Health Care Reform National Perspective:
Implications for Managing Chronic
Addiction and Mental Health Conditions
Michael L. Dennis, Ph.D.
Chestnut Health Systems
Normal, IL
Presentation at the Mental Health, Chemical Abuse and Dependency Services Division 1st
Annual All Providers’ Meeting, January 27, 2012. This presentation was supported by funds
from the King County Mental Health, Chemical Abuse and Dependency Services Division
using data from NIDA grants no. R01 DA15523, R37-DA11323, R01 DA021174,, CSAT
contract no. 270-07-0191 and several public data sets.. It is available electronically at
www.chestnut.org/li/posters or
http://www.kingcounty.gov/healthservices/MHSA/EventsTrainings/2012%201st%20Annual%2
0All%20Provider%20Meeting.aspx
. The author thanks We would like to thank Christy Scott, Belinda Willlis , Rodney Funk,, Brook
Hunter and Lilia Hristova, Lisa Nicholson, for their assistance in preparing this presentation.
Please address comments or questions to the author at mdennis@chestnut.org or 309-451-7801.
.p
1
The Goals of this Presentation are to:
1. Overview macro trends driving health care reform
2. Advances in understanding and improving
“identification” and access
3. Why evidenced based assessment and treatment
are useful
4. Demonstrating how well we do in analyses
looking at benefit-costs
5. Examples of how Addiction is a Chronic condition
and studies of how to best manage it.
2
Rise in the Cost of Health Care Spending
Per Capita By Time & Country
Health care spending
in the US has risen
faster than inflation
and is not twice what
you see in other
countries
Source: Kaiser Family Foundation
3
The “rate of increase” in both national
health expenditures and gross domesstic
product has been slowing.
Amount of growth
dropping over time
Source: Center for Medicare and Medicaid Services
4
Estimated Contributions of Selected
Factors to Growth in Real Health Care
Spending Per Capita
More use of new technology
and medicine largest factor
5
Impact of 2008-2012 Recession:
Effect of a 1% Point Increase in Unemployment
6
Average Annual Growth in Selected Factors
Accounting for Growth in Personal Health Care
Source: Center for Medicare and Medicaid Services
7
Physician and Clinical Services in Particular has
Slowed Down to Less Than the Rate of Inflation
Source: Center for Medicare and Medicaid Services
8
In the coming years Personal Health Care
Expenditures are Expected to Grow at or above
the Rate of Gross Domestic Product
Spike due to full
Implementation of Affordable
Care Act (ACA)
Source: Center for Medicare and Medicaid Services
9
8%
7%
Generalized Anxiety Dis.
Posttraumatic Stress Dis.
Source: Dennis, Scott, Funk & Chan forthcoming; National Co morbidity Study Replication (n=9282)
Agoraphobia
Other Specific Phobia
13%
2%
5%
12%
7%
Adult Separation Anxiety
31%
Yet many are in
Remission
(no systems in the
past year)
Social Phobia
Panic Disorder
2%
19%
Major Depressive Epi.
Almost half of all adults have been
touched by substance, internalizing
or externalizing disorders
Dysthymia
Bi-Polar I or II
Any Anxiety Disorder:
20%
37%
Any Mood Disorder:
4%
8%
Intermittent Explosive
Internalizing Disorder
8%
10%
Oppositional Defiant
ADHD
10%
25%
13%
8%
15%
Conduct Disorder
Externalizing Disorder
Drug Disorder
Alcohol Disorder
Any Substance Disorder
47%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Any Disorder
Prevalence of Lifetime Disorders and Past Year
Remission in the 2002 US adult pop (209.1 million)
Lifetime Disorder
Past Year Remission
10
42%
41%
Panic Disorder
Agoraphobia
Other Specific Phobia
30%
44%
48%
48%
39%
Social Phobia
Posttraumatic Stress Dis.
Generalized Anxiety Dis.
Adult Separation Anxiety
Any Anxiety Disorder:
31%
43%
71%
57%
Major Depressive Epi.
