Treatment Improvement Protocols (TIP) 13 |
As healthcare reform moves forward, adoption of uniform patient placement criteria (UPPC) on a national basis may help ensure consistent access to appropriate care for persons needing alcohol and other drug (AOD) abuse treatment. The statewide benefits of UPPC outlined in Chapter 4 are just as applicable on a national level. In addition, with national criteria in place, States' resources can be focused on implementation and oversight rather than on development. Using the national criteria as a base, States need only develop adaptations to reflect local special populations or resource configurations. The more comprehensive the national criteria, the less local adaptation will be necessary.
Currently, the major managed care providers cover enrollees in several States and use companywide criteria. Use of one set of criteria in all States will increase the likelihood that managed care providers will use UPPC.
This chapter discusses the process of developing support for the national implementation of UPPC and suggests strategies for implementation. Several immediate tasks are outlined that are necessary to overcome the barriers to acceptance of uniform criteria by the AOD abuse treatment system and stakeholder groups. Recommendations are presented for the formation of a national advisory panel to guide the consensus-building and implementation process and to play a continuing role in the refinement of UPPC. Suggestions about the panel's responsibilities and funding sources for the panel are discussed.
Those who are working to implement UPPC should have a thorough understanding of the role UPPC will play in research. Widespread use of UPPC will allow investigators to design and conduct the types of careful, narrowly focused studies that are needed in the AOD treatment field to demonstrate treatment effectiveness and cost effectiveness. The second section of this chapter describes areas of research that will be aided by adoption of UPPC.
An important step in developing UPPC is to establish consensus within the treatment community and among other stakeholders with regard to the strengths and weaknesses of existing criteria sets. A uniform set of criteria can then be developed based on the best features of established criteria—with short-term efforts focused on filling in gaps and creating missing elements, and long-term efforts focused on addressing new treatment modalities and populations.
However, no consensus currently exists about the patient placement criteria (PPC) now in use. As discussed in Chapter 3, several States have developed their own criteria sets, which they believe more adequately address the needs of patients in public-sector treatment systems. Private healthcare organizations have also created placement criteria based on their approaches to treatment and on the characteristics of the clients they serve.
Not only is there a lack of consensus about current patient placement criteria, but there also is a wide disparity in the level of knowledge about criteria among AOD abuse treatment providers. Many providers have developed hands-on knowledge by operating within a PPC framework and therefore understand the importance of uniform criteria in the current healthcare environment. Others in the field have not worked in such a framework or given much thought to UPPC as a common base for providing treatment. A primary goal of this Treatment Improvement Protocol (TIP) is to educate treatment providers about the use and current status of PPC.
Several immediate tasks must be addressed in order to develop consensus within the AOD treatment field—and among other stakeholders—on existing criteria, and to move toward the establishment of uniform criteria.
The most important task is to accumulate and analyze comprehensive data about the effectiveness of PPC in improving the quality of AOD treatment and in reducing the cost of treatment. Even the most comprehensive and carefully detailed criteria cannot gain wide acceptance among treatment providers, payers, and other stakeholders unless there is empirical evidence that implementing the criteria will accomplish expected goals. These goals include improved treatment and access to care, more efficient delivery of treatment, and cost savings. Validation through research is a crucial step in the process of establishing UPPC. However, carefully designed, large-group studies often take several years to complete. Other tasks must be addressed in the interim.
A second key task is to continue to familiarize treatment providers with patient placement criteria—how they are used and how they are related to the forces at work in the current healthcare environment. One strategy would be to develop and distribute an information packet about the advantages of adopting UPPC. An important point to be emphasized is that the creation of less expensive levels of care and more appropriate and effective placements achieved through the use of uniform criteria will result in improved treatment outcomes and significant cost savings.
Another strategy to promote understanding would be the dissemination of existing criteria and the use of forums to discuss their strengths and weaknesses. Treatment providers' concerns about the implementation of new criteria could be openly addressed. An important point to be emphasized during this effort is that the criteria should reflect the knowledge and experience of the entire treatment community and the many disciplines it comprises.
