Declaring that it is imperative that health maintenance organizations (HMOs) recognize that physicians and health care professionals possess different levels of education, training, and expertise in treating substance abuse disorders, the American Society of Addiction Medicine (ASAM) has teamed up with the American Managed Behavioral Healthcare Association to publish "A Guideline for Credentialing and Privileging of Clinical Professionals for Care of Substance Related Disorders."

"As the managers of networks seek to determine who is an appropriately trained and skilled provider," the guidelines state, "it is important for consumers and managers. . .that decisions about credentialing and privileging are made objectively, equitably, accurately, and based on data and reasonable criteria."

ASAM secretary Michael M. Miller, M.D., notes in the May/June ASAM News that one reason for the development of the guidelines is to address growing concern over the competence of a variety of nonpsychiatrist substance abuse professionals working for HMOs and other managed care organizations such as mental health care carveouts.

The guidelines categorize various clinical activities commonly associated with treating substance abuse disorders into three groups: those clinical activities appropriate for addiction specialists; those appropriate for primary care physicians, physician assistants, and nurse practitioners; and those appropriate for non-addiction-focused, mental health specialists.

For example, prevention activities and screening for addiction, intoxication, and withdrawal are, according to the guidelines, appropriate for health care professional in all three broad categories. Assessment and diagnosis of intoxication is listed as appropriate for any professional from any category that is legally authorized to diagnose.

However, the guidelines restrict the granting of privileges that would allow clinicians to perform more complex clinical activities to more highly trained and educated health care professionals. For example, for management of intoxication or withdrawal when it is severe or complicated, privileges should be restricted to a psychiatrist or primary care physician who specializes in addiction medicine, or to primary care physicians in internal medicine.

Similarly, assessment and diagnosis when a dual diagnosis is a consideration should only be performed, according to the guidelines, by a general psychiatrist or one who specializes in addiction treatment, by a primary care physician with demonstrated training/expertise, or by a doctoral-level psychologist with demonstrated training/expertise in this area.

For management of medical complications in substance abuse treatment, privileging should be restricted to a primary care/internal medicine physician, with or without an addiction treatment specialty.

The guidelines were particularly intended, according to ASAM, to help credentialing departments in HMOs and other managed care plans know how to evaluate nonpsychiatric education and training. The guidelines point out that, "What has been proposed should be viewed as a stimulus to managed care organizations and practitioners alike as they explore more fully their own privileging policies and procedures, and viewed as a guide, not an absolute standard."