Using Performance and Outcomes Measures to Improve Treatment March 20-21, 2008 Los Angeles, California

1. Using Cost Offset and Other Data to Impact PolicyAntoinette Krupski, Ph.D.University of Washington at Harborview Medical CenterSeattle, Washington Using Performance and Outcomes Measures to Improve TreatmentMarch 20-21, 2008Los Angeles, California

2. Overview • Types of data that have been used to impact policy in Washington State • Data documenting extent of the problem • Outcomes • Policy impacts • Where the data came from • Lessons learned—what has been helpful?

3. Extent of Alcohol and Other Drug (AOD) Problems In Washington State

4. Documenting Extent of the Problem • Multiple populations • General population • Criminal justice populations • Child welfare population • Disabled/SSI, Medicaid recipients • TANF recipients • Burden of costs

5. Extent of AOD Problems in Washington State—General Population • 10.9% of adult household residents estimated to need treatment in 2005 (Mancuso, 2005) • 13.6% of lower income adults were estimated to need treatment in 2005 (Mancuso, 2005) • In 2006, about 31% of eligible lower-income adults who needed treatment actually received it (Albert, 2007) • Among youth, about 32% of those eligible for treatment actually received it in 2006 (Albert, 2007)

6. Extent of AOD Problems in Washington State—Criminal Justice Populations • 70% booked arrestees (Seattle/Spokane) tested positive for alcohol and/or drugs (Kabel et al 1996) • 70% of adult prison inmates have an alcohol/drug problem (Department of Corrections) • 82% of youth in state correctional facilities have a substance abuse problem (Juvenile Rehabilitation Administration, Department of Social and Health Services)

7. Extent of AOD Problems in Washington State—Child Welfare Populations • 75% of parents of children in therapeutic foster care had documented substance abuse problems(OCAR, 1993) • 66% of parents of children in foster care had documented substance abuse problems(OCAR 1993)

8. Extent of AOD Problems in Washington State—Other Welfare Populations • 20% of disabled individuals on Medicaid (Blind, Disabled, GA-X) estimated to need alcohol/drug treatment (Mancuso et al 2005) • 30% of individuals on GA-U estimated to need alcohol/drug treatment (Mancuso et al 2005) • 13% of TANF recipients estimated to need treatment (Mancuso et al 2005)

9. Economic Costs of Substance Abuse in Washington State • $5.21 billion for 2005 • Most costly categories: • Mortality $2 billion • Crime $1.1 billion • Morbidity $1 billion • Medical care $791 million (Wickizer et al 2008)

10. Some Consequences of AOD Abuse

11. Study of Frequent Visitors to Emergency Rooms (ER) • Study based on records for all Medicaid aged, blind, disabled clients (n=130,274) eligible between 7/98-6/02 • Persons with AOD and mental health disorders identified from diagnoses in medical claims • ER events also available in medical claims Mancuso, Nordlund, & Felver, 2004

12. 100% 11% Clients With No Identified AOD or Mental Illness Disorder 23% 89% 69% Mental Illness AOD Disorder Only Had AOD Only disorder or 10% mental illness or both 56% Co - Occurring Diagnoses 23% BOTH • AOD Disorder AND • Mental Illness Disorder 4% 4% No Visits One Two 3 to 5 6 to 10 11 to 20 21 to 30 31+ n = 81,980 n = 19,393 n = 10,765 n = 11,474 n = 4,526 n = 1,607 n = 331 n = 198 Number of Visits to the ER, FY 2002 Opiate Treatment Savings Two-Thirds of Frequent ER Visitors Have High Rates of AOD Disorders

13. Average Number of Narcotic Analgesic Prescriptions Per Client in FY 2002 42.0 Yes 24.6 % 15.9 9.9 6.1 4.0 3.1 1.6 No Visits One Two 3 to 5 6 to 10 11 to 20 21 to 30 31+ n = 81,980 n = 19,393 n = 10,765 n = 11,474 n = 4,526 n = 1,607 n = 331 n = 198 Number of Visits to the ER, FY 2002 Opiate Treatment Savings Frequent Emergency Room Visitors Use High Volumes of Pain Medication

