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(828) 257-4460http://www.mahec.net2. The Past and Present of Behavioral Health CareA.Where have we been? A History of MentalHealth and Addiction ServicesThe 1950s to 1970sThroughout this period the dominant approach of alcoholism treatment wasthat of Hazelden, termed the Minnesota Model. Hazelden incorporated 12Step principles with traditional psychotherapeutic techniques, such as grouptherapy and didactic education. The Minnesota Model viewed alcoholism asa chronic, primary, progressive illness, resulting in involuntary disability. Thefundamental aspects of the illness were a pathological dependence onalcohol, impaired control of use, multiple harmful consequences as a directresult of abusive use of alcohol, minimization and rationalization of thedisease and its effects, and adaptive impoverishment. Total abstinence fromall psychoactive drugs was expected along with improved mental health.Signs of mental illness were seen as associated with alcohol abuse, whichwould disappear after a period of prolonged abstinence. (1)This attitude towards substance abuse and mental illness dominated thealcoholism field for twenty years into the 1980s. For example, a supervisortold this author in 1975 that any signs of mental illness would disappear withrecovery from alcoholism. On the other hand, mental health professionalsargued that alcoholism was symptomatic of underlying psychiatric problems,which, unless the mental illness was treated, one symptom of addiction wouldbe substituted by another. It was generally thought alcoholics and drugabusers should not be in treatment together. Professionals believed thatalcoholics did not abuse other drugs and drug abusers did not abuse alcohol.Central to alcohol and drug abuse treatment throughout the 1970s wasstaffing by recovering alcoholics. The passion and commitment of recoveringpeople was a foundation on which the field was built.This history is relevant to today’s developments for the following reasons:It created a divide between providers, breaking downcommunication, and causing power struggles between disciplines.Patients were affected as many were trapped between providers.Co-occurring disorders were not addressed to allow for continuity ofcare between disciplines.Purchasers and payers for services were confused aboutdiagnoses and why patients did not recover as readily as didmedical/surgical patients. 2001 DLC, LLC7

http://www.mtn.ncahec.org(828) 257-4493An expensive gap was created between the provider, patient,purchaser and payer. The gap was closed by managed careorganizations (MCO) to control the escalating costs of behavioralhealth care.A contributing factor to the problems in addiction and mental health care wascategorical funding by government organizations. There were (and continueto be) separate funding sources for substance abuse treatment, prevention,research, and mental health treatment and research. Congress becomesconfused as categorical funding (―stove-pipe thinking‖) trickles down toprogram management. Since Congress assigns state block grant anddiscretionary funding to separate federal institutes, state and local prioritiesfor treatment and prevention of behavioral health remain separate.Most training in the addiction field through the 1970s was ―on-the-job‖ andlittle clinical supervision was provided. The Eastern Area Alcohol Educationand Training Program (2) found that 57% of the treatment organizations in thenorth east provided no clinical supervision to staff and 25% did not know whatclinical supervision was. Ethical and legal codes were developed as theprofession grew without clarity of the ethical theories and principles uponwhich these codes were based.The 1970s and 1980sThe 1970s-80s saw developments in behavioral health care that prepared theway for the dramatic changes of the 1990s. An explosion of theory andknowledge occurred especially in systems theory and family therapy.Practitioners such as Haley (Strategic Therapy), Minuchin (StructuralTherapy), and Bowen (Family of Origin Therapy) came into prominence.Private practices boomed. Family therapy training institutes grew upeverywhere. Publishing houses pumped out mental health books.Considerable progress was made in understanding the nature of mentalillness and addictions. Researchers sought to find a physiological basis forillness. As a result of increased understanding of the nature and origins ofmental illness and addiction there have been outstanding refinements indiagnostics and treatment. The Diagnostic and Statistical Manual of theAmerican Psychiatric Association (DSM) in the 1960s-70s, with 134 pages.This author was a consultant on DSM III that expanded to 557 pages. DSM IVwas published in 1994 with 886 pages and is already being revised. Thesenew diagnostic classifications have generated new models of patientplacement criteria (such as the American Society of Addictions MedicinePatient Placement Criteria).8