Dysthymia
Bi-Polar I or II
41%
Internalizing Disorder
56%
45%
Intermittent Explosive
Any Mood Disorder:
50%
58%
89%
89%
77%
83%
66%
ADHD
Oppositional Defiant
Conduct Disorder
Externalizing Disorder
Drug Disorder
Alcohol Disorder
Any Substance Disorder
44%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Any Disorder
Past Year Recovery “Rates” (Remission/Lifetime)
by Disorders in the US
Past Year
Recovery Rate
11
Multimorbidity is Common
3 to 16
Disorders
18%
Pattern of Disorders
(n=3,179 age 18-44)
2 Disorders
10%
Substance
Only
3%
None
54%
1 Disorder
18%
Externalizing
Only
5%
Internalizing
Only
21%
None
48%
Sub.+Ext
1%
Number of Disorders
(n=9,282)
Sub.+Int
4%
Sub. + Ext. +
Int.
8%
Ext.+Int.
10%
12
Source: Dennis,
Scott, Funk & Chan forthcoming;
National Co morbidity Study Replication
Remission is Related to Number of Disorders and
Pattern of Multimorbidity
Lifetime Prevalence
10%
8%
Sub. + Ext. + Int.
Substance+Internalizing
1%
Substance+Externalizing
4%
21%
5%
Internalizing Only
Substance Only
Externalizing Only
Pattern of Disorders
Externalizing+Internalizing
Number of Disorders
None
3%
18%
3 to 16 Disorders
10%
2 Disorders
1 Disorder
19%
47%
53%
Current Remission
None
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
13
Source: Dennis, Scott, Funk & Chan forthcoming; National Co morbidity Study Replication
Pattern of Disorders
16%
Sub. + Ext. + Int.
24%
Externalizing+Internalizing
Substance+Externalizing
26%
41%
Internalizing Only
None
19%
3 to 16 Disorders
Number of Disorders
Substance+Internalizing
65%
Externalizing Only
Past Year
Recovery Rate
51%
68%
Substance Only
50%
2 Disorders
1 Disorder
None
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
64%
Recovery Rate is related to the to Number of
Disorders and Pattern of Multimorbidity
14
Source: Dennis, Scott, Funk & Chan forthcoming; National Co morbidity Study Replication
Treatment Participation is related to the
to Number of Dis. and Pattern of Multimorbidity
29%
79%
60%
49%
Sub. + Ext. + Int.
Substance+Internalizing
Substance+Externalizing
Externalizing Only
Substance Only
Internalizing Only
Pattern of Disorders
Externalizing+Internalizing
Number of Disorders
None
3 to 16 Disorders
SUD Tx Generally
Less common
2 Disorders
1 Disorder
4%
19%
50%
54%
64%
75%
Any Behavioral Health Tx
Any Mental Health Tx
Any Substance Disorder Tx
39%
5%
None
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
15
Source: Dennis, Scott, Funk & Chan forthcoming; National Co morbidity Study Replication
Substance Use Disorders are Common,
US Treatment Participation Rates Are Low
Over 88% of adolescent and
young adult treatment and
over 50% of adult treatment is
publicly funded
Few Get Treatment:
1 in 20 adolescents,
1 in 18 young adults,
1 in 11 adults
25%
Much of the private
funding is limited to 30
days or less and
authorized day by day or
week by week
20.1%
20%
15%
10%
7.4%
7.0%
5%
0.4%
1.1%
0.6%
0%
12 to 17
18 to 25
Abuse or Dependence in past year
Treatment in past year
Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]
26 or older
93%
97%
95%
95%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1%
1%
1%
10%
0%
1%
4%
8%
1%
3%
9%
15%
4%
5%
8%
11%
12%
13%
12%
23%
29%
35%
41%
49%
30%
41%
42%
46%
% Any Contact
Potential AOD Screening & Intervention Sites
Adolescents (age 12-17)
No use in past year
Less than weekly use
Weekly Use
Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]
Abuse or dependence
Less than weekly use
Weekly Use
Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]
54%
30%
27%
24%
38%
12%
13%
12%
23%
2%
1%
3%
11%
13%
9%
8%
11%
76%
79%
80%
No use in past year
0%
1%
4%
8%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1%
1%
1%
10%
% Any Contact
Potential AOD Screening & Intervention Sites
Adults (age 18+)
Abuse or dependence
61%
60%
75%
75%
Juvenile Justice
(n=2,024)
High on Mental Health
12%
11%
46%
35%
73%
62%
Student
Assistance
Programs
(n=8,777)
Comorbidity
is common
12%
12%
Substance Abuse
Treatment
(n=8,213)
Either
Problems could be easily identified
40%
37%
77%
