In the United States, alcohol and other drug (AOD) detoxification
services are provided in many different settings: general medical and
psychiatric hospitals, inpatient AOD treatment programs, outpatient
clinics, and social model detoxification programs. There is no one
national reporting system that tallies the number of detoxification
episodes each year in the United States. Discussions of the costs
associated with detoxification must address the following
considerations:
In a general medical hospital, detoxification may be provided
incidentally to treatment of injuries or complications of AOD
dependence.
Detoxification services may not be documented in the medical records
or through insurance billing because the indication of AOD abuse may
jeopardize insurance coverage and may alter the confidentiality
requirements for the records.
Methadone and other drug treatment clinics often provide
detoxification services as a component of comprehensive treatment.
State reporting systems do not distinguish admissions that involve
detoxification.
Given the uncertainties inherent in estimating the number of
detoxification episodes and the settings in which they occur, the annual
cost of detoxification services in the United States is unknown.
Current patterns of funding for AOD treatment are poorly coordinated
and inflexible. The percentage of public funding earmarked for treatment
has never been able to keep pace with demand. The following areas are
of key concern:
The need for coordination. More than three dozen
Federal agencies fund AOD abuse treatment programs. No formal system
exists to coordinate Federal agency activities. Furthermore, more than
75 congressional committees or subcommittees have oversight and funding
authority over AOD abuse programs (Wilford,
1993).
The need for flexibility. Many Federal programs are
categorical. This approach restricts efforts to construct an
integrated, comprehensive treatment system. Ancillary service
components such as transportation and child care are overlooked, and in
their absence clients are unable to gain access to available treatment
services (Center for Health Policy Research,
1993).
The Substance Abuse and Mental Health Service Administration
(SAMHSA), an agency of the Department of Health and Human Services
(DHHS) , is the major source Federal support for treatment and related
services for persons who are mentally ill or chemically dependent.
SAMHSA is composed of three agencies: (1) the Center for Substance
Abuse Treatment (CSAT), (2) the Center for Substance Abuse Prevention,
and (3) the Center for Mental Health Services.
SAMHSA administers the DHHS AOD block grant program, which is the
primary source of long-term Federal funding to the States for publicly
supported AOD abuse treatment and prevention programs. In creating
SAMHSA in 1992, Congress divided the block grant program into two parts:
one for mental health and one for substance abuse prevention and
treatment. The latter was authorized at $1.13 billion for fiscal year
1993, of which 35 percent was targeted to alcohol abuse services, 35
percent to drug abuse services, and 20 percent to prevention. Half of
the remaining 10 percent was earmarked as a set-aside for special
programs. Currently, this set-aside targets pregnant women and women
with dependent children. According to the Center for Health Policy
Research (CHPR), the remaining 5 percent was used by SAMHSA for
technical assistance, data collection, program evaluation, and the
creation of a national prevention database (Center
for Health Policy Research, 1993).
Block grant funds are awarded to the single State agency in each
State. The States distribute the funds according to their own
priorities, within established Federal guidelines. Each State that
receives block grant funds is required to submit a plan to the Federal
Government. This plan must incorporate input from the public.
Allocation procedures at the State level vary considerably. Each State,
moreover, has a different format for reporting use of funds;
consequently, tracking resource allocation and use of set-asides is
difficult.
Categorical SAMHSA programs that may provide support for
detoxification services include CSAT's Capacity Expansion Program,
Cooperative Agreements for Drug Abuse Treatment Improvement -- Campus
Treatment Program, and Cooperative Agreements for Drug Abuse Treatment
Improvement in Crisis Areas (Target Cities) Program. CSAT's major
demonstration program for Pregnant and Postpartum Women and Their
Infants does not cover detoxification services. (For detailed
information on CSAT programs, please contact the appropriate program
division. See Appendix C for addresses and
phone numbers.)
Categorical programs from other Federal Agencies may also provide
services as part of a comprehensive health model. Information on these
programs may be found in a report titled An Analysis of Resources to
Aid Drug-Exposed Infants and Their Families(Center
for Health Policy Research, 1993), as well as in directories of
Federal grant and contract assistance programs.
