TABLE OF CONTENTS Page XIV. Comparison of Services used by ADADS/SAI Populations 73

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2 TABLE OF CONTENTS Page Executive Summary 2 Background 13 Access to Substance Abuse Treatment 14 Cost of Substance Abuse Treatment to Purchasers & Families 21 Quality of Substance Abuse Treatment 29 Significant Substance Abuse Treatment Projects in New Jersey in the 1990s 34 Short-Term Task Force Recommendations 39 Legacy Recommendations 43 Figures: 1 Total Demand for Treatment 4 2 Percentages of Total Treatment Demand by 5 Treatment Type 3 Distributions of Treatment Modalities & Demand for Treatment 6 by County 4 Health Insurance Coverage for New Jersey Residents 15 for National Enrollment in Behavioral Health Care 16 6 Estimated Substance Abuse Treatment Spending, By Source 21 of Payment 7 Estimated Substance Abuse Treatment Spending, By Provider 22 Type 8 Average Annual Spending Growth Rate 22 9 Summary of Public Expenditures for Substance Abuse 23 Treatment in New Jersey 10 DHSS/DAS Treatment Expenditures FY Ranking of State Per Capita Treatment Expenditures Ranking of State Per Capita Non Federal Expenditures Medicaid/Charity Care Expenditures New Jersey Medicaid Expenditures 26 Appendices: I. Executive Order II. Summation of Public Testimony 49 III. Sub-Committee Reports 53 IV. Summary Tables for Statewide Treatment Demand 59 V. Distribution of Programs & Demand by County (A. Residential; B. Outpatient; C. Methadone) 62 VI HMO Census 65 VII. National Enrollment in MBHO by Program Type 66 VIII. Waiting List Summary 67 IX. Growth Rates for Total Estimated MH/SA Expenditures 68 X. Treatment Expenditures of NJ DAS XI. Per Capita Ranking of NJ and Similar States XII. Medicaid/Charity Care Inpatient Detox Expenditures 71 XIII. Medicaid Substance Abuse Treatment Expenditures XIV. Comparison of Services used by ADADS/SAI Populations 73

3 EXECUTIVE SUMMARY In May 2000, Christine Grant, Commissioner of the New Jersey Department of Health & Senior Services (DHSS), established the New Jersey Substance Abuse Prevention & Treatment Advisory Task Force (Appendix I). The membership reflected treatment service providers, family members of persons with substance abuse problems, insurance companies, staff from universities with special knowledge concerning treatment, representatives of state associations, state agencies that purchase substance abuse services, and other stakeholders. Commissioner Grant asked the Task Force to focus on: The demand for substance abuse treatment in comparison to the capacity of service providers in New Jersey to deliver substance abuse treatment; Primarily drug treatment, in addition to treatment services for persons who are dependent upon or abuse alcohol; and, The full range of privately and publicly funded treatment services. The Task Force was instructed to divide their recommendations into two lists: Short-term recommendations that can be considered for implementation and substantially completed during 2001; and Long-term or legacy recommendations that are of continuing importance and should be addressed in state fiscal year (SFY) 2002 or beyond. The Task Force met eight times, hearing presentations and selecting priorities. In order to have a full discussion of the status of substance abuse treatment in the time allowed, Commissioner Christine Grant asked that special emphasis be placed on treatment and so largely excluded substance abuse prevention issues. The Task Force held a public hearing at which 32 persons testified. Thirty-nine (39) persons and organizations also submitted written testimony for a total of 71 persons (Appendix II). Subcommittees were convened on access to treatment, quality of treatment, and the costs of treatment (Appendix III). This is the Task Force s Report and recommendations to Commissioner Grant. Even though representatives of other State Departments participated in Task Force discussions, these recommendations are not meant to express the views of those Departments. 2

