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3

Challenges in Delivery of Behavioral Health Care

The most unusual aspect of the care and financing system for mental health and substance abuse is the presence of a distinct and substantial publicly managed care system that serves as a safety net. Thus, public services are available for those with public insurance, as well as for those who have private insurance, under circumstances that will be described in this chapter. Public services are funded through a large number of categorical programs administered by different agencies, creating both duplication and gaps in service, and these programs almost always have different eligibility requirements. In addition, funding is fragmented, which leads to fragmented service delivery.

Another challenge is that much mental health and substance abuse care, for perhaps as many as half of all episodes, is provided in primary care settings, not in specialty programs (IOM, 1996). Despite clinical practice guidelines, continuing education courses, and other training programs, however, primary care practitioners tend to underdiagnose depression, substance abuse, and other behavioral health problems (IOM, 1996). This is changing, but there is a great need to improve the quality of mental health and substance abuse care delivered in primary care settings and also to better coordinate the care delivered in primary care and specialty sectors (IOM, 1996).

In addition, a significant portion of the public care system for individuals with the most disabling conditions extends beyond health care services to rehabilitative and support services, including housing, job counseling, literacy, and other programs. The coordination of these services requires collaborative and cooperative relationships among many agencies, including public health, mental health, social services, housing, education, criminal justice, and others. Most of



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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 3 Challenges in Delivery of Behavioral Health Care The most unusual aspect of the care and financing system for mental health and substance abuse is the presence of a distinct and substantial publicly managed care system that serves as a safety net. Thus, public services are available for those with public insurance, as well as for those who have private insurance, under circumstances that will be described in this chapter. Public services are funded through a large number of categorical programs administered by different agencies, creating both duplication and gaps in service, and these programs almost always have different eligibility requirements. In addition, funding is fragmented, which leads to fragmented service delivery. Another challenge is that much mental health and substance abuse care, for perhaps as many as half of all episodes, is provided in primary care settings, not in specialty programs (IOM, 1996). Despite clinical practice guidelines, continuing education courses, and other training programs, however, primary care practitioners tend to underdiagnose depression, substance abuse, and other behavioral health problems (IOM, 1996). This is changing, but there is a great need to improve the quality of mental health and substance abuse care delivered in primary care settings and also to better coordinate the care delivered in primary care and specialty sectors (IOM, 1996). In addition, a significant portion of the public care system for individuals with the most disabling conditions extends beyond health care services to rehabilitative and support services, including housing, job counseling, literacy, and other programs. The coordination of these services requires collaborative and cooperative relationships among many agencies, including public health, mental health, social services, housing, education, criminal justice, and others. Most of

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH these services are not covered by private insurance and have not been developed by most private behavioral health care companies. Any approach to reform of mental health and substance abuse care services or to the problem of accountability must reckon with these factors, which are not simultaneously present in any other substantial sector of health care services. The dynamics of the three interrelated sectors—privately funded primary and specialty health care and public health care systems—are complex and also highly idiosyncratic from state to state, community to community, and plan to plan. An additional layer of complexity comes from the historical separation of treatment systems for mental health, drug abuse, alcohol abuse, and the primary care system in both the public and private sectors. This chapter will set out the committee's views about the unique challenges in the delivery of behavioral health care. The chapter includes a description of the prevalence and costs of mental health and substance abuse problems, the difficulties and fragmentation of the current system for the delivery of care, the role of primary care, and a description of some of the support services that are needed for the long-term management of mental health and substance abuse problems. Historical perspectives on separate systems are also provided. EXTENT AND IMPACT OF BEHAVIORAL HEALTH PROBLEMS Prevalence The social consequences of mental health and substance abuse problems are much greater than generally appreciated. The prevalence of these conditions in society is quite large, and the economic burdens are substantial. The most recent estimates of the prevalence of behavioral health disorders suggest that almost a third of the adult population experiences some impairment due to a behavioral health problem in any one year (Kessler et al., 1994). The most common problems experienced by the adult population annually are anxiety disorders (17 percent), alcohol dependence (7 percent), and affective disorders (11 percent) (Kessler et al., 1994) (see Table 3.1). Many of the most serious and often disabling mental disorders (e.g., schizophrenia, major depression, bipolar illness, or manic depression) affect a total of 1 to 2 percent of the adult population annually. The incidence and prevalence of child and adolescent problems is not as well established, but levels of emotional disturbance that affect functioning are noted in about one of every eight children and adolescents (SAMHSA, 1996) (see Table 3.2a). Estimated annual prevalence of drug use among children and adolescents is presented in Table 3.2b. Estimates of the impact of mental health and substance abuse problems reveal the substantial effects of these conditions. The direct and indirect costs to society have been estimated at $257 billion for substance abuse (Rice, 1995) (see Table 3.3) and $148 billion for mental illness in 1990 (Rice, 1995; Rice and

