Dramatic changes have transpired in recent years in the availability of and reimbursement for treatment services for individuals with addictive disorders. Traditional inpatient and residential treatment settings have been replaced by intensive and extended outpatient settings. "Standard" addiction treatments, such as 28-day inpatient hospitalizations, are largely a phenomenon of the past. The process of treatment planning has also changed for providers and patients. Treatment decisions now depend relatively more on third-party coverage than on the nature and severity of illness. The procedures for determining eligibility and obtaining authorization for addiction treatment, which are often ponderous and impersonal, are determined through administrative procedures that are external to the treatment staff and facility. The criteria used to determine the type of treatment seem arbitrarily based solely on bottomline economic needs, exclusive of clinically driven patient needs.
The pervasive changes are the result of the reengineering of the American health care system to reduce overall health care costs and the yearly rate of increase in these costs. The proportion of money spent on health care in the United States in relation to the gross national product (GNP) is greater than in other economically and socially comparable countries. The rate of increase in health care costs, if allowed to continue, will eventually bankrupt the financial systems that pay for health care, particularly Medicaid and Medicare. Although a coordinated national policy has yet to be developed, insurers and other third-party payers have begun to manage the use of services and to impose limits on reimbursements to hospitals and providers. Often referred to as systems of "managed care," these changes have altered the treatment practices of most clinicians who provide addiction treatment to patients.1
Clinicians and their patients have been forced to adapt to these changes in addiction treatment without necessarily understanding or agreeing to the determining principles that led to their imposition. Clinicians must increase their knowledge about the economics of health care costs and the addiction treatment system, and must improve their skills in interacting with the addiction and mental health treatment systems. Clinicians must become advocates for their patients and for themselves by developing integrated addiction treatment services.
The clinician must understand the principles and rules that propel and guide the managed care environment and the movements toward integrated addiction and mental health systems. The purpose of this article is to provide clinicians with increased knowledge about the addiction treatment system in which they practice addiction medicine and provide mental health services. The impact of alcoholism and drug addiction on society, including their overall costs to society and their specific effects on health care costs, is presented as well as an explanation of the current addiction treatment system and how it continues to evolve in clinical practice. Substantial and compelling evidence is presented that addiction treatment is effective in reducing the economic and social costs of alcoholism and drug addiction, and improving the overall quality of life for individuals and society. Finally, it is explained how and why clinicians should be active advocates for themselves and for their patients in the political and economic processes that determine priorities for reimbursement of addiction and mental health services.
THE CURRENT ADDICTION TREATMENT SYSTEM
The principal way to reduce the impact of alcoholism and drug addiction on the health care system is through their effective treatment. Addiction treatment may be defined as medical, psychological, and social interventions that are short- and long-term methods to reduce or eliminate the adverse and harmful effects of alcohol and other drugs on the individual, his or her family and associates, and society. Comprehensive addiction treatment usually consists of the following components:
Evaluation- A diagnostic assessment.
Intervention- Initiation of treatment, referral, or both.
Detoxification- Cessation and removal of alcohol and drugs from the body and the treatment of their withdrawal.
Rehabilitation- Structured medical, psychological, and social treatment methods to reduce and avoid relapse to the use of alcohol and drugs in the future.
Continuing Care- Processes to assist in maintaining an abstinent state and maturation of cognitive, emotional, and spiritual states.
Reasonable options are available to treat alcohol and drug dependence. These range from low-cost interventions, such as brief advice and self-help programs through intensive outpatient settings, to higher cost inpatient detoxification and rehabilitation programs. Orientations toward addiction treatment range from the medical/biological to the spiritual/behavioral. Objective data on outcomes from addiction treatment are available. Without using objective data from outcome studies on the intensity and duration of addiction treatment, the least costly treatment alternative is likely to be adopted by managed care programs.