4 Key Conclusions There are five key conclusions that shape the recommendations. These are: 1. Persons who are medically indigent have significant problems accessing any type of substance abuse treatment in New Jersey, especially detoxification and residential care when they are incapacitated; 2. While private insurance policies generally cover substance abuse treatment to a limited extent, only 16% of New Jersey residents who enter treatment have private coverage, and those persons with insurance and severe substance abuse problems (such as heroin addiction) have problems accessing covered treatment services promptly. If services are authorized by their managed care organization, care is frequently of insufficient intensity or duration to lead to recovery; 3. Studies completed by New Jersey State government that compare demand for treatment to the number of persons that received substance abuse treatment show that overall treatment capacity is insufficient in this State (See Figures 1 and 2 and Appendix IV); 4. Some public purchasers (Medicaid) offer a substance abuse benefit, some of which carries in part into other public programs (NJ KidCare, NJ FamilyCare, Children s Initiative) while providing limited services; 5. The quality of substance abuse treatment, while not severely deficient in New Jersey, requires attention and additional resources to assure that citizens receive the care they need and deserve. Several studies were recently completed by the Division of Addiction Services (DAS), a Division within DHSS. These studies quantify the extent of the problem. Figure 1 shows total demand for treatment for all adults, women and adolescents; the number of persons served from each of these groups; and the unmet demand for substance abuse treatment services in New Jersey. Figure 2 shows percent of total treatment demand served by treatment modality. 3

5 Figure 1 This information shows that over 71,000 adults in New Jersey cannot access treatment for substance abuse due to limited capacity while 67,070 are served each year. The number of adolescents who cannot access treatment is over 9,400 while the number served is approximately 5,130. The good news is that more women are served (22,520) than the number of women whose demand for treatment remains unmet (19,400). However, as noted above, the treatment system serves only about one-half of those adult men and adolescents who demand treatment. The demand for treatment varies by the type of care. New Jersey uses the term modality to describe the various major kinds of treatment. Figure 2 shows the percentage of total demand that can be served in each type of care. For example, slightly over 40% of the demand for outpatient care (OP) is being met for the treatment of drug abuse and dependence. 4

6 Figure 2 This graph shows that sub-acute detoxification which includes primarily short-term methadone detox services, scores best, with over 65% of the demand being met. Partial care, which includes halfway houses and extended residential care programs has the greatest need for expanded capacity as only about 20% of the demand for this type of care is currently being met. Outpatient treatment (OP) and intensive outpatient treatment (IOP), two types of care where clients live at home while participating in treatment services, meet about 40% and 50% of the demand respectively. Short term (ST) residential and long-term (LT) residential treatment capacity is at about 57% and 38% of the capacity required to meet demand. Methadone maintenance (MM), a continuing service for opiate addicts, has sufficient capacity in New Jersey to meet about 46% of the current demand. Figure 3 shows the location of all treatment agencies throughout the State and how that distribution matches the projected treatment demand. (Appendix V. A., B. and C. show the distribution by modality). New Jersey can do better. The existing services are fully utilized and yet citizens are unable to access treatment that can lead to recovery from substance abuse and dependence. The following Task Force Report describes the access, cost and quality factors that led to today s situation, exploring recent trends and the current status of these factors. DHSS/DAS efforts that have been taken so far to improve the availability of substance abuse care for citizens are summarized in the Significant Substance Abuse Treatment Projects.. section. Finally, the report further describes a set of strategies that are needed to improve access to care and the quality of treatment services. These strategies are offered as short-term recommendations that may be considered by the Commissioner for implementation and substantially accomplished during

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8 Short Term Recommendations 1. Expansion of Detoxification and Residential Treatment. In addition to the South Jersey Initiative (SJI) that will add 50 beds for adolescents in the summer of 2001, DHSS/DAS should make every effort to expand the capacity of existing treatment providers to deliver detoxification, short term and long term residential treatment. The target population is primarily persons who are medically indigent. The purpose is to assure access to persons who meet the American Society of Addiction Medicine (ASAM) clinical placement criteria for these levels of care. Physical plant capacity of existing facilities, i.e. beds or wings that are empty and that are not being purchased or are currently underutilized are the target for this effort. The expansion is intended to add to total capacity for publicly funded populations and is not intended to displace capacity from another purchaser to DHSS/DAS. In some instances, it may be necessary to expand and modify a physical plant to accommodate additional beds. Service capacity should also be expanded for opiate addicts including expanded opioid maintenance therapy with methadone, LAAM and future use of buprenophrine. Ensure that clients receiving methadone, LAAM and other medications are also treated (as needed) for other substance abuse and psychiatric problems. Primary Responsibility: DHSS/DAS and Providers of Residential Treatment Services. 2. Establish a Forum for Analysis and Exchange Between Employers, Managed Care Organizations, Treatment Providers and Other Stakeholders. Creation of a forum for productive exchange between employers, managed care organizations, managed behavioral health care organizations (MBHCO), substance abuse treatment providers, family members, and other stakeholders has the potential to resolve several issues identified by the Task Force. These problems include difficulty of insured persons in accessing substance abuse treatment; limited benefit plans; denials of care for the appropriate level of care; the inability of some providers to secure contracts with HMOs and MBHCOs; and lack of agreement on criteria that should be used to determine medical necessity, level of care, and treatment authorization. Primary Responsibility: Deputy Commissioner/DHSS, DHSS Office of Managed Care, DAS and Department of Insurance. 3. List and Compare Rates Paid by All Public Purchasers. This task, to be completed in the short term, provides information to purchasers, providers and other stakeholders. The Task Force recommends that a list of all fee for service rates paid by public purchasers be prepared, on a service by service basis, and that, to the extent possible, rates paid by private purchasers be added to the list. This action could encourage consideration by all public purchasers to pay the same rate for the same substance abuse treatment service. It will also allow comparison between provider costs of care and existing 7

