MEDICAID MANAGED CARE, SUBSTANCE ABUSE TREATMENT, AND PEOPLE WITH DISABILITIES: Review of the...

Nearly 7 million Americans with disabilities receive federally sponsored cash support and health care benefits from the Supplemental Security Income (SSI) program (U.S. House of Representatives, 2000). These individuals experience a range of long-term disabling conditions that bring them into contact with health care and other social services systems. Social workers in these varied settings are likely to encounter individuals with disabilities who receive SSI.

Research has documented a high rate of co-occurring substance abuse disorders among SSI beneficiaries with mental health disorders. However, the prevalence of substance abuse disorders among individuals receiving SSI because of other long-term disabling conditions is not as well documented. Medicaid costs for providing health care to individuals receiving SSI are higher than costs for other Medicaid beneficiaries. A co-occurring substance abuse disorder may increase the expense and complexity of providing services to people who receive SSI.

We present the results of our literature review about the prevalence of co-occurring substance abuse and disability. In addition, we review published studies that addressed the utility of Medicaid managed care plans for providing services to people with disabilities and substance abuse disorders. Theoretically, capitation, a financing mechanism often used in Medicaid managed care plans, might offer social workers the flexibility they need to arrange comprehensive services that meet the needs of individuals with co-occurring disability and substance abuse disorders. However, in most states, individuals who receive SSI are enrolled in Medicaid managed care plans without a clear understanding of the prevalence of this problem or whether there are best practice managed care models available to meet their individual needs. We summarized the literature around three themes:

* the prevalence of substance abuse disorders among people with disabilities

* Medicaid managed care and people with disabilities

* substance abuse treatment and Medicaid managed care.

Implications for social work research, policy, and practice are presented.

LITERATURE REVIEW

Substance Abuse Issues among People with Disabilities

The Contract with America Advancement Act of 1996 (P.L. 104-121) mandated that individuals could no longer qualify for SSI solely because they were disabled as a result of substance abuse, and on January 1, 1997, the SSI benefits of about 200,000 individuals across the country were terminated (Gresenz, Watkins, & Podus, 1998). After this legislative change, about 43 percent of individuals receiving SSI had physical disabilities (including chronic illnesses); 28 percent had mental retardation or developmental disabilities; and the remaining 29 percent were people with mental illness (Social Security Administration, 1996). About 35 percent of individuals who lost SSI benefits on January 1, 1997, reapplied and were allowed to continue SSI benefits because they met eligibility criteria for another disabling condition (Watkins, Podus, Lombardi, & Burnam, 2001).

No studies have systematically examined the substance abuse treatment needs of individuals who receive SSI, particularly in the context of managed care. Results of related studies about substance abuse and disability provide a context for inquiry. For example, Moore and Li (1998) surveyed clients who were receiving services from state vocational rehabilitation agencies in Ohio, Michigan, and Illinois. Higher rates of drug use were found among people receiving rehabilitation services for all major drug categories, and use of crack cocaine was three times higher for this group than for the general population. Li and Ford (1998) showed that illicit drug use was higher for women with disabilities than for women without disabilities for most major drug use categories.

Buss and Cramer (1989) found that individuals with disabilities used alcohol at the same or higher rates as the general public, depending on the disabling condition. About a quarter of respondents reported abstaining from alcohol, 15 percent reported heavy drinking, and 20 percent reported moderate drinking. Similarly, the National Association of Alcohol, Drugs and Disability (1999) reported that half of individuals with traumatic brain injuries, spinal cord injuries, or mental illness had problems with substance abuse, compared with a prevalence of about 10 percent in the general population.

Over the past decade, the prevalence of co-occurring psychiatric and substance abuse disorders and the challenges of providing services to individuals with this dual diagnosis have been documented (Brown, Ridgley, & Pepper, 1989; Drake, McLaughlin, Pepper, & Minkoff, 1991; Drake, Teague, & Warren, 1990; Gournay, Sandford, Johnson, & Thornicroft, 1997). The national Epidemiologic Catchment Area (ECA) study demonstrated significant comorbid substance abuse among individuals with schizophrenia and bipolar disorder (Regier et al., 1990); other studies have shown that up to 80 percent of individuals disabled by mental illness also had a substance abuse disorder (Drake, Bartells, Teague, Noordsy, & Clark, 1993; Drake, Osher, & Wallach, 1989; Safer, 1987). Results of the ECA study and other research showed that substance abusers with psychiatric disabilities had treatment costs that were almost 60 percent higher than costs for non-substance abusers (Kivlahan, Heiman, Wright, Mundt, & Shupe, 1991; Regier et al., 1990).