(828) 257-4460http://www.mahec.netAddiction care went from being ―vanilla and strawberry‖ to ―fudge ripple andheavenly hash.‖ Initially, alcoholics and drug addicts were treated separately.In the late 1970s patients were treated together. In the early 1980s the fielddiscovered that many abusers were children of abusers, resulting in theexplosion of programs to treat adult children of almost anything. In the late1980s Melody Beattie coined the phrase co-dependency. We came to believe95% of all persons were co-dependent; the other 5% were in denial. Patientssought care for an array of problems and the cost of care skyrocketed.With this came tension and in-fighting between disciplines. Addictionprofessionals fought among themselves. Behavioral health professionalsfought each other as to who were the ―experts‖ in addictions. Mental healthprofessionals wrestled with state legislatures about who was to be licensed.In the end, behavioral health professionals fought with purchasers and payersover what services should be provided. Providers became bankers instead ofbuilders, in what Baer calls the ―corporatization of American health care.‖ (3)―Large publicly traded corporations are increasingly important actors in thehealth scene and, perhaps more importantly, are having an effect oncommunities, on patients, and on health professionals.‖ Avon purchased theMediplex Group; US Tobacco purchased Heritage Health and HumanaAddiction Programs and contributed to Ashley Treatment Center. Aetna LifeInsurance Companies purchased Human Affairs International, the largestemployee assistance program (EAP) in the world. Merck purchased PersonalPerformance Consultants (PPC), the second largest EAP; CIGNA purchasedMCC. When the behavioral health field needed to focus on outcome benefitsit focused on the bottom line and funds were not spent on research andoutcome studies.During this period there were profound changes in the provision of corporatehealth care. The HMO act of 1973 expanded HMOs. There was increasedreview of utilization of services as a means of driving hospitalization costsdown. The effectiveness of HMOs and the cost containment strategiesreached a plateau of effectiveness in the mid-l980s. Insurers and purchaserssought other means to bring costs down. These measures included physiciannetworks of care, termed Preferred Provider Organizations. But thesecontributed to a blurring of the distinction between purchaser, payer, andprovider. At the beginning of the 1980s only 69 of the Fortune 500 companieshad control mechanisms in place over their health insurance systems. (4)Employers feared that tighter claims controls would disrupt employeerelations. Companies feared that it might force an employee to select onetype of health care delivery system over another, risking alienation of workers.Self-insurance became a common form of cost containment for America’scorporations. Insurance companies were retained to administer the plans.Many employers used health promotion programs. They sounded like the 2001 DLC, LLC9

http://www.mtn.ncahec.orgcompany was taking an active interest in the health promotion of its workers.(5)In the 1980s this attitude changed because of soaring costs cutting intocorporate profits. (6) American industry was under stress in the 1980s as aresult of changes in oil prices, shock waves in the automotive industry, andthe perils of the global economy. Inflation, interest rates and unemploymentsoared. Throughout the US health care system continued to expand. Hospitalrates raised annually by 18-20%. Businesses were beginning to feel thesqueeze. There were dramatic changes in attitudes in corporate America, ascompanies demanded cost containment strategies. Private foundations,government agencies and payers encouraged companies to play anaggressive role in health care cost containment. (7)Lessons to be learnedWhat lessons should have been learned through these years? Medical care needs to demonstrate cost benefits. Professionals needto answer the question, ―If my customer knew I was doing this wouldshe pay for it?‖ What is success? What are the desired outcomes?Providers did not do well in informing the purchaser and payer aboutoutcomes and that addiction is a disease of recidivism. Peter Druckersaid, ―The primary reason nonprofits aren’t successful is because theyfocus on needs instead of results.‖ (8) The foundation for sound behavioral health care is committedprofessionals with compassion for patients. Recovering peoplecontributed greatly to the field. The addiction field lost many of therecovering people in the 1990s with its push for credentialing that wasdriven by the purchasers and payers to limit the number of caregivers.For example, in 1970, 70% of the students at the Rutgers SummerSchool for Addictions Studies were in recovery, by self-admission. In1998 25% in attendance were in recovery. (9) Behavioral health workers suffered from rust-out not burnout. Potsburn out when there is too much fire and rust out when there is notenough fire. The ―fire for patients‖ comes from always keeping one’seye on the patient. Robert Stuckey, one of this author’s supervisors,said, ―No matter how much you earn and how important you become,never lose sight of the fact that you are in this field to help the abuser.The minute you lose sight of the patient you might as well sellhamburgers.‖10(828) 257-4493