9 rates of payment and permit analysis of the various financial incentives used by public and private purchasers. Primary Responsibility: Treatment Providers Cost Subcommittee and Director of Treatment and Managed Care, DHSS/DAS. 4. Remove the Economy of Scale Adjustment in DHSS/DAS Slot Rates. The existing slot rates paid by DHSS/DAS contains a factor that reduces the annual slot rate by 10% when the size of the program exceeds 40 residential, 150 methadone or 75 outpatient slots. The Task Force recommends that this economy of scale factor be eliminated since providers feel the current reimbursement is too low to provide quality care. The revised rates should be inspected following completion of the Capital Consulting Cost Study in the fall of Primary Responsibility: DHSS/DAS. 5. Rates of Payment for Medicaid Outpatient Services. Medicaid is one of the State s largest payers for substance abuse treatment. Nonetheless, Medicaid rates for outpatient substance abuse treatment services established in 1984 have not been revised since that time. Treatment providers report that they limit the number of Medicaid and NJ FamilyCare beneficiaries that they are willing to serve, as they lose money due to the inadequacy of the rates. The recommendation is to increase outpatient rates for all federally matchable NJ Division of Medical Assistance and Health Services (DMAHS) sponsored services to the rates used for Work First New Jersey s Substance Abuse Initiative. Primary Responsibility: Treatment Providers Cost Subcommittee and Director of Treatment and Managed Care, DHSS/DAS, DMAHS. 6. Substitute State funding of DHSS/DAS Needs Assessment studies when, and if, federal funding is concluded. These studies are key to effective resource allocation, outcomes studies and long range prevention and treatment planning. Primary Responsibility: DHSS/DAS. 7. Quality Management Improvement Package # 1 ( package refers to quality improvement suggestions made later in this document). This includes establishing Centers of Excellence, completing a candid assessment of the quality of treatment, and assuring the ability of licensed treatment programs to meet the diverse needs of special populations, e.g. pregnant addicts, adolescents, women with children, Asians, persons of Hispanic origin, etc. 8

10 Primary Responsibility: DHSS/DAS, Providers, DHS, DOC, L&PS Various Administrative Items The following recommendations can be accomplished in an ongoing manner and can be achieved within existing fixed costs; a) Resolve the regulatory conflict between DHSS and the Department of Corrections (DOC) concerning smoking at treatment facilities. Primary Responsibility: Director of Prevention & Director of Licensure & Grants Monitoring, DHSS/DAS, DOC and Providers. b) Involve treatment facility directors more fully in DHSS/DAS development of new mandates or regulations, and in a legislative review process. Primary Responsibility: Assistant Commissioner, DHSS/DAS, Executive Directors of treatment agencies. c) Consider national accreditation in lieu of or in conjunction with state licensure of substance abuse treatment programs. Primary Responsibility: Director of Licensure & Grants Monitoring, DHSS/DAS, trade association representatives of treatment agencies. d) Consider 3-year contracts for substance abuse treatment services, and Chapter 51 county grants. Primary Responsibility: DHSS/DAS, Other State agencies that purchase substance abuse treatment services, counties, trade association representatives of treatment agencies. e) Secure entry-level positions for recovering persons as they work on counselor certification. Primary Responsibility: Treatment Providers. f) Continue the current mix of reimbursement mechanisms used by DHSS/DAS until the Cost Study is complete and the management implications of any possible rate changes are considered. Primary Responsibility: DHSS/DAS. g) Implement a revised policy regarding current restrictions on grantee s use of cash reserves. Primary Responsibility: DHSS/DAS and Treatment Providers. 9