An immediate task at hand is to recognize that all systems resist change—even positive change—and that providers and other stakeholders will need help overcoming their resistance to using placement criteria. Each stakeholder group has its own reasons for wanting to maintain the status quo, and it is critical to understand and include these points of view in the consensus development process. A particular
discipline, a particular type of treatment organization, or providers in a particular geographic area may have valid questions that cannot be overlooked. Such questions may include: "These criteria may work for you, but do they apply to us?" "Do they recognize our unique organizational needs?" "If we accept them, what will it mean in terms of our ability to continue to provide good treatment or even to continue as a provider entity?"
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These and other questions that might be posed relate to the general applicability of the criteria. The heterogeneity of the AOD treatment population has been increasingly recognized. Particular subgroups of patients have specialized treatment needs, and developing a uniform set of criteria that takes into account a wide spectrum of needs is a unique challenge that must be addressed in the short term.
It is also important to ensure that the criteria are relatively easy to use and implement. User-friendly criteria are more likely to gain acceptance. In addition, the framework on which the criteria are based should not be unnecessarily complicated and should be based on current concepts of treatment. The criteria must lend themselves to the use of checklists, flowcharts, and quick-reference guides. Treatment providers will be unwilling to refer to lengthy documents or complicated lists of categories and subcategories.
The consensus development process should be as inclusive as possible of all stakeholder groups. A detailed discussion of stakeholders' interests is included in Chapter 4, but it is worth noting here that given the realities of today's healthcare environment, the education of payers and legislators must be considered an important part of the process. A uniform set of placement criteria can provide the structure for a high-quality continuum of care. However, if payers do not recognize their worth and refuse to pay for services, and if Congress and State governments do not create mechanisms by which the continuum can be established and maintained, efforts to develop uniform criteria will not achieve the desired results.
Chapters 4 and 5 include detailed discussions of the benefits of UPPC and of strategies to build statewide or systemwide support for adopting uniform criteria. The same strategic issues must be addressed at the national level to gain support for UPPC. This section highlights points in the earlier discussions of the benefits of UPPC and strategies for implementation. The concept of a national advisory panel is presented.
Because UPPC is a complex issue involving a large number of participants, several strategies will be necessary to gather support for implementation. Strategic planning should be viewed as part of a consensus-building process that includes substance abuse treatment in the overall plan for healthcare reform and that addresses the onset of managed care.
Stakeholders should understand that adopting uniform criteria may be necessary for survival in the rapidly changing healthcare field. Emphasizing the importance of UPPC in the context of economic survival will bring stakeholders to the table. They will be invested in succeeding with the systems that will be put in place. Adopting UPPC and using them for appropriate patient placement can be proposed as a positive, proactive alternative to a "wait and see" approach and will prevent the failure of programs and the denial of treatment for some patients.
An effective starting strategy might be the preliminary implementation of uniform criteria in a system that does not hold providers responsible for following through on the dictates of the criteria. In other words, some providers may be reluctant to become involved with a system that, in effect, requires them to place patients in programs that do not yet exist, or to which they have no access. Providers can first be asked to simply collect the aggregate data generated from using UPPC over a specific time period. The data can then be used as a means of demonstrating to policymakers that some patients are not receiving needed services. Using this approach, providers may wish to become involved, as UPPC then will not be perceived as an imposed mandate that is difficult or impossible to implement.
Another issue to be emphasized is the role of UPPC in bringing stability to the AOD treatment field. The idea of bringing consistency in treatment to a field that is perceived to be in turmoil can be particularly attractive to legislators who may have to defend their support of alcohol and other drug programs.
It is useful to demonstrate the increased financial support that can be generated from revenue savings and better use of resources. While implementation of a new process may at first seem to be a costly proposition, it can be demonstrated that these costs will ultimately be offset by savings.
