abuse.

This monograph discusses the relevance of managed care to case management of substance abuse programs. The author argues that the goals of the two are contradictory; whereas the focus of case management is on providing comprehensive, coordinated care, managed care is concerned primarily with cost-effectiveness. Yet despite the differences in their goals, both case management and managed care have similar shortcomings. Among these are lack of criteria in assessment, referral, intervention activities, and followup as well as lack of documented cost-effectiveness.
Keywords: case management, substance abuse Annotated Bibliography 143

368. Zwick, W. R., & Bermon, M. (1992). Spectrum of services for the alcohol abusing patient. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (1st ed., pp. 273-304). Washington, DC: American Psychiatric Press.

This chapter discusses the elements of a successful program for alcohol-abusing patients in a managed care environment. The authors outline four assumptions that they believe should guide the design of a cost-effective managed program for the treatment of alcohol abuse and dependence. They discuss cost, staffing issues (type of staff and staffing ratios), and marketing of alcohol treatment services (to primary care providers, mental health providers, and the corporate community). They also describe integration of substance abuse in general mental health through education and suggest ways of overcoming some of the traditional conflicts between alcohol specialists and other mental health providers. Finally, they outline priorities and program qualities of an exemplary alcohol abuse pro-gram and describe the ideal spectrum of services that should be offered. Issues regarding referral to appropriate level of care are also described in detail.
Keywords: models, staffing, substance abuse

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This page was last reviewed by Dr Greg Mulhauser, Thursday, 14 October 2021.