Evaluation and Interventions
Treatment interventions begin with proper assessment, diagnosis, and referral to specific addiction treatment strategies. Physicians have an opportunity to diagnose accurately and intervene skillfully at all stages in the course of addictive illness. Patients with addictive illness can present to physicians with early, middle, and late stages of complications from addictive diseases. Each stage can be characterized by the types and severity of addictive illnesses and their medical and psychiatric comorbidities.2
Pharmacologic interventions can increase compliance and retention with behavioral forms of addiction treatment. Pharmacologic therapies are indicated to prevent life-threatening complications from withdrawal in addictive disorders, such as seizures and delirium tremens. Although detoxification is an essential process in the initial stages of engagement in treatment, many alcoholics and drug addicts experience a medically benign course of withdrawal. Detoxification without pharmacologic therapies is possible for a number of patients in alcohol and drug withdrawal. Social detoxification is behavioral support and monitoring of withdrawal without pharmacologic interventions unless medically indicated.3
The hallmark of addictive disorders is that they readily respond to specific and effective treatment methods. Abstinence is the goal in treatment and recovery. Short- and long-term abstinence can be achieved with the use of standard treatment methods. Evaluations of treatment practices in controlled and naturalistic studies have demonstrated that abstinencebased treatment methods are effective in inducing and maintaining abstinence from alcohol or drugs, and reducing psychosocial, legal, employment, and medical complications from addictive disease. The abstinence-based method is the predominant form of addiction treatment employed to treat the disease of alcohol or drug addiction. The abstinence-based method uses cognitive behavioral techniques, and referral to 12-step recovery programs, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).4
ADDICTIONS TREATMENT (PREVENTION OF REUPSE): COST-EFFECTIVENESS
Treatment of alcohol and drug withdrawal is often not sufficient to provide sustained abstinence from the use of alcohol and other drugs. Further referral to addictions treatment to prevent relapse to alcohol and drugs is indicated concurrently or following treatment of withdrawal.4
Treatment outcome studies have shown that 60% of patients have had continuous abstinence from alcohol and drugs at 1 year after discharge from abstinence-based treatment programs. One-year abstinence rates of 80% to 90% were achieved when weekly participation in continuing care, attendance at 12-step meetings, or both followed the discharge from the treatment programs. Also, medical care use and legal consequences were reduced and employment records were improved in association with 1-year abstinence rates (Tables 1 and 2).4
One-Year Abstinence by Continuum of Care and Self-Help Support
Use of Medical Care 1 Year Before and After Treatment
According to results of a triennial survey conducted by AA in 1992, recovery rates achieved in the AA fellowship were as follows: (1) of those sober in AA less than a year, 41% will remain in the AA fellowship another year; (2) of those sober more than 1 year but less than 5 years, 83% will remain in the AA fellowship another year; and (3) of those sober 5 or more years, 91% will remain in the AA fellowship another year. Of central importance, attendance in an abstinence-based treatment program can increase the recovery rates in AA (eg, from 41% to 80% or more with referral to AA following the addiction treatment program).4
STANDARD OF CARE FOR COMORBID PSYCHIATRIC AND ADDICTIVE DISORDERS
After detoxification and stabilization with pharmacologic agents, the current treatment of choice for addictive disorders is by predominantly nonpharmacologic or psychosocial methods. Further, several studies have shown that treatment of addictive disorders that results in abstinence can lead to improvement of the psychiatric syndromes associated with the alcohol and/or drug use and addiction. Severe psychiatric syndromes induced by alcohol and drugs that may meet severity for major depressive and anxiety disorders in DSM-IV can resolve within days to weeks with abstinence. Likewise, manic syndromes induced by cocaine can resolve within hours to days, and schizophrenic-like syndromes (eg, hallucinations and delusions) induced by cocaine and PCP often can resolve within days to weeks with abstinence.5,6
Further studies are indicated to confirm the clinical experience that psychiatric symptoms (including anxiety, depression, and personality disorders) respond to specific treatment of the alcohol and drug addiction. In clinical practice, cognitive behavioral techniques employed in the abstinence-based treatment approach have been effective in the management of anxiety and depression associated with addiction.