Another strategy to gain support is for UPPC designers to align with national groups such as the American Society of Addiction Medicine, the American Psychiatric Association, the National Treatment Consortium, State medical associations, the American Nurses Association, the American Psychological Association, the National Association of Alcoholism and Drug Abuse Counselors, the National Association of Social Workers, counselor associations, and provider associations. Professional endorsement lends credibility to the process. Also, many members of these professional organizations work in programs and are treatment providers, so their support will spread to their peers in the field.
Until new UPPC are available, there is a need for a national clearinghouse that would give States or other organizations that are developing uniform criteria access to the available models. The Alcohol and Other Drug Authority in Iowa is currently performing this function for other State agencies. Such a clearinghouse on the national level could be placed with an organization that ultimately takes on the responsibility for developing the next generation of UPPC. The National Center for Addictions Treatment Criteria at Harvard Medical School may also be appropriate to fulfill this function.
A national advisory panel should be established that represents stakeholder groups. The panel would have several functions and the composition of its members might evolve over time. The functions of the advisory panel would include:
Initially, the main function of the panel should be to develop consensus about existing criteria. To facilitate the participation of all stakeholder groups, each SSA could be invited to form a workgroup representative of the stakeholders in that State. The workgroups would respond to draft criteria generated by the national advisory panel. The panel could then consider the feedback from the State groups and draft a revised set of criteria. This process could be repeated until reasonable consensus is reached. Extensive use of electronic mail and bulletin boards, as well as the use of teleconferences, could facilitate wide participation at minimal cost.
An important consideration for the panel will be the effectiveness of criteria currently in use as demonstrated by the available empirical data. Multidisciplinary representation on the panel throughout this process is crucial. The criteria will have more relevance if the panel represents the input of individuals with clinical expertise in a broad range of treatment modalities, as well as those with expert knowledge of the overall treatment system, including the realities of managed care, third-party reimbursement, Federal financing, and healthcare reform. Diversity among panel members will help ensure that the resulting set of criteria reflects best practices and achieves the goal of reducing costs.
In the current environment, sets of PPC are proliferating rapidly within treatment programs, managed care organizations, and, in some cases, within individual SSAs. This can be confusing to treatment providers and consumers, can create friction between providers and funders, and can contribute to reduced credibility among professionals and policymakers outside the AOD abuse treatment field.
Ideally, before UPPC are implemented, field trials and other research would be undertaken to test the validity and reliability of the criteria. Based on the empirical evidence, the criteria would then be refined and prepared for implementation on a larger scale. However, the need for UPPC supported by broad consensus is immediate.
Therefore, the development of UPPC must include implementation and evaluation planning. It is recommended that the national advisory panel be responsible for the evaluation plan. It should include studies to assess the validity of the criteria with different populations and the reliability of the criteria when they are applied by various providers in a range of settings.
The next generation of UPPC must be based on all the available empirical information, and care must be given to update the criteria as research, feedback from patients and providers, and new developments in treatment become available.
Training in the use of UPPC will be essential, and the national advisory panel should coordinate the development of a uniform training package that highlights key concepts in every training session. This training should include:
If clinicians understand the purpose of UPPC and its core elements they can apply the information more effectively.
The panel will require professional and support staff supplied by a permanent organization. Reliable funding is essential. Creating a broad base of support and developing consensus requires funding from a source that shares the goals of stakeholder groups.
Because the task of reviewing criteria and making recommendations about their acceptance would be the panel's chief function, agencies that fund research bearing upon the criteria should not be involved in funding. A longer-term process similar to the one used to develop TIPs—making use of multidisciplinary consensus panels—may be used to develop the next generation of UPPC.
Such a process would ensure the involvement of many stakeholders and grant legitimacy to the resulting criteria. It would differ from the TIP process in that it would involve a series of meetings, allowing participants to reflect, gather resources, and consult with other interested parties. As will be shown in the discussion to follow, developing the next generation of uniform criteria to structure the treatment field and ensure the involvement of payers and legislators may be a discrete, time-limited step in efforts to improve the efficiency of AOD treatment. Hence, such funding may be relatively short term. Obtaining funding for a limited period and to meet certain agreed-upon goals may be easier than seeking funds for an ongoing, indefinite process.
