Page images
PDF
EPUB

duction of drug use as well as several indicators of the patients' success in building productive lives-decrease in criminal activity, excessive alcohol use, depression, and increase in employment. Generally, the study found that all of the modalities of treatment were effective in reducing drug use up to five years after a single course of treatment; they had a more limited measure of success in helping clients build more productive lives.

Basically, the TOPS study found that treatment resulted in substantial decreases in the abuse of both opiate drugs such as heroin and other drugs as well, but that the goal of abstinence was achieved by a relative few. Pretreatment levels of drug use declined dramatically during treatment, increased slightly immediately after treatment relative to in treatment levels, and again declined in subsequent periods after treatment. The prevalence of regular cocaine use increased slightly three to five years after treatment, while use of most other drugs continued to decline. These trends for use held for all three treatment modalities. Time in treatment, as in the DARP study, was among the most important important predictors of posttreatment drug abuse for all types of drugs, particularly for heroin abuse—the longer a client spent in treatment, the better the chances for positive outcomes. In contrast to the DARP study, however, the TOPS study found the time in treatment necessary for greater success was relatively long: 6 to 12 months. Time in treatment was a less successful predictor of reduced posttreatment drug use for cocaine abusers and multiple drug abusers.

The TOPS study also looked at the cost-effectiveness of treatment and found substantial reductions in crime-related and other costs to the Nation of drug abusers as a result of treatment. The study found that the investment of $5,000 for a year of outpatient drugfree or methadone treatment or $15,000 to $20,000 a year for residents of therapeutic communities—the average annual costs of treatments in the study-produced benefits that far outweighed the costs. The prevention of AIDS through reduction of intravenous drug use is another potential cost-related savings resulting from drug abuse treatment. The study concludes that the reduction in crime-related and other costs to society appears to be at least as large as the cost of providing treatment and that much of the expenditure is recovered during the time the abuser is in treatment. The study concludes that ". . . in that substantial benefits are to be gained during the treatment period in terms of reductions in criminal activity and associated costs to the nation, long-term drug abuse treatment appears to be an effective mechanism to limit the burden of drug abusers on the nation."

The TOPS study also recommends several ways in which existing treatment efforts could be substantially improved through increased outreach and recruitment to encourage more drug abusers into treatment, better patient assessment and planning to ensure that drug abusers receive the services they need, improved counseling and increased habilitation and rehabilitation and related services, and increased efforts to ensure that clients remain in treatment for the appropriate length of time to improve chances of success and receive adequate transitional and aftercare services after treatment is completed. The report also calls for more research on the difficult problems of matching different types of clients with the particular treatment modalities and settings that are most appropriate for those clients. The question of what treatment works best for what type of client is still difficult to answer and for publicly-funded treatment programs can be a crucial issue in allocating limited resources.

One major problem that some researchers have with much drug abuse treatment research, including the DARP and TOPS studies, is that they concentrate for the most part on treatment for heroin addiction. Little is known as yet on the effectiveness of treatment for cocaine abuse and polydrug use, which are becoming increasingly dominant among drug abusers in our society. TOPS study results that showed increased use of cocaine after treatment demonstrate the difficulty of successfully treating addiction to this drug.

Effectiveness of Treatment for Mental Illness-The NIMH in 1989 published a monograph of papers from a 1987 conference on the Future of Mental Health Services Research. One of the papers included in the monograph reviews research over the past two decades into the effectiveness of services for the severely mentally ill.12 This review classifies services effectiveness research that address similar issues or interventions about the following groups of treatments and treatment settings: inpatient milieu, 13 length of hospital stay and early discharge, alternatives to hospital admission, and aftercare following an acute episode.

Hargreaves and Shumway's review of research into the use of milieu therapies found mixed results-little benefit with chronically ill schizophrenic patients

12 William A. Hargreaves, and Martha Shumway, "Effectiveness of Services for the Severely Mentally Ill," in The Future of Mental Health Services, Carl A. Taube, David Mechanic, and Ann A. Hoffman, eds., National Institute of Mental Health, DHHS Publication No. (ADM) 89-1600, 1989. The following section of the paper uses this article as source.

