Substance abuse costs our society more than $260 billion a year for comorbidities, law enforcement, and treatment, but less than 2 percent — about $5.5 billion — goes for treatment, according to the federal government.
That’s partly because health plans fail to identify enrollees who need help, and because payers are sadly unmindful of the additional $110 billion in lost productivity that results from what many medical professionals consider the nation’s single most serious health problem.
"The truth is that too few payers care about substance abuse," says Monica Oss, president of OpenMinds, a behavioral health consulting company in Gettysburg, Pa." It’s the tail of the dog in health care."
Why is this? To begin with, substance abuse carries an onus of self-abuse. As health care costs escalate, the political willingness to treat someone perceived as having done it to himself diminishes.
"We’ve failed for too long to see the problem for what it is, a disease," says Georganne Chapin, president and CEO of Hudson Health Plan in Tarrytown, N.Y., a not-for-profit with about 50,000 mostly state-subsidized members. "Health professionals may see it as a disease, but most health plans lag far behind."
A few health plans are starting to re-evaluate the way they look at the issue, driven by a growing awareness of the economic impact of substance abuse on our society and even more by the realization that what’s being done now isn’t really working. And experts say an increasing number of primary care physicians view the problem as something they should be addressing aggressively with patients.
Treatment for substance abuse can be effective. According to a survey of 1,799 people by the Substance Abuse & Mental Health Services Administration, titled the "Services Research Outcomes Survey," the overall drop in the use of any illicit drug five years after treatment was 21 percent. The decline in alcohol use was 14 percent; marijuana, 28 percent; cocaine, 45 percent; crack cocaine, 17 percent; and heroin, 14 percent. The survey was done in the mid-1990s.
Numbers on increased productivity following substance abuse treatment are difficult to come by, but according to a program at the George Washington University Medical Center that studies alcoholism treatment modalities, an outcomes study of the 1.5 million federal employees and their family members covered by a federal employee assistance program demonstrated that treatment has a positive effect on productivity. The study found that 80 percent of workers who received treatment for an alcohol or other drug problem through the EAP reported in a follow-up survey that their work attendance improved following treatment.
"We may be experiencing something of a paradigm shift in public perception, and more important, a shift in the way primary care physicians perceive substance abuse," says Ed Jones, PhD, vice president and chief clinical officer of PacifiCare Behavioral Health. About half his company’s 5 million covered lives are with PacifiCare Health Systems and the balance are part of its service as a specialty behavioral health company for other health plans and employers.
A prime example of possible change is Aetna, which will begin managing its behavioral health benefit internally next year. "We’re moving to a holistic, integrated approach, focusing on a member’s total health," says Mary Fox, head of Aetna Behavioral Health. "We will use our medical claims and pharmaceutical data to identify the people who need help and reach out to the primary care physicians to reach those members." (See "Aetna Tries a Holistic Approach To Battling One of Society’s Scourges".)
And some health plan leaders say employers are becoming increasingly aware of the threat that substance abuse poses to their bottom line, and are turning to their health plans for a solution. "I do believe things are getting better," says Michael Brase, MD, vice president and medical director of WellPoint Behavioral Health, the subsidiary that manages mental health and substance abuse care for all of WellPoint’s 26.4 million lives except for the 2.6 million in Georgia. In that state, WellPoint carves out behavioral health benefits to Magellan Health Services, the nation’s largest managed behavioral health organization (MBHO) with 55 million covered lives.
"We’re finding that more employers are interested in offering benefits they view as highly tailored to their particular workforce demographics, especially as they become increasingly aware of the overall cost benefit in treating substance abuse," says Brase.
A development of some note is that last year, the National Committee for Quality Assurance expanded its HEDIS measures to include two new chemical dependency items. The measures were adopted at the urging of the Washington Circle, a not-for-profit policy group that was formed to develop performance measures for alcohol and other drug services.
The group estimates that about 5 million people who need treatment for an alcohol or other drug disorder are not receiving it, despite the availability of treatment resources.
That’s a very conservative estimate, some experts say. SAMSHA’s most recent survey puts the number of people who need but aren’t receiving treatment at four times that. (See "Significant Health Problem, Vastly Undertreated".)
Not enough change
"Science and countless personal stories demonstrate that substance abuse is treatable and that recovery is possible. Yet too many Americans who seek help for a substance abuse problem are unable to find care," said SAMHSA Administrator Charles Curie in announcing support for the new measures. "HEDIS will be a great asset in guiding health plans to take advantage of the science and resources available to connect people in need with people who provide care."
These are all good changes, say experts, but they aren’t enough. "Society’s view of substance abuse as an illness has improved in recent years," says Pamela Greenberg, executive director of the American Managed Behavioral Healthcare Association, "but we have a long way to go."
Greenberg, and virtually every other behavioral health expert, would like to see Congress and the states adopt legislation guaranteeing beneficiaries the same level of substance abuse care as medical care, including lifetime caps. But she’s not hopeful.
Only nine states had substance abuse parity laws in effect as of the end of last year: Maryland, Minnesota, Vermont, Virginia, Connecticut, Massachusetts, Rhode Island, Delaware, and West Virginia.