Various models have been proposed and are being implemented to treat addictive comorbidity in psychiatric populations- the serial, parallel, and integrated models. The serial model is the traditional practice of treating the psychiatric comorbidity in a psychiatry setting, and then transferring to an addiction setting for the treatment of the addictive disorders. A major disadvantage is that chronically mentally ill patients often do not respond favorably to the confrontative and active group participation used in the addiction treatment settings. The parallel model is a newer practice in which the patients primarily reside in a psychiatric setting and are referred to an addiction setting for addiction treatment. In the serial and the parallel models, the treatment staff and sites are separate and the patients must contend with disparate philosophies and methods.
The integrated model is an attempt to provide core addiction treatment that is integrated with psychiatric treatments in the same milieu by the same staff. The patient receives a consistent approach to the treatment of both categories of disorders because the staff is trained in both psychiatric and addictive treatments. The integrated approach is gaining significant popularity in treating those chronically mentally ill patients with an addictive disorder. In this model, the patient may be assigned to a case manager who integrates psychiatric and addiction services for the patient's total care. The patient is closely observed longitudinally for compliance and outcome by the case manager. Referring physicians need to consider the advantages and disadvantages of the different comorbid treatment settings when making referrals for addiction treatment of psychiatric patients.
MAGNITUDE OF ALCOHOLISM TREATMENT
On any given day, more than 800,000 clients are actively enrolled in specialized treatment programs for drug or alcohol addiction: 45% are in treatment for alcoholism, 29% for drug addiction, and 26% for both.7 However, studies indicate that on any given day approximately 18 million individuals require addiction treatment, which is a far greater number than those who actually receive it. The need for addiction treatment services is substantial, yet the financial support for providing addiction treatment is low.
ORGANIZATION OF THE ADDICTION TREATMENT SYSTEM
The addiction treatment system is a complex system that is influenced by many dynamic factors. Figure 1 shows the treatment system from the traditional, treatment-oriented perspective. In this model, the clinician attempts to match the patient to an optimal treatment type and setting, which depends on the intensity of treatment needed and the availability of resources. In the past, almost all modalities were available for most patients; however, more recently, clinicians and patients find themselves with restricted and prohibitive choices. Figure 2 shows the addiction treatment system from the perspective of an economic orientation. The product of multivariables in the system is service use, where a patient or client receives some type of addiction treatment service. Factors that influence service use, especially the amount and type of treatment provided, include sources of financing and amounts of reimbursement to providers and institutions. The availability of reimbursement for treatment services is usually determined by insurance companies or other third-party payers. In many cases, treatment is stipulated by national and state policies that mandate specific services and set eligibility for services. At the operational level, addiction treatment services are defined and delivered by organizations such as HMOs, hospitals, and groups of providers (individuals or organized) that develop specific services in response to population needs and market demands. Ideally, success or failure of the process may be measured by a determination of service outcomes, such as access, cost, quality assurance, and cost-effectiveness. However, often cost benefits are ignored and funding for treatment services is arbitrarily reduced or carved out of health care plans.
Currently, the major mechanism for financing of addiction treatment is derived from federal and state governmental sources. More than two-thirds of the funding for specialty drug and alcoholism treatment facilities is derived from federal block grants and state and local governments. Less than one-third of funding is derived from private insurers, Medicaid, and other public reimbursement programs.
There are operational models of service delivery that are discernible in the addiction treatment system. In the "fee-for-service" model, providers receive payment based on the number and the type of services performed. In this model, the economic incentives for the providers are to maximize use of services to maximize income. Under a "level payment" model, service providers are paid the same for each diagnosis treated, regardless of the intensity or duration of treatment. The Medicare Diagnostic Related Groups (DRG) payment schedule for hospitals is an example of this payment schemata. In the "capitation" model, providers receive a standard payment for each person covered, regardless of services performed, and assume responsibility for type and amount of treatment services. In the capitated model, the economic incentives for the provider are to minimize use of services to maximize income. Capitation models usually include some "risk sharing" by providers for cost overruns due to greater than expected use of services. Risk sharing implies that the providers take on some of the financial responsibility and "costs" for the system when expenditures exceed income.
