Counselors should develop a broader perspective of their work that goes beyond providing treatment to include increasing their knowledge about treatment research and strategies for impacting managed-care systems.

Treatment options available to individuals with substance abuse problems have changed markedly in recent years because of profound changes in the organization and delivery of health services. Managed-care models of healthcare delivery have attempted to keep costs in check by limiting access to treatment, decreasing the lengths of time that services are delivered, and providing incentives for outpatient rather than inpatient or residential care. Many of these changes in the private and public funded sectors have occurred without benefit of clinical research demonstrating effectiveness.

The frustration that many mental- health and substance-abuse professionals feel with systems of managed care have been well documented. Concerns have been raised about inadequate levels of care, confidentiality issues involved when submitting clinical reports to managed-care companies, and decisions affecting treatment by managed-care staff with limited clinical training. Many professionals feel that clinical decisions are often based on financial considerations and that they have limited influence over services offered.

Substance-abuse treatment has been affected by the reorganization of healthcare delivery in the United States in:

• utilization of treatment
• treatment intensity
• confidentiality
• provision of services to clients with more severe levels of addiction

There are many ways that counseling professionals might have a stronger impact on current changes.

• To justify their services to insurance companies, clients and the public, professionals might more aggressively emphasize recent research demonstrating the cost and clinical effectiveness of substance-abuse treatment.
• Counselors can use the assessment and referral procedures developed by the American Society for Addictive Medicine (ASAM) because they are conceptually based on a clinical assessment of client needs and are also consistent with the managed-care emphasis on limiting the provision of unnecessary services.
• Substance-abuse counselors can broaden their work to include conducting research on clinical and cost effectiveness and support stronger accreditation standards to monitor managed-care organizations.
• Counseling and substance-abuse organizations can increase their involvement in organizations that accredit managed-care companies.

Managed-care models of financing healthcare have become prominent over the last decade in response to escalating healthcare costs. The stated goals of managed care are to limit costs while providing access to high-quality care. To achieve these goals, managed care imposes controls on the level and quantity of treatment and selects providers who are willing to contract for services at a reduced rate. Over 125 million people are enrolled in some form of managed behavioral healthcare plan. Although managed care initially was implemented in private sector programs, it is increasingly being used to contain costs in public sector programs as well. Studies suggest that managed-care plans have been effective in limiting the costs of substance-abuse treatment by reducing inpatient care, increasing the use of outpatient care, authorizing fewer individual therapy sessions and more group therapy, and using less costly providers (National Institute of Alcohol Abuse and Alcoholism, 1997).

Critics of managed care have noted a number of problems. Although managed care emphasizes the importance of measures of access, effectiveness and treatment outcome, the NIAAA and the Institute of Medicine pointed out that the effects of managed care on access to services, quality and outcomes is largely unknown. They indicated that much of the data collected in managed-care organizations are not validated by external sources and that there is too much emphasis on the structure and process of care and not enough on measures of clinical outcome.

Another concern about managed care is the potential for private plans to treat only healthier individuals and shift those individuals with more costly care into publicly financed programs; a process known as "dumping" (Institute of Medicine, 1997). In this way, managed- care plans do not really assume risk for more costly individuals but simply pass them on to the public sector. As managed-care mechanisms of funding continue to grow in the publicly funded sector, concerns have been raised about its reluctance to treat chronic disorders which may not be time limited and may require a mix of services in addition to treatment for drug and alcohol problems. For example, individuals with more disabling conditions are likely to require a variety of "wraparound" services such as housing, job counseling, mental health, and social-support services. Although these kinds of broad-based approaches have received support in professional literature, they may not be consistent with managed care's emphasis on cutting costs.

External constraints on the level and amount of treatment funded have been a major frustration for substance-abuse and mental-health practitioners. Prior to managed care, practitioners were largely free to work with clients in whatever manner they viewed appropriate.

Few restrictions were imposed on long-term treatment or referrals to more costly levels of service, such as inpatient care. Advocates of managed care argue that in this situation, there was little accountability for the costs of services delivered and that clinicians did not present data demonstrating that more intensive treatment resulted in better outcomes.

Many practitioners feel that the limits on accessing treatment have gone too far and that clients are being denied services they require. This is particularly the case for individuals with more serious or coexisting problems. Managed-care staff with little or no clinical training may have the power to dictate the course of treatment and decisions may be more heavily weighted on financial rather than clinical criteria. The Institute of Medicine has recommended that independent accreditation agencies carefully monitor managed-care organizations to ensure that precertification of services and utilization review procedures are clinically appropriate. Examples of accreditation agencies include the Rehabilitation Accreditation Commission (CARF), Council on Accreditation of Services for Families and Children (COA), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and National Committee on Quality Assurance (NCQA). These organizations are beginning to exert a strong influence on healthcare systems by reviewing managed-care practices and reporting their findings to employers and individuals that purchase healthcare plans.

