Managed-care companies get much of the blame for lack of quality addiction-treatment services, and this criticism often is well-deserved: A managed-care firm that puts cost over quality can do a brutally efficient job of undercutting health-insurance benefits that look generous on paper.

But advocates for increased treatment services need to remember that it is employers, not managed-care firms, who ultimately make the decisions about the kind of health-care coverage their employees get, according to employee-assistance program (EAP) leaders who spoke at Join Together's recent Demand Treatment! (DT) Institute in Tempe, Ariz.

Behavioral-healthcare services "have become a commodity," said Paul Hedquist, CEO of the Employee and Family Resources EAP and a member of the Des Moines, Iowa DT team. "Employers are buying [coverage] on the basis of cost only ... Managed-care organizations and insurers are in fact very good businesspeople: They've seized upon what employers are willing to pay for."

On the other side of the coin, said Hedquist, "Insurance companies will write any coverage that companies are willing to pay for." That's why it is so important for treatment advocates not only to make the case about the cost-effectiveness of treatment to employers, but also to get employees to demand better treatment services for themselves.

Unfortunately, fear and stigma not only prevent many employees for advocating for better addiction coverage, they often stop them from utilizing whatever employer-provided treatment benefits they do have. "Some employees fear that once they access their benefits their employers will know about it, even though there laws to protect the confidentiality of records," noted Richard Barrett, EAP director for the city of Houston, Texas. "A lot of people private-pay so they don't have to deal with that."

But lack of outcry from employees is just one reason why employers and health insurers have been content to offer bare-bones coverage for addiction. Economics also plays a huge role, said experts on the DT meeting's panel on "EAPs and Other Non-Public Systems of Care."

In Iowa, for example, some employers have refused to let EAPs do orientation or management training to identify people with addiction problems because of the time and cost involved. And when treatment advocates try to argue that a short-term investment in treatment can yield big long-term cost savings, they are butting up against the reality of rapid turnover in HMOs and managed-care organizations. When these companies only are responsible for patients for short periods of time, experts note, arguments about prevention tend to fall on deaf ears.

EAPs, a traditional advocate for patients, have also fallen on hard times, industry leaders said. Many have been wiped out by managed-care companies like Magellan, which offers bargain-basement EAP services along with the managed behavioral-healthcare services it provides to employers. Some insurers even offer free EAP services as an enticement to employers, who seem unconcerned that employees who need help could end up talking to someone on the phone rather than meeting with a counselor in person.

Many EAPs also have shifted their focus away from addiction issues, reinventing themselves to address a broader range of "work-life" issues, including mental health, child care, elder care -- even concierge services -- said Hedquist. As a result, EAP staffing has changed, with fewer addiction counselors and more social workers and family therapists.

In the absence of a grassroots campaign to demand better treatment services, many advocates have turned to legislative intervention, such as parity laws, to improve patient care. Pointing to the relatively low utilization rates of employer-covered treatment services, EAP experts said a compelling argument can be made to legislators that behavioral managed care has led to huge cost-shifting from the private to public sectors. "The people being seen in the criminal-justice system now, we would have seen in the workplace 10 years ago," said Hedquist.

Even parity benefits can be watered down by managed care or other gatekeepers, however. In order to truly change the way addiction problems are treated by employers and the health-care system, advocates acknowledge that they must first address the stigma that colors the judgment of CEOs and benefits administrators and keeps employees from demanding better care.

"We need to look to and learn from the AIDS movement," said Hedquist. "Things only happened when the people who were afflicted with the disease demanded to be dealt with as people." Such advocacy may not be polite, experts said, but it can yield results.