67%
57%
47%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
86%
83%
Adolescent Rates of High (2+) Scores on Mental Health (MH) or
Substance Abuse (SA) Screener by Setting
in Washington State
Mental Health
Treatment
(10,937)
Children's
Administration
(n=239)
High on Substance
High on Both
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
4%
3%
17%
17%
18%
17%
Lower than
expected rates of
SA in mental health
& children’s admin
69%
69%
44%
51%
31%
64%
43%
53%
31%
65%
51%
46%
78%
73%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
81%
68%
69%
56%
Adult rates of High (2+) Scores on Mental Health (MH) or
Substance Abuse (SA) Screener
by Setting in Washington State
Substance
Abuse
Treatment
(n=75,208)
Either
Eastern State
Hospital
(n=422)
Corrections:
Community
(n=2,723)
High on Mental Health
Corrections:
Prison
(n=7,881)
Mental Health
Childrens
Treatment Administration
(55,847)
(n=1,238)
High on Substance
High on Both
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
Adolescent Client Validation of High Co-Occurring from GAIN
Short Screener vs. Clinical Records
by Setting in Washington State
Substance Abuse
Treatment
(n=8,213)
Juvenile Justice
(n=2,024)
GAIN Short Screener
Mental Health
Treatment (10,937)
9%
11%
15%
12%
34%
35%
56%
Two-page measure closely approximated all found
in the clinical record after the next 2 years
47%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Children's
Administration
(n=239)
Clinical Indicators
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
Higher rate in clinical record in mental
health and children’s administration
(But that was past on “any use” vs.
“abuse/dependence” and 2 years vs. past
year)
3%
17%
22%
39%
59%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
56%
Adult Client Validation of High Co-Occurring from GAIN Short
Screener vs. Clinical Records by Setting in Washington State
Substance Abuse
Treatment (n=75,208)
Mental Health Treatment Childrens Administration
(55,847)
(n=1,238)
GAIN Short Screener
Clinical Indicators
Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
Where in the System are the Adolescents with Mental
Health, Substance Abuse and Co-occurring?
0
5,000
10,000
15,000
20,000
25,000
Any Behavioral
Health (n=22,879)
Mental Health
(21,568)
Substance Abuse
Need (10,464)
SAP+ SA
Treatment
Over half of
system
Co-occurring
(9,155)
Substance Abuse Treatment
Juvenile Justice
Children's Administration
School Assistance
Programs (SAP)
largest part of BH/MH
system; 2nd largest of
SA & Co-occurring
systems
Student Assistance Program
Mental Health Treatment
Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders
Among DSHS Clients. Olympia, WA: Department of Social and Health Services.
Retrieved from http://publications.rda.dshs.wa.gov/1392/
Length of Stay Less that the 90 days
Recommended by Research
100%
90%
80%
1%
16%
28%
29%
91+ days
46%
70%
31 to 90
days
60%
50%
0 to 30
days
40%
30%
20%
10%
0%
Detox
Residential
IOP
OP
Total
(n=341,866) (n=317,967) (n=182,465) (n=786,707) (n=1,629,005)
Source: Office of Applied Studies 2007Discharge – Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm
Less than Half are Positively Discharged
100%
90%
34%
80%
70%
45%
52%
Completed
65%
60%
22%
50%
Transferred
14%
15%
40%
30%
36%
AMA
16%
12%
ASR
20%
10%
Other
0%
Detox
(n=341,848)
Residential
(n=317,945)
IOP
(n=182,441)
OP
Total
(n=786,662) (n=1,628,896)
Source: Office of Applied Studies 2007 Discharge – Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm
Programs often LACK Evidenced Based
Assessment to Identify and Practices to Treat:
• Substance use disorders (e.g., abuse, dependence,
withdrawal), readiness for change, relapse potential and
recovery environment
• Common mental health disorders (e.g., conduct, attention
deficit-hyperactivity, depression, anxiety, trauma, selfmutilation and suicidal thoughts)
• Crime and violence (e.g., inter-personal violence, drug
related crime, property crime, violent crime)
• HIV risk behaviors (needle use, sexual risk, victimization)
