111902

WHO BENEFITS FROM BETTER DRUG TREATMENT?

Paper prepared for Join Together Mark A.R. Kleiman

EXECUTIVE SUMMARY

Improving some dimensions of substance abuse treatment quality for some categories of patients would undoubtedly be cost-beneficial from an overall social viewpoint. But serious problems confront any effort to convert the beneficiaries of such improvements into effective advocates for them . The categories of benefit, and the needed steps to achieve those benefits, are so disparate to make assembling an effective coalition extremely difficult. Social stigma limits the effectiveness, as advocates, of sufferers from substance abuse disorders and their families. The politics of crime makes it highly unlikely that advocates for current and future crime victims - among those who would benefit most from improvements in pUblicly-paid treatment for offenders - will emerge as advocates for improved treatment quality. Health insurers and employers would also benefit, but the problem of adverse selection limits their enthusiasm for bringing about improvements in their own territory: being the insurer, or the employer, with the best substance abuse treatment program in the area risks attracting a disproportionate number of substance abusers into one's insurance pool or workforce. If treatment quality were easily measurable, the measurement alone would

create some pressure for improvement, but the multidimensionality of the substance abuse problem and the extreme variability among treatment population types means that any measurement system must also be multidimensional. Improved appreciation for the importance of substance abuse among health care professionals not specializing in such disorders might make a substantial difference, but that simply pushes the problem back one step, to how to influence the education and professional norms of those professions. Here, too, it is hard to identify a potent group of potential advocates .

DIMENSIONS AND DETERMINANTS OF TREATMENT QUALITY Substance abuse disorder is heterogeneous: its victims vary by primary drug of abuse, by the presence or absence of other abused substances, by age, by employment, housing, and family status, by criminal history, and by the presence or absence of other major physical and mental health problems, some related to the substance abuse as cause or consequence, some not. Some changes in quality influence the likelihood of palliation, temporary remission, or lasting remission of the substance abuse disorder itself. Those changes resemble improvements in medical care for other ailments. But another dimension of improvement has to do with the comprehensiveness of treatment with respect to how many of the client's problems are addressed. Compared to sufferers from most other diseases, victims of the most florid varieties of substance abuse disorder are at elevated risk of a wide range of somatic and mental health problems and of disordered relationships with family, neighborhood, the criminal justice system, and the labor market. A treatment program that helps its homeless clients find housing can be described as having higher quality than a program that does not, even holding the outcomes on substance abuse disorder constant. For those with the most varied and profound problems, "substance abuse treatment" is, or should be, shorthand for a much broader effort to put some order into disordered lives. A therapeutic community, for example, is not an especially specific treatment for substance abuse problems; rather, it is a general-purpose approach to creating self-respect and self-command where these are markedly lacking. Thus no single evaluation process can accurately measure treatment effectiveness across the full range of programs. Treating an otherwise healthy 40-year-old college graduate employed non-offender living in his own house for a case of iatrogenic benzodiazepine dependency secondary to sleep disorder is simply not the same sort of activity as dealing with an eighteen-year-old homeless primary cocaine abuser with severe borderline personality disorder, hepatitis C, and a felony criminal record for cocaine dealing and aggravated assault. Entrants to treatment programs also differ greatly in the chronicity of their problems, as measured both by the number of years since first meeting clinical criteria and the number of previous treatment episodes. (The rhetoric of "chronic, relapsing disorder" masks the reality that most substance abuse disorder clears up quickly and does not recur. It gets its surface credibility