Researchers also have shown a relationship between disability payments, schizophrenia, and substance abuse. Shaner and colleagues (1995) suggested that among a population of men with schizophrenia, there was a cyclical pattern of drug use, psychiatric hospitalization, and psychiatric symptoms that coincided with the arrival of disability payments. Other authors (Phillips, Christenfeld, & Ryan, 1999; Satel, 1995) suggested that the receipt of federal disability payments may be associated with increased drug use.

Other studies have shown that substance abuse disorders affect individuals with disabilities other than mental illness. For example, individuals with disabilities caused by central nervous system injuries are more likely to report substance abuse (Basford, Rohe, Barnes, & DePompolo, 2002). A study by Heinemann and colleagues (1991) showed that individuals with spinal cord injuries had rates of moderate and heavy drinking that were twice that of the general population. A large proportion of the sample reported problems with use of prescription medication, alcohol, and illicit drugs, and 70 percent of the sample reported one or more problems related to substance abuse (Heinemann et al.). In another study of individuals with traumatic brain injury, 38 percent of respondents reported lifetime abuse of alcohol or drugs (Fann, Katon, Uomoto, & Esselman, 1995). In some cases, substance abuse may have contributed to the injury that resulted in loss of function, but in other cases, substance abuse followed the injury.

Gilson and colleagues (1996) analyzed data from the National Household Survey on Drug Abuse, focusing on people who identified as "disabled, unable to work." Individuals who self-identified in this category were more likely than others to report that illicit drug use was a significant problem. Adlaf and colleagues (1992) found that people with moderate work disabilities were more likely to report alcohol problems and that tranquilizer use was more common among women with total limitations and over age 40 with sensory disabilities. Among those admitted to residential addictions treatment programs, people with disabilities were more likely to identify tranquilizer use as a problem (Ogborne & Smart, 1995). Tyas and Rush (1993) estimated that the prevalence of clients with disabilities in addiction treatment was highest for those with psychiatric disorders, followed by those with physical disabilities and developmental disabilities.

Westermeyer and colleagues (1996) found that individuals with mental retardation or developmental disabilities began using substances at a later age, used fewer substances, and demonstrated a milder and briefer period of use. Rivinus (1988) found that men with mental retardation or other developmental disabilities were affected by alcohol abuse more frequently than women. Also, women with mental retardation or developmental disabilities under age 35 were more likely to have an alcohol use disorder than those over age 35. Pack and colleagues (1998) investigated urban African American youths with mild mental retardation or developmental disabilities and found that they were more at risk of binge drinking than other African American adolescents. Poling (1997) indicated that controlled research about the origins, treatment, and prevention of drug abuse among people with mental retardation or developmental disabilities is insufficient.

We identified only two studies about substance abuse among deaf or blind individuals (Glass, 1980; Isaacs, Buckley, & Martin, 1979). A substantial body of literature focused on how substance use leads to long-term disability, such as spinal cord injuries (Heinemann et al., 1991), multiple sclerosis (Brousseau, Phillippe, Methot, Duquette, & Haraoui, 1993), and HIV/AIDS (Metzger, Navaline, & Woody, 1998; Ryan, Huggins, & Beatty, 1999). Rehabilitation professionals have expressed concern that substance abuse among people with traumatic brain injury has not received enough research attention (Langley, Lindsay, Lam, & Priddy, 1990).

The frequency with which people with disabilities recognize substance abuse problems and seek treatment has not been well documented. Participants in the Heinemann et al. (1991) study did not believe they needed treatment for substance abuse problems, or were using substances at the time of their spinal cord injury, possibly contributing to the injury. Beaudin and colleagues (1997) surveyed consumers in New Mexico and found that 23 percent of those seeking mental health or substance abuse treatment reported problems with access, particularly transportation barriers. Consumers also experienced other barriers to care, such as physical access barriers and limited knowledge among providers about the special needs of individuals with disabilities (Beaudin et al.).

In their survey of addiction treatment services for people with disabilities, Tyas and Rush (1993) found limited provider knowledge about how to best provide addictions services. Few agencies reported services targeted to people with disabilities and expressed the belief that specialized programs would be most effective, because general programs have neither the knowledge nor the resources to adequately serve these individuals. Polinsky and colleagues (1998) examined whether the drug treatment needs of special populations, including people with disabilities, were met in a large metropolitan area. Although a majority of programs did not serve individuals with disabilities, they claimed to be able to do so. A more recent study by Basford and colleagues (2002) showed that workers in a majority of inpatient rehabilitation training programs were concerned about alcohol and drug problems among their patients.