13 Milieu therapy is defined as a "socioenvironmmental therapy in which the attitudes and behavior of a treatment program and the activities prescribed for the patient are determined by the patient's emotional and interpersonal needs." The therapy "has particular meaning where functional behavior and activities are modeled in psychiatric settings," Lee Hyde, The McGrawHill Essential Dictionary of Health Care, 1988, 301.

treated in nonintensive milieus in one study, but in other studies, apparent benefits from intensive milieu therapy with nonchronic schizophrenic patients. Other studies found varying levels of effectiveness from different forms of milieu therapy with patient groups in a variety of settings.

Studies on the impact of length of hospital stay and early discharge on patient outcomes are in effect studies on the effectiveness of different forms of deinstitutionalization. One such study which followed patients who had spent varying lengths of time in inpatient treatment before discharge to aftercare in the community found that patients who were discharged after three weeks in hospital demonstrated fewer symptoms than patients who had been hospitalized for longer periods of time before release. However, intensive aftercare apparently reduced symptom levels regardless of the length of hospital stay. Hargreaves and Shumway conclude that the data suggest that clinical goals can usually be accomplished "in brief inpatient stays or in appropriately staffed residential treatment settings and supportive residences combined with day treatment, or through intensive outpatient case management. In a community lacking adequate capacity or quality in such facilities, or for patients who have insurance coverage that pays for inpatient care but not an alternative," they go on, "the clinician may be forced to substitute inpatient care, but these nonoptimal circumstances do not make extended inpatient care the treatment of choice in principle." They also found that studies consistently showed that early discharge of long-stay patients is possible if suitable community programs exist. Community placement does not always produce improvement in psychiatric symptoms, but does seem associated with improved social function as long as active treatment continues.

Studies of alternatives to hospital admission look at programs that substitute other residential care, day care, or alternatives carried out entirely in the community or in the patient's home in an attempt to avoid hospitalization in the first place. The authors found that the studies of alternatives to hospital treatment showed good consistency in their results, which they found remarkable because of various flaws in individual studies, and because the studies examined a wide variety of treatments in different settings with disparate patient groups. They found it possible to conclude from these studies that "caring for severely ill psychiatric patients in ways that avoid or shorten traditional hospital treatment is, on average, at least equally effective and may be more effective than standard use of hospital care. Well-organized services using alternatives to hospitalization can cost less, sometimes much less, without incurring offsetting social or private costs, and may provide greater improvement in

symptoms or social functioning." The authors do caution that, despite the positive results of these studies on alternatives to hospital admission, they may focus too much on crises leading to hospital admission. They also note that too few researchers have compared different alternatives to hospital admission or studied community settings in which particular mixes of strategies may be most cost-effective.

Studies of aftercare following hospitalization looked at a progression of more restrictive to less restrictive modes of aftercare, from residential settings such as community lodges and halfway houses, to day treatment, outpatient treatment, and case management. As with other techniques, the results of the studies on these alternatives are mixed. Some have been modestly effective, but others showed disappointing results. Despite the attention that case management is currently receiving in community mental health services, Hargreaves and Shumway found little research on the efficacy of the concept. They found that several demonstration projects seemed to show evidence for the effectiveness of case management, but concluded that project design limitations restricted their value. Another disappointing study found that randomly assigned case managed subjects, compared to a control group, received more services, cost more to maintain, and were hospitalized more often without showing higher scores on quality of life measures.

Hargreaves and Shumway conclude that mental health treatment services efficacy research has barely begun to "to identify the most cost-effective ways to organize entire service systems for this target population."

CURRENT PUBLIC PROGRAMS FOR SUBSTANCE ABUSE AND MENTAL HEALTH TREATMENT AND RELATED SERVICES

Federal Programs

Alcohol, Drug Abuse, and Mental Health Block Grant-The Alcohol, Drug Abuse, and Mental Health Services (ADMS) Block Grant, authorized under P.L. 97-35, the Omnibus Budget Reconciliation Act of 1981, authorizes grants to States for alcohol and drug prevention, treatment, and rehabilitation programs; and for grants to community mental health centers (CMHC) for the provision of mental health services, including services for the chronically mentally ill, severely mentally disturbed children and adolescents,

mentally ill elderly individuals, and other underserved populations.