from the fact that the minority of substance abuse sufferers whose condition is chronic and relapsing account for the majority of treatment episodes.) In many chronic disorders, treatment outcomes depend strongly on the degree of patient compliance with medical advice. Substance abuse disorder is emphatically a member of this class: in fact, recovery and compliance are substantially identical, since the primary medical advice to any substance abuser is to stop. A large body of research shows a strong correlation between treatment duration and outcomes. That correlation is not in itself adequate to show the nature of the causal link, which is no doubt bi-directional. Still, the mere capacity to keep patients coming back must count as an important dimension of treatment quality. Thus compliance and retention reflect important dimensions of treatment quality. But the heterogeneity of the underlying conditions makes it extraordinarily difficult to compare one program with another using such measures. In principle, quality measurement systems could be adjusted to account for variability in the entering population, but it seems unlikely that merely controlling for such measures as the ASI will so either adequately or correctly. Different aspects of quality are of interest to different beneficiaries, and under the control of different processes. These heterogeneities complicate the project of mobilizing the clout of the beneficiaries of drug treatment to improve its quality. The discussion that follows is intended to be illustrative rather than exhaustive. Two of the most important venues for improving treatment quality are outside the real of substance abuse treatment, narrowly defined: the primary care physician's office and the acute care hospital, including especially its emergency department and trauma ward but also the inpatient care it offers for a wide variety of conditions. Primary care physicians doing routine checkups or dealing with routine complaints have an opportunity to probe for the existence of substance abuse disorder. Early diagnosis might pay dividends in improved outcomes . The same is true of hospitals. (One study of acute-care hospital admissions found alcohol abuse present in 20% of the cases , but diagnosed in only 10% of that 20% .) Here the questions are whether the health care providers have adequate training, whether they perceive identifying, or ruling out, substance abuse as part of their clinical function, and whether the organizational and financial disciplines under which they operate require, encourage, or discourage that activity. How thoroughly is the diagnosis of substance abuse disorder covered in, e.g., medical school, nursing school, or EMT training? Do academic and licensure examinations include appropriate questions? Is some sort of substance abuse screen budgeted into the time allotted for a routine check-up?

Will a resident in trauma surgery be criticized by the attending, or the attending criticized by anyone else, if a gunshot victim is treated and released but never asked about his alcohol use at the time of the injury? When substance abuse is diagnosed or suspected in such settings, the question then becomes the adequacy of care available from the diagnosing physician or within the same clinical setting. Not all substance abuse that requires more than brief intervention needs specialist treatment. Smoking cessation with the use of the nicotine patch is one obvious example. The new Drug Addict Treatment Act will allow some opioid maintenance therapies to be managed by individual physicians rather than clinics. The extent of help available through primary care physicians might be thought of as an aspect of treatment availability rather than treatment quality, but under either label it is an important measure of the adequacy of the overall system response to substance abuse disorders. The competence of that help is clearly a quality issue. Here again, the key levers are likely to be professional education and standards and the policies of health care payors. Again, the questions are training, licensure, financing , and professional norms. Financing is driven in the first instance by insurers (which for these purposes includes HMO jPPO providers) and Medicare and Medicaid rules. Insurers can in turn be influenced by the employers who are their biggest customers, and by laws and regulations. But training, professional licensure, and professional supervision are much more difficult to influence from the outside. Even if General Electric or Microsoft were to decide that improving substance abuse treatment quality was an important issue, it is hard to see how that company could exert influence over the content of the medical school curriculum or the board exam in internal medicine. The usual interpretation of the term "treatment quality" is the quality of treatment available from specialized substance abuse clinics. The concentration of the activity, and the extent to which providers are paid under specific contracts with public agencies rather than under more ordinary health care finance arrangements, will tend to increase the amount of leverage that can be applied from the outside. The mix of payment sources (public pay, insurance, out-of-pocket) and the mix of clients will influence which outside agencies are most influential in each case. The state and local drug-program offices have enormous potential influence, but face the problem of "regulatory capture." Criminal justice agencies are less likely to be subservient to the interests of incumbent treatment providers, and insofar as they can determine where their clients go for services they have potential influence over the treatment system, but they also have less expertise and less authority. The "drug court" model, where the judge acts in a supervisory capacity over the treatment of individual offenders, might create a situation in which an outsider to the treatment field - in this case, the judge - acquired the interest, competence, and power to create effective pressure for quality improvements.

