Comprehensive Alcohol and Drug Treatment System of Care

Blueprint for a Comprehensive Treatment and Recovery System of Care - 2002

"An estimated 43% of the total population with AOD problems will be able to achieve successful recovery without formal treatment, utilizing Alcoholics Anonymous, Narcotics Anonymous, and other peer-based non-professional support programs."

Background

The Community Recovery Network (CRN) - an organization of people in recovery and family members and allies - spent four years developing and refining a blueprint for a comprehensive treatment and recovery support infrastructure at a level that is adequate to meet the needs of everyone with alcohol and other drug problems (AOD) problems. We have also done extensive research and held focus groups with a broad spectrum of people in the treatment and recovery field in order to determine the cost of developing and supporting the infrastructure.

Two decades ago, the cost of going to treatment at a hospital-based program was established at between $20 and $40 thousand dollars for a thirty-day in-patient stay. Not only was this cost excessive, resulting in a severe "back lash" of reduced AOD treatment benefits in the private insurance industry, but there is no research evidence that thirty days was an adequate treatment period. According to the National Institute on Drug Abuse (1999), "Research indicates that for most patients, the threshold of significant improvement is reached at about 3 months in treatment. After this threshold is reached, additional treatment can produce further progress toward recovery." Very successful drug court programs retain clients for from one year to eighteen months, and optimum program duration is sometimes even longer for adolescents, people with co-occurring mental illness, and pregnant and parenting women.

The term infrastructure is important to our services proposal. In the past, AOD services have been generally considered as programs. Ours is not a plan to simply adding more programs to the current treatment system, because the primary weaknesses we have identified in this system are larger than the individual programs. These programs - while dramatically under-funded for the work they do - tend to be isolated, fragmented, and disconnected from each other and from the larger systems of public health, social services, criminal justices, public safety, mental health, and other institutions where AOD problems are most likely to surface, such as families, schools, the workplace, and churches.

Our research, and the collective experience of CRN's constituency as expressed through surveys and focus groups, requires that any significant improvements in the current treatment system must include the following:

It is the belief of the CRN that the quality, consistency, appropriateness, and timeliness of services received should not be determined by any consideration other than that they are experiencing a problem with alcohol and other drugs.

Assumptions

For purposes of illustration and of meeting Goal #2 of the Foundation for Addiction Recovery, this Blueprint is applied to California; the same statistics may be applied to any State. We have estimated the number of Californians with AOD problems who are not yet in recovery at 2.5 million based on the latest statistics published by the Substance Abuse and Mental Health Services Administration (2002). In determining the investment required for our proposed infrastructure to successfully serve all of these individuals, we have made the following assumptions based upon research and surveys of our constituency:

Most modern treatment services for AOD problems have evolved in response to reimbursement mechanisms for the treatment of physical illnesses. While alcoholism and drug addiction have been identified by the medical and research communities as diseases, five very significant factors distinguish substance disorders from other diseases. These five factors must be systemically addressed in order to optimize successful outcomes in any system of care.

The most common indigenous community supports are the 12-Step Anonymous programs, but there are many other examples such as Women for Sobriety; Secular Organization for Sobriety; Rational Recovery; Native American Healing Circles; Religious, "Faith-Based," or other spiritual institutions, groups and societies such as the Calix Society, Jewish Alcoholics, Alcoholics Victorious, Alcoholics for Christ, and Mountain Movers.

Most of these are abstinence-based, but there are other "Harm reduction" indigenous support programs for persons on methadone maintenance, and there are also "moderate drinking" programs and a host of other alternative therapies for alcohol and other drug problems. It is important to note that there are stages and degrees of alcohol and other drug problems, and not all people with problems are alcoholics. Drinking and other drug problems are sometimes the result of life situations such as elderly persons who lose their life mate, or persons in combat or other traumatic settings.

The Absence of Effective Utilization Management in California's Drug-Medi-Cal System

The Sobky v. Smoley lawsuit in 1994 ended limits on utilization of DM-C by ruling that drug treatment is an entitlement under Medicaid guidelines. In response, utilization of outpatient and day treatment services increased dramatically. There were no caps on rates, and reimbursement occurred for clinic "visits" only, not for specific services. While providers were required to have perfunctory "Utilization Review Committees," ultimate decisions concerning both utilization of services and the rates charged for those services were being made by the service providers themselves without external regulations.

Interestingly, an analogous problem was occurring in the private sector; hospital-based chemical dependency treatment programs were charging private insurance companies thirty to forty thousand dollars and more for thirty-day residential programs, often with no limitations on the number of patient repeat visits.
In short, the chemical dependency service delivery system - both public and private - had become a fiscal "runaway train."

While the response in the private insurance sector was either strict managed care practices or the elimination of chemical dependency benefits altogether, the response of the DM-C system in 1996 was cost containment achieved by constricted services such as limits imposed on rates and on the number and kinds of services a client could access. The DM-C system appeared - because of Sobky v. Smoley - unable to adopt the kinds of managed care strategies that characterized other venues. The services received by clients under DM-C, therefore, came not to be based on clinical guidelines or recovery principles but rather on constrictions devised to contain costs. These constrictions remain in place today.