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH TABLE 3.1 Estimated Annual Prevalence of Behavioral Health Problems in the United States (Ages 15–54) Behavioral Health Problems Prevalence (percent) All behavioral health problems 29.5 Any mental disorder 22.9 Any affective disorder 11.3 Major depressive episode 10.3 Manic episode 1.3 Dysthymia 2.5 Any anxiety disorder 17.2 Panic disorder 2.3 Agoraphobia without panic disorder 2.8 Social phobia 7.9 Simple phobia 8.8 Generalized anxiety disorder 3.1 Other disorders Antisocial psychosis N/Aa Nonaffective psychosisb 0.5 Substance abuse or dependence 11.3 Alcohol abuse without dependence 2.5 Alcohol dependence 7.2 Drug abuse without dependence 0.8 Drug dependence 2.8 aN/A, not available. bNonaffective psychosis includes schizophrenia, schizo-phreniform disorder, schizoaffective disorder, and atypical psychosis. Miller, 1996; Varmus, 1995) (see Table 3.4). Mental health and substance abuse factors are associated with a majority of suicides, whereas alcohol abuse alone is implicated in 50 percent of all homicides and 30 percent of all accidental deaths (NIAAA, 1990). One third of all criminal justice costs relate to mental health and substance abuse problems (Rice et al., 1990), and general health care costs are significantly increased by the presence of these disorders (NAMHC, 1993). Perhaps the simplest summary of the scope of these conditions is that mental health and substance abuse problems are comparable in magnitude to cancer and heart disease (see Table 3.5). SOURCE: Kessler et al. (1994). Underestimating the Scope of the Problem Although the stigma associated with seeking treatment for mental or addictive disorders is a significant factor in masking the scope of these problems by keeping them “in the closet,” the unusual fragmentation of these sectors of care is

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH TABLE 3.2a Sample of Estimated Annual Prevalence of Behavioral Health Problems in Children and Adolescents   Lavigne et al., 1996 Bird et al., 1988 Offord et al., 1989 Costello et al., 1988 Anderson et al., 1987 Velez et al., 1989 Methods Child (Play observation and developmental evaluation) Parent (Checklist and Interview) Child (Interview) Parent (Interview) Child (Checklist) Parent (Interview) Teacher (Checklist) Child (Interview) Parent (interview) Child Interview Parent (Checklist) Teacher (checklist) Child (Interview) Parent (Interview) Sample size N = 510 N = 777 N = 2,679 N = 789 N = 782 N = 776 Age 2–5 years (percent) 4–16 years (percent) 4–16 years (percent) 7–11 years (percent) 11 years (percent) 11–20 years (percent) All mental disorders 21.4 18 18.1 22.0 17.6 17.7 Attention deficit disorder (w/wo hyperactivity) 2.0 9.9 6.2 2.2 6.7 4.3 Oppositional disorder 16.8 9.5 — 6.6 5.7 6.6 Conduct disorder — 1.5 5.5 2.6 3.4 5.4 Separation anxiety — 4.7 — 4.1 3.5 5.4 Overanxious disorder — — 9.9 4.6 2.9 2.7 Simple phobia — 2.3 — 9.2 2.4 — Depression (dysthymia) — 5.9 — 2.0 1.8 1.7 Functional enuresis — 4.7 — 4.4 — — NOTE: The prevalence rates listed above reveal the range of rates estimated for specific disorders among different age groups. Studies are under way at NIMH and CMHS to update these estimates. SOURCES: Anderson et al. (1987), Bird et al. (1988), Costello (1989),Costello et al. (1988), Lavigne et al. (1996), Offord et al. (1989),and Velez et al. (1989).