(828) 257-4460http://www.mahec.net With the rush to professionalism an asset was lost, compassion andsimple presence.The Winds of ChangeThroughout the 1970-80s winds of change forecast what lay ahead,especially the rising cost of health care. Psychiatric care rose at twice the rateof inflation. Public health service costs rose 14% annually. Medicare andMedicaid psychiatric costs doubled from 1988 to 1998. By 1998 Medicaid was20% of state budgets. (10)Faced with escalating health care costs, employers struggled in the1990s tofind alternatives to cover care. In 1950, health care costs in America were4.4% of the gross national product (GNP). By 1987, that rose to 11.2%. In1997, the cost skyrocketed to 17.5%. (11) The Rand Corporation estimatedthat by the year 2000, health care would represent 20% of the GNP.Fortunately, this has not occurred and the percentage of health care costshas settled at 14-16%. Hospital costs rose from 129/per day in 1950 to 3527 in 1986 and 5,500 in 1995. These increases were passed on toemployers.According to the Hartford Courant, Oct 3, 1999, ―Surging health insurancerates will whack employers and their workers in 2000 and beyond and manyemployees will face higher out-of-pocket costs for medical care.‖ (12) Ratesare rising because of soaring spending on prescription drugs, more use ofoutpatient services and the ever-growing list of benefits mandated bylegislation. To save money businesses will switch to plans that make workerspay more for their care and many will pass at least part of the increases on toworkers. The fastest growing part of the medical costs is drug spending—rising by 20% per year, driven by the growing number of costly newprescriptions gaining government approval and marketed directly toconsumers. (13)Costs rose because there was little incentive to keep costs down. Payerspassed the costs to purchaser who paid the bills. There was a reliance oninstitutional care for psychiatric patients. As medical/surgical beds remainedempty during the 1980s due to cut backs in surgical procedures, adult andadolescent psychiatric patients filled them. There was no incentive todiscourage use of residential treatment. Addiction professionals would say,―Residential treatment program is best and the longer the better.‖Further, Americans were getting older. The most significant impact on healthcare today has been the aging of the baby boomers that wish to take their 2001 DLC, LLC11

http://www.mtn.ncahec.org(828) 257-4493youth with them into older age. (14) People are living longer and expect tohave good health throughout their life span. With this demand for healthylifestyles technology has responded with dazzling breakthroughs inpharmacology, surgical procedures, genetic and bio-technical engineering,organ transplantation, diagnostics, and an array of scientific discoveries.Perhaps the Garden of Eden is not far away, but at what cost is immortality?Managed Care Organizations (MCOs) became the answer to the rising costsand their growth was phenomenal. In 1991, MCOs had 18% of the total healthcare market. By 1995, MCOs had 30% and by the year 2000 MCOs had 65%of the market share. Managed Medicare has risen from 18.2% in 1990 to 54%in 1994. (15) Private sector managed care Preferred Provider Organizations(PPOs) have risen by 1994 to a staggering 66.7% of the market share forservice delivery systems. In 1984 the enrollment of managed care plans (inthe form of PPOs and HMOs), represented 4% of the market, and withindemnity plans a staggering 89% of the market share. By 1997 PPOs andHMOs dominated the market with 80% of the share of health care business.(16) Behavioral health markets for MCOs rose from a 53 billion-dollar industryin 1993 to a 100 billion-dollar market in 2000. (17)B.The World of Behavioral Health at the end of the MillenniumChanges in the Four PsBy the end of the decade the war between the provider, patient, purchaserand payer (the 4 Ps) was over and providers lost. In the 1990s providers wereforced to deal with a new treatment environment, defined by differentpayment systems, a new language of care and the exodus of practitionersfrom the field that had enough of the fight and sought greener pastures inother areas. According to a survey by the Harvard School of Public Health,37% of doctors dropped out of health plans from 1997-99 because offrustration. ―The level of conflict between doctors and health plans is as badas it has ever been.‖ (18)By 1996, 161 million Americans were enrolled in MCOs (approximately 60%of American). (19) Over 52 million Americans had some form of behavioralhealth problem, of these nearly 142 million were enrolled in a behavioralhealth program and 124 million were in a managed behavioral health plan.(20) 16.9 million were enrolled in HMOs. (21) By the 1990s 75% of care wasprovided in outpatient programs. This shift from in-patient to outpatient is notinherently a problem. The issue is the quality of care provided, itsaccessibility, and the outcomes desired, limiting or denial of services needed,and the addition of a gatekeeper between with the doctor and patient.12

