Access and Consumption of Substance Abuse Services

1. Access and Consumption of Substance Abuse Services Academy Health Washington D.C. Robert Wood Johnson Foundation’s New Connections Program Juliette Roddy, PhD University of Michigan Dearborn June 9, 2008

2. Problem • Behavioral Health lags behind the medical mainstream in measurement of evidence based practice • Behavioral Health lags behind the medical mainstream in application of evidence based practice

3. Problem • Provision of Behavior Health Issues: • Lack of agreement on best practices • Limitations on treatment funding regardless of whether the behavior is ceased • Clinics that specialize in specific care • Methadone treatment, abstinence, 12 step Particularly in the field of substance abuse, practice has been guided more by preferences and training of the providers than the research results on effectiveness (Miller, Aweben and Johnson 2005)

4. Problem • There is a recognizable gap between diffusion of research, innovation, and implementation to practice in substance abuse treatment (Miller 2006) • There is enough research for experts to rank evidence based treatments according to strength and type of evidence (Miller, Aweben and Johnson, 2005)

5. Broad Questions • The Robert Wood Johnson Foundation’s Addiction Prevention and Treatment team (renamed) identified tracking the use of evidence-based treatment approaches as one of its top priorities • Brief screening for substance abuse in primary care • The use of pharmacology to treat addiction • Psychosocial interventions in specialty care settings • The variety and prevalence of multi-systemic treatment • Follow up care

6. Specific Questions • How often are adult consumers given brief screening interventions in the primary care setting? • How often are adults offered pharmacological solutions to treat addiction/abuse disorders? • Among adults engaged in outpatient treatment, how many are offered the services of: psychosocial interventions, wraparound services, and aftercare services? • What was the consumers’ opinion on the services that were offered? Were the services effective?

7. Proposed Study • Answer the specific questions in terms of frequency • Use two separate existing data sets (not pooled) • Fighting Back Data National Comparison Set • National Survey of Alcohol, Drug and Mental Health Problems • Investigate influences on consumption of services through correlation, regression, factor and cluster analysis

8. Data • National Survey of Alcohol, Drug and Mental Health Problem (NSADMH) • Part of RWJF’s Health Tracking Initiative • Designed to track changes in American health and healthcare • A broad national survey with questions on demographics, drug use, use of medications, and access and utilization of behavioral healthcare services

9. Data • NSADMH, year 2000 • N= 12,158 • Mean age 49 (min 18, max=98) • Nationally representative • Phone Interview • Restricted Use

10. Data • National Evaluation of the Fighting Back Program • Specifically associated with RWJF’s community based drug abuse prevention program and the national comparison survey • Survey collected information on health and mental health, knowledge and utilization of AOD treatment services, attendance in drug education courses or lectures in school. Background variables include sex, race, household composition, marital/cohabitation status, education status and achievement, employment status, occupation, religious preference, and income.

11. Data • NFB, year 1999 • N= 3,297 • Mean age 31 (min 16, max=44) • Nationally representative • Phone Interview • Publicly available

12. Methods • Begin with descriptive statistics that can be identified as direct measures that answer the research questions • Examine correlations of a variety of variables to identify interesting relationships • Eight separate categories of insurance provision were included in the FB Data • Many insurance categories were correlated with types/categories of substance abuse care

13. Methods • Regression analysis was used to verify the correlation results • Consumption of SA services examined for significant components • Insurances entered together and separately (ie Medicare and Medigap) • Betas from regressions would be unreliable, however significance could be determined

14. Methods • Cluster analysis examined for unifying characteristics • Factor analysis scattered and difficult to interpret

15. Results Abbreviated Correlation Matrix rf (phi)

16. Results Regression Results Dependent Variable Treatment for MH/SA past 12 months

17. Results Clusters (N=1311)

18. Results

19. Discussion • Analysis suggests insurance influences access and provision of treatment for substance abuse disorders • Significant in correlations, regressions and clusters • Hardly new information • 2001 RWJF reported that 2/3 of the funding for alcohol and drug treatment is from public sources with Medicare and Medicaid paying for a full 21 percent of treatment services

20. Discussion • Often assumed that providers of insurance will not cover treatment that is ineffective and that efficient treatments will be covered by insurance • Not necessarily the case • Literature has expressed that absence of insurance coverage for treatment does not always indicate that a treatment is neither safe nor effective • Furthermore, the fact that treatment is covered by insurance does not ensure that it is effective (Steinberg and Luce, 2005)

21. Discussion • Evidence based treatment standards and cost considerations will continue to impact treatment for behavioral health • Does evidence based suggest integrity of care? • Evidence ranges from gold standards (double blind clinical trials) to anecdotal case reports

22. Discussion • Considerations other than the strength of evidence may also be useful • Impact of the treatment, relevance to subject population, and the consequences of treatment could all be considered when examining efficacy • It is also important to note absence of evidence for efficacy does not equate to ineffective treatment

23. Conclusions • Insurance influences both access to and provision of care • Behavioral healthcare standards are changing • Reimbursement of care is slowly being tied to outcomes (Miller et al 2005) • Insurers will require evidence (and there will be a direct relationship between strength of evidence and allowance)

24. Future Research/Lessons Learned • Data is limited • Without full investigation it becomes very difficult to understand it the care offered was evidence based or not • (I even understand the APT team’s questions better now) Must explore probit or logit analysis for the regresstion. These are linear.

25. Thanks! Dr. Debra Joy Perez Dr. Margarita Alegria Catherine West Dr. Allen Goodman