Substance Abuse & Healthcare

Substance Abuse and Health Care:

Finally, employers, insurers, and payers are taking a closer look at substance abuse problems and its costs.

Substance abuse costs society more than $260 billion a year! That figure includes law enforcement, treatment and comorbidities, but less than 2 % of that amount ($5.5 million) is allocated for treatment. Why is that? Partly because health plans don’t identify enrollees who need help and because payers are not concerned about the loss of productivity (estimated at $110 billion). Health professionals believe that it is this country’s most serious health problem.

SAMSHA (Substance Abuse and Mental Health Services Administration) in 2004 published a National Household Survey on Drug Use and Health that revealed:

* 19.5 million Americans (8.2% of the population) age 12 and older were illicit drug users.
* 54 million (22.6%) participated in binge drinking at least once in the 30 days prior to the survey and 16.1 million (6.8%) were heavy drinkers.
* 22.2 million people age 12 and older need treatment for alcohol or illicit drug problems. That is a whopping 9.3% of the total population. 3.3 million people received treatment (leaving 18.9 million people with no treatment.)
* A decline in those receiving treatment from 2.3 million to 1.98 million
* Substance abuse spending dropped to almost 80% from 2001.

Historically, substance abusers are believed to be self-abusers so the willingness to treat someone for something s/he does to her/himself is not so acceptable. Health professionals actually now see substance abuse as a disease, but health care plans do not.

Treatment does work as proven in a survey in 1990s conducted on 1799 people by SAMSHA confirmed the overall drop in the use of any illicit drug 5 years after treatment was 21%. The decline in alcohol use was 14%, marijuana 28%, cocaine 45%, crack 17%, heroin 14%.

Some health care plans are re-evaluating the way they look at the issue with the economic impact, and the recognition that what is currently being done simply doesn’t work.

George Washington University Medical Center analyzes alcoholism treatment modalities and in a study of 1.5 million federal workers demonstrated that treatment had a positive effect on productivity. The study noted that 80% of workers who received treatment for alcohol or other drug problems reported their work attendance improved after treatment.

Employers too are becoming increasingly aware of the threat that substance abuse poses to the bottom line and are looking at health care plans for a solution. More employers are interested in benefits that are tailored to their particular workforce, especially as their awareness increases relating to the overall cost benefit in treatment substance abuse.

The fear that covering addictive problems and mental illness with other medical problems will raise insurance premiums is common, however, just 2% annually of current costs is more of a reality a research group at George Washington University Medical Center revealed. Their studies found that appropriate coverage eased the pressure on state budgets by cutting health, welfare and criminal justice costs. Minnesota reported that 80% of addiction treatment costs were offset in the first year as a result of reduced use of hospitals, emergency departments, detoxification centers, and reduced arrests.

A California study noted that there was a 55% decrease in criminal activity and 33% fewer hospitalizations.

Though state laws may require some level of coverage, it usually isn’t at mandated levels. Seventy health plans in 36 states were evaluated and at least 10 major plans in five states failed to comply with state law governing coverage for treatment.

Typically state legislators do not view substance abuse as an illness that is treatable. The perception problem is widespread: Compulsive use of illicit or over-the counter drugs or alcohol is detrimental to health and functionality.

Most employers and plans lump substance abuse treatment under mental health and call it “behavioral health.” Though it’s true that about 65% of the people with substance abuse problems also have mental health problems, it isn’t realistic that if one problem is fixed, so is the other. Outcomes are hard to measure too. Results are not as readily observable as to the success of any treatment. Behavioral health treatment is far different than medical treatment. Substance abuse treatment falls into three categories: inpatient (20 days), intensive outpatient (daily therapy) and intermittent therapy. Most health plans shy away from managing behavioral problems on their own and work under specialty contracts. The idea is to shift the risk to an entity expert at managing such risk.

Joseph A. Califano, Jr., President of the National Center on Addiction and Substance Abuse at Columbia University said: “We won’t begin to successfully address the problem until it is recognized as a medical issue by the public, politicians, and employers.”

Aware of the problems, Aetna Insurance recently announced they are willing to try a holistic approach to battling a major societal problem. Aetna plans to implement a holistic, integrated model that uses its database to address addiction at the primary care level and aggressively deal with the problems.

While predictive modeling has been a staple in disease management programs for identifying potential DM candidates and managing member care, Aetna has embraced a holistic view of patients using predictive modeling in a different way. It plans to leverage vast information assets from multiple data points in real time to recreate a patient’s episodes of care to give clinicians and providers the best possible information to treat patients.

The database will hopefully create a partnership between care plans and providers to provide physicians with access to information vital to achieve improving clinical care and outcomes. “This idea is at the core of Aetna’s approach,” says Hyong Un, MD, national medical director for Aetna Behavioral Health. “But if a plan uses claims and pharmaceutical data to identify a member who has a pattern of behavioral health treatment, or identifies medical data that implies a risk, notification of his or her primary care physician of the risk may help stem the need for more treatment.” He says that “in a traditional model of behavioral health care, an alcoholic may go through detoxification and rehabilitation only to get lost in the system for years, then reappear again needing the same treatment all over again. Management of these people has never focused on alcoholism as a chronic disease, which is what it is.”

The data base would help to stratify treatment. Primary care physicians would address and evaluate the issues.

“Aetna’s philosophy is that the body and mind are connected,” Tina Brown-Stevenson, president and head of Aetna Integrated Informatics, said. “This means that prescriptions and dental care can impact courses of therapy.”

Therefore, Aetna is integrating such information gleaned from lab, provider, pharmacy, disability and even dental claims to map out a patient’s care events, using predictive modeling tools. Brown-Stevenson pointed out that Aetna is the first payer with a patented predictive modeling tool for disability.

According to Brown-Stevenson, Aetna is able to provide such a holistic view because it has services and thus an infrastructure already in place, in dental, pharmacy management, and disability, as well as a network of providers, pharmacies and clinicians.

Jocelyn Young, research director for healthcare technology for Datamonitor, said one trend in healthcare is to share claims, treatment and patient data among stakeholders in the healthcare system to improve care and equip consumers with information to make better healthcare decisions. But having access to data doesn’t guarantee success. “A much higher value is placed on what you actually do with that data,” Young cautioned.

Clearly, the statistics on the economic impact of the disease of substance abuse is finally opening the eyes of more and more decision-makers. It will be interesting to observe the Aetna project results.