THE MIXED MOTIVES OF EMPLOYERS AND INSURERS

Since substance abuse can cause, or exacerbate, a wide variety of somatic and mental health problems, whatever entity pays for a person's health care has a financial interest in the quality of the substance abuse treatment available to that person. That ought to make health insurers and employers powerful advocates for improved treatment quality for the employed, insured population. However, the nature of the institutional arrangements involved substantially dilutes the likely effectiveness of those interests in promoting treatment quality. The cost savings incident to the provision of high-quality substance abuse treatments accrue over periods measured in years. The higher the turnover rates among employees and the rates at which employees switch from one health plan to another, the less of those benefits accrue to the employer or the insurer who pays for the actual treatment. Much of the benefit will accrue instead to the future employers or future health plans of those individuals. Thus their interest in the average quality level available in their communities is stronger than their interest in improving the quality of service available to their own employees or enrollees . The growing prevalence of "behavioral health carve-outs" adds another layer of complexity. Carve-outs are arrangements in which the financial responsibility and the gate keeping process for substance abuse and mental health are subcontracted by an insurer to a "behavioral managed care" organization, which pays all costs and receives a fixed amount per enrollee. Under such an arrangement, even the health care cost savings that d o accrue to the current insurer (as opposed to future insurers) do not accrue to the behavioral managed care organization. Its incentives, therefore, are to minimize the cost of substance abuse and mental health care, not to minimize total health care expenditures. Then the question is whether the insurer buying the carve-out has the incentive and the capacity to monitor, and demand improvements in, treatment quality. Some of the incentives built into the system are perverse. Employees seek employers, taking into account a variety of conditions of employment. Likewise individuals seek out health plans . Employers want employees who will be productive and low-maintenance, on and off the job. Health plans want enrollees who will be cheap to serve. While providing high-quality substance abuse treatment may improve the productivity and reliability of current employees, and reduce the cost of providing the health care of current enrollees, there is danger for an employer or health plan that earns the reputation for providing the best substance abuse treatment in its market. Insofar as individuals with substance abuse problems tend to migrate toward such employers or plans, insurers and employers will face the problem insurance analysts call "adverse selection": the incidence of substance abuse disorder among their employees or enrollees will be higher than the community average. Since, even with high-quality treatment, victims of substance abuse

disorders will tend to be, on average, costlier employees and enrollees than those fortunate enough not to suffer from those disorders , the disadvantage created by adverse selection will at least partly counterbalance - and may actually outweigh - the advantages for employers and health plans created by better treatment quality. Like the problem of deferred benefit s , the adverse selection problem creates an interest for each employer and each health plan in the quality of treatment services available through competing employers or plans. Where a few employers or insurers employ or insure a large proportion of the total working or insured population , it may be possible to negotiate agreements on such issues, but that is not the typical case . The analysis above constitutes an argument for a regulatory solution, but that is not something employers or insurers are likely to advocate. It may in some sense be in their organizational inter est for all of them to be forced to do the right thing, but the threat to organizational autonomy is likely to loom larger in organizational decisionmaking than the potential for cost-saving.

WHO BENEFITS?

The beneficiaries of improved quality are those damaged by untreated substance abuse disorder. That list always includes the sufferer and his or her family. But the identities of the other beneficiaries, and the extent of their stakes, varies greatly from case to case. Patients and their families are prominent beneficiaries of quality improvements. But the large number of patients whose problems are relatively transient are unlikely to become strong advocates for improvement, while the smaller number whose problems are severe and chronic have their efficacy as advocates limited both by the social stigma involved in substance abuse and by its behavioral effects. The stigma problem is especially severe for those dependent on illicit drugs, and there may be some difficulty in mobilizing the much larger group of those with alcohol problems to demand service impr ovements for illicit drug abusers. And it seems unlikely that many people whose sole drug problem is nicotine d ependency will be motivated to demand that the health care system improve the quality of interventions for that condition. Even if they did , neither pride nor political calculation would dictate that they try to make common cause with those whose problems involve intoxicants, still less illicit intoxicants. The families of those with substance abuse disorders may be in a stronger position to act as advocates . A model here would be the National Alliance for the Mentally Ill. (That no one expects NAMI to address the treatment-quality