Practitioners are also concerned about how managed care affects the clinical relationship. Many substance-abuse professionals have felt limited in their authority to negotiate a treatment plan with clients because of the possibility that the client's managed-care plan may not authorize the services agreed upon. In this situation, the client and practitioner experience treatment that is controlled by external bureaucratic forces rather than negotiation within a treatment relationship.

Practitioners have concerns about compromising confidentiality, in particular how private are healthcare records at work, because current methods of financing healthcare strongly emphasize external monitoring of treatment.

Proponents of managed care have been critical of many substance-abuse treatment approaches because they have failed to adequately document clinical and cost effectiveness. However, a number of recent publications have addressed this concern. In its recent report on managed-care funding of behavioral healthcare, the Institute of Medicine concluded that substance-abuse and mental-health treatments are effective. McLellan has argued that even chronic substance-abuse problems compare favorably with the treatment of other chronic medical conditions such as diabetes.

Many private-practice therapists and staff in substance-abuse treatment programs are not aware of the studies supporting the effectiveness of treatment. Knowledge of recent research should be used by counselors to justify the costs of treatment and identify potential benefits. Further, federal agencies that fund research, such as the Center for Substance Abuse Treatment, have made it a priority to develop collaborative relationships between treatment providers and researchers. The hope is that these collaborative relationships will yield studies that are more relevant to treatment and more widely disseminated in the practitioner community.

One of the most important recent studies documenting the efficacy of professional treatment was the multi-site study conducted by the Project MATCH Research Group in 1977. Project MATCH was originally designed to match clients with alcohol problems to different types of alcohol treatment. Clients were randomly assigned to one of three different types of individual treatment: cognitive behavioral, motivational interviewing (Miller, et al., 1992), or 12-step facilitation (Nowinski, et al., 1992).

Overall, results did not support the matching hypotheses proposed. Different types of clients did not do better or worse in different modalities. However, at one- and three-year follow-up, clients in all three modalities showed substantial and sustained reductions in drinking. Although this study was not aimed at examining costs issues, it should be noted that interventions were relatively inexpensive because they were limited to 12 weeks of treatment in outpatient settings. The results from Project MATCH have not been used often enough to justify professional outpatient treatment for alcohol abusers. The success of the treatment methods employed requires more attention in professional publications, the media, and discussions between therapists, clients and families.

Recent studies have demonstrated that a variety of specialized treatment programs for substance abuse disorders are both cost and clinically effective, including residential social model, outpatient, methadone maintenance, and therapeutic community modalities (Gerstein, et al., 1994, 1997). In a large study of specialized treatment programs in California, Gerstein and colleagues (1994) sampled 1,850 individuals in a variety of publicly funded treatment programs and found improvements in decreased drug and alcohol use, decreased criminal justice involvement, increased employment, and improved health. Further, decreases in criminal behavior were associated with longer lengths of time in treatment. A cost benefit analysis found that one dollar invested in substance abuse services yielded a savings of seven dollars. All treatment modalities studied were found to be cost effective (Polcin, in press).

In a more recent national study of 5,388 clients in publicly funded programs Gerstein (1997) again found substantial improvement in drug and alcohol use, decreased criminal activity, improved health and increased employment. The results also documented a decrease in psychiatric hospitalization, improved housing and decrease in HIV high-risk behavior.

A study examining the effectiveness of Alcoholics Anonymous (AA) found that AA was as effective as cognitive behavioral treatment for treating alcohol dependence (Ouimette, Finney and Moos, 1997). Both approaches resulted in decreased alcohol use and improved psychosocial adjustment.

One of the reasons there has not been enough attention paid to studies validating the effectiveness of substance-abuse treatment is that the substance-abuse field does not speak with a unified voice (Polcin, 1992, 1997, in press). Strong divisions exist among researchers, practitioners, and paraprofessional recovery counselors which hinder the dissemination and impact of research findings (Polcin, 1997). An important step in the right direction would include counselors becoming more aware of the research findings that support their work and more actively disseminating these findings in the treatment programs, the professional literature, conferences, the public media and interactions with clients and families.