• Child maltreatment (physical, sexual, emotional)
• Recovery environment and peer risk
Other Structural Challenges to Delivery of
Quality Care in Behavioral Health Systems
1. High turnover workforce with variable education
background related to diagnosis, placement,
treatment planning and referral to other services
2. Heterogeneous needs and severity characterized by
multiple problems, chronic relapse, and multiple
episodes of care over several years
3. Lack of access to or use of data at the program level
to guide immediate clinical decisions, billing and
program planning
4. Missing, bad or misrepresented data that needs to be
minimized and incorporated into interpretations
5. Lack of Infrastructure that is needed to support
implementation and fidelity
Some Common Record Based
Performance Measures
PFP
NIATX
NOMS
CSAT
WCG
NQF
Initiation: Treatment within 2 weeks of diagnosis
X X
X X X
Engagement: 2 additional sessions within 30 days
X X
X X X
Continuing Care: Any treatment 90-180 days out
X
X
X
Detox Transfer: Starting treatment within 2 weeks
X
X
Residential Step Down: Starting OP Tx w/in 2wks
X
Evidenced Based Practice: From NREP/Other lists
Within Cost Bands: see French et al 2009
X
X X
X
X X
* NQF: National Quality Forum; WCG: Washington Circle Group; CSAT: Center for
Substance Abuse Treatment evaluations; NOMS: National Outcome Monitoring
System; NIATX: Network for the Improvement of Addiction Treatment; PFP: Pay for
Performance evaluations
Evaluation of Existing Measures
•
•
•
Strengths:
– Easy to collect/ calculate in electronic health records
– Give broad overview of where problems
– Useful for program evaluation and pay for performance
Weaknesses:
– Doesn’t lead to specific changes or intervention with
individuals
– Doesn’t address case mix or context issues
– Doesn’t easily lead to specific improvement at the program
level
– Doesn’t address relationships with other gaps in the macro
system
Linkage to other behavioral health record systems is efficient,
but limited by the coverage, content and quality of those systems
Additional NQF Standards of Care
•
•
•
•
•
•
Annual screening for tobacco, alcohol and other drugs
using systematic methods
Referral for further multidimensional assessment to
guide patient-centered treatment planning
Brief intervention, referral to treatment and supportive
services where needed
Pharmacotherapy to help manage withdrawal, tobacco,
alcohol and opioid dependence
Provision of empirically validated psychosocial
interventions
Monitoring and the provision of continuing care
Source: www.tresearch.org/centers/nqf_docs/NQF_Crosswalk.pdf
In practice we need a Continuum of Measurement
(Common Measures)
Quick
Comprehensive Special
More Extensive / Longer/ Expensive
Screener
•
•
•
•
Screening to Identify Who Needs to be “Assessed” (5-10 min)
– Focus on brevity, simplicity for administration & scoring
– Needs to be adequate for triage and referral
– GAIN Short Screener for SUD, MH & Crime
– ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD
– SCL, HSCL, BSI, CANS for Mental Health
– LSI, MAYSI, YLS for Crime
Quick Assessment for Targeted Referral (20-30 min)
– Assessment of who needs a feedback, brief intervention or referral for
more specialized assessment or treatment
– Needs to be adequate for brief intervention
– GAIN Quick
– ADI, ASI, SASSI, T-ASI, MINI
Comprehensive Biopsychosocial (1-2 hours)
– Used to identify common problems and how they are interrelated
– Needs to be adequate for diagnosis, treatment planning and placement of
common problems
– GAIN Initial (Clinical Core and Full)
– CASI, A-CASI, MATE
Specialized Assessment (additional time per area)
– Additional assessment by a specialist (e.g., psychiatrist, MD, nurse, spec
ed) may be needed to rule out a diagnosis or develop a treatment plan or
individual education plan
– CIDI, DISC, KSADS, PDI, SCAN
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
12
0
10
10.36
6
4.5
4
2.8
36%
GAIN-SS
4-6 mins
(OR=1.0)
8
70%
GAIN-Q3
25-35 mins
(OR=4.1)
87%
GAIN-I
60-120 mins.