11 (h) Compile an inventory of safe, available, affordable, sober housing to ease client reintegration into communities Primary Responsibility: DHSS/DAS, Department of Community Affairs (DCA) and Department of Human Services (DHS) (i) Review and analyze the effectiveness of drug treatment providers to serve clients with HIV/AIDS and determine the impact of transmission. Use this rationale to determine whether there should be a prioritization of treatment for clients with HIV. Increase education regarding HIV/AIDS treatment regimens and providers role in medical management of these diseases. Primary Responsibility: DHSS/DOAPC, DHSS/DAS and Treatment Providers. In addition to short-term recommendations, the Task Force Report also provides a set of legacy or long-term recommendations. These strategies for capacity expansion and treatment improvement may require several years to complete. We recommend that these recommendations be a blueprint for improving the substance abuse treatment system. Implementation of such a blueprint will generate continuing returns in recovery for addicts, increased hope for the families of persons with substance abuse problems, productive employees for business in New Jersey, and reductions in social problems such as driving under the influence, repeated arrests for drug dealing or felonies while using, and the health care costs associated with addictions. Legacy Recommendations This section describes longer-term Task Force recommendations for expanding capacity and quality, including supportive strategies during SFY 2002 and beyond. This is a summary. The full text is contained later in the Task Force Report. 1. Continue the expansion of detoxification and residential treatment services. Primary Responsibility: DAS, County Directors. 2. Expand selected services and funding, including: a) services for persons with co-occurring mental health and substance abuse disorders, b) intensive outpatient services in combination with sober housing, and c) funding for persons who are medically indigent. Expansion of items a) and b) should be done in conjunction with other State Departments. Primary Responsibility: DAS, DHS, DCA, Providers. 3. Establish a prison-based methadone treatment program similar to Riker s Island in New York that connects clients to community-based services upon discharge. Develop office-based opioid maintenance treatment. Primary Responsibility: DAS, DOC, Providers. 10

12 4. Restructure benefit packages, including expanding the scope of Medicaid benefits for substance abuse to include all Work First New Jersey Substance Abuse Initiative federally matchable services, which is a broad benefit package exceeding most privately covered services. Add these expanded substance abuse treatment services to the Children s Initiative, NJ Kid Care and NJ Family Care to the extent federally matchable and consider adding intervention as a covered treatment service. Primary Responsibility: DHS/DMAHS and DHSS/DAS. 5. Quality management improvement package # 2 ( package refers to quality improvement suggestions made later in this document) includes assuring that treatment providers have the ability and resources to routinely diagnose, treat and refer women (50% of the population) and persons with co-occurring mental health and substance abuse disorders, as a standard expectation and not as special populations. Primary Responsibility: DAS, Providers. 6. Quality management improvement package # 3 ( package refers to quality improvement suggestions made later in this document) includes requiring use of evidence-based treatment and best practice guidelines, and implementing a uniform outcome measurement system. Such a system would determine the effectiveness of various types of substance abuse treatment for specific kinds of individuals. Primary Responsibility: DAS, Providers, a university. 7. Advocacy and education includes establishing strong legislative advocacy for substance abuse treatment issues, establishing parity for substance abuse treatment with medical and mental health benefits, and advocating with the public, school administrators and courts for more consideration of substance abuse treatment issues in all populations. Primary Responsibility: Governor s Council on Alcoholism & Drug Abuse (GCADA), Providers, DAS. 8. Rates of payment package # 1 ( package refers to rates of payment suggestions made later in this document) includes completion of the Capital Consulting cost study and comparing provider costs to public and private rates of payment, determining the costs required for providers to meet State licensure standards, adjusting rates as appropriate, and considering setting treatment rates that are common across all public purchasers. Primary Responsibility: DAS. 9. Rates of payment package # 2 ( package refers to rates of payment suggestions made later in this document) includes estimating the costs of adoption of the quality management recommendations and adjusting rates specifically to support the quality management initiatives. 11

13 Primary Responsibility: DAS. 10. Management information system includes implementing an improved MIS that standardizes waiting list procedures and capacity management, as well as client tracking and client information and service utilization, using state of the art technical approaches, and which considers operations of the MIS by DHSS/DAS, providers, or a third party vendor. Primary Responsibility: DAS, Providers. 11. Administrative issues include establishing a Commissioner s Work Group to plan and coordinate substance abuse treatment services across State executive and judicial branches of government. The Work Group would be institutionalized but only meet on demand or on a specific issue. For example, the group could address uneven rate structures for the same service or disparate smoking regulations and coordination of client management access systems. Primary Responsibility: DHSS Commissioner. 12