One way that counselors can address both clinical and cost concerns is through the application of the Patient Placement criteria developed by the American Society for Addiction Medicine (ASAM, 1996). The ASAM criteria provide guidelines to practitioners and utilization review personnel in managed-care organizations for referrals to different levels of care. When considering which level of care is most appropriate for an individual client, they suggest clinicians assess the need for detoxification, biomedical complications, psychiatric conditions, resistance to treatment, potential for relapse, and the social environment of the client. The more severe the problems in each of these areas, the higher the level of service required. The ASAM criteria delineate four levels of care:

1. outpatient
2. partial hospitalization
3. residential
4. inpatient treatment (Polcin, in press).

Mee-Lee (1997) has developed a model that uses the ASAM criteria in a somewhat different manner. Rather than focusing on levels of care, he suggests that clinicians assess the six problem areas identified and refer the client to the specific services required. In this model, clients receive the services that they need in the least intensive but safe level of care. Individualized service delivery becomes more important than the level of care in which services are provided. Mee-Lee (1997) argues that treatment programs need to develop a more flexible menu of services that can help individualize treatment, rather than provide a pre-packaged program for everyone (Polcin, in press).

The major strength of the ASAM criteria is that it is conceptually based upon sound clinical practice and recommendations in the treatment literature while it also addresses managed care's emphasis on limiting unnecessary and overly restrictive services. The ASAM criteria provides practitioners with a method of expanding their vision of treatment to include consideration of cost while ensuring that clinical concerns remain paramount. It also provides them a rationale they can use to justify triage and referral to different levels of care and a mix of different services to everyone (Polcin, in press).

The reorganization of health services financing has profoundly impacted substance-abuse treatment, but it has proceeded with limited empirical support and minimal input from treatment providers. It is therefore important for substance abuse counselors to adopt a broader view of their work that goes beyond providing services. They must take steps to increase their impact on healthcare systems, ensure that managed-care procedures are supported by relevant clinical research, and support efforts to create more monitoring of managed-care practices. Improving systems of care will require an examination of cost, measurement of clinical outcome, involvement in accreditation procedures which monitor managed care organizations, and increased advocacy efforts with local and federal government, funding sources and the public.

A number of recent surveys have revealed that the American public is concerned about issues of access to care, quality, and confidentiality with managed-care systems of financing (APA Monitor, 1997, 1998; IOM, 1997). Increasingly, Americans feel that managed-care companies need to be held accountable and that legal action should be an option when administrative appeals have been exhausted.

This widespread concern presents an opportunity for the implementation of stronger accreditation processes to oversee managed care (IOM, 1997). The Institute of Medicine publication, "Managing Managed Care," (IOM, 1997) provides an overview of some organizations that accredit managed-care behavioral treatment: Rehabilitation Accreditation Commission (CARF), Council on Accreditation of Services for Families and Children (COA), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and National Committee on Quality Assurance (NCQA). These organizations play a critical role in current healthcare systems by reviewing managed-care practices, rating managed-care companies' performance, and making the findings available to employers, consumers, and the public.

A major step in the right direction would be a stronger role for counselors in accreditation organizations that evaluate managed-care treatment of substance abuse problems. This would present opportunities to impact concerns such as "dumping" high cost clients into public systems of care, confidentiality, provision of appropriate levels and mix of services, and utilization procedures. It would also present an opportunity to bring these issues into a public forum for an open and thorough discussion that would include the perspectives of substance-abuse professionals.

The American Psychological Association has already taken important steps to influence accreditation standards. APA has formed an alliance with the National Committee for Quality Assurance (NCQA), a national group that assesses the quality of managed-care plans (APA Monitor, April, 1999). The result of this alliance has been the creation of the Health Care Practitioner Advisory Council (HCPAC), a 13-member non-physician group that advises NCQA on accreditation standards. As a result of APA influence, NCQA changed its standards to recognize the competence of clinical psychologists to oversee triage and referral decisions in inpatient hospital settings. Clearly, similar efforts are needed by counselor organizations, such as the American Counseling Association (ACA), the International Association of Addiction and Offender Counseling (IAAOC), the American Association of Marriage and Family Therapists (AAMFT) and the California Association of Marriage and Family Therapists (CAMFT). Although Substance Abuse and Mental Health Services Administration is a national substance-abuse organization that has developed a performance rating system for managed-care organizations, other national organizations such as the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) could play a stronger role in accreditation.

Douglas L. Polcin, EdD is a research psychologist
at Haight Ashbury Free Clinics, Inc., San Francisco, California.

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