The original formula for the block grant resulted in national allocations for substance abuse and mental health programs which were approximately equal to each other, although the proportions of allocations varied from State to State. The authority for the ADMS block grant has been amended several times, most recently by the 1988 Anti-Drug Abuse Act, P.L. 100-690. Under the revised block grant authority, approximately two-thirds of the appropriation nationwide is allocated for substance abuse programs and one-third for mental health services activities. In FY 1988, according to NASADAD, a total of 4,786 alcohol and/or drug treatment units received block grant funds from their States. These treatment units, which also receive financial support from other sources such as State, county, and other local agencies, and from other sources such as client fees and private health insurance, admitted nearly 1.2 million clients for treatment during that year.

The total FY 1989 appropriation for the ADMS block grant was $805.6 million, from an authorization level for the year of $1.5 billion. In FY 1990, approximately $1.1 billion will be available for allocation among the States, an estimated $237.6 million for mental health activities and $895.6 million for substance abuse activities.

Department of Veterans Affairs-The VA operates an extensive network of mental health and substance abuse treatment programs within its medical centers and outpatient clinics and related facilities. In FY 1988, over 50,000 veterans were treated in these facilities for identified drug abuse problems, over 200,000 were treated for alcohol abuse problems, and over 214,000 were treated for mental health problems. The VA in FY 1988 operated 56 drug treatment inpatient programs with 965 beds, 66 drug treatment outpatient programs, and 35 methadone maintenance programs. For alcohol abuse treatment, it operated 128 inpatient programs with 3,500 beds and 139 outpatient treatment programs. For mental health treatment, the VA operated 22,169 psychiatric beds in its various facilities in FY 1988.

EXISTING COVERAGE FOR SUBSTANCE ABUSE AND MENTAL HEALTH TREATMENT UNDER PUBLIC AND PRIVATE HEALTH CARE FINANCING PROGRAMS

Public Health Care Financing

Medicare-Medicare provides limited services for the mentally ill and for substance abusers over the age of 65, and for those who have been on SSDI for at least 24 months. Medicare services are primarily limited to inpatient services, reimbursed under part A of Medicare. Medicare does not provide a specific benefit for treatment of alcoholism or drug abuse, but services are covered which are medically necessary and available in a covered setting. Coverage for such treatment is available in both general and specialty hospitals, such as psychiatric hospitals. Medicare pays for treatment in short-term acute care hospitals for mental health or substance abuse services under its prospective payment system (PPS), while psychiatric hospitals and qualified distinct part psychiatric units in general hospitals are exempted from PPS and continue to be reimbursed on a reasonable cost basis subject to annual rate of increase limits. Medicare coverage of inpatient care furnished in a psychiatric hospital, for mental health or substance abuse services, is limited to 190 days during a person's lifetime. In FY 1985, Medicare part A benefits for mental health services totalled $1.3 billion, of which $252 million represented payments to psychiatric hospitals.

Part B of Medicare, until FY 1987, recognized, for purposes of reimbursement for outpatient mental health services, a maximum of 62.5 percent of $500 of such charges in a year, or $312.50, and would reimburse 80 percent of this amount, or $250 a year. Under OBRA87, the outpatient reimbursement limit was increased. For each year after FY 1988, part B would recognize the lesser of $1,100 a year or 62.5 percent of expenditures during that year. Under OBRA89, the outpatient reimbursement limit of $1100 a year was eliminated; the coverage limit of 62.5 percent of total outpatient expenditures in a year still applies, again with the beneficiary responsible for 20 percent of that total. Thus, Medicare still pays 50 percent of total expenses for outpatient mental health services. Originally, coverage for mental health services under part B of Medicare was limited to services provided by or supervised by a physician; OBRA87 included reimbursement, as of July 1, 1988, for therapy provided by a clinical psychologist in a rural health clinic or community mental health center. Under OBRA89, coverage was extended to services

of clinical psychologists and social workers without regard to location. Under accepted medical references that have classified alcoholism as a mental disorder, the limitations that apply under Medicare to mental health services have been applied also to treatment for alcoholism. Such restrictions include the 190 days limit on the lifetime number of days of coverage available for inpatient care in a psychiatric institution, as well as the dollar limit on reimbursement of outpatient treatment services. In addition, coverage is permitted only for care that represents "active treatment." In FY 1985, Part B expenditures for mental health services subject to the limit totalled $180 million.