Medicaid is a cooperative Federal and State program that is
administered by the Health Care Financing Administration. Medicaid is an
entitlement program and therefore is not subject to the congressional
appropriations process. States receive Federal contributions based on
per capita income; in poorer States, the Federal contribution may be as
high as 83 percent -- in wealthier States, 50 percent. States may increase
the Federal match by voluntarily raising their contribution to the
program. The States participate in Medicaid voluntarily and administer
the program within broad Federal guidelines. Eligibility requirements,
covered benefits, and provider payment mechanisms vary enormously.
Although not designed to fund AOD abuse treatment services, Medicaid
has become the most stable source of funding for such services.
Medicaid reimbursement for AOD abuse treatment doubled between 1982 and
1987 (Center for Health Policy Research, 1993;Wilford, 1993). As with the overall program, there
is little consistency from State to State with regard to individual
coverage for AOD abuse treatment or the treatment settings for which
services are reimbursed. Federal statutes stipulate that Medicaid is to
cover "medical and remedial" services. It will cover most
hospital-based services. In regard to AOD abuse treatment services, for
example, a majority of States may cover a hospital stay for a 3- to
6-day inpatient detoxification and a limited number of visits for
followup outpatient counseling (Center for Health
Policy Research, 1993). To improve access to extended treatment, Gates, (1992) suggested that States reimburse for
detoxification services contingent on coordination with long-term
treatment placement or that they design specialized case-management
services as part of the State plan.
Medicaid beneficiaries have few long-term options for coverage of AOD
abuse treatment. This lack may contribute to the cycle of relapse and
return to episodic hospital-based detoxification for some persons.
Medicaid inpatient payment statistics reflect the unrealistic structure
of the Medicaid reimbursement system. In fiscal 1994, the portion of
Medicaid hospital costs attributable to AOD abuse treatment is expected
to exceed $7.4 billion. Approximately 20 percent of annual Medicaid
expenditures for hospital care are associated with substance abuse (Center on Addiction and Substance Abuse at Columbia
University, 1993).
Many States are discouraged by the complex regulations that govern
Medicaid. Some application procedures make it difficult for individuals
to obtain benefits. Other States have responded creatively to the
challenge (Center for Health Policy Research,
1993).
States also have demonstrated resourcefulness in developing ways to
raise State revenue and thereby gain access to additional Medicaid
funding (Gates, 1992). One technique is to
transfer general State revenues intended for AOD services to the State
Medicaid agency rather than to the State Division of Alcohol and Drug
Abuse. The transferred funds become eligible for the Federal match.
Some States apply revenues from alcohol excise taxes to their Medicaid
match funds. Some States allow persons filing income tax returns to
designate that a portion of their refunds be directed to AOD abuse
treatment. Still others have enacted laws under which revenue generated
by the sale of property confiscated during convictions for drug-related
crimes are applied to the Medicaid match. And some practices are under
close scrutiny by Federal agencies and may not have produced long-term
solutions that are viable or cost effective.
Health care reform efforts, a matter of major debate at the Federal
level at the time this consensus panel convened, are having a strong
impact on clinical practice. Many States have already taken the lead in
health care reform. Since the national health care reform act was not
passed by Congress, States will continue to develop reform strategies
consistent with a managed care environment. In all likelihood, the
primary efforts for health care reform effort will proceed individually,
State-by-State, rather than on a national basis.
Facing growing financial pressures to contain costs, many States have
enacted comprehensive health care reform legislation. Coverage for
addictive disorders has been the subject of extensive State house
debate; "of more than 70 major reform bills considered in 45 States
during 1993, two thirds contained some benefits for AOD abuse treatment"
(Callahan, 1994).
Drawing on clinical experience, the continuum of care set forth in
the CHPR Model, and an appreciation of fiscal realities, the panelists
agreed that the following principles should govern the design and
implementation of AOD detoxification services and benefits systems.