A public and private partnership involving funds from the Federal agency or agencies and from other stakeholder groups is a possible alternative.
The funding agency or groups could nominate individuals from the stakeholder groups to serve on the panel. It is important to include consumers since they are the ultimate assessors of the quality of services. Once initial criteria are in place, the panel would meet periodically and researchers who were conducting studies related to the criteria would present their findings for review. In determining how often an advisory panel should meet, consideration should be given to the fact that careful empirical studies are long term and that sufficient new data might not be available to justify meeting more than once or twice a year.
A report of the proceedings from the panel's review would perform the important function of disseminating the panel's recommendations about changes in the criteria and about the need for further research. As envisioned here, the panel would not have the power to force service providers and other stakeholder groups to adopt the criteria or adhere to recommended changes in the existing criteria. However, the authority of the panel would strengthen and support efforts at the State level to implement the panel's recommendations.
With the advisory panel in place, the evaluation of future technology and progress in treatment methods would continue. For the criteria to remain viable, the multidisciplinary approach must be ensured by continued representation of many groups on the panel. Participation by consumers, patient advocates, and an ethicist will add validity and acceptability to the evaluation of new concepts, tools, and technology.
Another important area that must be considered is the need to keep the criteria flexible and amendable. There are dangers in structuring treatment of any kind according to a defined set of criteria. Treatment must remain flexible to meet patients' individual needs and incorporate evolving modalities of care. Clinicians must remain able to exercise judgment in all cases. In addition, if a single approach to care is widely adopted and strictly adhered to as the "correct" approach, treatment innovation may be stifled. The chief value of any criteria set is the added power it gives providers to identify specific patient needs by means of a consistent and detailed assessment process, and to choose a level of care that will specifically address those needs.
Future criteria must be flexible and amendable. Clinicians must remain able to exercise judgment in all cases.
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To focus on the criteria themselves and forget their goal—placing patients in appropriate levels of care —is to value the rules above the process and to make rigid what should best remain an open and flexible approach to the complex biopsychosocial problem of AOD abuse and dependence. The principles of the criteria will outlast any single criteria set.
It may be beneficial to regard the implementation of uniform criteria as a major step toward a broader goal of unbundling services to meet individual patient needs. As developments in assessment and treatment technology—guided by future research—open up improved treatment options, the current emphasis on uniform criteria as central to the model of care may lose its urgency. Once the criteria are incorporated into the structure of the treatment system, and patient needs drive the treatment process, the need for criteria (or for central elements of the criteria, such as specific directives about levels of care) may diminish or even disappear.
No matter how comprehensive a uniform set of placement criteria is, individual providers will modify the criteria to fit the needs of the specific patients and populations they serve. Aspects of the criteria that are important in one area with one group of patients may have little relevance to other patient groups. Future developers and implementers of criteria should recognize that the needs of the patients will determine whether elements of the criteria remain viable. Careful research on treatment outcomes should reflect the realities of patient needs and ensure that criteria will evolve to meet changing demands. As in any area of medical treatment, protocols necessarily evolve over time as the understanding of complex conditions increases.
The importance of continued research in the AOD abuse treatment field cannot be overemphasized. One result of nationwide healthcare reform efforts has been to reveal that many people outside the treatment field have little awareness of the efficacy of treatment and are reluctant to include coverage for treatment in a standard benefits package. AOD professionals at all levels have a responsibility to change this perception. Careful research that generates solid data showing the benefits of treatment is the most powerful way to change this perception.
As this TIP was being prepared for publication, results of an important long-term study on the effectiveness of AOD abuse treatment were published (California Department of Alcohol and Drug Programs, 1994). The two-year CALDATA study followed a rigorous probability sample of the nearly 150,000 persons who received AOD abuse treatment in California in 1992. The sample included patients in a spectrum of treatment modalities. The cost of treating the approximately 150,000 participants in 1992 was $209 million, while the benefits received during treatment and in the first year afterwards were worth approximately $1.5 billion.