(OR=11.7)
Source: CSAT 2010 AT Summary Analytic Data Set (n = 17,356)
2
0
Mean of 0-12 problems
% with 0-4+ problems
Longer Measures Assess and
Identify More Problems
1
2
3
4+
Mean
Count of Major Clinical Problems at Intake
Other drug disorder
34%
Cannabis disorder
33%
Alcohol disorder
21%
Four
CD
50%
ADHD
43%
Depression
Three
35%
25%
Trauma
Anxiety
Five to
Twelve
Two
14%
79%
Violence/ illegal activity
Victimization
Suicide
One
62%
12%
Major Clinical Problems*
None
13% 13% 11% 9% 6%
48%
0%
20%
40%
60%
Source: CSAT 2010 AT Summary Analytic Data Set (n=17,978)
80%
100%
Count of Major Clinical Problems*
at Intake by Level of Care
100%
None
90%
80%
One
70%
60%
Two
50%
40%
63%
30%
20%
42%
68%
80%
48%
Four
10%
0%
OP
(OR=1.0)
IOP
(OR=1.2)
Three
CC-OP
(OR=2.3)
M-LTR
(OR=2.9)
Source: CSAT 2010 AT Summary Analytic Data Set (n=17,681)
STR
(OR=5.5)
Five to
Twelve
Count of Major Clinical Problems*
at Intake by Severity of Victimization
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
None
One
Two
74%
Three
49%
16%
Low
Severity
(OR=1.0)
Four
Moderate
Severity
(OR=5.1)
High
Severity
(OR=15.2)
Source: CSAT 2010 AT Summary Analytic Data Set (n=18,120)
Five to
Twelve
Change (post-pre) Effect Size for Core
Figure 9. ChangeOutcomes
(post-pre) Effect Size
Core Treatment
Outcomes
Treatment
byforType
of Treatment
CHS
A-CRATreatment CYT/AAFT
(n=192)
(n=2144)
MST
(n=85)
MDFT
(n=258)
-0.37
-0.38
-0.38
-0.36
Seven
Challenges
(n=114)
-0.39
-0.45
-0.43
-0.39
-0.38
-0.41
by Type of Evidenced Based Treatment
METCBTCYT/EAT
(n=5262)
METCBTOther
(n=878)
FSN
(n=369)
A-CRAOther
(n=276)
-0.29
-0.36
-0.48
-0.23
-0.18
-0.31
-0.29
-0.30
-0.37
-0.29
-0.47
-0.51
-0.34
-0.33
-0.26
-0.19
-0.17
-0.26
-0.27
-0.37
-0.38
-0.33
-0.18
-0.28
-0.23
-0.36
-0.45
-0.43
-0.42
-0.17
-0.11
0.04
-0.43
-0.37
-0.30
-0.11
0.00
-0.80
-0.50
-0.60
-0.65
-0.40
-0.30
-0.20
-0.32
-0.15
0.00
-0.54
-0.62
Change Effect Size d
((mean follow-up - mean intake)/ std dev. intake)
0.20
Four best on treatment outcomes
include A-CRA, MST, MDFT, & FSN
Emotional Problem Scale
Substance Problem Scale
Substance Frequency Scale
HIV Risk Scale
Illegal Activity Scale
Average
% Point Change in Abstinence
Change in Abstinence by level of Support:
Adolescent Community Reinforcement
Approach (A-CRA)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Effects associated with
Coaching, Certification
and Monitoring (OR=7.6)
24%
4%
Training Only
Training, Coaching,
Certification, Monitoring
Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961)
37
Similarity of Clinical Outcomes :
Cannabis Youth Treatment (CYT)
Trial 2
Trial 1
300
50%
280
40%
260
30%
240
20%
But better than
the average for220
OP in ATM (200
200
days of
abstinence)
10%
MET/ CBT5
(n=102)
MET/
CBT12
FSN
(n=102)
MET/ CBT5
(n=99)
ACRA
(n=100)
MDFT
(n=99)
Total Days Abstinent*
269
256
260
251
265
257
Percent in Recovery**
0.28
0.17
0.22
0.23
0.34
0.19
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.12
Source: Dennis et al., 2004
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.16
0%
Percent in Recovery .
at Month 12
Total days abstinent
over 12 months
.