Many of the recommendations concerning the number of treatment episodes
and lengths of stay are based on the Legal Action Center's Model
Legislation Mandating a National Health Insurance Benefit for Prevention
and Treatment for Alcoholism and Drug Addiction(Legal Action Center, 1993).
Each client should be assessed before entering detoxification. The
severity of predicted withdrawal symptoms, the intensity of care needed
to ensure appropriate management, and identified psychosocial and
family-support needs should determine the selection of treatment setting
and the duration and type of services offered.
A majority of patients safely undergo detoxification without being
admitted either to a hospital or to a residential setting. Nonetheless,
patients' clinical and other needs, not the likelihood for
reimbursement, should govern the choice of treatment setting. Inpatient
detoxification should not be arbitrarily limited, for example, to
patients with concurrent psychiatric problems.
The care system should be grounded in the understanding that
individuals entering AOD detoxification programs have diverse and
wide-ranging needs. While most patients will not require every
available service, the system should be structured to meet each discrete
need as well as any combination of needs. In most cases, development of
such a structure will require the creation of a system of referral and
interagency linkages. Timely and dependable communication among such
agencies is essential. If, for example, a woman who has primary child
care responsibilities enters a residential detoxification setting or is
admitted to a hospital, appropriate child care services, possibly
including room and board, should be available.
Ideally, there should be no caps on the number of covered inpatient
detoxification episodes and no limits on length of stay. At a minimum,
each participant in a health benefits plan should be eligible for 10
days of treatment in a hospital, nonhospital, or ambulatory
detoxification program, as medically necessary, during any calendar
year. If medical conditions require additional lengths of stay,
benefits should be available.
Alcoholism is a chronic disease, and most alcoholics will experience
at least one relapse. Some patients experience several detoxification
episodes before they enter long-term treatment and achieve lasting
abstinence. Given this reality, no arbitrary limits should be placed
upon the number of detoxification episodes for which a patient will
receive reimbursement or upon the length of these episodes.
Ideally, health plans should provide benefits that ensure
short-term inpatient treatment (30 days per year) in a hospital or
freestanding facility, as well as long-term treatment (up to 18 months)
in residential programs for persons who have undergone AOD
detoxification.
Outpatient treatment options should be broad. Within any calendar
year, they should include, at a minimum, as many as 160 days of
intensive and/or nonintensive outpatient visits and as many as 60 family
outpatient visits.
Planners must examine the issue of client copayments.
One view holds that even a modest copayment may pose a burden to many
clients and may discourage those initially seeking services as well as
those patients remaining in aftercare. Others believe that revenue
gained from such payments may be more than offset by the negative effect
on patient retention rates and, in the long term, recidivism. However,
some clinicians believe that even modest copayments reinforce the notion
of commitment to treatment. Requiring patients to pay something may
assign to treatment an importance equal to that of abusing AODs.
Clinicians who hold this view do not necessarily recommend full
copayments as an effort to raise revenue because they are aware that,
especially in public sector programs, most clients lack the financial
means to pay. They argue that
Case management and pharmacotherapeutic intervention should
be offered to all patients, as clinically appropriate
Benefit plans should cover the provision of patient and family
education programs in all detoxification settings; human
immunodeficiency virus/acquired immonodeficiency syndrome education is
especially important
Benefit plans must include provisions for appropriate utilization
review. Uniform patient placement criteria for AOD detoxification
services should be developed and used to support the utilization-review
process; utilization review should be performed only by individuals who
have adequate knowledge of AOD treatment issues.
Some States, including Oregon and Massachusetts, have begun to
develop patient placement criteria based on the American Society of
Addiction Medicine model (Hoffman, 1991) and to
tailor them to local needs. Properly used, such criteria ensure greater
uniformity in care and more appropriate and cost-effective allocation of
resources. They provide a safety net that protects the client from
falling to an inappropriate level of care.
Patient placement criteria, however, may be subject to
misinterpretation. For example, should a criteria set support a
specific detoxification setting under well-specified conditions,
benefits managers might seize on that recommendation to the exclusion of
others and use it to justify expansion of lower cost and potentially
inappropriate services. Individual clinical need as the primary concern
in patient placement cannot be overemphasized.