Medicaid Medicaid is a major source of funding for services for the mentally ill. State Medicaid programs, may, at their option, cover services in two types of institutional mental health providers: "institutions for mental diseases," or IMDs, and inpatient psychiatric hospitals. Services in IMDS may be covered only for beneficiaries aged 65 and older, while services in inpatient psychiatric hospitals may be covered only for beneficiaries under age 21. Beneficiaries who are under 21 at the time they enter such a facility may continue receiving care until they reach age 22. In FY 1986, an estimated $1.1 billion in Medicaid funds was spent on these institutional mental health services for nearly 52.8 thousand beneficiaries.

Medicaid beneficiaries between age 22 and 65 may receive services for mental illness in hospitals and nursing facilities that are not IMDS or psychiatric hospitals. It is not possible to provide data on the extent of this coverage as Medicaid data do not distinguish expenditures for treatment for mental as opposed to physical problems by providers other than mental institutions.

Medicaid also covers mental health services for its beneficiary population in a variety of outpatient settings. Coverage limits for such services vary from State to State. In 1984, for instance, services in mental health clinics were covered by 44 States. Clinic providers in those States may include State or county facilities, some of them also funded through the ADMS block grant, as well as private providers. States also cover mental health services furnished in hospital outpatient departments. In a number of States, outpatient mental health services may include "partial hospitalization" or "psychiatric day care" programs. These provide services in a structured setting for part of the day for patients living in the community. Some States cover comparable programs furnished by mental health clinics.

In most States, Medicaid beneficiaries may obtain services from psychiatrists under the same rules that apply when they obtain services from physicians in other specialties. Beneficiaries may also receive some mental health care from physicians who are not psychiatrists. For reasons relating in part to State reimbursement and coverage policies, however, many psychiatrists have been reluctant to participate in the program.

Only a few States cover the services of other types of mental health professionals. Clinical psychologists were covered in 21 States in 1984, but only three covered any other type of professional, such as clinical social workers or psychiatric nurses. Some States may pay for services furnished by psychologists or other mental health professionals if they are providing services under the direct supervision of a physician, either in the physician's office or in a clinic setting.

Some States also cover alcohol and drug abuse treatment services in their Medicaid programs. A 1984 State survey found 10 such States, including 7 (Connecticut, Florida, Georgia, Kentucky, Louisiana, North Carolina, and South Dakota) which provided services in community mental health centers and/or clinics. Three other States, Washington, Minnesota, and Wisconsin also reimbursed for alcohol and drug abuse treatment services under the following categories: inpatient hospital, physician services, and nonphysician services, respectively.

Private Health Insurance

State Laws Mandating Health Insurance Coverage for Substance Abuse and Mental Illness-Because of the traditionally limited coverage for treatment of substance abuse and mental illness in the private insurance marketplace, State governments in recent years have been asked to exercise their regulatory authority over the insurance industry and require the expansion of such benefits. Starting in the early 1970s, a number of State legislatures began enacting legislation to require benefits for alcohol, drug abuse, and mental health treatment to be covered by health insurance available in the State. Other State legislatures enacted less stringent versions of such legislation to require only that health insurers offer such benefits to the policyholder at his option.

A 1986 survey of State laws regulating private health insurance benefits for mental health and substance abuse found that 14 States had statutes mandating insurers to pay for mental health care in group insurance policies, some of these States also man

dated coverage in individual policies as well. Twelve States required only that insurance policies “offer" such coverage at the policyholder's option. Three States had laws with both mandatory and optional provisions.

