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APHA Scientific Session and Event Listing

Elizabeth L. Merrick, PhD, Constance M. Horgan, ScD, Deborah W. Garnick, ScD, Sharon Reif, PhD, and Dominic Hodgkin, PhD. Schneider Institute for Health Policy, Brandeis University, 415 South St, Mailstop 035, Waltham, MA 02454, 781 736 3917, merrick@brandeis.edu

The way a health plan structures treatment entry, including gatekeeping requirements, shapes the experience of enrollees seeking care. It is therefore essential to understand these mechanisms to determine their effects on access to treatment for substance use disorders. Our survey allowed us to ascertain what actions enrollees and providers must take for a plan member to access regular outpatient specialty substance abuse care. We surveyed commercial health plans in 60 US market areas regarding administrative and clinical aspects of behavioral health care delivery in 2003, yielding national estimates (N=368, response rate 83%). Products typically had no requirements for entry into specialty substance abuse treatment (42%), or required that either the member or provider contact the plan, structuring this as a choice of how to meet the requirement (43%). There were significant differences by contracting arrangement: 67% of products with comprehensive (medical and behavioral health) contracts had no requirements versus 37% of products that contracted with managed behavioral healthcare organizations. Nearly all products that required enrollees to call their phone center indicated that at least one outpatient visit was always authorized. Structural gatekeeping requirements for regular outpatient care are often minimal (although procedures may vary), with primary care gatekeeping rare, and initial access is routinely approved. Ease of entering specialty behavioral health treatment is important from the client point of view, and also from the perspectives of both specialty and general medical providers whose attempts to guide patients toward appropriate resources would otherwise be hindered.

Learning Objectives:

• Identify methods of managing entry into specialty substance abuse treatment.
• Understand how treatment entry requirements vary by the type of managed behavioral health care and the contracting arrangements used.

Presenting author's disclosure statement:

Not Answered