We recently presented to the State Associations of Addictions Services (SAAS) at their annual summit in Tucson where they had joined forces with NIATx (and by extension SAMHSA and NIDA) in the interest of exploring patient engagement strategies, the exchange of process improvement ideas, and understanding how healthcare reform and the Mental Health Parity and Addictions Equity Act (MHPAEA or “Parity”) can energize the field. Our presentations focused on Parity and strategic business modeling in an era of considerable change. Parity is a very new concept for most substance use disorder treatment providers. Similarly, “addiction equity” is a new concept for payers, managed care and otherwise. The question we visited most often over our three-days in Tucson was: “under Parity, will Residential be a covered level of care?”
Levels of Care and Types of Provider
Until the MHPAEA of 2008 Regulations are issued in October, we have to concede that nobody knows with any certainty what consumers, providers and payers can expect in terms of coverage for substance use disorders. The most vexing questions concern coverage for specific types of providers and the levels of care they offer. Historically, the private, commercial managed care sector has frowned upon residential treatment. While the public sector (SAMHSA in particular) has recognized the value of residential treatment and developed standards for care, funded best practice research, measured outcomes, and considers residential to be an integral component in the continuum of services, managed behavioral health organizations (MBHOs) and managed care organizations (MCOs) tend toward coverage for medical detox and outpatient counseling only – preferring to marginalize if not exclude residential levels of care including associated “step down” levels Partial and Intensive Outpatient Programs (IOP). The conventional thinking and mind-set is that “residential” is just what it sounds like – provision of a place of residence while someone receives other forms of care. Sadly, the treatment field has not done enough to advocate for itself and has largely ignored the need to properly educate policy-makers with respect to residential levels of care. Consequently, the mis-perception persists. Payers, in turn, have no reason (yet) to believe that residential levels of care are medically necessary. Poor and inconsistent measures of outcomes over the decades hasn’t helped either.
Enter ASAM
We hope that this particular coverage “knot” can be untied with the help of the American Society of Addiction Medicine (ASAM). If managed care organizations truly want to provide evidence-based and scientifically-validated medical necessity guidelines, then they should look no further than ASAM’s Patient Placement Criteria (PPC) for substance use disorders. Assuming the MHPAEA requires equitable treatment and the regulations include coverage of residential levels of care, ASAM’s PPC will become indispensable tools for all care managers. If the Federal regulators leave these questions to be answered by the States and – by extension – insurers and employers – then we hope each will look to ASAM for guidance. Including residential levels of care will not result in noticeable premium cost increases and is often part of a larger solution to the real problems associated with comorbidity.
The American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria (ASAM PPC-2R) is the most widely used and comprehensive national guidelines for placement, continued stay and discharge of patients with alcohol and other drug problems. The ASAM PPC-2R provides two sets of guidelines, one for adults and one for adolescents, and five broad levels of care for each group. The levels of care are: Level 0.5, Early Intervention; Level I, Outpatient Treatment; Level II, Intensive Outpatient/Partial Hospitalization ;Level III, Residential/Inpatient Treatment; and Level IV, Medically-Managed Intensive Inpatient Treatment. Within these broad levels of service is a range of specific levels of care.
“For each level of care, a brief overview of the services available for particular severities of addiction and related problems is presented; as is a structured description of the settings, staff and services, and admission criteria for the following six dimensions: acute intoxication/withdrawal potential; biomedical conditions and complications; emotional, behavioral or cognitive conditions and complications; readiness to change; relapse, continued use or continued problem potential; and recovery environment.”
“The diagnostic terminology used in the ASAM PPC-2R is consistent with the most recent language of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The “unbundling” of clinical services is addressed, recognizing that these services can be and often are provided separately from environmental supports. With unbundling, the type and intensity of treatment are based on the patient’s needs and not on limitations imposed by the treatment setting. Criteria are also included which attempt to match a patient’s severity of illness along Dimension 1 (Acute Intoxication and/or Withdrawal Potential) with five intensities of detoxification service.”
Providers and payers alike are encouraged to “get on the same page” when it comes to coverage of substance use disorders. ASAM’s PPC-2R enables that kind of coordination. We shouldn’t perpetuate the two systems of care we have in place presently (public and private) any longer and all care should be appropriate to the need of the individual consumer. When providers and payers align on medical necessity guidelines and levels of care, everybody wins – especially the consumer. It’s always less expensive to treat a substance abuse disorder in the right setting than it is to treat a directly-related medical condition (and the list is long) in the hospital. Let’s all keep it simple, cost-effective and geared towards the right outcomes.
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