CLINICAL-BASED VS INSURANCE-BASED RECOMMENDATIONS FOR SUBSTANCE-ABUSETREATMENT LEVEL

An exploratory study of 250 patients was conducted at three treatment facilities in Western Pennsylvania, USA, to determine: 1) the extent o f disagreement between clinical-based [using American Society of Addic tion Medicine (ASAM) criteria] and insurance-based [using Managed Care Organization (MCO) criteria] recommendations for treatment levels, an d 2) the extent of ASAM recommendations that become the actual treatme nt. Cross-tabulations showed: 1) ASAM and MCO recommendations were the same for 85% of the cases, and 2) ASAM recommendations became the act ual treatment in 93% of the cases. The exceptionally high level of ASA M-MCO agreement suggests a convergence in ASAM and MCO criteria and a deference to ASAM criteria in practice.