"Managed care" is the system that oversees the delivery of type and magnitude of treatment services under these models and monitors outcomes, such as access to treatment services, treatment effectiveness, and cost benefits. Under the fee-for-service model in managed care, payment and level of services depend on specific criteria that are assessed by constant and close administrative review. Under the capitated model in managed care, the system attempts to promote less costly use, while maintaining quality of care and minimizing costs. Historically, addiction treatment services can reduce the overall use of medical and psychiatric services by reducing the costly complications of addictive illness.
Types of Providers
The range of providers in the field of addiction treatment can be different from that in other forms of medical and surgical health care, as addiction treatment occurs in more multifaceted and multidisciplinary settings. Addiction treatment can be integrated in many settings, including the traditional medical and psychiatric settings, drug and alcohol specialty programs, residential settings, and prisons. Providers from different professional disciplines, ranging from physicians to credentialed counselors, may provide addiction treatment services that are unique or may overlap. Managed care has placed providers in competition with each other, which has drastically reduced the number of treatment providers. As with traditional fields of medicine, addiction treatment providers are increasingly becoming part of larger groups of practitioners or are working within institutional settings.
THE EVOLUTION OF THE ADDICTION TREATMENT SYSTEM
Table 3 shows the probable evolution of the addiction treatment system during the next several years. The model describes 3 stages of evolution toward an integrated health care delivery. In stage 1, the event-driven fee-for-service model predominates; however, care is heavily managed to reduce costs and treatment services. Addiction treatment may be carved out and managed separately from regular medical and surgical care in many managed care plans. In stage 2, costs have been reduced, and more emphasis is placed on treatment outcome and "user-friendly" services to attract customers to treatment services. Stage 2 has acquired more experience with the new procedures and can begin to explore cost-effectiveness of addiction treatment services.
In stage 3, treatment services are based on deferred populations and providers assume responsibility for capitated contracts. The health care system is integrated within medical and psychiatric systems, so that risk for costs is pooled across disciplines within settings. The implications are that if consequences of addictive illness increase medical or surgical costs, addiction treatment is more likely to be integrated into health care delivery to maintain or reduce overall costs in the capitated system. Prevention activities also become more emphasized as status and subsequent cost of health impacts on the financial structure of the entire capitated system. Currently, most systems are in stage 1 or stage 2. However, some systems, particularly in the western United States, have entered stage 3 as managed care companies seek to distribute liability for risks and respond to political pressure to provide more treatment services.
ADDICTION TREATMENT IS COST-BENEFICIAL
Historically, addiction treatment was marginalized and not integrated with the rest of the health care system. During the Clinton administration's discussions of health care reform, some "experts" considered providing access to addiction treatment for all of those in need as too expensive. The available data actually show the contrary- that addiction treatment is effective and reduces health care costs, as well as other social costs. Available data on treatment outcomes and cost benefits must become widely known so that informed and rational decisions can be made to provide addiction treatment to those who need it. The following section presents the results of severa! recent research studies on health care services that unequivocally demonstrated the cost-effectiveness and cost benefits of addiction treatment.
A study of addiction treatment was undertaken by the state of California Department of Drug and Alcohol Programs called the CALDATA Study.8 Researchers measured outcomes in 16 counties in California on 1,850 randomly selected participants in 4 types of treatment programs- residential, residential "social model," outpatient, and outpatient methadone. Follow-up interviews were conducted after addiction treatment was provided to patients/clients. The findings showed that treatment was effective, in that alcohol and drug use was reduced by approximately two-fifths in those who received addiction treatment. Only slight or no differences were found in treatment effectiveness for men and women, young and old, or among African-Americans, Hispanics, and Whites. On the average, $1 of treatment costs saved at least $7 in other medical and social costs. The cost-benefit ratio was favorable for all treatment modalities: highest for methadone and lowest for "social model" residential treatment. Finally, criminal activity declined by approximately two-thirds following addiction treatment. The amount of decline was related to the amount of treatment services provided in the modalities.
