Treating Drug Problems Volume 1 (1990) / Chapter Skim
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7 Public Coverage
7 Public Coverage
Pages 220-272
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From page 220... ...
With the existence and legitimacy of the public tier no longer at issue, the questions for public coverage are instead ones of management objectives and techniques. The task of this chapter is to consider the present system of public coverage in light of the needs, wants, and demands placed on it and to make appropriate recommendations for improvement.
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From page 221... ...
These considerations divide into three instrumental questions: · What should be the respective state and federal roles in public coverage of drug treatment?
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From page 222... ...
Instead of four prison treatment sites, there are several thousand public-tier programs in communities and institutions in every state, treating well over 600,000 annual admissions and interacting with federal institutes, state offices, county agencies, elected officials, local bureaucracies of criminal justice, education, welfare, and health care organizations, and occasionally even private insurers. The issue certainly is not whether there will be large-scale public support for treatment but how much, what kinds, and for whom.
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From page 223... ...
As a result of studies in public-tier programs, which are reviewed in Chapter 5, there are now reasonable grounds to believe that at least some modalities of treatment do in fact reduce the external costs of drug abuse and dependence in greater measure than the cost of the treatment itself. Moreover, in doing so, treatment provides some benefits that drug-abusing and drug-dependent individuals themselves seek (although it often takes a substantial amount of exterior pressure or interior misery or both to bring them to that point)
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From page 224... ...
Subsidies should go only to those who would purchase treatment at some below-market price, and the amount should be only what is necessary in each case to assure the purchase. If the external costs of untreated drug consumption (which, on average, treatment can be expected to reduce significantly)
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From page 225... ...
In summary, the combination of high external costs and a reluctant clientele may lead society to want not only to provide treatment for illicit drug abuse and dependence at a reduced cost but even to provide some selected inducements, at least to some potential clients, that go beyond the cost of bare-bones treatment. (A more technical analysis of the issue of treatment demand and pricing is sketched in Figure 7-1.)
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From page 226... ...
If treatment episodes are expected to provide benefits to the public beyond those to the recipient by reducing the external costs of untreated drug problems, then that expectation should be reflected in the market by raising the demand schedule for treatment. In other words, at any given price, the amount of treatment demanded should be greater than just that sought by individual clients.
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From page 227... ...
Positive Response to Treatment There is a third principle besides external costs and income constraints that is worth mentioning: the treatment should do good; that is, the client should respond well. Of course, some do not.
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From page 228... ...
However, to calculate precisely for each drug-abusing and dependent Treatment programs do in fact exclude some people whose personal history is unpromising. However, these negative prognostic signs are attended to mostly out of a desire to minimize the risks that nonresponding behavior will disrupt other clients or endanger the clinical setting for example, programs are leery of admitting individuals who are chronically assaultive or known as large-volume drug trallickers.
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From page 229... ...
that general conditions of racial and income inequality might help cause and perpetuate drug problems and retard recovery, further reinforcing the urgency of public intervention. The principal decision criterion in public coverage is and should be to make publicly subsidized treatment available to those who are doubly needy those who most need treatment according to clinical criteria and who most need financial help to afford it.2 Generally, having a serious 2 exact titration of the inability to pay, so as to marginally reduce public payments to those who are partially able financially, may be expensive and may reduce the desirable incentives that help draw reluctant individuals into treatment; in otherwords, the resulting revenue gains from copayment requirements may not be worth it.
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From page 230... ...
The external costs of poor job performance and parental deficiencies may justify positive incentives as well, given that criminal justice coercion of drug-abusing and dependent individuals who are steadily employed or taking care of children, or both, may be impractical or unlikely. In summary, the committee recommends that the principle of public coverage be to provide adequate support for appropriate and timely admission, completion, or maintenance of good-quality treatment for individuals who cannot pay for it, either fully or partly.
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From page 231... ...
In light of the principles articulated above and the current status of the public treatment system, the committee's recommendation is that priority be given to the following: · closing the most obvious regional gaps in coverage—that is, reducng delays in admission as evidenced by waiting lists for treatment; · improving the average quality, performance, and retention rates of existing modalities by raising the level of service intensity, personnel quality, and experience; by having programs assume more integrative roles with respect to related services; and by instituting systematic performance monitoring and follow-up; i, expanding treatment through more aggressive outreach to pregnant women and young mothers, those for whom it promises the greatest potential reduction in external social costs; and · further expanding community and institutionally based treatment services to provide treatment to drug-abusing and dependent individuals under criminal justice supervision.
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From page 232... ...
The 1988 Anti-Drug Abuse Act included a one-time grant program providing $100 million for the reduction of waiting lists. Because this is a one-time allocation, many programs have been leery of applying for the funding: the implication of expanding admissions is to commit to additional space and staffing, and such a commitment would fly in the face of the nonrenewability of these funds.