Thus, for every dollar spent on treatment, $7 in future costs were saved. These savings were largely in relation to reductions in criminal activity and in the number of hospitalizations for health problems. For a smaller sample followed through the second year, results have indicated that projected cumulative lifetime benefits of treatment will be substantially higher than the shorter-term benefits.
The study found that, from before treatment to one year after treatment, criminal activity declined by two-thirds and hospitalizations by one-third. Declines of about two-fifths also occurred in the use of alcohol and other drugs from before to after treatment. Treatment for major stimulant drugs (crack cocaine, powdered cocaine, and methamphetamine), which were all in widespread use, was found to be just as effective as treatment for alcohol problems, and somewhat more effective than treatment for heroin problems. No differences in treatment effectiveness were found by gender, age, or ethnic group.
In 1990, an Institute of Medicine report on treating alcohol abuse asked the question, "Which kinds of individuals, with what kinds of alcohol problems, are likely to respond to what kinds of treatments by achieving what kinds of goals when delivered by which kinds of practitioners?" (Institute of Medicine, 1990). Future research must investigate questions at this level of detail, taking into account in systematic ways the myriad variables that contribute to treatment success.
Important work is already being done to address these needs. For example, one ongoing naturalistic outcome study found that approximately 90 percent of people whose AOD treatment continued in some form over the course of 1 year remained abstinent for that year (Hoffmann and Miller, 1992). This finding provides strong support for the concept of providing treatment of sufficient intensity and duration, which is a central principle underlying the concept of UPPC. A study of relapse of AOD patients found that those who returned to treatment over a 2-year period had a greater number of diagnoses at first admission than patients who did not return to treatment over that time frame. (Renz et al., in preparation).
McLellan and others have conducted small-scale studies showing that matching patients to programs or services that best meet their needs will improve treatment outcomes. (McLellan et al., 1983; 1993). McLellan and Alterman (1991) have stressed the need for much larger efforts involving diverse populations and services to attain the goals of improving treatment outcomes and determining cost effectiveness.
The National Institute on Drug Abuse has provided a grant to the National Center for Addictions Treatment Criteria at Harvard Medical School to study placement criteria. Information gained through the funded studies will aid in the development of the next generation of criteria. Experience gained in conducting the studies will also provide guidance to the development of an evaluation plan for UPPC.
Matching patients to treatment based on their needs, with the flexibility to adjust services for individuals, has long been an important goal of the AOD abuse treatment system. The widespread acceptance of UPPC will bring the field much closer to achieving this goal. Having UPPC in place will work to ensure that treatment continues to be driven by patient needs rather than solely by fiscal considerations, ideology, or other factors imposed from outside the treatment system.
One of the most important aspects of uniform criteria is the consistency that their application can bring to the AOD assessment and treatment process. A viable set of uniform criteria will describe all the areas to examine in a comprehensive biopsychosocial assessment of patients at all entry points to the treatment system. The criteria should also describe specific levels of care, treatment modalities, and components that will effectively address patients' needs uncovered in the assessment. The criteria must address a wide spectrum of needs—from acute care needs, such as the need for detoxification, to needs for support services, such as childcare and transportation, which often make the difference in successful access to treatment.
In effect, the criteria and the structure they provide to the placement and treatment process create the possibility for establishing several ongoing feedback loops, allowing researchers to ask precise questions and design appropriate studies. Careful research at every stage is essential to the interaction among UPPC and assessment, treatment, and outcome. Figure 6-1 illustrates this interactive process and provides a way of visualizing the role of research at various points in the process. As discussed below, most research will focus on the effectiveness of treatment based on UPPC—that is, the focus will be on the "Treatment Outcomes" box in Figure 6-1. However, there are several other areas where careful research can improve treatment and cost effectiveness.