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH TABLE 3.2b Estimated Annual Prevalence of Drug Use Among Children and Adolescents, 1995   National Household Survey on Drug Abuse, 1995 Findings (SAMHSA, 1996) Monitoring the Future Study, 1995 Findings (Johnston et al., 1996) Age 12–17 years (percent) 8th graders (percent) 10th graders (percent) 12th graders (percent) Any illicit drug use 18.0 21.4 33.3 39.0 Marijuana use 14.2 15.8 28.7 34.7 Cocaine use 1.7 2.6 3.5 4.0 Alcohol use 21.1* 45.3 63.5 73.7 Cigarette use 26.6 19.1* 27.9* 33.5* *Indicates past month prevalence. SOURCES: Johnston et al. (1996) and SAMHSA (1996). also part of the problem. A first factor is that, unlike most other health conditions, separate publicly managed health care systems are maintained for mental illness and substance abuse treatment. The publicly managed systems, with responsibility divided between federal, state, and local governments, and also divided for mental illness and substance abuse care, permit a de facto catastrophic insurance function that allows private purchasers to strictly limit behavioral health care coverage because they know that they will not be leaving their employees without an alternative. The magnitude of the public-sector role is substantial, especially in caring for individuals with histories of chronic mental illness, alcoholism, and drug dependence. The public-sector commitment is not just in the form of public insurance programs like Medicare and Medicaid but is also through state and local funding of systems of care. Estimated 1994 mental health care costs were about $81 billion, of which state and local funding was about $22 billion (Oss, 1994). In several states, Medicaid supports about one third of the community mental health center program and may be the sole funding source for community support and rehabilitation services funded through state mental health agency appropriations and reimbursed by Medicaid (AMBHA and NASMHPD, 1995). Thus, the public role is much larger than that in the rest of the health care system, and there is a fragmented division of labor between the public and private sectors. This makes estimating total treatment costs more difficult. High Indirect Costs Some costs incurred in the care of behavioral health disorders—especially for

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH TABLE 3.3 Estimated Annual Economic Costs of Substance Abuse, 1990 (millions) Type of Cost Illicit Drugs Alcohol Nicotine Total Total $66,873 $98,623 $91,269 $256,765 Core Costs 14,602 80,763 91,269 186,634 Direct 3,197 10,512 39,130 52,839 Mental health/specialty organizations 867 3,469 – 4,336 Short-stay hospitals 1,889 4,589 21,072 27,550 Office-based physicians 88 240 12,251 12,579 Other professional services 32 329 a 361 Prescription drugs – – 1,469 1,469 Nursing homes – 1,095 3,858 4,953 Home health services – – 480 480 Support costs 321 790 – 1,111 Indirect 11,405 70,251 52,139 133,795 Morbidityb 7,997 36,627 6,603 51,227 Mortalityc 3,408 33,624 45,536 82,568 Other Related Costs 45,989 15,771 – 61,760 Direct 18,043 10,436 – 28,479 Crime 18,035 5,807 – 23,842 Motor vehicle crashes – 3,876 – 3,876 Fire destruction – 633 – 633 Social welfare administration 8 120 – 128 Indirect 27,946 5,335 – 33,281 Victims of crime 1,042 576 – 1,618 Incarcerationd 7,813 4,759 – 12,572 Crime careerse 19,091 – – 19,091   6,282 – – 6,282 Fetal Alcohol Syndrome – 2,089 – 2,089 NOTE: The costs in 1990 for illicit drugs and alcohol abuse are based on socioeconomic indexes applied to 1985 estimates (Rice et al., 1990); direct costs for cigarette smoking are deflated from 1993 direct cost estimates (MMWR, 1994); indirect costs for cigarette smoking are from Rice et al. (1992). aAmounts spent (nicotine) for other professional services are included in office-based physicians. bValue of goods and services lost by individuals unable to perform their usual activities because of drug abuse or unable to perform them at a level of full effectiveness. cPresent value of future earnings lost; illicit drugs and alcohol are discounted at 6 percent and nicotine is discounted at 4 percent. dValue of lost productivity of incarcerated individuals. eValue of lost productivity of people who engage in criminal activity as a result of drug abuse. SOURCE: Rice (1995).

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH TABLE 3.4 Estimated Annual Economic Costs of Mental Disorders by Disorder, 1990 (millions) Type of cost Total Mental Disorders Anxiety Disorders Schizophrenia Affective Disorders Other Disorders Total $147,847 $46,551 $32,538 $30,373 $38,385 Core Costs 141,887 46,184 29,292 29,073 37,338 Direct 67,000 10,748 17,296 19,215 19,741 Mental health organizations 19,516 1,985 6,520 4,873 6,138 Short-stay hospitals 13,392 388 2,595 4,695 5,714 Office-based physicians 3,655 356 406 1,171 1,722 Other professional services 6,599 645 710 2,047 3,197 Nursing homes 16,478 5,460 5,316 4,543 1,159 Drugs 2,191 1,167 397 406 221 Support costs 5,169 747 1,352 1,480 1,590 Indirect 74,887 35,436 11,996 9,858 17,597 Morbiditya 63,083 34,161 10,694 2,195 16,033 Noninstitutionalized population 58,988 33,105 8,837 1,556 15,490 Institutionalized population 4,095 1,056 1,857 639 543 Mortalityb 11,804 1,275 1,302 7,663 1,564 Other Related Costs 5,960 367 3,246 1,300 1,047 Direct 2,292 229 599 656 808 Crime 1,777 178 464 508 627 Social welfare administration 515 51 135 148 181 Indirect 3,668 138 2,647 644 239 Incarceration 573 58 150 164 201 Family caregiving 3,095 80 2,497 480 38 NOTE: 1990 costs are based on socioeconomic indexes applied to 1985 cost estimates. aValue of goods and services lost by individuals unable to perform their usual activities or unable to perform them at a level of full effectiveness. bPresent value of future earnings lost discounted at 6 percent. SOURCE: Rice and Miller (1996).

