Since pop-culture analysts routinely refer to the U.S. as an addictive society, it's ironic that experts say Americans' access to addiction treatment is seriously inadequate.
Managed behavioral healthcare companies and the American Society of Addiction Medicine recently teamed up to begin addressing that inadequacy, which experts say has a tremendous impact on the healthcare industry and the nation's well-being.
Since the early 1900s, the number of Americans with significant alcohol or drug dependencies has remained fairly constant at 10% to 15% of the population, says Anthony Radcliffe, M.D., regional coordinating chief of addiction medicine at Kaiser Permanente Southern California.
In May, the American Managed Behavioral Healthcare Association, which represents 17 companies serving more than 80 million enrollees, and the ASAM began a dialogue "to seek ways to successfully screen, assess and treat individuals with addictive disorders."
The ASAM is an international medical specialty society of more than 3,500 physicians from all areas of medicine who treat and conduct research on alcohol, nicotine and other drug dependencies and also engage in preventive work.
The organizations issued a joint statement recognizing "that addictive disorders are primary disorders; that treatment must be individualized and be both clinically effective and cost-efficient; that the field must develop common screening tools, diagnostic criteria and nomenclature; and that standardized data sets (including administrative, clinical and performance) should be developed for measuring outcomes."
Despite the prevalence of addictive disorders, stigmas against people battling addictions are greater than those attached to mental illness, says Clarke Ross, executive director of the AMBHA.
The ASAM defines addiction as "a disease process characterized by the continued use of a specific psychoactive substance despite physical, psychological or social harm." But often addictions are viewed as a willpower problem, Ross says. The main obstacle to adequate addiction treatment is the lack of parity in healthcare benefits, he adds.
"We do not have parity for the treatment of addictions in health benefit packages. We're managing a highly discriminatory and highly limited benefit to begin with," Ross says.
Parity would mean that "if my problem is alcoholism, I have access to appropriate treatment, just as if I had lung cancer," says James F. Callahan, the ASAM's executive director.
That's rarely the case. "For the most part, addiction is not treated, and that's terribly wrong," Callahan contends. "People who come in with addictions-either in fee-for-service or managed-care plans-are often treated for the physical or psychological consequences of the addiction, but the addiction itself is not addressed."
Callahan gives four main reasons why this is so: Doctors lack training in recognizing addiction; they don't routinely ask their patients about smoking, drinking and other drug use at key points of care such as maternity clinics and emergency rooms; doctors don't have adequate training in addiction treatments; and insurance coverage for proper treatment is generally inadequate.
For example, if an alcoholic goes to a primary-care physician for a bleeding ulcer, the doctor may determine the condition was caused by excessive drinking, treat the ulcer and advise the patient to cut down on alcohol.
"But the doctor should really take a history of alcohol use and look at other conditions that relate to the patient's dependence on alcohol, then determine how severely impaired he is and whether to work with him on an outpatient basis or consider admitting him to a hospital," Callahan says.
The doctor should have the knowledge and freedom to prescribe appropriate addiction treatment, he says. That would be parity.
Ross and Callahan say most benefit plans have a one-size-fits-all formula for substance-abuse treatment. For example, enrollees may be allowed only one or two inpatient detoxification periods per lifetime, and they may have practically no outpatient benefit at all, Ross says.
A notable exception is Kaiser's Southern California region, where "we treat chemical addiction problems as if they are primary medical diseases like diabetes" or other chronic conditions, Radcliffe says. There are no caps or limits on a Kaiser enrollee's addiction treatment, except that a Kaiser professional must deliver the care, he said.
An enrollee with an addiction can walk into any of several departments of addiction medicine throughout Southern California, bypassing the primary-care physician, and receive treatment, Radcliffe says. Kaiser assigns case managers to addiction patients who have more than three hospital admissions a year "so we can see what's wrong," Radcliffe says.
He says Kaiser's Northern California region has been doing "much the same" work with addiction and adds that other health plans are beginning to treat addictions as chronic diseases.
While Congress last year passed a law mandating a degree of coverage parity for mental health benefits, an addiction treatment provision failed to make it into the statute, mainly because opponents believed the cost would be too onerous. But Callahan says research has shown it would cost only $35 or $40 more per person per year to provide parity for addiction treatment.
Federal law now bans annual and lifetime caps on mental healthcare benefits that are lower than caps established for physical care (Oct. 14, 1996, p. 82).
The AMBHA and the ASAM have joined a coalition, including prestigious providers such as the Betty Ford Center, that has commissioned a study by Milliman & Robertson on affordability of parity for addiction treatment, Ross says. That study is scheduled for release in August. The organizations also are preparing a document to try to interest lawmakers nationwide in sponsoring parity legislation, he says.
The AMBHA and the ASAM are "on the same page" on many issues relating to addiction treatment, Ross says. But Callahan and Ross agree that a sticking point is the ASAM's 180-page patient placement criteria that provide guidelines on assessing and treating addiction.
The ASAM wants managed-care companies to use the criteria, which direct a provider who is assessing a patient for addiction, to look at six "dimensions" of that individual and then prescribe one of four levels of care, Callahan says (See chart, p. 84).
He says "some managed-care companies feel you should attend to the degree of the addiction and the physical and psychiatric consequences, but nothing else matters," such as the individual's living circumstances, social environment, likelihood of relapse or readiness for treatment.
Ross believes the ASAM's criteria, although "a tremendous contribution to the field," are biased toward inpatient care. "We start with a bias that one starts treatment closest to an individual's home and community in the least restrictive setting." By contrast, the ASAM's guidelines "start with inpatient care and move away from that depending on circumstances," Ross says.
Ross says he hopes the organizations can come together on patient criteria "after we work together for a couple of years on a variety of other things in a positive way. We have not allowed this disagreement to prevent productive collaboration in other areas."