(828) 257-4460http://www.mahec.netThe most profound change in the behavioral health field in this decadeoccurred in payment systems. Until recently payment for medical andpsychiatric services was based on a fee-for-service model. The patient (or theinsurer) paid the doctor directly for the cost of the service—either in monetaryform or in bartering for services. Every payment system entails potentialconflict of interest and the fee-for-service system (FFS) was not exempt. Inthe FFS system there was a greater incentive to over-treat. The bill for theseservices became excessive, driving the purchaser and payer to put limits oncare. Along with limits came creative ways of arranging payments, such asincreased payment (termed ―co-pays‖) by the patient and increasedgatekeeping functions by a primary care physician (PCP). Pre-determinedlimits on the range and nature of services were established by formulasdesigned by purchasers and payers. The administrative cost to all aspects ofthe system to manage care grew. MCOs today spend 17% of the healthcarebudget to monitor providers. (22) Treatment providers devote 15-22% of theirbudget to maintain administrative systems demanded by MCOs. Directclinical costs must be reduced by at least 32% to break even. MCOs reducedthese administrative costs by forming treatment alliances, mergers andacquisitions, competition, and ―one-stop shopping‖ for resources. This bringsan array of ethical challenges as the health industry seeks to justify care andmanage costs.An essential question is who pays the bill. According to a USA Today articleof October 23, 1999, government and insurance companies have beenpicking up more of the costs of care over the past 30 years. In 1960, 55% ofthe costs were paid out-of-pocket by individuals, 23% by private insurance,and 22% by government. In 1997 45% was paid by government, 36% byprivate insurance, and only 19% by individuals. This shift has been one of themost significant, yet little understood aspects of the health care costescalation process for its far-reaching repercussions for the purchasers andpayers. (23)A second change in the payment system was increased capitation systemsthat involve the settlement of a flat amount paid to an MCO for each individualin a population of ―covered lives.‖ The MCO was responsible for meeting theidentified needs of each eligible person for a specific period of time regardlessof the cost. Capitation rates were negotiated by the MCO to pay the caregivera flat amount for services regardless of how many patients she saw or forwhat services. By having financial incentives for the provider to keep downthe nature, type, and extent of services provided, an inherent risk of underservice is raised. Financial risk is spread throughout the system, in contrast tothe former system of FFS system where the purchase and payer bore therisk. 2001 DLC, LLC13

http://www.mtn.ncahec.orgA third change in the four Ps was brought about by the increased role oftechnology in the collection of patient data. This is done through modelingprograms. Purchasers and payers maintain information on providers’ feestructures, the diagnoses with which they are most effective, outcome dataand an array of other information using algorithmic formulas. Called ―providerprofiling,‖ a managed care case manager can examine the background of theprovider before a referral is made and pre-determine the anticipated results oftreatment and the estimated costs. In medical/surgical care this may bereliable information. In substance abuse, a disease of recidivism and relapse,this information is less reliable. In behavioral health, the field has notdetermined outcomes for care. Such data is unreliable and potentially anexcuse for the denial of services.In response the behavioral health field has developed improved diagnostictools, such as the American Society of Addiction Medicine’s (ASAM) PatientPlacement Criteria #2. Funding sources such as the US Department of Healthand Human Services (HHS), the Center for Substance Abuse Treatment, andthe National Institutes of Drug Abuse and Alcoholism and Alcohol Abuse(NIDA and NIAAA) have conducted patient matching studies to show whattreatment works best with which patient. NIAAA's Project MATCH (the mostextensive patient matching study ever performed in any medical andbehavioral health care field) has produced fascinating results. The singlemost important variable in treatment outcome is not the specific treatmentprovided or intervention made but the proper matching of patient needs withprogrammatic resources. The quality of the initial patient contact and thepatient’s readiness for change are major contributing factors to outcome,regardless of the type of services provided. (24)Changes have also occurred in where patients a

This Distance Learning Course (DLC) was developed for the Distance Learning Center for Addiction Studies (DLCAS) by David Powell. It is based on his original work by the same name. This manual contains the complete set of course materials along with the post test that is required to obtain the credit certificate for the course. We have