Not only are such constrictions without reference to our knowledge about successful recovery, or to research-based clinical principles or science-based treatment practices, but they sometimes frustrate the goals of other State-sponsored services and result in far greater costs than those that were "saved." For example, a chemically dependent pregnant woman on the caseload of Child Protective Services will be eligible for DM-C services during her pregnancy, but her eligibility will be removed shortly after her child is born. With non-DM-C perinatal day treatment services experiencing dramatic waiting lists in many Counties, this can result in substance relapse, loss of custody of the child, and the ultimate failure of family reunification. Or a chemically dependent severely mentally ill person who is in need of comprehensive residential treatment will find that it is not a covered Medi-Cal benefit and hence unavailable in the County, resulting in psychiatric emergency. In these cases, the "cost containment" measures result in costs to the State that are far greater than those of treatment, such as out-of-home foster care placement and exorbitant psychiatric emergency services.

Not surprisingly, these "cost containment" measures in 1996 were soon followed by the elimination of State mandates for providers to perform the monthly utilization review that had provided the only mechanism of outside monitoring of quality assurance in the system. Although an annual Utilization Review mechanism was to have been instituted by the State, this has occurred only sporadically, and the only specific control on provider utilization of DM-C is the occasional and expensive provider audit.

Both the five distinctions of substance disorders listed above, and the absence of utilization management in California and many other jurisdictions, suggest a critical need for comprehensive and diverse case management services. But the recovery community's collective experience suggests that traditional case management as utilized in the health and mental health systems of care may not adequately or appropriately address all of these unique characteristics of substance disorders.

Our blueprint therefore recommends a "Recovery-Based Case Management" System in each local jurisdiction. The system would be operated under contract with the State or County by a private entity who was not a treatment service provider (click here for "Guidelines for an Entry Level Recovery Advocacy and Case Management System).

Recovery Advocacy in the AOD treatment system is not an unprecedented concept. Many drug court venues in California and around the country have adopted a "Court Liaison" function - a person who mediates between the court, probation, and treatment system on behalf of the client or offender. The role of the Liaison is to assess and explain options to the client, to propose referral recommendations to the drug court judge, and then to "leave no stone unturned" in assuring that the client is successfully engaged and retained in the recommended services. Many Counties in California adopted a similar "recovery advocacy" model for their perinatal case management services, and similar case management services were successfully provided to SSI recipients before the elimination of the alcoholism and drug addiction disability benefit.

The recovery community has learned that not everyone with AOD problems needs formal treatment. For many people, 12-Step and faith-based activities and their equivalent, which may or may not be in combination with clean and sober housing, are adequate for successful recovery. The proposed system would be distinguished from traditional case management services that are used in the public and private health sector in that their primary objective would not be exclusively clinical (e.g. to access clinical services), but to assist the client in engaging in those natural community supports that enable long term recovery.

The State will experience a significant return on this investment. The ultimate return is illustrated in the chart below. The chart begins on the left with the current cost to California State government of untreated AOD problems - $34 Billion. The increase over the first three years results from the cost of the new treatment investment. During the initial few years, this return is a theoretical one only. The reason is that the State government is now heavily invested in a massive infrastructure (14.3% of its 2002 budget) to address untreated AOD problems, and it will take some time to begin to downsize these bureaucracies of public health, criminal justice, social services, mental health, and public safety.

Because it is always the natural tendency of government to expand, a significant continuing role of the Foundation will be to monitor the decline of these wasteful services and to advocate for their appropriate reduction. There will be an eventual commensurate decline for Californians in the costs of such things as automobile and health insurance, and in goods and services, whose current prices reflect the significant loss in productivity that results from untreated AOD problems in the workplace.

It is interesting to note that part of the reason that AOD problems have not been addressed in the past is that the benefits do not accrue within the tenure of any of our elected State offices.

For purposes of comparison, the chart below shows both the projected treatment investment and the return. The red (dark) bars and the blue (light) bars represent respectively the cost of untreated AOD problems and the proposed treatment investment. The ones furthest left represent the current relationship of a $34 Billion cost and a $600,000 investment. Note again that the cost is always higher than the return because it is a combination of the investment plus the cost of remaining untreated AOD problems.

CASA (2001), "Shoveling Up: The Impact of Substance Abuse on State Budgets." The National Center on Addiction and Substance Abuse at Columbia University.

McLellan, Thomas; Lewis, David; O'Brien, Charles, and Kleber, Herbert (2000). Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation. Journal of the American Medical Association. 284:1689-1695.

NIDA (1999). Principles of drug Addiction Treatment: A Research-Based Guide. National Institutes of Health, U.S. Department of Health and Human Services.

NIDA/NIAAA (1995). The Economic Costs of Alcohol and Drug Abuse in the United States-1992, Executive Summary. National Institute on Drug Abuse/National Institute on Alcohol Abuse and Alcoholism, 1995.

Substance Abuse and Mental Health Services Administration (1998), "National Household Survey on Drug Abuse," U.S. Department of Health and Human Services. Rockville, MD.

Substance Abuse and Mental Health Services Administration (2002), "National Household Survey on Drug Abuse," U.S. Department of Health and Human Services. Rockville, MD.

White House Office of National Drug Control Policy (2001), The Economic Costs of Drug Abuse in the United States 1992 - 1998.