For example, researchers may choose to focus on evaluating the first step in the process, which is the relationship between UPPC and the biopsychosocial assessment. Research at this point might examine the extent to which patient assessments in a large agency or several agencies actually gather the assessment data specified in the criteria. Differences in placement between subgroups of patients may lead to further research about new areas to assess, which may in turn lead to suggestions for improving the assessment process. In some agencies, research at this level might reveal that certain dimensions of need are not being assessed because no services exist to address those needs. As discussed below, important data about patient populations may be lost if assessments are not conducted according to the criteria.
Research at the next point in the process—that is, research focusing on the "Patient Matching/Treatment Placement" box in Figure 6-1 —will provide invaluable data for needs assessment and resource management within agencies and across systems. Even though many AOD treatment agencies and systems will conduct thorough biopsychosocial assessments, they may not have the ability to place patients in levels of care or provide services specified by the criteria because of a lack of resources or other factors. Researchers can capture aggregate data that will show, for example, that a large subgroup of patients with specific needs is not receiving appropriate care. Resources may then be directed to developing these services. Systems can be creatively linked to pool scarce resources, such as medical care, childcare, and transportation services.
One way that UPPC will greatly improve the quality of treatment outcomes research is by improving the capability to describe research samples. (Another TIP currently in development in this series is Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment.) In effect, structuring the AOD assessment based on UPPC will result in categorizing patients according to illness severity and a wide spectrum of needs.
Figure 6-1 Interaction Between UPPC and Assessment, Treatment, and Outcomes
Researchers will be able to focus on and compare specific samples and subsamples of patients with a similar severity of illness and with specific needs profiles. It is universally agreed that making comparisons between more carefully described samples leads to more valid results.
For example, a group of patients with a particular needs profile, such as single adolescent mothers with a defined severity of illness and specific assessed needs for certain social supports, will be assigned to a particular level of care with a core set of treatment modalities. Researchers can then evaluate differences in their treatment outcomes, which may identify other factors that need to be addressed. For example, it may be found that differences in interpersonal functioning may greatly affect outcome. One subgroup of adolescent mothers with significant deficits in interpersonal skills may have notably poorer treatment outcomes (as measured, for example, by a greater number of or more severe relapses) than a comparable subgroup with good interpersonal skills. AOD treatment services that address these deficits may be found to improve treatment outcomes as well as cost effectiveness of services (as measured by fewer inpatient episodes or reduced need for costly have found themselves withintensive services).
These research findings can be fed back into the process of reviewing criteria (dotted lines in Figure 6-1). New research may address the question of interpersonal functioning and its importance in the initial biopsychosocial assessment. Research may subsequently lead to the specific inclusion of this dimension in the UPPC. Many programs and providers will not have to wait for the published results of empirical research to perceive that certain placements and services for certain subgroups of patients are not as effective as expected, and they will develop new services to meet those needs.
The role of UPPC in quality improvement and program accountability is clear. The advantages that the criteria give to researchers, they give also to programs and systems. This results in more effective outcome monitoring and program and service evaluation. In effect, implementation of UPPC can help establish the self-correcting system that is the foundation for total quality management (TQM) (Walton, 1990). TQM is a focused management philosophy for providing the leadership, training, and motivation to continuously improve an organization's operations. For a more detailed description of TQM in an AOD treatment setting, see the TIP in this series, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse.
At the time of this TIP's development, legislators and policymakers were engaged in the process of reforming the healthcare delivery system. The goals of uniform patient placement criteria and those of healthcare reform are the same: improved quality of care, greater access to care, and reduced costs. Both healthcare reform and UPPC place a major emphasis on outcome evaluation. It is essential that both groups—those working toward reform and those working toward consensus building around UPPC—recognize that their goals are shared, or they will be working at cross-purposes.
The benefits sets proposed as a part of healthcare reform have included standard limits on AOD treatment. These limits are specified as a fixed number of days or hours of service or number of treatment admissions over a given period of time. UPPC could lay the groundwork for legislators to address AOD treatment in the same manner as other health problems, rather than impose arbitrary cost or time limitations.