Not significantly
different by condition.
$20
$16
ACRA did better than
MET/CBT5,
and both
Trial 2
did better than MDFT
MET/CBT5 and
Trial 1
12 did better
than FSN
$20,000
$16,000
$12
$12,000
$8
$8,000
$4
$4,000
$0
MET/
CBT5
MET/
CBT12
CPDA*
$4.91
CPPR**
$3,958
$0
FSN
MET/
CBT5
ACRA
MDFT
$6.15
$15.13
$9.00
$6.62
$10.38
$7,377
$15,116
$6,611
$4,460
$11,775
* p<.05 effect size f=0.48
** p<.05, effect size f=0.72
Source: Dennis et al., 2004
* p<.05 effect size f=0.22
** p<.05, effect size f=0.78
Suggest the need to consider cost-effectiveness of
treatment approaches
Cost per person in recovery
at month 12
Cost per day of abstinence
over 12 months
Moderate to large differences
in Cost-Effectiveness by Condition
Screening & Brief Inter.(1-2 days)
Outpatient (18 weeks)
In-prison Therap. Com. (28 weeks)
Intensive Outpatient (12 weeks)
Adolescent Outpatient (12 weeks)
Treatment Drug Court (46 weeks)
Methadone Maintenance (87 weeks)
Residential (13 weeks)
Therapeutic Community (33 weeks)
$70,000
$60,000
$50,000
$40,000
$30,000
$20,000
$0
SBIRT models popular due to
ease of implementation and
low cost
$10,000
The Cost of Substance Abuse Treatment is Trivial
Relative to the Costs Treatment Reduces
$407
• $750 per night in Medical Detox
$1,132
• $1,115 per night in hospital
$1,249
• $13,000 per week in intensive
$1,384
care for premature baby
$1,517
• $27,000 per robbery
$2,486
• $67,000 per assault
$4,277
$10,228
$14,818
$22,000 / year
to incarcerate
an adult
$30,000/
child-year in
foster care
$70,000/year to
keep a child in
detention
Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004 in 2009 dollars
Investing in Substance Abuse Treatment Results in
a Positive Return on Investment (ROI)
• Substance abuse treatment has an ROI of between
$1.28 to $7.26 per dollar invested.
• Consequently, for every treatment dollar cut in the
proposed budget, the actual costs to taxpayers will
increase between $1.28 and $7.26.
• How will this happen? Individuals needing substance
abuse treatment will not disappear but instead interface
with much more expensive systems such as emergency
rooms and prisons.
• Bottom line = The proposed $55 million dollar cut will
cost Illinois taxpayers between $70 and $400 million
within the next 1 to 2 years.
Source: Bhati et al., (2008); Ettner et al., (2006)
Examples using Unit Costs
Description
Inpatient hospital day
Emergency room visit
Outpatient clinic/doctor’s office visit
Nights spent in hospital
Times gone to emergency room
Times seen MD in office or clinic
Days bothered by any health problems
Days bothered by psychological problems
How many days in detox
Nights in residential for AOD use
Days in Intensive outpatient program for AOD use
Times did you go to regular outpatient program
Days missed school or training for any reason
How many times arrested
Days on probation
Days on parole
Days in jail/prison/detention
Days detention/jail
*Quarterly cost to society 2009 dollars
Unit
Days
Visits
Visits
Nights
Times
Times
Days
Days
Days
Nights
Days
Times
Days
Times
Days
Days
Days
Days
Cost in 2009 dollars
$
1,409.69
$
265.52
$
75.59
$
1,409.69
$
265.52
$
75.59
$
25.22
$
9.74
$
254.82
$
149.21
$
102.51
$
276.17
$
18.08
$
2,091.51
$
5.67
$
18.29
$
79.75
$
111.77
Example #1: Haymarket Clients
• Under a NIDA grant, a cohort of 436 adults admitted to
Haymarket Center in Chicago were interviewed at intake
between February to March, 2004 and quarterly for 4 years
(with over 95% completion).
• In 2009, dollars these clients averaged $3,698 in costs to
society in the 90 days before accessing treatment ($15,383 in
the year before intake).
