Different Sectors, Different Services? Examining variations in treatment program caseloads

1. Different Sectors, Different Services?Examining variations in treatment program caseloads Paul M. Roman, Ph.D. Lori J. Ducharme, Ph.D. Meredith P. Huey, M.A. Center for Research on Behavioral Health & Human Services Delivery Institute for Behavioral Research With research support from the National Institute on Drug Abuse (R01-DA13110, R01-DA14482, R01-DA14976) The University of Georgia

2. Background • Organizational theorists suggest multiple categorizations of public and private organizations based on public interest, ownership, funding, and profit status (Dahl and Lindblom 1953; Wamsley and Zald 1973; Bozeman 1987; Perry and Rainey 1988). • Yet, within the substance abuse treatment field there has been longstanding attention to the notion of a “two-tiered” system of treatment delivery. • “There are two highly contrasting tiers of drug treatment—one for the poor under public sponsorship and one for those who can pay with insurance or out-of-pocket funds…”(Gerstein and Harwood 1990: 200) • Assertions have been made that differences between public- and private-sector programs translate into significant disparities in the scope and quality of services available to patients assessing treatment (Yahr 1988; Gerstein and Harwood 1990; Wheeler et al. 1992). The University of Georgia

3. Clarifying the Public-Private Distinction in the Substance Abuse Treatment Field • Prior research has distinguished public from private centers by ownership—private vs. government owned (state and federal)—and profit status—for profit vs. not for profit. • Research has confirmed differences in characteristics of private for profit and government owned centers, however, little knowledge has been generated about not for profit centers. • The characteristics of not for profit centers fall somewhere between those of private for profit and government owned programs. • Comparisons of private for profit, not for profit, and government owned centers suggest a system characterized by multiple tiers. The University of Georgia

4. Alternative Classification: Revenue Sources • In addition to disparities in caseloads, research has shown that public and private programs differ in sources of revenue • Private centers receive a majority of funds from out-of-pocket payments or from private insurance; public centers receive revenues mainly from government sources (Heinrich & Lynn 2002). • An alternative method for classifying public and private centers is based on ownership, profit status, and funding resulting in a “four tiered” system: • Privately Funded For Profit, Privately Funded Not for Profit, Publicly Funded Not for Profit, and Government Owned programs. The University of Georgia

5. Research Question • Are there meaningful differences among treatment centers differentiated by these four “types”? • Specifically, to what extent do these four types of treatment centers differ in terms of their caseloads characteristics? The University of Georgia

6. Sample: The National Treatment Center Study • National samples of publicly-funded (N=345) and privately-funded (N=401) substance abuse treatment centers • Eligibility Criteria: • Community-based programs providing treatment for substance abuse at a level of care equivalent to structured outpatient programming (as defined by ASAM Patient Placement Criteria) • Exclusion Criteria: • Counselors in private practice, DUI / driver education programs, halfway houses, and programs offering exclusively methadone maintenance services were not eligible • correctional facilities and VA facilities were not eligible The University of Georgia

7. Definitions: • “Private” centers receive < 50% revenues from government block grants/contracts • “Public” centers receive > 50% revenues from government block grants/contracts • Data collected via on-site interviews with center administrators in 2002-’03 • Private center response rate=80% • Public center response rate=88% • Pooled, unweighted data (N=746) are reported in all analyses. The University of Georgia

8. Measures and Analysis • We used one-way analysis of variance (ANOVAs) to identify differences in caseload characteristics across the four types of centers: • Referral Sources • Proportion from: EAPs, other workplaces, legal system, and social service agencies • Caseload • Proportion who are: Women, Adolescents, Racial/ethnic Minorities, Charity Patients, Relapsers, Probationers/Parolees • Primary Diagnosis • Proportion with primary dependence on alcohol, cocaine, opiates, and methamphetamine The University of Georgia

9. Distribution of Sample by Center Type The University of Georgia

10. Findings: Referral Sources Shading denotes significant between-group differences (p<.05) The University of Georgia

11. Findings: Caseload Shading denotes significant between-group differences (p<.05) No significant differences on % women or % adolescent clients The University of Georgia

12. Findings: Primary Diagnosis Shading denotes significant between-group differences (p<.05) The University of Georgia

13. Summary of Findings • These data show significant variation among treatment centers classified by a combination of revenue source and profit status. • Several of these findings are consistent with previous research describing a “two-tiered” system (i.e., privately funded programs differ from publicly funded programs). • However, these data show significant contrasts within “nonprofit” programs when considering the centers’ primary funding source. • Differences between publicly-funded non-profits and privately-funded non-profits deserve further research: • Are there differences in organizational structure and staffing? • Are there differences in service provision? • Are there differences in innovative behavior? • Implications for patient retention and outcomes. The University of Georgia