Access to services in the substance abuse treatment system. Variations by facility characteristics.

In view of the importance of type and intensity of services during substance abuse treatment, this chapter looks at treatment and support services that substance abuse clients have access to during treatment. Trends in services over recent years are described. Services available to clients in the current treatment system are reviewed. Several facility characteristics affecting access to services are examined. Different ways of defining access to services are discussed. Findings from the Alcohol and Drug Services Study are used to illustrate service patterns in the national substance abuse treatment system. Variations in service patterns by facility characteristics such as type of care, treatment setting, ownership, percent of facility dependence on public revenue, and level of affiliation are analyzed. The implication is that clients who enter into treatment at different types of facilities are likely to have access to certain types of services.

Organizational and financial issues in the delivery of substance abuse treatment services.

Examination of organizational and financial characteristics of the specialty substance abuse treatment system allows an understanding of how to meet the needs of clients in the system. Further, this assessment may afford insights into how the specialty sector may adapt in the changing environment of managed care. Data from Phase I of the Alcohol and Drug Services Study (ADSS) describe the specialty substance abuse treatment system in terms of type of care, setting, level of affiliation, licensure/accreditation, ownership, revenue sources, client referral sources, client's primary substance of abuse, and managed care. Although the system is largely outpatient and remains substantially two tiered in terms of public/private funding mix, it varies along a number of organizational and financial dimensions which have implications for system structure and facility viability in the changing environment of substance abuse treatment service delivery.

Effects of a statewide carve out on spending and access to substance abuse treatment in Massachusetts, 1992 to 1996.

OBJECTIVE: We studied the first four years of the statewide carve out for Medicaid enrollees in Massachusetts to assess its effect on access and spending. DATA SOURCES/STUDY DESIGN: Using administrative data, we compared the state's fiscal years 1992 (the last year before the carve out) through 1996 (the final year of the state's first carve-out vendor, MHMA). We evaluated the effect on spending by converting expenditures to constant (1996) prices using the medical services component of the Consumer Price Index for Boston and standardizing directly for the changing proportion of Medicaid enrollees who were disabled. We measured access through the penetration rate (proportion of enrollees using at least one substance abuse treatment service in a year . PRINCIPAL FINDINGS: Overall this carve out reduced real adjusted spending per enrollee by 40 percent from 1992 to 1996. At the same time, access improved from 38 to 43 unduplicated users per 1,000 enrollees per year f rom 1992 to 1996, adjusted for changes in Medicaid eligibility. these savings were achieved by a shift in the type of 24-h our services (hospital, detox, and residential treatment ). In 1992, 87 percent of these services were provided in hospital compared to only 1 percent in 1996. the reductions were achieved within the first two years of the carve out and sustained, but not enhanced, in subsequent years. CONCLUSIONS: By arranging Medicaid reimbursement for lower levels of care and limiting use of the most expensive settings, managed care achieved substantial cost reductions over the first four years in Massachusetts.

Bringing managed care incentives to Medicare's fee-for-service sector.

The Health Care Financing Administration (HCFA) could work with eligible physician organizations to generate savings in total reimbursements for their Medicare patients. Medicare would continue to reimburse all providers according to standard payment policies and mechanisms, and beneficiaries would retain the freedom to choose providers. However, implementation of new financial incentives, based on meeting targets called Group-Specific Volume Performance Standards (GVPS), would encourage cost-effective service delivery patterns. HCFA could use new and existing data systems to monitor access, utilization patterns, cost outcomes and quality of care. In short, HCFA could manage providers, who, in turn, would manage their patients' care.

Do preset per visit payment rates affect home health agency behavior?

This article reports on preliminary impacts during the first year of a demonstration in which home health agencies (HHAs) were paid a prospectively set rate for each Medicare home health visit rendered, rather than being reimbursed for costs. Forty-seven agencies in five States participated. The evaluation compared the experiences of randomly assigned treatment agencies and their patients with those of control agencies and their patients and found no compelling evidence of any demonstration impact on agency cost per visit, the volume of home health services, agency revenue and profit, patient selection and retention, quality of care, or use and cost of Medicare services.

Properties and relative immunogenicity of various preparations of recombinant DNA-derived hepatitis B surface antigen.

The gene for hepatitis B surface antigen was cloned into vectors for expression in yeast and mammalian cells. These hosts assemble the surface antigen protein into spherical structures containing cell-derived lipids. Particles were isolated from these cell cultures and purified by standard biochemical and biophysical means. Protein micells were formed from such particles by removal of lipid with nonionic detergent. Both particle and protein micellar preparations were formulated with alum adjuvant and tested for their immunopotency in mice. All the materials so analysed proved to be highly immunogenic. Safety and regulatory aspects of these materials and other potential and current hepatitis B vaccines are discussed. It is concluded that the yeast-derived materials and certain mammalian cell production systems present the most suitable opportunities for new hepatitis B vaccines.