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH TABLE 3.5 Estimated Annual Costs of Illness for Selected Diseases and Conditions (billions of dollars) Disease Year Total Direct Indirect Other Relateda Drug addiction, totalb,c 1990 $256.8 $52.8 $133.8 $61.8 Alcoholb 1990 98.6 10.5 70.3 15.8 Illicit drugsb 1990 66.9 3.2 11.4 46.0 Nicotineb 1990 91.3 39.1 52.1 d Mental disorders, total 1990 147.8 67.0 74.8 6.0 Anxiety disorders 1990 46.5 10.7 35.4 0.4 Schizophrenia 1990 32.5 17.3 12.0 3.2 Affective disorders 1990 30.4 19.2 9.9 1.3 Other disorders 1990 38.4 19.7 17.6 1.1 Diabetes 1992 137.1 91.1 46.6 d Heart diseasee 1991 125.8 70.9 54.9 d Cancer (all sites)e 1990 96.1 27.5 68.7 d Alzheimer's disease 1992 87.9 13.3 74.6 d Arthritis 1992 54.6 12.7 41.8 d Stroke 1993 30.0 17.0 13.0 d AIDS 1992 N/Af 10.3 N/A d NOTE: Data in table may not sum to totals due to rounding. aOther related costs of drug addiction include direct and indirect costs of crime, motor vehicle crashes, fire destruction, and social welfare administration. bTotal includes costs of AIDS and fetal alcohol syndrome. cThe year 1990 is used as the base year because it is the most recent date for which the total costs of drug addition to society has been estimated. More recent figures were not available at the time of the study. dNot calculated. eIncludes costs of adverse health effects of prescription drugs. fN/A, not available. SOURCES: NHLBI (1994), Rice (1995), Rice and Miller (1996), and Varmus(1995). patients with the greatest disabilities cared for in public-sector programs—are not health care-related costs. The services needed by these individuals may include housing supports, job training and rehabilitation, and a wide variety of other forms of assistance not considered and rarely funded by health insurance. Partly because of the disability associated with serious mental health and substance abuse problems and partly because of poor private insurance coverage for treatment of these conditions, many people with serious conditions permanently lose employment and require income maintenance benefits for extended periods. Because they are transfers rather than social costs, these expenses often are not included in estimates of total costs.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Some of the problems attributed to behavioral health disorders have already been mentioned, including higher mortality, disability, and lost employment. In general, levels of impairment are comparable for mental disorders and common medical disorders. Because of this pattern and poor access to treatment, a significant proportion of societal costs due to behavioral health problems are not a result of treatment costs but are due to lost productivity and related costs. The Potential of Treatment In broad terms, research on treatment outcomes seeks to answer questions such as whether an intervention has been successful, whether it is more effective than other treatments, whether its effectiveness is better with some groups than with others, whether the setting of care makes a difference, and so on. Outcomes research has many subfields, including quality of care, consumer satisfaction, quality of life, provider-patient relationships, patterns of practice, technology assessment, cost-effectiveness, and bioethics (e.g., Brook and Lohr, 1985; Bunker, 1988; Eddy, 1990; Greenfield et al., 1992; Guadagnoli and McNeil, 1994; Lohr, 1988). Surprisingly little is known about the comparative effectiveness of different practitioners, because most outcomes research focuses on the treatment setting or approach rather than the practitioners who deliver care. It is exceedingly difficult if not impossible to generalize about the findings from treatment research in behavioral health, which includes drug abuse, alcohol abuse and alcoholism, and mental illness. Research histories stretch back decades in some cases, such as methadone maintenance, whereas other areas are relatively recent. Studies tend to be published in dozens of specialty journals, and relatively few studies have been published in mainstream medical journals. Moreover, the quality of the evidence is generally viewed outside the fields as unconvincing, and this is given as one reason for justifying a lack of insurance coverage for behavioral health. For at least 20 years, drug abuse researchers have been studying treatment effectiveness, including work with cocaine abuse, methadone maintenance, and marijuana abuse (e.g., Hubbard et al.,1989; IOM, 1990a, 1996; McLellan et al., 1980, 1982). Research on drug abuse treatment has shown consistently that effectiveness depends on the length of time in treatment, the intensity of treatment, and the availability of aftercare to maintain recovery (CSAT, 1995). Alcoholism treatment research is generally a research “culture” separate from drug treatment research, but the two areas of research have come to many of the same conclusions: no single treatment approach works for everyone, but most people benefit from a combination of modalities (e.g., IOM 1990b; McLellan et al., 1996). Drug and alcohol treatment research thus focuses on the use of a particular substance. In contrast, much more clinical uncertainty is associated with the diagnoses in mental health. Still, mental health outcomes research studies tend to be concentrated according to diagnosis; the majority of research has been conducted on depression, anxiety disorders, schizophrenia, and attention deficit and