Unregulated utilization review decisions by health professionals who
are not experienced in AOD issues and treatment have led to the denial
of needed AOD abuse treatment services and inappropriately restricted
lengths of stay. Improperly performed and regulated, utilization review
may be counterproductive and may ultimately increase the costs
associated with AOD abuse.
Health care providers, administrators, benefits managers, and
legislators should examine the merits of developing new configurations
for the delivery of AOD detoxification services. New,
intermediate-level service configurations are needed that will bridge
service gaps and ensure cost-effective, high-quality delivery of care.
Issues associated with the development of such settings, including
allocation of staff, licensing requirements, prescribing authority, and
interagency networking, should be explored.
The panel discussed various models available in the literature that
service providers and administrators may use in developing cost
estimates. One model they found particularly useful can be found in the
book Treating Drug Problems (Gerstein and
Harwood, 1990). The authors present and illustrate the use of a
formula for estimating the cost of AOD abuse treatment.
The process begins with the acknowledgment that it is impossible to
meet all needs. As treatment resources are limited, providers must
establish priorities to ensure the optimum use of energy and financial
resources. The authors developed an estimate for expansion of public
coverage of certain AOD abuse treatment services nationwide and
recommended consideration of the following four priorities as quoted
below:
"End delays in admission when treatment is appropriate, as
evidenced by waiting lists
"Improve treatment (by raising the levels of service intensity,
personnel quality and experience, and retention rates of existing
modalities; by having programs assume more integrative roles with
respect to related services; and by instituting systematic performance
monitoring and follow-up)
"Expand treatment through more aggressive outreach to pregnant women
and young mothers, as this could result in a great reduction of external
social costs
"Further expand community-based and institutionally based treatment
services to provide treatment of criminal justice clients."
Next, the model suggests three strategic options for attaining
service delivery goals:
A core strategy to deal with existing waiting lists, remedy
deficiencies in program quality and management, and implement modest
program initiatives for young women and children
A comprehensive strategy, adding to the core plan a substantially
greater induction of criminal justice clients and a more ambitious plan
for treating drug-abusing and drug-dependent mothers. This
comprehensive plan would . . . provide the optimal level of public
treatment resources
An intermediate strategy to be enacted between the core and
comprehensive approaches.
Having established quantifiable targets (such as "Increase daily
treatment enrollment by 66,000") and using documented sources to develop
assumptions about variables such as capital costs, training needs, and
the number of individuals who could be expected to enter treatment, the
authors estimate the cost of services to meet the four goals under each
of the three strategies (Gerstein and Harwood,
1990).
Field reviewers of the Treatment Improvement Protocol (TIP) were
asked to provide specific cost data for a model detoxification program,
a social model detoxification program, and an intensive outpatient
program. Some general information on medical model and social model
detoxification programs is included in this TIP in 6-2, and 6-3. Data on intensive outpatient costs are
not included as there is a comprehensive section on costing for this
type of treatment program in the TIP titled Intensive Outpatient
Treatment for Alcohol and Other Drug Abuse (TIP 8;
Center for Substance Abuse, 1994).
The cost data presented here are based on information provided from
field reviewers in six different regions of the country and include both
private and public programs. The types of the represented localities
are rural, suburban, and urban. Because of regional and programmatic
differences, it is not possible to ascertain definitive costs for the
delivery of detoxification services. The actual costs vary considerably
depending on the size of the program, the rent or purchase price of
treatment facilities, and varying labor costs from one region of the
country to another. Costs are examples only but may provide useful
estimates of these models of detoxification services. It is important
to emphasize that the cost data that appear in 6-2,
and 6-3 were not gathered in a controlled
study. The following marks indicate characteristics of the programs
represented by the exhibits:
*Described by program director as modified medical model, not
necessarily consistent with the modified medical model discussed in the
TIP. (Costs are estimates for 20 beds based on actual
experience with a six-bed program. Estimates and costs reflect a 90
percent utilization rate.)
**Represents the number of
clients/patients that can be treated at one time.
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