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From page 233... ...
The external costs of drug abuse and dependence among this group are especially worrisome because these children's present and future welfare depends so heavily on their mothers' welfare. High risks of drug problems and other severe dysfunctions inhere in children of parents who are abusing or dependent on illicit drugs.
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From page 234... ...
The problem of pregnant women who take illicit drugs has received a great deal of attention recently. Although no study has specifically examined the number of expectant mothers in drug treatment, applying the roughly 10 percent annual fertility rate for women demographically similar to those currently in treatment indicates that about 30,000 expectant women receive some drug treatment each year very few of them in programs with a primary focus on and special services for pregnant women.
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From page 235... ...
Although there is no way to substantiate this impression, the committee deems it plausible that the erosion of resource intensity and surveillance capacity within treatment programs during the period of retrenchment in the 1980s contributed to the increasing pressure on the criminal justice system, particularly from probation and parole violators. THREE STRATEGY OPTIONS The public tier is now on a rapid expansion course, largely as a result of decisions at the federal level.
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From page 236... ...
· 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, in the committee's judgment, provide the optimal level of public treatment resources. The comprehensive plan would entail an annual operating increase over 1989 levels of about $2.2 billion, plus a $1 billion one-time investment.
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From page 237... ...
As relevant data collection processes are improved and analytical research performed, the models underlying these cost estimates will, over time, be capable of adjustment. The Core Strategy Option The core option focuses on three of the four priorities noted earlier: reduction of waiting lists, improvement of treatment quality, and dedicated
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From page 238... ...
Although many waiting list clients and some of the pregnant women to be added to treatment censuses under the core plan are under criminal justice supervision, there would not be enough of them under the core expansion to make an appreciable difference in the
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From page 239... ...
The committee has set the number of expectant mothers to be reached and treated in a comprehensive strategy at 57,250, or three-quarters of the number estimated nationally to need treatment but who are not now receiving it. This figure also seems to be an outer possible limit, a view conditioned by the formidable difficulties that prenatal outreach programs have experienced in trying to induce less severely impaired and dysfunctional populations to enter prenatal care programs, which make far fewer demands on time, concentration, motivation, or level of organization than drug treatment would.
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From page 240... ...
The committee believes that the most informed judgment on how to resolve these issues effectively must begin with a careful consideration of the lessons of the recent past, namely, how these types of questions were handled in the period of the last "war on drugs" and its aftermath in the 1970s and during the block grant period of the 1980s. Federal and State Roles in the 1970s The high point of centralized federal command of the drug treatment system was the early 1970s, the period of SAODAP—the Special Action Office for Drug Abuse Prevention (Table 7-2; also see Chapters 2 and 6 and Besteman, 1990~.
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From page 241... ...
NIDA converted all direct contracts with treatment providers into grants, which implied less federal direction and greater autonomy for the treatment programs. At the same time, additional resources and authorities were directed to "single state agencies" designated to take over most of the management responsibilities for administering federal funding for treatment; by 1981 nearly 90 percent of federal support to community-based treatment was routed through the state agencies, mainly in the form of statewide formula grants.
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From page 242... ...
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From page 244... ...
With the Anti-Drug Abuse Act of 1986 came a significant boost in federal support for treatment, nearly doubling the federal funding nominally allocated to drug treatment, adding an alcohol and drug abuse treatment and rehabilitation (ADTR) block grant on top of the ADMS grant, and implementing other increases as well.
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From page 245... ...
There was a one-year appropriation for the purpose of grants to reduce waiting lists. The 1988 act also created the new Office of National Drug Control Policy, with broad coordinative authority over federal budgets and activities.
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From page 246... ...
The financing mechanism that appears most appropriate for achieving these managerial tasks in the near term is neither block grants hedged in with formulas nor federal demonstration grants to providers but rather categorical support of treatment programs administered through state agencies by a mechanism like the former statewide services grants or contracts used in the 1970s. The state agencies in turn should develop cooperative agreement-type mechanisms to ensure the involvement of and coordination with appropriate units of state and local government and community-based
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From page 247... ...
to "umbrella grant" proposals for the waiting list funds authorized in the 1988 Anti-Drug Abuse Act. Cooperative agreements can be multilateral, involving multiple levels of government.
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From page 248... ...
It is clear that adequate drug treatment benefits under Medicaid would diminish the need for direct service support of drug treatment programs, particularly if broader eligibility for Medicaid were to emerge for presently ineligible indigent populations. Nevertheless, even if completely universal insurance coverage were achieved, there would still be a need for direct support of public-tier programs to offer outreach and other important adjunctive services to the many individuals for whom low income is not the only barrier to seeking and responding well to treatment.
