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Identifying Best Practices among Managed Care Plans that Provide Substance Abuse Treatment Services to Medicaid Recipients with Disabilities

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Project Summary:

The research objectives of this project were to: •Identify the special and unmet substance abuse treatment needs of individuals with disabilities, focusing on how these needs vary for different disability subgroups; and •Identify any innovations or “best practices” that have been developed by Medicaid managed care plans that enroll people with disabilities and are responsible for providing substance abuse treatment services. To meet these objectives, the researchers completed the following major tasks: •Reviewed data from three previous studies to identify states that provide substance abuse treatment services to Medicaid recipients with disabilities through managed care. The data source included the Lewin Group’s SAMHSA-funded study of behavioral health services within Medicaid managed care programs, a Medicaid managed care quality survey conducted jointly by the Harvard School of Public Health and the Health and Disability Working Group at the Boston University School of Public Health that included questions about substance abuse, managed care, and people with disabilities; and an Urban Institute publication that identified states with different types of Medicaid managed care models. •Conducted a complete review of the literature related to substance abuse and disability, with a particular emphasis on understanding the special need for substance abuse treatment among people with different types of disabilities, as required to meet the first project objective. •Developed a telephone survey instrument, which was used to guide interviews with key state agency representatives of targeted states. The purpose of these interviews was to learn more about specific issues they encountered in providing substance abuse treatment services to people with disabilities, and to identify any innovations among managed care plans in each state. •Developed a series of semi-structured interview protocols to guide site visits to seven managed care plans in four states that appeared to be the most innovative with respect to providing substance abuse treatment to persons with disabilities. In each state the researchers interviewed key informants including consumers, substance abuse treatment providers and representatives of the managed care plans. Results, Policy Implications and Policy Impact: •Despite literature that suggests high rates of substance abuse among people with disabilities, few states have focused their policymaking on this issue. Only nine states met our preliminary criteria for initial telephone surveys. These criteria included: 1) the state must enroll the SSI disabled population in managed care and 2) the state must offer a minimum of three of the following substance abuse treatment services through managed care: outpatient substance abuse counseling, detoxification, opiate treatment, and residential treatment. •Substance abuse is a major concern for people with disabilities, but state policymakers and managed care plans are frequently uncertain or unaware of the scope of the problem. •Behavioral health resources tend to be used more for mental health than substance abuse treatment, and more attention has been paid to the dual diagnosis of mental illness and substance abuse, than to that of any other disability combined with substance abuse. •Within Medicaid managed care, there are two primary models of substance abuse treatment for people with disabilities; receipt of care through large behavioral health carve-out programs that serve a large population of Medicaid recipients and smaller health plans or programs that were designed specifically for the SSI disabled population. While the larger carve outs increase overall access to services for a large number of individuals, those designed for the SSI Disabled population demonstrated more evidence of innovation. Smaller and more focused health plans demonstrated the greatest knowledge about the population, the most intensive individual relationships with enrollees, and the most innovative programs. •Among the managed care plans examined by this research, the most common innovations included home based care and exceptions to benefits to introduce flexibility into the benefit packages. •Most consumers were positive about their relationship with their care manager or a particular provider. Among the plans that were studied, consumers identified only a few issues that were problems for them. These included having fewer providers available to them than prior to the advent of managed care; Difficulty in changing providers; problems with service authorization and service limits; problems with transportation; concerns about the physical accessibility of substance abuse services for people who are deaf or hard of hearing. •Larger behavioral health carve-outs are more likely to focus on strategies that help facilitate achievement of population levels goals such as increased access to care and cost-efficiency. The carve out plans are more likely to offer specialized services only to people with co-occurring mental health and substance abuse problems. These plans introduce some measure of accountability into their systems such as provider standards that address the needs of the general population. However, with the exception of HIV/AIDS, these plans demonstrated less knowledge about or attention to disability-specific issues. This research has resulted in several important finding related to the importance of substance abuse treatment for people with disabilities. It has clarified that persons with disabilities often experience substance abuse problems. When individuals with disabilities need substance abuse treatment, their need for health care may become more expensive and complicated. The state Medicaid program often absorbs these costs. However, when the researchers contacted both states and managed care plans to talk about substance abuse treatment services for persons with disabilities, many of the key contacts knew relatively little about these needs, or they thought the researchers were only talking about persons who use wheelchairs. Alternatively, when the researchers explained that they were thinking more broadly and focusing on substance abuse services for people with all types of disabilities, respondents typically focused on persons with serious mental illness. The researchers hope that the results of this project will help key policymakers and managed care plans think more broadly about disability and substance abuse treatment needs, recognizing both the range of conditions that affect people with disabilities as well as how important substance abuse treatment is for persons with disabilities.

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