14 BACKGROUND The Task Force commenced its work with great enthusiasm because Commissioner Christine Grant showed great interest in jointly determining recommendations for DHSS priorities in the substance abuse treatment area for the next few years. Substance abuse treatment is currently a field in great transition, both scientifically and in the public s perception. Scientifically, much neurochemical, genome, social research, outcomes research, systems and standards development are moving quickly to redefine the field from a social cause for the criminal drug addict to a medically based model of care for the defined disease of addiction. Public perception is also starting to change with beginning recognition of the cost of addiction to physical health care, more companies using Employee Assistance Programs, courts and prisons recognizing the role of addiction in criminal behavior, school and community prevention efforts, parents advocacy groups and smoking awareness campaigns to name a few. Since substance abuse treatment providers and other interested groups are struggling to keep up with these sweeping changes, the Task Force welcomed the opportunity to discuss these topics and potential and real barriers to accessing treatment with the Commissioner of Health and Senior Services. Complicating these many changes are heightened expectations for easy access to quality treatment, increased credential requirements for professional and para-professional staff to care for more clinically complicated clients and reimbursement rates largely unchanged for years. For example, this report shows that only about half of the demand for publicly subsidized treatment is being met. In some rural areas of the state and in parts of several southern counties, residential and outpatient services are not located nearby. Heroin use is quite high in New Jersey as compared to other states, but it remains difficult to site new methadone facilities, the most effective immediate treatment for this addiction. Increasingly, public funding of substance abuse is reserved for certain types of abusers i.e., pregnant women, welfare recipients, drug court participants, adolescents in undeserved areas, etc, while those who don t fall into these groups have much more difficulty accessing publicly funded treatment. Through more sophisticated diagnosis and recognition of need for treatment, more persons with co-occurring disorders that is, both mental health and substance abuse problems, are seeking care at substance abuse treatment agencies. And those persons with private insurance whose substance abuse treatment is provided through managed care companies have great difficulty gaining access to the limited benefits which are promised. Managed care companies and providers struggle to agree on an acceptable definition of medical necessity for care. Finally, providers strain under these demands and others to deliver care which meets heightened standards of quality resulting from best practice research. Into this substance abuse treatment environment, the Task Force began discussing a direction to most efficiently and effectively address some of the more pressing problems in the field. 13

15 ACCESS TO SUBSTANCE ABUSE TREATMENT Introduction This section describes how New Jersey residents access substance abuse treatment. It presents information about factors that influence how easily citizens can get the care they need or how difficult it has become. The information includes: The number of uninsured persons and the impacts of managed care for the insured, including the experiences of New Jersey parents seeking treatment services for their adolescents and young adult children; The trends in admissions to substance abuse treatment agencies, a waiting list survey conducted by DHSS/DAS and the opinions of other stakeholders; and The observations and recommendations of the Task Force subcommittee on access. How Access is Influenced by Insurance Benefits One pundit described the population of the United States as divisible into those with private or public health insurance, the entitled, and those without any health benefits, the un-entitled. The first group experiences the problems of a health care system that is evolving rapidly toward managed care, while the second group experiences illness and emergency rooms. The over simplification does point out that the problems of access to substance abuse treatment vary depending upon whether or not you have health insurance. There are an estimated 42.6 million persons in the United States without health insurance. Many of these individuals are children, or members of a family with an employed person who cannot afford insurance for family members. Recent information from the U.S. census shows that 13.4% of New Jersey residents are uninsured. Figure 4 displays the percentages and number of persons of all ages that had health coverage during