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From page 249... ...
Those respective accreditation organizations, by the same token, need to be pressed when developing standards to explicitly recognize and incorporate knowledge of the public tier of drug treatment providers and their procedures. The second useful step is to begin stipulating matching requirements rather than maintenance-of-effort requirements for increases in grant support to the states.
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From page 250... ...
These personnel should have appropriate clinical credentials that include the understanding that longer residential and outpatient durations are strongly correlated with beneficial results among public clients. Effective utilization management should recognize that drug abuse and dependence are chronic, relapsing disorders and that for any one client, more than one treatment episode may be needed and different types of treatment may need to be tried.
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From page 251... ...
dictate hospitalization, drug treatment may begin in an acute care setting and continue elsewhere or shift to more appropriate cost rates when acute care requirements end. The scientific basis of utilization management of drug treatment is at present rudimentary, but intake specialists should at least be required to demonstrate an understanding of diagnostic criteria and effectiveness findings for drug treatment programs.
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From page 252... ...
Performance is to be demonstrated by outcome evaluation, and the standards of performance adequacy should be informed by past and ongoing treatment effectiveness research on retention and outcomes. THE SPECIAL CASE OF VETERANS' COVERAGE The Department of Veterans Affairs represents a special case of public coverage.
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From page 253... ...
Consumption rates declined dramatically, however, upon their return home, and only 10 percent reported any use in the first six months or more after returning; 4 percent reported more-than-weekly use for a month or more (Robins et al., 1974~. A more recent study found drug abuse or dependence in about 1.5 percent of veterans who served during the Vietnam War era, which would equal about 125,000 veterans of that era in need of drug treatment (Robins, 1974~.
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From page 254... ...
At the very least, outpatient or residential drug treatment services furnished directly by VA facilities or by contract should be made available to meet the needs of former inpatients. CONCLUSIONS The committee has developed recommendations regarding the public coverage of drug treatment in light of some explicit principles that justify public coverage, and these principles in turn suggest specific priorities for the expansion of the public tier that is now under way.
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From page 255... ...
; · expand treatment through more aggressive outreach to pregnant women and young mothers; and · further expand community-based and institutionally based treatment of criminal justice clients. it Is possible to estimate the amount of new public financing needed to meet these priority objectives, although to do so, key assumptions must be made about such parameters as capital costs, training expenses, and the number of individuals who could be induced to enter treatment at various levels of effort.
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From page 256... ...
There is probably a need to expand VA outpatient drug treatment programs, and the adequacy of the VA residential system needs comprehensive evaluation. APPENDIX 7A BASELINE AND STRATEGY OPTION CALCULATIONS Baseline Comparison Values All cost estimates for the committee's three strategy options are based on the most recent data available at the end of 1989 concerning the size and financing of the public treatment system.
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From page 257... ...
. CORE STRATEGY OPTION Annual Recumng Costs Eliminate waiting lists Increase daily treatment enrollment by 66,000 (survey of 43 states in September 1989 by NASADAD shows minimum need of 66,000 slots)
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From page 258... ...
x [$25 + (0.25 x $200~] = $75.9 million Active outreach to expectant mothers Assume active outreach to drag-using expectant mothers reaches 18,750 at a cost of $1,000 each (about the cost per expectant mother reached in a demonstration outreach in Harlem, NY, cited in Institute of Medicine report on neonatal care [Brown, 1988~.
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From page 259... ...
Waiting list expansion requires 7,000 beds. Expectant mothers expansion requires 4,688 beds.
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From page 260... ...
. 10,000 x $2,000 + 3,300 x $4,000 - $33.2 million COMPREHENSIVE STRATEGY OPTION ~ nual Recurring Costs Eliminate waiting list Same as under core option.
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From page 261... ...
18,750 x $1,000 + 18,750 x $2,000 + 18,750 x $3,000 $112.5 million Meat 56,250 expectant mothers = Assume half of recruited expectant mothers participate in 6 months of therapeutic community treatment (currently $12,500 per year, funding upgraded by 25%) , and half get 6 months of outpatient treatment (currently $2,500 per year, funding upgraded by 25%~.
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From page 262... ...
$90 million Repair existing outpatient facilities Same as under core option. $118.1 million Main additional staff Assume minimum of 26,000 staff in 1989.
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From page 263... ...
18,750 x $1,000 + 18,750 x $2,000 = $56.3 million Meat 37,500 expectant mothers Assume half of recruited expectant mothers participate in 6 months of therapeutic community treatment (currently $12,500 per year, funding upgraded by 25%) , and half get 6 months of outpatient treatment (currently $2,500 per year, funding upgraded by 25%~.
