Alcohol and Alcoholism Vol. 38, No. 1, pp. 95-96, 2003
© 2003 Medical Council on Alcohol
BOOK REVIEW
Recent Developments in Alcoholism — Vol. 15. Services Research in the Era of Managed Care.
Edited by Marc Gallanter. Kluwer Academic/Plenham Publishers, New York. 2001, 465pp., £105.75. ISBN: 0-306-46441-1.
This is the 15th volume in a series which has a well-established reputation for providing authoritative and up to date information about alcohol and alcohol misuse.
During the past 10 years ‘managed care’ has transformed the character of treatment for individuals in the USA. Many believe this has rationed and constrained treatment to the detriment of patients, while others contend that it has simply brought about overdue rationalization, rather than rationing. The American Society of Addiction Medicine, of which this is an official publication, believes that managed care has been associated with a drastic reduction in the frequency and duration of in-patient hospitalization which has not been balanced by a corresponding increase in the availability and prevalence of out-patient treatment. Most treatment programmes for alcohol problems are governed by the system of ‘managed behavioural healthcare’, which aims to control cost and maintain quality. The UK National Health Service is very familiar with trying to balance this equation. The complexities of the debates concerning managed care may be unfamiliar to readers outside the USA, but it is easy to recognize the issues of cost containment, cost effectiveness and value for money, which challenge all healthcare systems at present.
This book demonstrates the way which the burgeoning of managed care has concentrated the minds of service providers and challenged treatment services to think again and evaluate the effectiveness of existing patterns of care and individual treatments. Many of the research projects which have informed those debates are reported in this volume. In consequence, this book will be of interest to all practitioners, particularly those concerned with the delivery and evaluation of services, health economists and service planners.
Although there is understandable concern about the impact of these trends, the good news now is that ‘treatment works’ as Connie Weisner points out in a section entitled ‘Access to Treatment in the 21st Century; old worries and new optimism’. The clinical trials and a large number of Health Service studies set in ‘real world’ public and private agencies have demonstrated that, not only is treatment effective, but it can be cost effective. Much of the evidence giving rise to this conclusion is reviewed here. She introduces a section containing chapters about access to care and the organizational and financial factors that influence this. There has been a significant move towards the mainstreaming of services, for which specialist agencies provide the training and templates for assessing and treating individuals with alcohol problems. In this way, the specialist service becomes a resource for other frontline agencies and focuses its clinical activities on the most complex cases. The concept of stepped care now seems to be well established. Patients are treated in the simplest and most accessible way in the first instance, and only progress on to very specialist interventions if these are truly necessary. In this way, a wider range of patients/clients will be reached, but ensuring the quality and equity of this care is a concern. The diversity of alcohol-related problems inevitably places a premium on ensuring the capacity to recognize and respond to hazardous drinking at point of first contact and particularly within primary health care. It also places an imperative on linkages between an effective co-operation amongst a wide range of agencies. Funding mechanisms need to facilitate rather than frustrate this process. It is often difficult to persuade agencies, particularly where there are already starved funds, to collaborate in joint commissioning and joint care ventures. Different communities pose different challenges and the particular problems of organizing and accessing care in rural areas are examined in a chapter by Fortney and Booth.
A proper concern about cost has prompted an increasing literature on the economic aspect of service delivery. This topic is carefully considered in this volume, although from an exclusively USA perspective. Nonetheless it considers issues of a universal significance, the need to assess outcomes in terms of cost to the individual, their family and the larger society. When physical decline is averted, employment regained and family disruption minimized, then these gains need to be measured econometrically. It is too narrow to focus only on drinking behaviour. Looked at from this broad perspective, treatment becomes eminently worthwhile, not only in that it benefits the individual, but also for the economic benefits of the community at large. It is still true that many of the studies that have been undertaken have been disappointingly short-term and narrow in focus. Longer term perspectives and broader outcome measures are urgently needed.
This book is a worthy addition to this well established series. It is somewhat more focused on the problems existing in the USA than some of its predecessors, but it contains much of interest to the wider reader and volume 15 should join its predecessors on many specialist library shelves.
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