16 Figure 4 Health Insurance Coverage for New Jersey Residents for 1999 Type of Insurance % People Commercial insurance (1) 69.2% 5,603,570 Public insurance (2) 17.4% 1,411,030 Uninsured 13.4% 1,089, % 8,104,499 (1) individual group employment related, non-group & other. (2) Medicaid and Medicare age 65+ and others. Source: U.S. Census Bureau, Current Population Survey of March The group with the highest percentage of no coverage was persons age 19-34, an age group with a high incidence of substance abuse problems. Over 63% of the persons under age 65 with family incomes under 300% of the federal poverty level have no insurance coverage. This uninsured population of medically indigent persons relies entirely on public funding in order to access substance abuse treatment services. DHSS/DAS defines medically indigent persons as those with family income under 250% Federal Poverty Level (FPL) for outpatient services and under 350% FPL for residential services. Information from DHSS/DAS shows that in 1998, 58% of the clients receiving substance abuse treatment in non-hospital facilities had no insurance benefits, while 16% had private benefits, 14% had public benefits, and for 12% insurance coverage was unknown. The lack of health insurance coverage, as reported by treatment agencies in the DHSS/DAS information system, is worse in Essex, Monmouth and Hudson Counties. The Growth of Managed Care and Managed Behavioral Healthcare Managed care is now the dominant paradigm in commercial healthcare, and is rapidly becoming the preferred way to do business in many states in the public sector. However, some states are moving away from corporate managed care models for substance abuse treatment because these models rely heavily on acute care while substance abuse is actually a chronic, recurring disease of the brain (NIDA). The growth of managed care during the 1990 s was astounding. On a national basis, the number of enrollees grew from 34.7 million in 1990 to 81.0 million in The greatest rate of increase nationally was 1996, when the number of enrollees increased by 18.5%. In 1999, the rate of increase lowered to 2.6% nationally (Source: InterStudy Competitive Edge HMO Directory). In New Jersey, enrollment in health maintenance organizations (HMOs) went from 935,228 persons in 1990, to 2,358,474 persons in The middle of the decade saw annual HMO growth rates of 26.7% in 1995, and 34.4% (1996) in New Jersey. Recently enrollment has 15

17 leveled off, and the number of HMO s licensed in the State has been reduced to 17 through consolidation. (Appendix VI). Most HMOs do not administer a substance abuse benefit themselves. They contract with managed behavioral healthcare organizations (MBHO s) to manage the mental health and substance abuse services provided to their members. National data on MBHOs comes from an annual survey performed by Open Minds starting in Enrollment increased from 78.1 million persons in public and commercial managed behavioral healthcare in 1992, to million persons in Figure 5 In 1999, an estimated 71.8% of persons with public or private health insurance were also enrolled in a managed behavioral healthcare organization. (Appendix VII). One direct result of the managed care revolution has been a significant reduction in the delivery of substance abuse treatment by hospitals in New Jersey. In the late 1980 s there were 17 specialized inpatient units for alcohol, drug abuse or dependency that operated a total of 587 beds (1987 data) in this State. By 1998, only 11 hospital units existed operating a total of only 337 beds. By 1993, 52 hospitals had established outpatient services for substance abuse. As of 1998, there were only 33 hospital outpatient units in New Jersey. The Federal Substance Abuse and Mental Health Services Administration (SAMHSA) maintains a managed care tracking system that reports on the use of managed behavioral health care by 16

18 states, primarily in state Medicaid programs. The State Profile report for 1999 (May, 2000) reported that: The number of states with managed behavioral health care programs has tripled in three years from 1996 to By 1999, 42 states, including the District of Columbia, operated some level of managed behavioral health care. (DHHS Publication No. SMA ) New Jersey was one of nine states without public managed care programs for Medicaid benefits, including Alaska, Kansas, Louisiana, Maine, Mississippi, Montana, North Carolina and Wyoming. However, New Jersey is using some managed care techniques such as care coordination, utilization review, level of care determination and prior authorization in the Work First New Jersey (WFNJ) Substance Abuse Initiative (SAI). Using these techniques without financial risk as DHSS/DAS is doing is actually a care management approach, rather than the rigorous clinical and financial controls at the base of private sector managed care. The care management technique which seems to be critical to easing access is care coordination, i.e., a clinical professional who acts as an advocate and facilitator in actually securing a client s treatment in an appropriate level of care. The function of advocate and facilitator assists families in crisis, fills empty beds quickly and initially places the client in the most effective level of care. One obvious conclusion is that care management technologies such as mentioned above are becoming standards of practice across much of the U.S. The challenge is to use these technologies wisely when serving substance abuse clients who are at great risk. Experiences of New Jersey Parents and Families Members of the Parents to Parents group in Marlton, New Jersey report severe difficulty accessing substance abuse treatment for family members, including persons addicted to heroin. These problems, not unique to New Jersey, existed whether or not the family had private insurance. When the family had insurance, the problems included: Insurance companies and managed care organizations that approved only outpatient care would not approve detoxification or residential treatment; Inability to find a treatment provider with treatment available immediately, and waiting lists when the need for services was critical; Lack of awareness of DHSS consumer and provider appeals and complaint procedures. For example, only six of 955 complaints received by DHSS/Office of Managed Care from January through October of 2000 concerned substance abuse. (The DHSS complaint phone number is ). 17