Medicaid Managed Care and People with Disabilities

Since the inception of the Medicaid program, there has been a steady growth in health care expenditures for beneficiaries. From 1975 to 1990 total Medicaid payments increased from $12.2 billion to $66 billion (Reilly, Clauser, & Baugh, 1990). From 1990 to 1998 national Medicaid expenditures tripled to nearly $200 billion (U.S. House of Representatives, 2000). Contributing to the growth in Medicaid expenditures were payments for SSI beneficiaries who received health care coverage through Medicaid.

Although the number of individuals who receive SSI increased rapidly over the past 25 to 30 years, the rate of growth in Medicaid expenditures for this group exceeded the rate of growth in number of recipients. In 1974, 2.4 million SSI beneficiaries accounted for Medicaid expenditures of approximately $3.1 billion (U.S. House of Representatives, 1998); by 1996, 6.7 million SSI beneficiaries had Medicaid expenditures of more than $57 billion (Kaiser Commission, 1999). SSI beneficiaries account for a disproportionate share of costs based on their portion of the overall Medicaid population. For example, in 1996, SSI beneficiaries accounted for about 16 percent of the Medicaid population, but accounted for almost 37 percent of total Medicaid dollars (Kaiser Commission). Acute care, including acute mental health and substance abuse treatment, accounted for 58 percent of Medicaid spending for SSI beneficiaries (Kaiser Commission). State policymakers have sought to improve and maintain high-quality care for this population, while controlling costs. One policy was to expand Medicaid managed care options (U.S. House of Representatives, 1998). In 1985 the number of Medicaid beneficiaries in managed care plans was fewer than 1 million; by 2000 this number had increased to 18.8 million, representing 56 percent of all Medicaid beneficiaries (Health Care Financing Administration, 2001).

In 1998, 1.6 million nonelderly people with disabilities were enrolled in Medicaid managed care, representing 12 percent of total Medicaid managed care enrollment (Kaiser Commission, 1999). This level of Medicaid managed care enrollment by people with disabilities represents significant growth in managed care for this population. In 1994 only 15 states encouraged or required individuals who receive SSI to enroll in Medicaid managed care (U.S. General Accounting Office, 1996). In 1996 this number increased to 25 states. Because the Balanced Budget Act of 1997 (P.L. 105-33) allows states to mandate managed care enrollment for adults with disabilities without a federal waiver, states have further increased enrollment of people with disabilities in Medicaid managed care. In 1999, 36 states enrolled SSI beneficiaries in Medicaid managed care (Kaiser Commission). Of these, 30 states enrolled these individuals in capitated managed care plans (some include both capitated and fee-for-service options), whereas six states operated only fee-for-service managed care programs.

Substance Abuse Treatment, Medicaid Managed Care, and People with Disabilities

As a response to better understanding of the impact of substance abuse on overall health care costs, many states have used managed care to deliver and pay for substance abuse treatment. In 1991, 80 percent of all substance abuse treatment was fee-for-service, but by 1995, about 75 percent of substance abuse treatment was financed through managed care (McLellan et al., 1997). Irrespective of managed care, research has shown that substance abuse treatment contributes to the overall growth in Medicaid expenditures. Fox and colleagues (1995) examined substance abuse prevalence among the overall Medicaid population and the contribution of substance abuse disorders to rising Medicaid costs. They found that 20 percent of Medicaid inpatient days were spent on care related to substance abuse. Managed care plans are likely to be offered as a solution to these high costs.

According to the federal Substance Abuse and Mental Health Services Administration's (SAMHSA, 1999) Managed Care Tracking System data collected by the Lewin Group between January and July 1997, 47 states implemented some form of behavioral health managed care. Of these states, 44 used Medicaid (or a combination of funds including Medicaid) to fund 70 managed care arrangements. Of these 44 states, 33 enrolled people with disabilities in behavioral health managed care programs, either on a voluntary or mandatory basis. Although the SAMHSA data indicate that 25 of the states that enrolled people with disabilities in behavioral health managed care included substance abuse treatment as part of the behavioral health benefit package, there is great disparity among states about what substance abuse benefits are available (McCarty, Frank, & Denmead, 1999). In some state Medicaid programs, it is difficult to identify which substance abuse treatment benefits are covered.

Studies also have been done about whether states should "carve-in" or "carve-out" mental health and substance abuse services in their Medicaid managed care programs (Bachman, Burwell, Albers, Herz, & Jackson, 1997; Frank & McGuire, 1997), and the successes and failures of different carve-out models (Chang et al., 1998; Frank & McGuire). Few of these evaluations focused on individuals with long-term disabilities or specifically on substance abuse.