The Evolution of Integrated Health Care Delivery
Several other recent studies have supported the cost-effectiveness of addiction treatment. A Fortune 100 company that analyzed the savings of its employee assistance program (EAP) found that the annual medical costs for workers with addictive illness fell from $2,068 per year to $165 per year after the employees received addiction treatment. Even when treatment costs were added in, the total health care cost savings was approximately $500 per employee. Moreover, indirect cost benefits were even greater- employee absenteeism was reduced and work-related productivity increased.
Although the preceding studies focused on the benefits of addiction treatment, in general, several studies have examined the cost-effectiveness of alcoholism treatment. Holder and Blose conducted a longitudinal study of the effect of alcoholism treatment on health care costs in a population of workers.9 The researchers reviewed approximately 20 million health insurance claims filed by alcoholics that were identified during a 14-year period, and compared 3,068 alcoholic employees who received alcoholism treatment with 661 alcoholic employees who did not receive treatment. The results showed a significant 24% decline in post-treatment health care costs for the treated alcoholics, including the costs of alcoholism treatment, as compared with the nontreated group.
The state of Minnesota offered managed, comprehensive addiction treatment services to severe alcoholics who had exhausted their medical coverage. The cost of the addiction treatment was $50 million. The program returned 80% of utilization costs of treatment during the first year, and returned 100% of costs within 3 years.10 A study of health care costs of 3,572 patients who received alcoholism treatment between 1983 and 1986 was conducted across 38 addiction treatment sites in the United States. The results showed a significant decrease in health care costs after addiction treatment, as compared with before treatment. The reduced costs were seen in those who remained abstinent during the 2-year follow-up period and those who relapsed, although there was less of a decrease in costs for those who relapsed to alcohol and drugs.
Thus, the results of these studies and others clearly demonstrated the cost benefit of providing addiction treatment. Additional cost offsets are produced by decreases in motor vehicle accidents, work-site accidents, family violence, and work and school absenteeism.
AN INTEGRATED SYSTCM OF ADDICTION AND MENTAL HEALTH SERVICES
Despite variability in studies, the prevalence of comorbid substance-related disorders among those with chronic mental illness is substantially higher than that in the general population. Schizophrenic patients were four times as likely to have a substance-related disorder than were persons in the general population. Comorbid substance use and severe mental disorders were associated with an array of negative outcomes (eg, increased vulnerability to rehospitalization and additional psychiatric and medical treatment services). Fragmentation of treatment services was identified as a principal factor related to negative outcomes in the comorbid psychiatric population.
The separation of addictive and mental health services has been an outstanding deficiency in providing treatment services for these disorders, coupled with ambivalence on the part of psychiatric professionals to treat addictive disorders, as reflected and promoted by public policy. Addiction was historically a medicai disorder and was treated in asylums, and AA was a growth that occurred within the community. Federal response to addictive and mental health disorders was to pass acts for separate services for addictions or mental health and to fund each uniquely (eg, the National Institutes on Alcoholism and Alcohol Abuse [NIAAA], the National Institutes on Drug Abuse [NIDA], and the National Institute on Mental Health [NtMH]). The Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) was formed to oversee combined mental, alcohol, and drug formula grants (eg, block grants). States mimicked the federal government and formed separate addiction and mental health agencies within their government structure.
Considerable effort was made to define eligibility to the exclusion of individuals with cooccurring disorders or comorbid addictive and psychiatric disorders. ADAMHA was split into the Substance Abuse and Mental Health Services Administration (SAMHSA), NIMH, NIAAA, and NIDA. SAMHSA created separate centers- the Center for Substance Abuse Treatment (CSAT) and the Center for Mental Health (CMH). Separate certification by the American Society of Addiction Medicine (ASAM) and added qualification by the Addiction Psychiatry Board (ABPN) were established for physicians who specialize in clinical addictions. However, managed care organizations are now looking to consolidate provider networks, treatment sites, and use review.11
Most dually diagnosed persons are in and out of each kind of treatment, with little crossmonitoring from addiction to mental health sites. Most longitudinal studies pertain to parallel treatment studies and short follow-up (3-6 months). Most prospective studies show that persons with severe illness and co-occurring substance disorders have poorer psychosocial adjustments, at least in the short term (eg, homelessness and institutionalization). Studies also suggest that abstinent schizophrenic patients with a history of substance disorder were found to have treatment service use patterns similar to those of patients who never abused drugs, which is significantly lower than the actively substance-using patient. Also, they had fewer schizophrenic symptoms, which suggests they may be less ill when not using addictive drugs. These findings stress the importance of addiction treatment to induce remission of addictive disorders in the chronic mentally ill. Results from studies of addicted chronic mental illness tend to be similar to those for substance - related disorders that tend to be a chronic relapsing problem.