19 Some insurers do not recognize and so do not pay for levels of care that are common in New Jersey, such as sub-acute detoxification services; Approval by some managed care organizations (MCOs) of only very brief residential stays for stabilization, followed by approval of extremely brief outpatient services, when the professional recommendations as well as family experience led to a conclusion that extended treatment would be necessary. These experiences with MCOs led many families with insurance to immediately seek access to publicly funded services as their only alternative. A national report confirmed this pattern by noting that privately insured individuals end up turning to the public sector for treatment. This increased costs to federal, state and local governments by as much as 20%. (Lewin-VHI, Healthcare Reform and Substance Abuse Treatment: The Cost of Financing Under Alternative Approaches 1994). Family members report calling all the 800 numbers and calling all of the community based organizations in their area seeking a placement. The most common problem in this system is the lack of detoxification programs in the local area, and a mal-distribution of residential treatment that concentrates residential beds in Northern New Jersey. Even then, waiting lists and limited treatment capacity result in extreme difficulty accessing care. Admission Information, 1992 to 1999 Drug and alcohol-related admissions to New Jersey treatment facilities have been steadily declining, primarily due to the closure of hospital-based discreet detoxification units and the growth of managed care. In 1992, there were 32,825 admissions for primary drug problems. That number increased to 40,941 in 1995, largely as a result of dollars received in federal discretionary grants. However, the number of drug treatment admissions declined to 35,592 in Admissions for persons with primary alcohol problems declined from 32,637 in 1992 to 17,528 in Overall, the number of admissions decreased from 65,462 in 1992 to 53,120 in New Jersey can do better. Waiting List Information Another way to determine whether the treatment system has sufficient capacity is to analyze waiting lists maintained by providers. DHSS/DAS conducted a survey of treatment providers during the summer of Waiting lists are problematic as precise tools for knowing needed capacity, as they are not maintained in a uniform manner. However, the size of the list can indicate whether a general problem exists. About one-half of the providers who responded to the DAS survey do not keep waiting lists at all. The 12 treatment providers who deliver residential care reported waiting lists of 952 men and 161 women, a total of 972 or almost a thousand individuals. Treatment providers that deliver outpatient care reported that 222 men and 202 women were on their waiting lists (Appendix VIII) 18

20 There are two treatment providers who plan to add a total of 107 residential beds, which should decrease somewhat the critical need for additional capacity. In addition, 50 beds will be added for adolescents through the South Jersey Initiative, as reported in a later section. Expanding outpatient care is primarily a funding and staff recruitment issue. Providers reported that additional capacity for outpatient care could be added sufficient to serve 12,781 additional clients. (Source: DHSS/DAS waiting list survey, August 2000). Stakeholder Comments Finally, another indication of the problem that citizens in New Jersey have in access to treatment services is contained in a statement of the Senate Task Force on Alcohol related Motor Vehicle Accidents and Fatalities in New Jersey. This Task Force found: convicted drunk drivers, who must compete in a large pool of persons in need of treatment for substance abuse, are disproportionately under represented among those receiving such services in New Jersey s publicly funded treatment programs. Task Force Subcommittee on Access The subcommittee made eight recommendations: A full continuum of substance abuse treatment services should be available for New Jersey citizens, within the travel times and distances called for by DHSS regulations, with specialized services for persons with specialized needs. A regional client transportation system may be necessary. Parity should be legislated so that substance abuse benefits are equal to medical benefits. The reasons for treatment denials by managed care organizations should be determined. Client s rights to appeal and complain through the Office of Managed Care, DHSS, should be well publicized to clients and providers. The New Jersey Children s Initiative should include a full range of substance abuse benefits. Additional funds to expand treatment capacity should be allocated if need is documented by waiting lists and current case management systems. A-1932 has recently been unanimously passed by the New Jersey Legislature. This legislation, if signed by Governor Christine Todd Whitman, would provide $10 million primarily for the treatment of convicted Driving While Intoxicated (DWI) offenders with alcohol related problems. This would partially allow for some expanded treatment capacity. 19

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