Reliance on managed care organizations to provide substance abuse treatment services for Medicaid recipients with disabilities may either limit access to substance abuse treatment services or provide opportunities for innovation in how these services are delivered. However, there is scant published data about outcomes associated with the use of managed care for substance abusers who also have disabling conditions (Batki & Selwyn, 2000). The policy environment in which these service systems operate is complex. For example, federal law does not require state Medicaid programs to cover substance abuse services. Even if the services are covered by Medicaid, substance abuse treatment providers that participate in the Medicaid program may not be physically accessible to people with disabilities or able to accommodate their medical or cognitive needs.

IMPLICATIONS FOR RESEARCH

The literature reviewed in this article suggests three themes that may influence policy and practice related to the needs of individuals who experience both a disabling condition and a substance abuse disorder. First, individuals with a wide range of disabling conditions, including mental illness and other cognitive and physical disabilities, may also experience substance abuse disorders. Second, individuals with long-term disabling conditions may receive benefits through the SSI program and as a result are more likely than ever to be enrolled in Medicaid managed care plans. Third, substance abuse treatment services are increasingly included in managed care benefit packages. These trends suggest that individuals with disabilities may be at greater risk of substance abuse disorders, may be more expensive and complicated to serve, and are more likely to be enrolled in Medicaid managed care plans.

Despite the fact that some people with disabilities need substance abuse treatment, there is little research about whether substance abuse treatment models are tailored to meet the access and clinical needs for this population. Moreover, no research documents whether Medicaid managed care plans use the flexibility afforded them by capitation to develop creative substance abuse treatment delivery models for individuals with serious disabilities. More research is needed to determine how the substance abuse treatment needs of individuals with disabilities can be met through Medicaid managed care. Research projects are needed to

* clarify the prevalence of substance abuse disorders among subgroups of individuals with disabilities who receive SSI

* investigate the prevalence of illicit versus licit substance abuse among individuals with disabilities who receive SSI

* clarify the difference between substance use and abuse among individuals with disabilities who receive SSI

* demonstrate innovative ways to use social work expertise in care management for people with disabilities who also experience substance abuse disorders

* develop strategies to monitor and maximize consumer satisfaction with substance abuse treatment in managed care plans

* identify gaps in substance abuse treatment services available for people with disabilities and use the flexibility of managed care to determine the role of social workers in filling these gaps

* identify the role that social workers play in intervening or creating circumstances that promote treatment of substance abuse among people with disabilities

* assess substance abuse treatment provider competence and experience in serving people with disabilities

* assess whether providers that serve people with disabilities are included in provider networks of managed care plans

* examine cost and utilization of health care and substance abuse treatment services by people with disabilities in managed care plans

* examine variation in need for substance abuse treatment according to disabling condition and level of disability

* catalogue the methods managed care plans use to serve individuals with disabilities, including identification of best practices

* identify alternative provider and managed care financing that maximizes the flexibility afforded by capitation

* study the relationship between substance abuse and the disability, including the role substance abuse had in acquisition of the disability and how substance abuse affects the course of the disability

* determine whether managed care arrangements affect patterns of substance abuse and disability treatment, including an analysis of the benefits of integrated versus carve-out arrangements

* estimate the appropriate mix of care management and treatment services for people with disabilities in managed care plans.

IMPLICATIONS FOR SOCIAL WORK POLICY AND PRACTICE

Social workers are well positioned to take a leadership role in these research activities and extend the knowledge base with respect to substance abuse treatment, managed care, and people with disabilities, especially given the roles of social work in in multiple health care settings. For example, from a practice perspective, social workers are trained to develop and evaluate the care management and service coordination functions of managed care plans. Social workers are also well suited to conduct client assessments and identify and coordinate the services that individuals with complex disabling conditions need. Social workers can determine gaps in service delivery networks and develop creative ways to fill these gaps with respect to substance abuse treatment alternatives. Moreover, the social work framework of understanding the individual in a social environment may be the most appropriate perspective for creating innovative strategies to address the complex, multidimensional needs of people with disabilities who also experience substance abuse problems.

From a policy perspective, social workers can contribute to research and evaluation to identify innovative models of organizing, financing, and delivering substance abuse treatment services to people with disabilities in a managed care setting. Because social workers are actively involved in treatment and social services care coordination, they can identify alternative providers and financing arrangements that maximize the flexibility afforded by capitation and draw from a range of services to best meet consumer needs. Research could include a determination of whether various managed care arrangements affect patterns of substance abuse and disability treatment, including an analysis of the benefits of integrated compared with carve-out arrangements. From either the practice or policy perspective, the research agenda is extensive and the contribution of social work to improving the lives of people with disabilities could be significant.