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH hyperactivity disorder in children (Burnam, in press). Randomized controlled clinical trials have been conducted to test the effectiveness of medications, whereas other studies have compared the differential effects of therapeutic strategies, such as cognitive therapy or psychosocial support for depression (McLellan et al., 1996). Thus, generalizations are difficult to make with the existing data, but it would be appropriate to say that individuals can benefit from a variety of treatment strategies, including medication and psychotherapy or counseling, and that most practitioners seek to find an effective combination for each individual whom they treat. In the committee's view, then, the available evidence suggests that most forms of mental health and substance abuse treatment are effective for some of the many people affected by behavioral health problems (see Box 3.1), but much remains to be learned about which treatments work best for which individuals to improve their functioning and reduce their symptoms. The lack of systematic studies of treatment outcomes, however, is not unique to behavioral health. From an outcomes research perspective, relatively little has been done to substantiate the majority of medical practice. In other words, the accuracy and reliability of diagnosis and the effectiveness of behavioral health treatment are viewed as comparable to equivalent measures for medical care in general (NAMHC, 1993). In the mental health field, there is justified optimism about improving the effectiveness of treatment. In the case of schizophrenia alone, for example, improved medications including clozapine and risperidone have become available in recent years, other antipsychotic medications will soon be made available, and the effectiveness of relatively new psychosocial treatments including assertive community treatment and multiple family group treatment has been validated (AHCPR, 1995). There is more evidence that the long-term prognosis of recovery is better than was previously thought, even for the most serious disorders (Harding et al., 1992). Thus, the mental health field shares considerable optimism that was neither present nor justified in past generations. In the drug treatment field, there is confidence about the effectiveness of treatment when it is delivered appropriately. Some of the most recent data have been developed in the National Treatment Improvement Evaluation Study (NTIES) sponsored by the Center for Substance Abuse Treatment (CSAT) (1995). CSAT is supporting pilot studies to develop and test outcomes monitoring measurement systems in a number of states. Preliminary data indicate that treatment is effective in reducing drug use and associated crime and that the reductions are more likely to be maintained with case management and ongoing aftercare (CSAT, 1995). In essence, the challenge for the drug treatment field is not so much developing more evidence of treatment effectiveness as it is convincing decision makers that investments in treatment are worthwhile and cost-effective. Treatment effectiveness is discussed further in Chapter 7, Outcomes, and in the papers by McLellan et al. and Steinwachs, in Appendix A, Appendix B and Appendix C, respectively.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH BOX 3.1 The Case for Treatment of Mental Disorders and Addiction Mental Disorders In the United States, more than 50 million Americans are faced with a mental disorder or addiction each year. Of these Americans, fewer than half receive treatment (Regier et al., 1993). Anxiety disorders affect more than 23 million Americans in a given year. On average, anxiety disorders cost $625 per patient for inpatient treatment. Outpatient treatment for anxiety disorders commonly costs as little as $500 a year, with the same results (NIMH, 1995). Affective or mood disorders affect nearly 18 million Americans annually, exacting an enormous human toll and cost to the U.S. economy—$43.7 billion a year in treatment, disability, and lost productivity, a figure comparable to that for heart disease. Nearly 85 percent of people with unipolar depression or dysthymia also respond positively to antidepressant medication or psychotherapy, either alone or in combination (NIMH, 1995). Schizophrenia, one of the most chronic and disabling mental disorders, affects about 1 percent of the U.S. population, with economic costs from treatment and lost income totaling more than $30 billion annually. However, new antipsychotic medications are helping to reduce the symptoms of schizophrenia, as well as the adverse side effects of past medications (NIMH, 1995). Addiction In the United States, more than 18 million people who use alcohol and 5 million who use illicit drugs are in need of substance abuse treatment. Of that number, fewer than one in four receive treatment (Institute for Health Policy, Brandeis University, 1993). A 1994 California study of the cost-effectiveness of alcohol and other drug treatment programs found an average return to taxpayers of $7 for every $1 invested (Gerstein et al., 1994). The same study found that the level of criminal activity declined by two-thirds, from 73.6 percent before treatment to 20.3 percent after treatment (Gerstein et al., 1994). In California, hospitalizations were reduced by approximately one-third after treatment, including a reduction of 58 percent in drug overdose admissions and a reduction of 44 percent in mental health admissions (Gerstein et al., 1994). In Minnesota, an evaluation of Consolidated Chemical Dependency Treatment Fund activity found that almost 80 percent of treatment costs were offset in the first year alone. The savings were achieved through reductions in medical and psychiatric hospitalizations, detoxification admissions, and arrests (Minnesota Department of Human Services, Chemical Dependency Division, 1995). The Health Insurance Association of America estimates savings of from $48,000 to $150,000 in costs for maternity care, physicians ' fees, and hospital charges for each delivery that is uncomplicated by substance abuse (CSAT, 1995).