The 1986 survey found 35 States which had passed legislation requiring insurers either to provide benefits for alcoholism and drug abuse treatment services or to offer such coverage. Twenty-two States had mandatory coverage laws. These coverage laws are not uniform and mandate a wide variety of benefits; some States combine a mandate with an option, such as inpatient coverage might be mandated, while outpatient coverage might only be offered. Twenty-one States chose to require health insurers to make coverage available for substance abuse services. Different States mandate coverage of varying numbers of days of inpatient hospital coverage for mental illness or for substance abuse treatment-30 to 70 days year for inpatient mental health treatment, and from 3 to 21 days for detoxification, and from 10 to 45 days for inpatient substance abuse treatment. States also mandate coverage of varying numbers of outpatient treatment days, and provide for different limits of dollars of coverage. 14

Private Employer-Based Health Insurance Coverage-A BLS survey of employee benefits in medium and large firms in 1988 describes mental health and substance abuse treatment coverage in employee health insurance benefits. The survey found that mental health coverage, although available to nearly all participants, was commonly subject to special limitations. The BLS found that 71 percent of participants in plans with mental health benefits had more restrictive hospital coverage for mental illness than for other illnesses-up from 61 percent in 1986 and 43 percent in 1982. Plans generally limited the duration of hospital stays, often to 30 or 60 days per year for mental illness, compared to 120, 365, or unlimited days for other illnesses; and sometimes they imposed a separate, lower, maximum on covered hospital expenses, such as a lifetime maximum of $50,000 on all mental health benefits.

Plans had even more restrictive coverage for mental health care outside the hospital (psychiatric office visits). Such special limits affected 95 percent of participants in 1988, up from 91 percent in 1986 and 84 percent in 1982. Outpatient mental health care also was generally covered for fewer visits per year than other outpatient services, subject to special maximum

14 Intergovernmental Health Policy Project, State Laws Mandating Private Health Insurance Benefits for Mental Health, Alcoholism, and Drug Abuse, State Health Reports: Mental Health, Alcoholism, and Drug Abuse (January 1986).

dollar limits on annual payments, and covered at a coinsurance rate of 50 percent rather than the 80 percent often paid by plans for other illnesses. Also, outpatient mental health care expenses often did not count toward the maximum out-of-pocket expense limitation, and the reimbursement for these expenses did not increase to 100 percent if the out-of-pocket expense limitation was met, as with other services.

The BLS survey of private employee benefits in 1988 found that alcohol and drug abuse treatment benefits covered 80 and 74 percent of health care participants, respectively. Treatment covered under substance abuse care included detoxification and rehabilitation. Ninety-five percent of all participants with some form of alcohol abuse benefits were covered for inpatient detoxification, and 78 percent for inpatient rehabilitation. As detoxification is generally considered medically necessary, nearly all plans that cover alcohol abuse treatment benefits cover it. There is a greater tendency, according to the BLS survey, to exclude inpatient rehabilitation, since it requires less constant, immediate care. Outpatient alcohol abuse treatment, generally for rehabilitation services, was available to 84 percent of participants with alcoholism coverage. Coverage patterns for drug abuse benefits were similar.

As with mental health coverage, plans were more restrictive in covering substance abuse treatment than other illnesses. It was more likely, however, for inpatient detoxification to be treated the same as other conditions than inpatient rehabilitation or outpatient care. Slightly more than two-thirds of participants with inpatient alcohol detoxification care had their coverage either subject to separate limitations or to the same limitations as for mental illnesses. This contrasts with inpatient rehabilitation and outpatient care, where about four-fifths of participants had their coverage subject to separate limitations or covered the same as mental health care.

Separate limitations for substance abuse treatment most commonly included restrictions on the number of days of inpatient hospital care per year, the number of outpatient visits per year, and maximum dollar amounts of benefits per year or per lifetime. Limitations on days and dollars were often combined for alcohol and drug abuse care. A typical limitation on inpatient care was 30 days a year. Similarly, outpatient care might be restricted to 20 or 30 visits per year. 15

15 Bureau of Labor Statistics, Employee Benefits in Medium and Large Firms, 1988, BLS Bulletin 2336 (August 1989), 39 and 40.

« PreviousContinue »