• Before entering outpatient treatment, clients incurred lower
quarterly costs when compared to clients entering long-term
residential ($2,191 vs. $4,749). More intensive treatment
serves clients that cost taxpayers more.
• During the year prior to treatment, this cohort of 436 adults cost
taxpayers $6,707,103. Without treatment, these costs would
have continued.
• It only took an average of 18 months before the cost of treating
these people at Haymarket was off set by reductions in other
costs to society and at the end of 4 years, there was an
average net savings of $14,589 per client.
Investing in Treatment has a Positive Annual
Return on Investment (ROI)
• Substance abuse treatment has been shown to
have a ROI of between $1.28 to $7.26 per
dollar invested
• Even the long term and more intensive
Treatment Drug Courts programs have an
average ROI of $2.14 to $2.71 per dollar
invested
This also means that for every dollar treatment
is cut, we lose more money than we saved.
Source: Bhati et al., (2008); Ettner et al., (2006)
44
Example #1: Haymarket Clients
• Under a NIDA grant, a cohort of 436 adults admitted to
Haymarket Center in Chicago were interviewed at intake
between February to March, 2004 and quarterly for 4 years
(with over 95% completion).
• In 2009, dollars these clients averaged $3,698 in costs to
society in the 90 days before accessing treatment ($15,383 in
the year before intake).
• Before entering outpatient treatment, clients incurred lower
quarterly costs when compared to clients entering long-term
residential ($2,191 vs. $4,749). More intensive treatment
serves clients that cost taxpayers more.
• During the year prior to treatment, this cohort of 436 adults cost
taxpayers $6,707,103. Without treatment, these costs would
have continued.
• It only took an average of 18 months before the cost of treating
these people at Haymarket was off set by reductions in other
costs to society and at the end of 4 years, there was an
average net savings of $14,589 per client.
Quarterly Costs to Society
Change in Quarterly Costs To Society:
Haymarket Center Adult Cohort
$10,000
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
Treatment costs initially increase costs
Followed by a sustained period of
reduced quarterly costs
Intake
12
24
Months from Intake
Source: Dennis & Scott NIDA Grant no. R37 DA011323
36
48
Cumulative Net Cost to Society
Cumulative Actual Costs Minus Expected
Costs To Society
Over 4 years, cumulative saving
of $14,589 per person
($6,360,804 for 436 person
admission cohort)
$10,000
$5,000
$0
($5,000)
($10,000)
($15,000)
Additional Cost of Treatment
offset by Savings in other
costs within 18 months
($14,589)
($20,000)
Intake
12
24
Months from Intake
Source: Dennis & Scott NIDA Grant no. R37 DA011323
36
48
Cumulative Actual Minus Expected Costs
To Society: Haymarket by Level of Care
Cumulative Net Cost to Society
10,000
All Levels of
Care Produced
Net Savings
5,000
0
STR , -4,542.00
-5,000
-10,000
OP , -$8,552
Similarly, IOP produced
greater savings than OP
-15,000
-20,000
Though the most expensive initially,
long term treatment also produced the
most long term savings
IOP , -$18,433
LTR , -$21,698
-25,000
Intake
12
24
36
Months from Intake
Source: Dennis & Scott NIDA Grant no. R37 DA011323
48
Example #2: Chestnut Health Systems
• As part of a NIAAA grant, a cohort of 355 adolescents were
recruited at discharge between 2004 and 2008 from
Chestnut’s residential treatment programs in central and
southern Illinois and interviewed quarterly for 1 year (with over
90% completion).
• In 2009 dollars, they averaged $6,554 in costs to society in the
90 days before intake ($26,217 in the year before intake).
• This 4 year cohort of 355 adolescents cost society $9,307,163
in the year before they were admitted to treatment – costs they
would have continued to incur if they were not treated.
• Usual continuing care produces a net benefit of $4,816 per
adolescent within 12 months post discharge. Three more
intensive types of continuing care produced greater net
benefits of between $7,876 to $11,559 within 12 months post
discharge.