issue, despite the fact that substance abuse disorders are psychiatric diagnoses, is worth pondering, as is the exclusion of substance abuse from most versions of "parity" legislation.) While the stigma attached especially to illicit substance abuse remains powerful, the secondary stigma that attaches to having a substance-abusing child has begun to fade. But here again heterogeneity is a problem: interests diverge, and coalitions may not form naturally. Those who pay for health care, directly or indirectly, save money if the quality of substance abuse treatment improves. But, as noted above, worries about adverse selection are likely to limit the activity of employers and insurers. And it's hard to imagine the administrator of the Health Care Financing Administration or a state Medicaid director becoming a powerful advocate for improvements in the quality of substance abuse treatment. If the numbers could be shown to be large enough, it is conceivable that chief elected officials or the chairs of appropriations committees might bestir themselves, but that would require that the cost savings from improvements be both demonstrable and large and that there be some lever (e.g., a parity requirement) within the grasp of such officials. The same analysis applies to the impact of better substance abuse treatment on other public budgets: for foster care, for example, or shelter for the homeless . There is no obvious way to go from showing a benefit to mounting an effective campaign to change things. One important class of benefits from improved substance abuse treatment is the reduction in crimes and accidents due to intoxicated behavior, crimes due to the need for money to support expensive drug habits, and violence and disorder incident to the illicit markets. The first of these relates primarily to alcohol, while the other two are almost exclusively illicit-drug problems. (None of them has much relation to nicotine.) That relationship makes potential crime and accident victims beneficiaries of improvements in substance abuse treatment quality. Their advocacy organizations, such as Mothers Against Drunk Driving and the National Center for Victims of Crime, have demonstrated power to influence legislation, though their capacity to move the levers influencing treatment quality is open to question. But can they be brought into a coalition for treatment quality improvement in the first place? MADD strongly supports programs of mandated treatment for those convicted of DUI/DWI, but its emphasis is on the requirement to seek treatment, not its quality. NCVC has not spoken out on drug-treatment issues at all (or, if it has, that fact is not reflected on the NCVC website). As long as treatment is seen as primarily benefiting those receiving it, it will be difficult to persuade those who identify with victims to support improving its quality. This is a problem that applies to all forms of crime control: while there is a substantial community of interest between offenders and victims, in

that both sides would benefit from reductions in offense rates, that community of interest does not translate into a community of sympathy. Criminal justice agencies - police, community and institutional corrections agencies, and the courts - may tend to take a more pragmatic view than the advocacy groups. Untreated alcoholism among the homeless or marginally housed population accounts for a large proportion of the police workload, and illicit substance abuse is deeply tied in with serious crime . Even mediocrequality treatment for offenders involved with illicit drugs is highly cost-effective crime control, and better quality treatment would probably be even better. Criminal justice agencies are already entangled with the treatment system, through probation supervision, diversion programs, drug courts, and prison drug treatment programs. The association of drug treatment with a rehabilitative model that is widely seen as having failed as an approach to corrections , and the high treatment and prison recidivism rates among the population of active user/offenders are both barriers to an enthusiastic embrace of treatment by criminal-justice officials, but those barriers are not insurmountable. In particular, it might be possible to induce the police, already strongly identified with the substance abuse prevention effort, to identify improving the availability and quality of drug treatment as an important way to help them do the job of crime control. But unlike the case of prevention, where DARE has gotten the police operationally involved, all they can do on the treatment side is cheerlead. That would be much better than nothing, but it's not clear how effective that cheerleading would be in actually improving treatment quality.

CONCLUSION

Substance abuse treatment is not a unitary activity, and its quality is not a unitary characteristic. Both the beneficiaries and the mechanisms for improvement vary sharply from category to category, suggesting an approach to making progress that is retail rather than wholesale. The potential coalition of those who would benefit from treatment improvements is an impressive one, but actually assembling that coalition around an particular improvement, or

around a proposed bundle of improvements, will demand formidable political and organizational skill.

Who Benefits from Better Drug Treatment_Mark ...

Page 3 of 8. Who Benefits from Better Drug Treatment_Mark Kleima ... blic Health program Join Together_November 2002.pdf. Who Benefits from Better Drug ...

4MB Sizes 2 Downloads 162 Views

Recommend Documents

Who Benefits from Concentrated Affluence? A Synthesis of ... - jpmsp
on education outcomes according to race and gender. The findings show that the presence of ..... absolute income of the top quintile. Education Outcomes, the ...

Who Benefits from Information Disclosure? The Case ... -
Apr 6, 2017 - policies meant to allow consumers to compare prices and product ... and the NBER Winter IO meeting 2016 for helpful comments and ..... interest rate r, transportation cost t, and, more importantly, both the fraction of informed ..... sa

Who Benefits from Concentrated Affluence? A Synthesis of ... - jpmsp
pervades neighborhoods and their institutions, including schools. ...... accelerated placement programs), which often leads to greater variation in learning.

Who Benefits from Information Disclosure? The Case of ...
Apr 6, 2017 - would allow the Comisión Nacional de Energıa (CNE, National Energy Commission) to ... this increase in margins is not explained by alternative hypotheses such as an ... findings about the effect of disclosure on market outcomes.4 AlbÃ

Who Benefits from Concentrated Affluence? A ...
on education outcomes according to race and gender. The findings ... prompting one social scientist to call the twenty-first century the “age of extremes”. (Massey ...