A national benefits package for AOD treatment that does not recognize the provisions for levels of care and treatment components laid out in the criteria will render the criteria useless. It is important that those who develop UPPC take into account the current realities of the healthcare environment. There is a need for close collaboration between UPPC and healthcare reform efforts. Criteria should help define the parameters of reimbursable services.
However, the reality is that these groups, which are united in principle, have had very little interaction. The proposed benefits packages that have included AOD treatment and that have been discussed in the national arena have not mentioned UPPC. Early versions of healthcare reform plans focused on service units and on limiting coverage according to units used. Defining care according to limited amounts is not within the spirit of UPPC—or even within the recognized realities of treatment outcomes. For example, in one study, a quarter of those who had successfully completed treatment (defined as 1 year of sobriety) had exceeded the limit on units of treatment, according to one of the healthcare reform proposals (NSI Congressional Briefing, 1994). Studies have shown that a minimum of 3 to 6 months of continuing care is critical to recovery (Hoffmann and Miller, 1992). A benefits package that limits care short of critical thresholds does not recognize the importance of a continuum of care and will not serve the needs of patients. Those who are currently involved in efforts to build consensus around UPPC have not created a strong enough constituency to have political consequence at the level that healthcare reform is now being addressed.
The advantage of using UPPC as unifying treatment structure is that the criteria can work within any healthcare reform plan. For example, if research finds that 35 percent of those who require a certain level of care are not receiving it, then the data can be used to change funding mechanisms and make reform efforts more responsive to clinical realities.
If criteria are part of the reformed healthcare delivery system, they will work toward ensuring equal access to treatment. Based on the criteria, patients with similar needs will be placed in the same level of care and will receive similar services. They will work toward making some services available to most people—a significant step in ensuring equal access to care.
The rationing of treatment services is not widely discussed, but it does occur. Many discussions about the topic portray managed care organizations as the culprit because they sometimes do not authorize the level of care, frequency, or length of care that is requested. In fact, healthcare services are rationed in other ways that have similar effects on those needing AOD abuse treatment.
For example, in the AOD abuse treatment field, rationing occurs in the sense that those who have private insurance or financial resources to pay for their care generally experience fewer impediments to receiving treatment than those who are uninsured or underinsured. Those who have Federal Medical Assistance or Medicare traditionally have had access to care, although primarily in the public system. Those lacking insurance or sufficient income have depended primarily on the public system to provide their AOD treatment services. Those with some income but without insurance (either because they have no policy or because the policy does not cover AOD treatment services) have found themselves with little access to care in either the private or the public system. When the public system is overloaded, another kind of rationing occurs because the number of treatment slots does not meet the demand for treatment. In fact, most insurance of any description has limitations on the type of service, the number of visits, or the amount of payment it will provide for AOD abuse treatment.
Thus, rationing occurs among both managed care organizations and AOD treatment programs and providers. Public policy also plays a role when it establishes eligibility criteria for publicly funded programs and identifies target populations for service priority. While such decisions may be necessary because of the scarcity and lack of access to sufficient treatment resources for the affected populations, the end result is that care is rationed.
UPPC cannot solve the dilemmas posed by these circumstances. However, when UPPC are linked with healthcare reform, with the overall needs of individual clients, and with responsive public policy, they have the potential to provide a reasonable basis for decisionmaking about the placement and range of AOD treatment services necessary for an individual.
UPPC will help to shape the direction of the AOD treatment field on a national level. Therefore, it is important to reach reasonable consensus within the field on the strengths and weaknesses of existing criteria sets in order to move forward. More empirical evidence is needed to demonstrate that uniform criteria can accomplish expected goals. The panel recommends the formation of a national advisory panel while research is continuing. The panel could guide the consensus-building and implementation process and play a continuing role in the refinement of UPPC.
The use of UPPC will greatly increase the ability of investigators to design and carry out the types of careful studies that are needed to demonstrate the effectiveness of AOD abuse treatment.