Change in Quarterly Costs To Society:
Chestnut Adolescent Cohort
Quarterly Costs to Society
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
Outpatient Continuing Care plus other
Costs Consistently Below Baseline Costs
$0
3
6
9
Months from Intake
* Cost of residential treatment
Source: Godley NIAAA Grant no. R01 AA 10368
12
Usual
Continuing
Usual
ContinuingCare
Care(UCC)
(UCC)
$4,816
UCC+
Management
UCCContingency
+ Contingency
Management(CM)
(CM)
$10,910
UCC+Assertive Continuing Care (ACC)
$11,559
UCC + Assertive Continuing Care (ACC)
UCC + CM + ACC
UCC + CM + ACC
* Cost of residential treatment
$12,000
$8,000
$4,000
$0
More Intensive Continuing Care
Produced Greater Savings*
$7,876
* Defined as 12 month post discharge costs to
society minus 12 months pre intake costs to society
Source: Godley NIAAA Grant no. R01 AA 10368
Example #3: SAMHSA/CSAT’s Clients
• As part of SAMHSA/CSAT contract 270-07-0191, data were
pooled from 22,045 clients from 148 local evaluations,
recruited between 1997 to 2009 and followed quarterly for 6 to
12 months (over 80% completion).
• In 2009 dollars, the 2,793 adults averaged $1,417 in costs to
taxpayers in the 90 days before intake ($5,669 in the year
before intake).
• In 2009 dollars, the 16,915 adolescents averaged $3,908 in
costs to taxpayers in the 90 days before intake ($15,633 in the
year before intake).
• This would be $1.4 Million per 1,000 adults served and $3.9
Million per 1,000 adolescents served.
• Within 12 months, the cost of treatment provided by CSAT
grantees was offset by reductions in other costs producing a
net benefit to taxpayers of $1,992 per adult and $4,592 per
adolescent.
SAMHSA/CSAT’s Adult Clients
by Level of Care
Adult Level of Care
Year
before
intake
Year
after
Intakea
One
Year
Savingsb
Outpatient
$12,806
$9,241
$3,565
Intensive Outpatient
$15,263
$15,197
$ 66
Outpatient Continuing Care
$34,057 $14,310
Residential
$19,443 $24,297 ($4,854)c
Total
$17,035 $12,442
\a Includes the cost of treatment
\b Year after intake (including treatment) minus year before treatment
\c Cost of residential treatment is not offset yet at one year after intake
$19,748
$4,592
SAMHSA/CSAT’s Adolescents Clients
by Level of Care
Adolescent Level of Care
Year
before
intake
Year
after
Intakea
One
Year
Savingsb
Outpatient
$10,993
$10,433
$560
Intensive Outpatient
$20,745
$15,064
$5,682
Outpatient Continuing Care
$34,323
$17,000
$17,323
Long Term Residential
$27,489
$26,656
$833
Short Term Residential
$25,255
$21,900
$3,355
Total
$15,633
$13,642
$1,992
\a Includes the cost of treatment
\b Year after intake (including treatment) minus year before treatment
SAMHSA/CSAT’s Adolescents Clients
by Level of Care
Adolescent Level of Care
Year
before
intake
Year
after
Intakea
One
Year
Savingsb
Average Outpatient
$10,993
$10,433
$560
A-CRA Outpatient
$17,255
$10,615
$6,640
$11,122
$6,475
$4,648
$13,614
$10,489
$3,125
$10,100
$7,686
$2,413
Just Health Care Cost
A-CRA in Schools
Just Health Care Costs
\a Includes the cost of treatment
\b Year after intake (including treatment) minus year before treatment
Prior Research and These Three
Examples Provide Converging Evidence that
• Substance abuse treatment programs serve individuals who
are costing society a great deal. Eliminating treatment will NOT
eliminate costs associated with substance abuse….Illinois
taxpayers will pay and pay more if money for treatment is
reduced.
• Costs incurred prior to and after treatment vary by the severity
of the clients served.
• While providing more intensive treatment and continuing care
costs more in the short run, it also produces the greatest
benefit in the long run to tax payers.
• Cutting substance abuse treatment will likely increase total
costs to Illinois taxpayers via increased costs associated with
healthcare, welfare and incarceration.
The proposed $55 million cut will cost Illinois taxpayers
between $70 to $400 million within the next 1 to 2 years.