14. Percent Arrested At Least Once, FY 2002 21% 19% 16% 14% 13% 10% 9% 5% No Visits n = 81,980 One n = 19,393 Two n = 19,393 3 to 5 n = 11,474 6 to 10 n = 4,526 11 to 20 n = 1,607 21 to 30 n = 331 31+ n = 198 Number of Visits to the ER, FY 2002 20% of Frequent ER Visitors Were Arrested in the Last Year

15. Outcomes and Cost Offsets of AOD Treatment

16. Study of All SSI Recipients in Washington State • Study of all SSI recipients in WA State between 7/97 and 12/01 (n=128,913) • 16% identified as having a need for AOD treatment (n=20,952) • 50% rec’d AOD treatment (n=10,380) • 50% did not (n=10,572) • Study compared costs of treated and untreated groups Estee & Nordlund, 2003 E

17. AOD Treatment Resulted in Significant Medicaid Savings

18. 75% (MAA) 25% MAA Medical Assistance Administration non Related MAA Medical 37% Reduced Medical Costs Were 75% of the Overall Cost Offset from AOD Treatment - ER - Other MAA Medical Nursing Mental Home Health 38% 14% 11% Per client per month – $154 – $157 – $56 – $47 per client per month GROSS OFFSET = $414 • AOD Treatment Cost = $162 • NET OFFSET = $252 Nordlund, Mancuso, & Felver, 2004

19. AOD Treatment Leads to Reductions in Arrests • 16% reduced likelihood of subsequent arrest for persons entering AOD treatment • 34% reduced likelihood of subsequent felony conviction for those entering AOD treatment • 43% reduced likelihood of subsequent arrest for persons completing AOD treatment

20. Conclusion • High cost of not funding alcohol/drug treatment • Significant medical costs • High ER use • High rate of arrests & convictions • Treatment results in significant cost offsets and reduced arrests/convictions • Funding treatment is a good investment in health care cost containment and public safety

21. Policy Impacts • Consistent budget increases from 1988 to present • In 2005, a 30% budget increase • Because of anticipated cost offsets, $32 million dollars for additional treatment for Medicaid-eligible adults and $16 million for criminal justice clients • $6.7 million for additional treatment for youth • Increase in residential treatment rates • Most of the increase reflects shifts from other budgets (Medical Assistance, Criminal Justice)

22. Where the Data Came From

23. Databases Where Information Resides • Substance abuse database (TARGET)--publicly funded AOD treatment • Medicaid Management Information System (MMIS) • Medicaid-paid medical use/costs • Some MH treatment/costs • State Patrol—arrests

24. How Confidentiality Is Protected • Follow 42CFR Part 2 for all data sharing • All identified records kept in secure location • Identified records cannot be re-disclosed except to the program that provided it • Small number of qualified staff have access to identified records & they sign confidentiality oaths • Identifiers removed from analytic data files as soon as possible

25. Other Confidentiality Safeguards • Obtain entire data set from data-sharing partner • Embed AOD client identifiers in larger subset of identifiers

26. What Was Helpful?

27. Maintaining Collaborative Relationships with Data-Sharing Partners • Sharing findings with data-sharing partners prior to dissemination • Conducting analyses of interest to data-sharing partners

28. Collaborations with Research Community • Research position within the division • Maintaining a committee of substance abuse researchers • Write grants on topics of mutual interest • Publish papers in peer-reviewed journals • Provide input to division’s research efforts • Support responses to legislative requests

29. Lessons Learned • High quality data and analysis essential • Publication in peer-review journals adds credibility • Data are not enough • Policy impacts take time • Outcomes are not free!

30. Thank you!

31. Contact Information Toni Krupski, PhD Dept of Psychiatry and Behavioral Sciences University of Washington at Harborview Medical Center Seattle, Washington krupski@u.washington.edu 206.897.4215