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH NIDA consolidated federal funding for services into grants to states rather than direct funding for service providers, and the states were encouraged to develop treatment systems (Besteman, 1992; IOM, 1990b). New federal awards required a transition of support to state funding and stimulated increased state appropriations for the treatment of drug abuse (Besteman, 1992). Federal funding and oversight declined throughout the 1970s, and NIDA increasingly emphasized biomedical research (IOM, 1990b). Federal funding and oversight for the treatment of alcoholism, drug abuse, and mental illness declined most dramatically in 1981 when the Omnibus Budget Reconciliation Act (P.L. 97-35) combined funds from direct project grants and state formula grants into the Alcohol, Drug Abuse, and Mental Health Services Block Grant (Lewis, 1988; McCarty, 1995). Total funding was reduced 26 percent, but reporting requirements that were perceived as burdensome to the states were eliminated (IOM, 1990a; GAO, 1995). Treatment advocates perceived the reduction of federal support for the treatment and prevention of alcoholism, drug abuse, and mental illness as a major retreat, and the administrator of ADAMHA stated publicly that the federal government was unlikely to resume its role in the treatment of alcohol and drug abuse (Lewis, 1982). In a period of less than 20 years (1964 through 1981), alcohol and drug abuse treatment services incubated in NIMH and community-based mental health centers. After brief developmental periods in separate federal institutes, they were transitioned to states to grow into treatment systems that reflected the unique needs and personalities of the states, and these services varied substantially among the states. Three separate treatment systems evolved with federal support and incentives, because (1) alcoholism and drug abuse treatment were not integrated with medical or psychiatric care, (2) drug abuse and crime policies frequently overlapped, and (3) there was strong advocacy for autonomy in the alcoholism treatment field. Ultimately, the funding reductions associated with the implementation of the Alcohol, Drug Abuse, and Mental Health Services Block Grant may have facilitated integration of alcoholism and drug abuse treatment systems in many states. The cutbacks required program consolidations and, even if it was not immediate, created pressures that weakened many services and encouraged the eventual combination of treatment systems. At the same time, the men and women seeking treatment were increasingly likely to report abuse of both alcohol and other drugs. Block grant requirements emphasized an increased capacity for the treatment of drug abuse and priority access to treatment for pregnant women abusing drugs and injection drug users (GAO, 1995). In many states, the best source of additional capacity was a strong alcoholism treatment system. Consequently, during the 1980s, state authorities for alcoholism and drug abuse were combined, and treatment services for alcoholism and drug abuse began to be fully integrated.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Criminal Justice System Background As just described, a unique relationship has developed between the criminal justice system and the public addiction treatment system. During the 1960s and 1970s the numbers of crimes related to illegal drug use increased dramatically. The drug of abuse of most concern to politicians and policymakers was heroin, which had been shown to be related to highly recidivistic criminal behavior, particularly income-generating property crimes. Thus, programs were born to interrupt the drug-crime cycle. During the 1980s the drug of abuse among offenders shifted from heroin to cocaine, and by the late 1980s crack cocaine had become a major concern. Research such as the National Institute of Justice's Drug Use Forecasting (DUF) project, begun in the 1980s, showed alarmingly high rates of substance abuse among offenders nationwide (IOM, 1990b, 1996). With the simultaneous increase in the human immunodeficiency virus infection rate among intravenous drug abusers, efforts to direct treatment resources to the criminal justice population intensified. At the same time, criminal penalties related to drug abuse increased nationwide, mandatory minimum prison sentences were imposed and increased for drug-related crimes, and many drug misdemeanors were upgraded to felonies (IOM 1990b, 1996). By the end of the decade, the criminal justice system was flooded with substance-abusing offenders. Another factor that has added to the pressure on the treatment system is the increasing interest of public policymakers in addressing the toll of drunk driving on society. This has led to the development of specialized intervention and referral programs that mandate drivers convicted for driving under the influence to involuntarily participate in treatment programs. Jurisdictions vary in the degree to which courts use referrals for evaluation and treatment and in the use of treatment as a sentencing option (IOM, 1990a). Extent of the Problem The National Institute of Justice's DUF report on adult and juvenile arrestees provides drug use information for those arrested or detained for committing crimes. DUF data indicate that nationally in 1994, 69 percent of males and 72 percent of females tested positive for an illicit drug at the time of arrest (NIJ, 1995). These rates are significantly higher than the current use data reported in the National Household Survey on Drug Abuse, which report 7.9 percent for males and 4.3 percent for females (SAMHSA, 1996). The Center for Substance Abuse and Treatment (CSAT) has also provided funding for technical assistance to individual states for studies of drug use by their incarcerated populations. Recent studies conducted by the Criminal Justice Policy