Requiring insurers to cover addiction and mental illness at parity with other medical disorders raises insurance premiums just 0.2 percent annually, according to a study of state parity laws by Ensuring Solutions to Alcohol Problems, a research group based at the George Washington University Medical Center. It reviewed 11 previously published studies by states that examined the effect of their own parity laws. The studies found that parity eases pressure on state budgets by cutting health, criminal justice, and welfare costs, and increases the number of individuals entering treatment. Minnesota officials reported, for example, that 80 percent of addiction treatment costs were offset in the first year by reduced use of hospital, emergency department, and detoxification services, as well as by reduced arrests. California’s study found that treatment parity yielded a 66 percent reduction in criminal activity and 33 percent fewer hospitalizations.
Even when state laws require some level of coverage, Ensuring Solutions found, coverage isn’t guaranteed at mandated levels. It found that of 70 health plans in 36 states, at least 10 major health plans in five states failed to comply with state laws governing insurance coverage for addiction treatment.
The federal Mental Health Parity Act, signed into law in 1996, requires that annual or lifetime dollar limits on mental health benefits be no lower than limits for medical and surgical benefits. Its sunset provision has been extended four times. The current extension runs through Dec. 31, 2005.
"But that law does not apply to substance abuse," says Greenberg, "and no one realistically expects that it will. Substance abuse is just not generally viewed by legislators as an illness that can be treated."
The perception problem begins with definition: Substance abuse is the compulsive use of prescription, illicit, and over-the-counter drugs or alcohol to a detrimental effect on a person’s health or functionality over time.
The criteria for what qualifies as obsessive, harmful, and long enough aren’t easy to establish. Abuse is not like a tumor or a fever; health plans tend to see the problem as more like a member smacking his head against the wall until he bleeds, then doing it again.
Most plans and employers don’t know what to do to get the guy to stop. To get some kind of handle, they lump substance abuse treatment in with mental health treatment and call the package behavioral health. "Payers like to see substance abuse as a mental health problem," says Oss. "They see it as more efficient."
For two reasons: First, about 65 percent of people with substance abuse problems are also diagnosed with mental health problems, so the pipe dream is that if you fix one problem, you’ll fix both. Second, it’s hard for plans to measure outcomes for mental health and substance abuse treatment. You set a broken bone or remove a growth, that’s that. You talk to somebody until you’re blue in the face, who knows whether you’ve been successful?
Plans attempt to control treatment costs by limiting the amount of treatment. That’s akin in some professionals’ eyes to saying we’ll treat your cancer for a year, then you’re on your own.
Because it’s so hard to determine treatment effectiveness, health plans hire specialty plans to manage whatever behavioral health benefit they’ve sold to an employer.
"Behavioral health treatment is very different from medical treatment, with an entirely different set of treatment requirements," says Greenberg. "That’s why MBHOs came into existence in the first place, to provide specialty care and accountability, and to reign in escalating costs."
Substance abuse treatment generally falls into three categories: inpatient, which is usually about 20 days of rehabilitative therapy; intensive outpatient, in which a member spends hours a day in therapy, often in the evening if he or she is working; and traditional outpatient, when a member may see a therapist a couple of times a week.
In each of those approaches, deductible and copayment structures may differ significantly.
In 2003, about 71 percent of health plans shied away from managing behavioral health treatment on their own, according to a survey by Brandeis University’s Schneider Institute for Health Policy, and hired 1 of about 370 existing MBHOs in what Horgan calls "specialty contracts."
Those arrangements are carve-outs, and usually a health plan passes risk to its MBHO. "The carve-out remains very attractive to health plans, for a number of reasons," says Constance Horgan, ScD, a professor at Brandeis and director of the Schneider Institute. "The idea is to shift risk to someone who is expert at managing the risk. Lots of folks want to dump on MBHOs these days, but many of these organizations are very good at what they do."
In 2003, about 14 percent of health plans contract ed with a network that includes behavioral health care providers. The balance — 15 percent — handled everything internally. That’s a drop of 13 percentage points from the number that handled the benefit internally in 1999.
The Brandeis data show that fewer health plans are managing behavioral health internally, but that may be changing. "Plans are beginning to re-evaluate this issue," says Carl McDonald, an analyst at Morgan Stanley.
"Magellan loses the Aetna contract in 2006, and we have greater certainty that WellPoint plans to bring its behavioral health business in house," McDonald said in a research note. "Its contract with Magellan expires on Dec. 31, 2005."
Earlier this year, PacifiCare Behavioral Health started providing services to 800,000 Harvard Pilgrim Health Care enrollees who were covered by ValueOptions. So the substance abuse arena is changing. But whether all that will mean that more people who need help will get it remains to be seen.
"The problem of substance abuse is greatly underestimated and misunderstood in our society, among many people who should know better," says Joseph A. Califano Jr., president of the National Center on Addiction and Substance Abuse at Columbia University.
"We won’t begin to successfully address the problem until it is recognized as a medical issue by the public, politicians, and employers."