Benefit determination under managed care for substance abuse treatment clients.

The purposes of this study were to examine the process of benefit determination, approval, and variation among Substance Abuse Treatment (SAT) clients. A convenience sample of 20 SAT clients admitted to 1 of 2 treatment programs within Matrix Center were followed. Clients of clinicians who agreed to participate were given an invitation letter to hear more about the study. After informed consent, clients granted 3 interviews and gave permission for the researcher to examine client records to ascertain the benefit determination process. Referral sources were the clients' insurances, their MDs, a counselor, hospital, Employee Assistance Program, case manager, and another treatment program. Ten of the insurances were PPOs, 9 were HMOs, and 1 was a contract. All but 2 had benefits managed by a behavioral care organization (MBCO). Case managers of the MBCOs were all clinicians, most frequently ACSWs. All programs authorized outpatient care and the first approval authorized from 6 to 52 visits. From 1 to 5 different authorizations were used for each client. The co-pay ranged from $0 to $35 per visit. This study illustrates the details of how benefits for substance abuse treatment under managed care are negotiated and used.

The CSAT methamphetamine treatment program: research design accommodations for "real world" application.

The Methamphetamine Treatment Program (MTP), funded by the Center for Substance Abuse Treatment, has the objectives of implementing the Matrix outpatient model and evaluating that model in comparison to the existing community "treatments as usual." Seven organizations in three western states (California, Montana, and Hawaii) were selected to participate in this randomized, controlled, multisite project in what constitutes the largest trial to date of treatment for methamphetamine (MA) dependence. One hundred fifty MA-dependent patients recruited at each site are randomly assigned to receive either the Matrix model, a manualized program of intensive outpatient treatment, or the site's standard treatment, "treatment as usual." Participants are evaluated at admission, weekly during treatment, at the time of scheduled discharge, and at six and 12 months after admission. Dependent measures assess changes in drug use, HIV risk behaviors, quality of life, and patient satisfaction. Cost analyses to quantify treatment costs and determine the association between costs and clinical outcomes will be conducted. A number of adjustments in the original study design have been necessitated by the realities of community sites' strengths and limitations. Experiences from this multisite project will also provide a model for other efforts to transfer research-based treatments into community settings. This article describes the main aims of the project, the background and rationale for the study design, a brief description of the research plan, and methods implemented to protect the integrity of the science.

Moving research into community settings in the CSAT methamphetamine treatment project: the coordinating center perspective.

The CSAT Methamphetamine Treatment Project (MTP) has been established to conduct a ground-breaking exercise in bringing research into a closer relationship with community-based treatment service organizations. In this article, some of the opportunities and challenges faced by the MTP coordinating center as it has attempted to bring research into community treatment organizations are described. Initially, there has been an active, energetic effort to design the study protocol, focus the activities of the project, and prioritize the tasks to be accomplished. The methods for training the research staff and monitoring the conduct of the research in the community sites are described. A number of observations have been made about the different "cultures and values" of the researchers and the seven clinical organizations where the project has been conducted. The myriad mistakes made and lessons learned about how to conduct a rigorous randomized clinical trial in community treatment organizations may be important for future research-treatment efforts. There has been a wealth of experience gained in the first year of this project that may be of use as efforts move forward to reduce the gap between research and practice.

Conducting trials in community settings: the provider perspective.

Providers and their treatment programs are the focus of efforts to translate research into practice. In the best of partnerships, they are more than the recipients of research efforts, because they are actively involved in developing and evaluating healthy links between practice and research . This article reports on experiences in a multisite methamphetamine treatment trial funded in October of 1998 by the Center for Substance Abuse Treatment. The goal of the trial is to generate knowledge about how a comprehensive treatment protocol developed by the Matrix Center in Los Angeles can be effectively transferred to the community drug treatment system. The Matrix model provides a three-times-per-week outpatient treatment experience that combines behavioral, educational, and 12-Step counseling techniques. When complete, the study will compare outcomes of the 16-week Matrix program with the usual treatment offered by the programs at the eight participating sites. The UCLA Drug Abuse Research Center and the Matrix Institute on Addictions coordinate the trial. This article describes factors that have fostered or hindered the development of this partnership. These factors can be divided into three temporal phases, although the circumstances presented may occur at any time during the research process. The first set of factors affecting the development of a healthy research-to-practice relationship exists prior to the establishment of that relationship. A second set of circumstances occurs at the initiation of the collaborative enterprise, and the third set of factors is more involved in the development and maintenance of ongoing productive collaboration between researchers and providers.

Treatment-as-usual in the methamphetamine treatment project.

The Methamphetamine Treatment Project is a multisite trial that compares the effectiveness of eight models of outpatient treatment for methamphetamine dependence to that of the Matrix model. These eight "treatment-as-usual" models represent diverse approaches developed in a variety of settings to serve markedly different populations. The theoretical foundations of these treatments are described as well as the settings in which they are delivered. To facilitate comparisons, details are presented with respect to frequency of group and individual sessions, duration of treatment, therapist qualifications, and access to ancillary services. The populations served by these programs vary with respect to race and ethnicity. Most programs serve primarily non-Hispanic Caucasians, but some programs serve significant proportions of Hispanics, Asians, Pacific Islanders, and Native Americans. Usual route of administration of methamphetamine also varies by site, with snorting, smoking, and injecting each reported as the most common route of administration at one or more sites. The Minnesota model and cognitive-behavioral approaches are most commonly used in these programs, although contingency management and psychodynamic approaches are also represented. The intensive phase of treatment ranges between four and 24 weeks; the number of hours per week of client contact varies between one and 13. This trial will provide the opportunity to test the effectiveness of a wide range of treatments currently in use in community settings.

The matrix model of outpatient stimulant abuse treatment: history and description.

The Matrix model was originally developed in response to the cocaine epidemic of the 1980s. The program consists of relapse prevention groups, education groups, social support groups, individual counseling, and urine and breath testing delivered in a structured manner over a 16-week period. The treatment is a directive, nonconfrontational approach which focuses on current issues and behavior change. Several evaluations of the model have supported its usefulness and efficacy with methamphetamine (MA) users. Methamphetamine users appear to respond to treatment similarly to cocaine users and many continue to show improvements at follow-up.

An intensive outpatient approach for cocaine abuse treatment. The Matrix model.

The Matrix model of outpatient treatment was developed during the 1980s in response to an overwhelming demand for cocaine abuse treatment services. The model was constructed using components based upon empirically supported findings from the substance abuse research field. Over the course of development, data were collected on the treatment model and the model was modified based upon empirical evaluation. A pilot study comparing the Matrix outpatient model with an inpatient hospital treatment program produced preliminary support for the clinical utility of the model. An open trial comparing publicly and privately funded patients demonstrated that patients with fewer resources were more difficult to engage and retain in this model of outpatient treatment. In a controlled trial, a clear positive relationship was documented between duration and amount of treatment involvement in the Matrix model and positive outcome at 1 year. Due to a variety of methodological issues, the study was not able to answer definitively the question of clinical efficacy. In all of these studies, patients treated with the Matrix model demonstrated statistically significant reductions in drug and alcohol use and improvements in psychological indicators. This body of work, along with the public acceptance the model has received in the treatment community, support the usefulness of this intensive outpatient approach for cocaine abuse. Further research is underway to provide additional controlled information on the value of this treatment approach.

Addiction treatment in the mid-1990s.

The rapid and dramatic changes now transforming the American healthcare system are also being felt in the addiction treatment field. How this change will be manifested in the structure, content and financing of substance abuse treatment over the next three to five years is described in the following article.