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Council, State of Texas, and the Illinois Department of Alcoholism and Substance Abuse and Illinois Department of Corrections have found similar high rates of illicit drug use among inmates entering state correctional systems. In Texas, 34.7 percent of male inmates and 43.8 percent of female inmates reported that they had used illicit substances in the month before being incarcerated. In Illinois, 65.6 percent of male inmates and 62.4 percent of female inmates indicated that they had used illicit drugs in the month before being incarcerated. Treatment The Bureau of Justice Statistics has reported that inmates sentenced for drug offenses accounted for 54 percent of the federal prison population in 1990 and over 20 percent of the total state prison population in 1991 (BJS, 1992). Treatment programs based in prisons are most often therapeutic communities, which operate in varying degrees of separation from the general prison population, and 12-step approaches are also found (IOM, 1996). Because of the numbers of persons addicted to drugs who are arrested for drug-related crimes, the public sector has developed a variety of treatment programs designed to serve addicted nonviolent offenders. These programs may be operated as pretrial drug courts, the programs may be alternatives to incarceration, or they may be treatment programs operated within correctional institutions. Funding for some of these programs is available through the Substance Abuse Prevention and Treatment Block Grant, and for others through CSAT's discretionary funds. CSAT has also provided technical assistance to support the development of state correctional treatment plans. The goal of these programs, in addition to the treatment of addiction, is to remove a substantial number of people from jails and prisons to relieve overcrowding, although an unintended consequence is to increase the pressure on community-based programs. Most of the treatment of drug-involved offenders takes place in community-based settings as an alternative to incarceration or as a condition of parole or probation (IOM, 1996). The best-known example is Treatment Alternatives for Special Clients (formerly known as Treatment Alternatives to Street Crimes), which is found in more than 25 states. In general, programs that link treatment to parole and probation produce favorable results (Chavaria, 1992; IOM, 1996; Van Stelle et al., 1994). Researchers have found that drug treatment is less expensive than the alternatives, including incarceration, probation, and drug control strategies and costs less than the costs of crime and lost productivity associated with untreated addiction (Gerstein et al., 1994; IOM, 1996). A RAND Corporation study analyzed the costs required to achieve a 1 percent reduction in cocaine usage by comparing treatment (demand control) with three strategies for controlling the supply: domestic enforcement, interdiction, and source country control. At a cost of $34

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH million, treatment was the least expensive, with the costs of the other strategies ranging from $250 million to $800 million (Rydell and Everingham, 1994). Implications for Managed Care The result of criminal justice system involvement with treatment for addictions is that a number of people are mandated to attend treatment programs for a specified amount of time. These models are consistent with a sentencing rather than a medical or a clinical necessity approach. This situation places requirements on programs to serve clients for a minimum period of time, which is often unrelated to the client's medical need or clinical progress. Nonetheless, the requirement exists, and compliance is necessary for the offender to complete his or her obligation to the court. Consistent with national trends, some health care in prisons is provided under contract with independent managed care organizations. Although specialty behavioral health companies are not yet contracting with prisons, the committee believes that it should be possible to provide appropriate substance abuse treatment within the criminal justice framework. Planning should involve the criminal justice and the addiction treatment experts and must address the lack of fit of the managed care principles with the current structure of the criminal justic system. Employee Assistance Programs The field of employee assistance programming began in the mid-1930s, coinciding with the founding of AA. Major corporations such as the New England Telephone Company, Western Electric Company, E. I. DuPont de Nemours & Company, Eastman Kodak Company, and Illinois Bell Telephone Company recognized the negative impact that alcoholism had on employee productivity (Presnall, 1981). These companies chose to develop programs that encouraged the use of AA, which was at that time referred to as occupational alcoholism programming or occupational programming. In the beginning of the field of employee assistance programming, the primary focus was on dealing with the employed alcoholic; however, employers such as Caterpillar Tractor Company and DuPont also addressed mental health problems (Presnall, 1981). Several events over the next 20 years began to establish a foundation for the field. The Yale (later Rutgers) Center for Alcohol Studies was founded in 1942, and in the 1950s, along with the National Council on Alcoholism, collected and disseminated information on effective programs in different companies (IOM, 1990a). The passage of the Hughes Act in 1970 created the single most important influence on the growth of the field of employee assistance programming. The Hughes Act established NIAAA, which included the Occupational Programs Branch. In 1972,

