Two of the latest buzzwords are transparency and accountability. It has become fashionable to speak about transparency in interactions, exchanges, business relationships, and service delivery. All levels of healthcare services have been examined through the lens of transparency. Accountability also has taken on a life of its own as healthcare organizations increasingly are scrutinized. Implicit in these terms’ application is the understanding that when organizations deliver services, there needs to be organizational transparency and accountability to ensure that the fees paid are related to the services provided.
Nearly 20 years ago, healthcare reimbursement, especially reimbursement connected to employer-sponsored health plans, was based on the concept of retrospective payment. Services were provided, a bill was generated, and the insurance company issued payment (usually a percentage of the bill) based on a client's policy. In hindsight, it was relatively easy to be successful in that business climate—and accountability often was left out of the equation.
Managed care then came along and demanded transparency and accountability. Chemical dependency treatment experienced managed care's entry more painfully than any other healthcare sector. Moving from retrospective payments to tightly managed payments was a quantum leap for the field. And that leap was required because payers perceived that the chemical dependency treatment system lacked transparency and accountability.
In some ways, managed care was right. In the 1980s, chemical dependency treatment providers had a tendency to admit persons who had embarrassed themselves or others because of their involvement with alcohol or other drugs. Providers made less of an attempt to clinically differentiate among persons who were problem, abusing, or dependent drinkers/users. The concepts of transparency and accountability, to some extent, were set aside so as to be able to include as many persons in treatment as possible.
Clinical sophistication and research advancements have moved us a considerable distance from where we were in the 1980s. We now know that there is a continuum of drug-using behavior, with abuse near one end and dependence on the other. We now have much more discrete criteria by which to make a dependency diagnosis. Yet too often we continue to confuse abuse and dependence.
The difference between abuse and dependence has real consequences. Federal and state governments are overwhelmed with increasing healthcare costs, and U.S. businesses are losing the competitive advantage in the global economy because of rising healthcare costs. If we continue to blur the distinction between abuse and dependence, we will commit precious healthcare dollars to include persons in treatment when they do not meet the criteria for dependence.
Persons who abuse alcohol or drugs, but don’t meet the criteria for dependence, need help from a separate system, one that recognizes the tremendous social implications of their actions but is not funded with healthcare dollars. As competition for ever scarcer healthcare dollars increases, chemical dependency treatment organizations must be clear that their primary focus is on the chemically dependent population and that the process to determine dependence is both transparent and accountable.
Suffering public embarrassment, indiscretion, or intoxication because of alcohol/drug use does not automatically mean a person is chemically dependent and qualifies for treatment. We must have a transparent process for admitting people to chemical dependency treatment, and we must be held accountable for spending the healthcare dollars entrusted to us. Our field has struggled because we did not pay attention to this in the ’80s and early ’90s, so managed care made us pay attention. Now we have an opportunity to take the initiative and demonstrate transparency and accountability. I believe that we are up to the task.
Ronald J. Hunsicker, DMin, is President and CEO of the National Association of Addiction Treatment Providers. He is also a member of Behavioral Healthcare's Editorial Board.