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From page 264... ...
Waiting list expansion of 25% requires 7,000 beds. Criminal justice system expansion also adds 25% (7,000 beds)
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From page 265... ...
Assume requirement for 23,750 additional staff, which equals 26,000 staff in 1989 divided by 275,000 clients in 1989 times 478,300 clients in future times 1.1 for increase in staffing intensity. Assume $2,000 per additional staff for first 10,000 (assumes most with some prior experience or related training in drug problems)
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From page 266... ...
APPENDIX 7C MEDICAID Although the ADMS block grant has been the principal federal mechanism to support the public drug treatment system during the 1980s, the public health insurance plans, Medicaid and Medicare, have devoted a notable amount of resources and attention to drug treatment in recent years. Coverage by Medicaid is the major alternative to grant and contract mechanisms as the way to provide public coverage.
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From page 267... ...
In 1987 the NDATUS found that third-party public payments to reporting providers were $139 million, or nearly 11 percent of total reported revenues (Table 7C-1~. Third-party public reimbursements included Medicaid, Medicare, and some payments by insurance programs for military families using nonmilitary treatment services.
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From page 268... ...
It always covers single-parent families, pregnant women, and young children in two-parent families provided their household of residence has an income below a financial "standard of need" that is usually configured in terms of a percentage of the federal poverty line. States may at their option cover as "medically needy" categorically eligible persons in households with incomes somewhat above the AFDC standard (that is, individuals who cannot receive AFDC)
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From page 269... ...
($000s) State Total All National Alabama 644 6,987 9.2 0.5 Alaska 16 3,366 0.5 0.0 Arizona 948 24,328 3.9 0.7 Arkansas 354 2,641 13.4 0.3 California 17,779 256,530 6.9 12.8 Colorado 3,753 18,458 20.3 2.7 Connecticut 1,797 20,832 8.6 1.3 Delaware 5 1,352 0.4 0.0 District of Columbia 17 7,306 0.2 0.0 Florida 2,446 61,729 4.0 1.8 Georgia 478 24,288 2.0 0.3 Hawaii 22 4,730 0.5 0.0 Idaho 5 1,429 0.3 0.0 Illinois 1,227 40,484 3.0 0.9 Indiana 1,092 17,391 6.3 0.8 Iowa 1,118 11,553 9.7 0.8 Kansas 498 6,443 7.7 0.4 Kentucky 1,161 7,745 15.0 0.8 Louisiana 1,880 13,967 13.5 1.4 Maine 245 3,459 7.1 0.2 Maryland 3,031 27,837 10.9 2.2 Massachusetts 642 20,300 3.2 0.5 Michigan 1,613 36,408 4.4 1.2 Minnesota 2,337 25,772 9.1 1.7 Mississippi 115 1,769 6.5 0.1 Missouri 500 15,103 3.3 0.4 Montana 9 1,786 0.5 0.0 Nebraska 146 4,725 3.1 0.1 Nevada 21 2,971 0.7 0.0 New Hampshire 196 5,637 3.5 0.1 New Jersey 788 32,797 2.4 0.6 New Mexico 610 6,363 9.6 0.4 New York 58,773 250,382 23.5 42.2 North Carolina 1,337 18,848 7.1 1.0 North Dakota 725 6,486 11.2 0.5 Ohio 6,209 59,123 10.5 4.5 Oklahoma 527 8,227 6.4 0.4 Oregon 223 10,918 2.0 0.2 Pennsylvania 14,190 69,845 20.3 10.2 Puerto Rico 0 10,127 0.0 0.0 Rhode Island 28 5,115 0.5 0.0 South Carolina 431 7,263 5.9 0.3 South Dakota 0 778 0.0 0.0 Tennessee 1,016 9,279 10.9 0.7 Texas 4,856 64,341 7.5 3.5 Continues on new page
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From page 270... ...
Federally required Medicaid services primarily include inpatient and outpatient hospital services and physician services. Although these services are sometimes necessary to treat some kinds of drug problems and to deal with such sequelae or complications as trauma, AIDS, and other infectious diseases, the primary components of drug abuse treatment are psychosocial services (counseling, social work, psychotherapy)
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From page 271... ...
In many other states, however, drug treatment providers receive almost no Medicaid support. The Current and Future Status of Medicaid Coverage In theory, the Medicaid system could cover many drug-abusing and dependent individuals because the clients served by the public tier are mostly indigent and that population is the group Medicaid was designed to serve.
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From page 272... ...
This provision is limited to health services related to pregnancy and to conditions that threaten the well-being of the infant. Maternal drug abuse certainly threatens the health of the infant, but whether this provision leads to the induction of such women into appropriate forms of care remains to be seen.
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