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH the Occupational Programs Branch provided funding for each state in the country to hire two professionals known as occupational program consultants. The occupational program consultants received extensive training and were charged with influencing the growth of employee assistance programs (EAPs) within the states that they represented. As a result, hundreds of EAPs were formed, typically with public agencies providing services to employers. The first professional association for those working within the field was founded during this period of growth. The Association of Labor-Management Administrators and Consultants on Alcoholism later became the Employee Assistance Professionals Association (EAPA), as it is known today (EAPA, 1996). The 1980s brought about the evolution of the private-sector side of the EAP field. Individuals who had been trained in the public sector began moving to the private sector and established private companies to serve employers. The number of employers contracting for EAP services grew at a rapid pace during this decade as employers realized that they had to deal effectively with mental health and substance abuse problems to be competitive in the marketplace. During the 1980s, EAPA led an effort to establish the principal credential for professionals within the field, called the certified employee assistance professional. By 1996, the number of certified employee assistance professionals had grown to more than 4,000 (EAPA, 1996). In the 1990s, the EAP field experienced the same kinds of transitions as other sectors in the health care industry. The public-sector EAP effort began to diminish as public funding decreased, and employers began to debate whether to have internal programs or to contract those services out to external vendors. The acquisition of local and regional companies offering EAPs began to take place as delivery systems began consolidating. Employers began to ask for “integrated services,” referring to the linkage of EAPs with managed care services. This integration creates system efficiencies and avoids the potential for overlap of services. Employers also began seeking the consultation of employee assistance professionals on a multitude of issues such as stress, violence, change, child and elder care, disability management, regulatory compliance, financial and legal matters, and critical incidents (EAPA, 1996). For more than 60 years, the EAP field has grown from a simple approach of assisting major employers in dealing with their employees with alcohol problems to a sophisticated approach of servicing the employer as a consultant in the workplace on a wide array of behavioral issues. EAPs maintain a set of core technologies, and on this foundation, it has become recognized as a critical component in the effective management of difficulties of employees and reducing the impact of these problems on workplace productivity. SUMMARY: SYSTEM INTEGRATION Currently, state and federal budget reductions are again creating pressures

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH and incentives to integrate services. By now, many states have initiated integration of the state authorities for mental health and substance abuse. Although state agency integration is primarily an issue of merging staff and reducing duplication, in most states, the mental health and substance abuse treatment systems are still distinct and separate. Thus, differences in patient populations, organizational cultures, programmatic philosophies, and funding mechanisms will continue to inhibit full integration for some time. We are in the process of moving ultimately toward integrated delivery systems. We have a long way to go to get there. It may take seven to ten years for that to occur. Robert Valdez Deputy Assistant Secretary for Health, Department of Health and Human Services Public Workshop, April 18, 1996, Washington, DC The IOM (1996) report on the future of primary care has called for the development of models of coordinated, integrated care, including better integration among mental health and primary health care professionals. Studies of existing models would help to identify the best practices in the coordination of all care, particularly primary and behavioral health care. Carved-out behavioral health services do not necessarily lead to poor coordination of care or to coordination poorer than that in a fee-for-service system. However, the separation of primary care and behavioral health care systems brings risks to coordination and integration that may not be in the best interest of patients and consumers. REFERENCES Aaron P, Musto D. 1981. Temperance and prohibition in America: A historical overview. In: Moore MH, Gerstein DR, eds. Alcohol and Public Policy: Beyond the Shadow of Prohibition. Washington, DC: National Academy Press. AHCPR (Agency for Health Care Policy and Research). 1993. Depression in Primary Care. Publication No. 93-0551. Rockville, MD: Agency for Health Care Policy and Research. AHCPR. 1995. PORT and PORT-II Abstracts. AHCPR Publication No. 95-0070. Rockville, MD: Agency for Health Care Policy and Research. AMBHA (American Managed Behavioral Healthcare Association) and NASMHPD (National Association of State Mental Health Program Directors) . 1995. Public mental health systems, Medicaid re-structuring, and managed behavioral healthcare. Behavioral Healthcare Tomorrow September/October:63-69. Anderson J, Williams S, McGee R, Silva P. 1987. DSM-III disorders in preadolescent children. Archives of General Psychiatry 44:69-76. Baumohl J. 1986. On asylums, homes, and moral treatment: The case of the San Francisco Home for the Care of the Inebriate, 1859-1870. Contemporary Drug Problems 13:395-445.

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