Because of denial of substance use (assessments based on self-reports alone), urine drug testing is positive in cases where drug use is denied, and actual rates for substance-related disorders may be underestimated in studies of coexisting addictive and psychiatric disorders.
In the serial and parallel models (separate mental health and addiction treatments), the burden of integrating addiction and psychiatric treatments falls on the patient. Integrated models of treatment services for comorbidity are being put forth in greater numbers. However, studies of integrated addiction and mental health treatment are available that support their effectiveness. Overall, studies suggested that integrated treatment can lower hospitalization costs, reduce or eliminate substance use, reduce psychiatric symptoms, and lead to other improvements in quality of life. Unfortunately current policy and reimbursement focus on short-term, not long-term, integrated treatment programs, as most persons with dual disorders require long-term treatments. Separate organizational structures contribute to low rates of detection and funding for long-term, integrated treatment for dual disorders.12
The answer for integrated treatment services is not to develop a third system for persons with co-occurring illnesses in addition to those for addictions and mental health that would create new boundaries. A truly integrated system would provide a seamless delivery of addictions and mental health services through a variety of agencies across behavioral health fields. An ideal system is longitudinal and continuous, individualized, comprehensive, flexible, personal, accessible, and cohesive. Continuous addictions and psychiatric training is provided to all treatment staff. Professional leadership and outcome evaluation to ensure continued progress toward identified goals for service integration of patient care are needed on all levels- clinical, administrative, financial, institutional, political, and governmental.13
1. Iglehart JK. The American health care system: managed care. N Engl J Med. 1992;327:742-747.
2. Miller NS, ed. Principles of Addiction Medicine. Washington, DC: American Society of Addiction Medicine; 1994.
3. Miller NS, Gold MS, eds. Pharmacological Therapies for Drug and Alcohol Addiction. New York: Marcel Dekker; 1995.
4. Miller NS. Treatment of the Addictions: Applications of Outcome Research for Clinical Management. New York: Haworth Press; 1995.
5. Miller NS. Comorbidity of psychiatric and alcohol/drug disorders: interactions and independent status. J Addict Dis. 1993;12:5-16.
6. Schuckit MA, Montero MG. Alcoholism, anxiety, depression, Br J Addict. 1988;83:1373-1380.
7. Subetance Abuse and Mental Health Services Administration (SAMHSA). Highlights From the 1991 NDATUS Survey. Rockvffle, MD: SAMHSA; 1992.
8. Gerstein DR. Evaluating Recovery Services: The California Drug and Alcohol Treatment Assessment (CALDATA). California Department of Alcohol and Drug Programs; 1994.
9. Holder HD, Blose JO. The reduction of health care costs associated with alcoholism treatment: a 14 "year longitudinal study. J Stud Alcohol. 1992;53:293-302.
10. Tumure C. Minnesota Consolidated Fund: Annual Cost Offsets. Minnesota Department of Human Services; 1993.
11. Osher FC, Drake RE. Reversing a history of unmet needs: approaches to care for persons with co-occurring addictive and mental disorders. Am J Orthopsychiatry. 1996;66:4-11.
12. Drake RE, Mueser KT, Clark RE, Wallach MA. The course, treatment, and outcome of substance disorder in persons with severe mental illness. Am J Orthopsychiatry. 1996,66:42-51.
13. Osher FC. A vision for the future: toward a service system responsive to those with co-occurring addictive and mental disorders. Am J Orthopsychiatry. 1996;66:71-76.
One-Year Abstinence by Continuum of Care and Self-Help Support
Use of Medical Care 1 Year Before and After Treatment
The Evolution of Integrated Health Care Delivery