Managed care approach to substance abuse treatment
An examination of people’s behaviors as they relate to drug use in the 20th century has shown that people will expend a large amount of energy to acquire any agent that has the ability to alter their minds, bodies, or behaviors in order to achieve a euphoric effect.
An examination of people’s behaviors as they relate to drug use in the 20th century has shown that people will expend a large amount of energy to acquire any agent that has the ability to alter their minds, bodies, or behaviors in order to achieve a euphoric effect. It is with prolonged use of a substance that addiction or tolerance can develop, which can lead to impairments in social, academic, or occupational functioning.1 Drug abuse is a heterogeneous syndrome, but the substances that are predominately abused generally possess a common characteristic that is the foundation for their abuse potential. From the initial intake, there is an increase in the likelihood of a pattern of continued substance misuse.2 In 2004, it was estimated that 6 million people older than aged 12 years were taking psychotherapeutic drugs (eg, pain relievers, tranquilizers, stimulants, and sedatives) in the United States, but these medications were not for medically intended purposes.3 Besides the socially accepted drugs such as alcohol and tobacco, there are the legal drug classes that are heavily marketed, such as opiates and benzodiazepines, which can be associated with increased susceptibility to acute and more common chronic abuse by some users. As the abuse of substances within our society continues to escalate to rival that of illicit drug use, it is becoming glaringly apparent that health care professionals must take a more proactive and collaborative approach in the identification and management of substance abuse cases and devise cost-effective therapeutic approaches in the process.3 It was estimated that the total spending on substance abuse treatment in the United States was around $21 billion in 2003 with the vast majority of financing coming from federal, state, and local governments.4 The challenge that faces federal and state governments and policymakers is how to efficiently allocate the limited funds while at the same time avoiding over- or under-treatment of substance abuse patients. The longstanding belief is that only programs that meet the minimum set of performance standards should receive funding, and reimbursement rates should be linked primarily to clinical outcomes and economic benefits.5,6
The implementation of managed care has become a vital component of the United States healthcare system with outcomes being observed on cost and treatment patterns.7 Given the primary focus of containing costs and improving performance of services, managed care has the potential to reduce utilization and change the pattern in healthcare delivery as it relates to substance abuse treatments. The history of public substance abuse treatments emerged in the 1970s under a mental health system that encompassed administrative, financing, and regulatory structure, but, over the years, this has evolved to a smaller substance abuse treatment system compared to mental health.8 Managed care techniques continued to be applied to mental healthcare in the 1980s because of unprecedented, often unwarranted, expansions.9 The current literature on the impact of managed care on substance abuse treatment has been mixed. A study conducted by Lemak and Alexander (2001) that examined the impact of managed care on outpatient treatment providers discovered that the treatment intensity (months and number of treatments received) was negatively impacted by the strictness of managed care (average number of visits per patient that was authorized by the managed care).10 On the other hand, other studies such as the one conducted by Steenrod and colleagues (2001) found that managed care on substance abuse treatment can reduce the utilization of inpatient or outpatient care and resources, while at the same time achieving positive treatment outcomes.11
From a healthcare standpoint, once an initial identification is made of the presence of substance abuse, healthcare professionals should engage in a collaborative effort to provide their level of specialized knowledge and expertise to assist with the development of cost-effective therapeutic interventions that are designed to specifically target the symptoms of the substance abuse.12 The interprofessional management of substance abuse treatment among different disciplines can allow for many opportunities to identify cases of substance abuse management. Screening and assessment are considered to be important first steps in the substance abuse treatment process, particularly when used in conjunction with a collaborative healthcare approach.13 The information that is gathered during the screening and assessment phase can assist with identifying needs and referral for follow-up services. Furthermore, the screening process can identify the existence of co-occurring mental problems that must be taken into consideration for treatment planning and cost coverage.14 There is a wide array of substance abuse assessment instruments, but the general characteristics of reliable instruments include the ability to produce severity rating and assess functional areas that may be affected by the substance abuse. The use of computerized instruments has been found to be more reliable, faster to administer, and more cost-effective in comparison to interview versions.15 With the current state of healthcare and mental health burgeoning US businesses and healthcare systems and the perceived misuse of mental services, managing care reduced the intensity of services to only those services that were considered to be appropriate for the management pathways for substance abuse.16 The economic impact of substance abuse treatment can vary based on the selected therapeutic approach, but proper screening, identification, assessment, and the development of cost-effective measures can help to form the foundation of more advanced economic evaluations, which can include improved program organization, delivery of optimal treatment, consideration of available resources, and patient characteristics.17
References
1. Edwards G. 100 years ago in addiction science. Addiction 2012;107(4):858–859.
2. Kendler KS, Ohlsson H, Sundquist K, Sundquist J. A latent class analysis of drug abuse in a national Swedish sample. Psychol Med 2013:1-10.
3. Kenna G. Substance Use Disorders. PSAP: Pharmacotherapy Self-Assessment Program, 6th ed. 2006.
4. Kenna G. Substance Use Disorders: Therapeutic approaches for more complex diagnoses. PSAP: Pharmacotherapy Self-Assessment Program,6th ed. 2006.
5.French MT, Popovici I, Tapsell L. The economic costs of substance abuse treatment: Updated estimates and cost bands for program assessment and reimbursement. J Subst Abuse Treat 2008;35(4):462–469.
6. Alterman AI, O’Brien CP, McLellan AT, et al. Effectiveness and costs of inpatient versus day hospital cocaine rehabilitation. J Nerv Ment Dis 1994;182:157–163.
7. McCarty D, Dilonardo J. State substance abuse and mental health managed care evaluation program. J Behav Health Serv Res 2003;30(1):7-11.
8. Olmstead T, White W, Sindelar J. The impact of managed care on substance abuse treatment services. Health Serv Res 2004;39(2):319–344.
9. Burman MA, Watkins KE. Substance abuse with mental disorders: Specialized public systems and integrated care. Health Affairs 2006;25(3):648–658.
10. Boyle P, Callahan D. Managed care in mental health: the ethical issues. Health Affairs 1995;14(3):7-22.
11. Lemak CH, Alexander JA. Managed care and outpatient substance abuse treatment intensity. J Behav Health Serv Res 2001;28(1):12-29.
12. Steenrod S, Brisson A, McCarty D, Hodgkin D. Effects of managed care on programs and practices for the treatment of alcohol and drug dependence. In: Gallanter M (ed). Recent developments in alcoholism, vol. 15, Services research in the era of managed care. New York: Kluwer Academic/Plenum; 2001:51-71.
13. Chan YF, Huang H, Sieu N, Unutzer J. Substance screening and referral for substance abuse treatment in an integrated mental health care program. Psychiatr Serv 2013;64(1):88-90.
14. Center for Substance Abuse Treatment. Substance abuse treatment for adults in the criminal justice system. Rockville, MD: Substance Abuse and Mental Health Services Administration ; 2005. (Treatment Improvement Protocol (TIP) Series, No. 44.)
15. Budman SH. Computer-mediated addiction services: Tomorrow won't look like today. Behav Healthcare Tomorrow 2002;11(2):14-21.
16. Employers cite need for comprehensive reform to reduce costs, look to managed competition for relief. Psychiatric News 5 March 1993:8-9.
17. Longo LP, Parran T, Johnson B, Kinsey W. Addiction: Part II. Identification and management of the drug-seeking patient. Am Fam Physician 2000;61(18):2401–2408.
Dr Farinde is a clinical staff pharmacist at Clear Lake Regional Medical Center, Webster, Texas, and a Formulary advisor.
Disclosure information: The author reports no financial disclosures as related to products discussed in this article.
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