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Article Excerpt
Introduction
Managed care is now a ubiquitous feature of substance abuse treatment services in the United States. Managed care--the administration of health care delivery and financing according to rules and procedures that control access, length, or nature of treatment--became popular in general medical care in the United States during the 1960s and 1970s as a way to contain costs. When similar cost pressures came to bear on substance abuse services in the 1980s, behavioral health managed care organizations emerged in the private sector to manage substance abuse and mental health treatment, often under general medical care umbrella managed care organizations (MCOs) (Sosin & D'Aunno 2001; Sabin & Daniels 2000).
In the United States, the introduction of managed care to substance abuse treatment services soon spread to the public sector and private services supported by public funding, where two-thirds of all substance abuse treatment services are provided (Steenrod et al. 2001). Most state and local authorities initiating managed care contract with private managed behavioral health organizations, health maintenance organizations, or other MCOs (Essock & Goldman 1995; Kushner & Moss 1995; Surles & Shore 1996). These behavioral health MCOs introduce a new element into the traditional relationship between providers and the government entity with which providers have established ties. The treatment population is unlike that served in the private sector, and counselors often view MCO procedures not simply as fiscal and organizational strategies to rationalize client access to quality care but as a violation of the integrity of their public sector work (Kirschner & Lachicotte 2001). In some cases, the community organizations and mental health centers that had traditionally offered treatment are no longer eligible as service providers; thus, consumers, even if found eligible for care under the new system, cannot continue treatment with their established counselors (Chang, et al. 1998).
It is instructive to consider that public health care reform in other countries has taken a different approach. The United Kingdom's National Health Service, for example, has been seen as the exemplar of the New Public Management approach (Hunter 1996). Under this system, rather than contract with an external organization, public sector managers are responsible for incorporating private sector management strategies--such as cost cutting and concern for standards, performance, and outcomes--into their public sector mission (Hunter 1996; Hannigan 1998).
This study, part of a larger project examining the impact of managed care on publicly funded substance abuse treatment systems in three California counties (Beattie et al. 2006), examines a system in "MidState," California in which the government entity, like New Public Management approaches, chose to manage internally its own care, working with its established providers. An increasing number of public sector substance abuse systems in the United States are choosing a similar path, adopting managed care principles as they are called to contain costs and be publicly accountable (Bergman 1999; Burns et al. 1999; Cash 2004; Hodgkin et al., 2004). This study analyzes the organizational changes--whether intended or not--that resulted from the implementation of an internally-managed system, and staff attitudes towards those changes, in order to shed light on how an internally managed organizational structure copes with the transition to managed care.
Following reviews of salient literature about managed care and a discussion of study methods, we examine the sociopolitical environment and history of implementation of managed care in MidState county, review staff perspectives on gatekeeping, levels and quality of care, and performance standards. We conclude with a discussion of the tradeoffs involved in the introduction of internally managed care to a public sector substance abuse treatment system, and find both similarities to and differences from reported experiences in externally-managed public sector systems.
Managed care
Managed care principles are adopted to control access to and length, level, quality, and/or cost of treatment. A tension exists between whether managed care protocols primarily promote equity, quality, and accountability or multiply barriers to access to and the provision of treatment (Edmunds et al. 1997).
Access
Several organizational procedures are employed to manage access to care, or gatekeeping, and counties, states, and private payers adopt them either singly or in combination. This is typically one of the first areas addressed as public sector substance abuse agencies begin their endeavors to improve treatment systems, as seen in such efforts as the Ontario approach in the 1980s (Rush et al. 1995) and the United States' Substance Abuse and Mental Health Services Agency's Target Cities project (Guydish & Muck 1999). Gatekeeping typically establishes a single point of entry or other control over access to the treatment system and may include elements such as telephone or in-person administration of a precertification screening tool, the application of medical necessity criteria, and triage to treatment or other programs. While gatekeeping may establish barriers to treatment or distract from needed expansions in treatment capacity (Guydish et al. 1999), the reverse outcome is also possible. This was evident in the shift to Medicaid managed care in Oregon and Massachusetts, which resulted in increased access to substance abuse treatment (Beinecke et al. 2002; Callahan et al. 1995; Deck et al. 2000; Frank & McGuire 1997).
The management of public sector care has the potential to promote more equitable access to services, in part through greater marketing (McNeese-Smith 1998), and gatekeepers may even provide an added referral source for providers (Guydish et al. 1999). As a result, services should be more easily accessible to clients with more severe symptoms, as well as, to women, men, and to clients of all races and ethnicities, some of whom may be more vulnerable to gaps and lack of communication in a system of care (Snowden 1993). There is, however, concern that some individuals, particularly ethnic minorities, may be deterred by impediments such as an impersonal telephone triage, even if conducted in their first language (Varma & Siris 1996; Abe-Kim & Takeuichi 1996).
Length and level of treatment
Once the treatment gate has opened, treatment length and care level may be managed by concurrent and/or retrospective case review, use of case managers, clinical protocols, limited services, or benefit restrictions. Declines in the utilization of substance abuse treatment have often accompanied the transition to managed care (Schmidt & Weisner 2003). Studies note fewer inpatient days and more outpatient and detoxification days that do not necessarily compensate for the drop in inpatient care (Galanter 1999; Galanter et al. 2000; Goldman et al. 1998; Mechanic et al. 1995; Sturm & Sherbourne 2000). In Massachusetts, shorter treatment episodes under managed behavioral health care were associated with more rapid re-admission (Shepard et al. 2002), suggesting that treatment did not allow enough time for recovery.
Quality
Universal assessments, protocols, and program performance standards may bring increased professionalism and facilitate individualized treatment, as was the case in the Oregon Health Plan (D'Ambrosio et al. 2003). However, if treatment options emphasize lower-cost ambulatory care and group rather than individual therapy, treatment gaps, limits on number and type of treatment visits, and reduced intensity of services may become evident (Edmunds et al. 1997). Particularly in the public sector, the cost of training for, providing, and monitoring individual therapy, the usual modality for evidence-based treatments, may be prohibitive (Miller et al. 2005). A major concern is that changes brought by managed care come at the expense of service providers' flexibility and autonomy (Beinecke et al. 2001; Shepard et al. 2002). Recent reports of substance abuse providers' evaluations of the Massachusetts program suggest that despite limitations in program autonomy, quality care was maintained under managed care. When providers evaluated the program eight years after it was initiated, the quality of care in general was considered good or very good by the majority of providers responding to the survey (Beinecke et al. 2002).
Administrative burdens
More paperwork and other administrative burdens...
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