Who Benefits from the Education Saving Incentives, NTJ 2004.pdf ...
Who Benefits from the Education Saving Incentives, NTJ 2004.pdf. Who Benefits from the Education Saving Incentives, NTJ 2004.pdf. Open. Extract. Open with.

Who Benefits from the Education Saving Incentives, NTJ 2004.pdf ...
Who Benefits from the Education Saving Incentives, NTJ 2004.pdf. Who Benefits from the Education Saving Incentives, NTJ 2004.pdf. Open. Extract. Open with.

BOTEC_Costs And Benefits Of Drug Treatment And Drug Enforcement ...
BOTEC_Costs And Benefits Of Drug Treatment And D ... Rand Studies_David Boyum_for ONDCP_Jan 1995.pdf. BOTEC_Costs And Benefits Of Drug Treatment ...

Drug Discovery From Natural Sources
Jan 24, 2006 - reduced serum levels of low-density lipoprotein-cholesterol. (LDL-C) and .... not available in the public domain)] of epothilone B, epothi- lone D ( 46), and 9 .... West CML , Price P . Combrestatin A4 phosphate. Anticancer ...

Drug Discovery From Natural Sources
Jan 24, 2006 - been elaborated within living systems, they are often per- ceived as showing more ... Scrutiny of medical indications by source of compounds has ... written record on clay tablets from Mesopotamia in 2600 ...... An open-label,.

Who Benefits May 2004, WP 10470.pdf
... tax-advantaged savings. accounts. I find that the advantages of the 529 and Coverdell rise sharply with income, for three. reasons. First, those with the highest ...

Who Gains and Who Loses from Card Reward ...
After a merchant charges a buyer's debit or credit card, the merchant must submit a request for payment to a contracted acquirer. The acquirer then submits the ...

Can Benefits from Malaria Eradication be Increased ...
Aug 4, 2016 - the malaria eradication campaign of Costa Rica that began around ... A return to education of 10.5% can only account for 10% of the ... surance institution “Caja Costarricense de Seguro Social” (C.C.S.S.) ..... malaria rates in 1963

Optimistic Parallelism Benefits from Data Partitioning
Mar 5, 2008 - may reduce performance. A simple reductio ad absurdum shows .... flow.inc(cap); ..... In our earlier work, we introduced set iterators to express.

Benefits from recycling used nuclear fuel
Adding fast reactors to the system would provide … – More complete consumption of transuranics, hence better waste mgt. Page 14. 14. For more information.

scenes from a demonstration: merging the benefits of ...
computers that support Windows 95 and Pen Windows. One characteristic of ... of information (e.g., “telephone number”) than it's content description (e.g. ...

Competitive advantage from better interactions
Aug 25, 2007 - such as managers and salespeople, whose jobs consist primarily of such activities, now make .... Cisco Systems' manufacturing managers, who direct the connections among .... The kind of network building that tacit workers.

Accepting Reproof from Those Who Love Us
Like apples of gold in settings of silver .... or call USA 1-800-772-8888 • AUSTRALIA +61 3 9762 6613 • CANADA 1-800-663-7639 • UK +44 1306 640156.

Accepting Reproof from Those Who Love Us
What is missing in these scenarios of compliance and lip-service? A trusting ... The second Greek word is ektrephete, which means “nourish.” Compare its usage ...

Creative Collaborations From Afar - The Benefits of Independent ...
Regarding the number. of locations, many would predict an inverse relation- ship with citations, given the potential problems with. communication, coordination ...

Optimistic Parallelism Benefits from Data ... - ACM Digital Library
Mar 5, 2008 - The Galois system was designed to exploit this kind of irregular data parallelism on multicore processors. Its main features are. (i) two kinds of ...

Benefits from recycling used nuclear fuel
Energy in the Mountain. West: Colonialism and. Independence. Steve Piet,. Lloyd Brown, Robert Cherry,. Craig Cooper, Harold Heydt,. Richard Holman, Travis McLing. Idaho Academy of Sciences Meeting. April 19-21, 2007 ...

Benefits of Foreign Lanugage Study from an Historical ...
ate professor of education in the College of. Education, Florida Atlantic University in Boca. Raton. She has been president, ... tion for all students. Specifically, the.