BETHESDA, MD. — Treatment for substance use disorders continues to be out of reach for many people who need it at a time in which funding for treatment and health plan coverage of substance abuse remains stagnate, Constance M. Horgan, Sc.D., said at the annual conference of the Association for Medical Education and Research in Substance Abuse.
Dr. Horgan used data obtained from the 2003 and 2004 National Survey on Drug Use and Health (NSDUH, formerly called the National Household Survey on Drug Abuse) and her own two surveys of behavioral health service coverage in managed care health plans to chart recent trends in substance abuse treatment.
“Not many people are making the link to specialty treatment” of substance use disorders, said Dr. Horgan, director of the Center for Behavioral Health at the Schneider Institute for Health Policy at Brandeis University, Waltham, Mass.
Only 9% of the estimated 22.5 million people 12 years of age or older with a drug or alcohol problem needing treatment actually received specialty treatment in an outpatient or inpatient rehabilitation setting, a mental health center, or as a hospital inpatient, averaged data from the 2003 and 2004 NSDUH show.
Of the people who were thought to need treatment but did not receive specialty treatment, 94% felt that they did not need treatment, according to the 2004 NSDUH. Among those who thought they needed treatment, 2% made an effort to receive it, and 4% did not.
Of the 6% who felt they needed treatment, most reported that they had not received specialty treatment because they were not ready to stop using drugs (40%), had cost and insurance barriers (35%), were afraid of stigma (22%), felt they could handle the handle the problem themselves through friends or other support (14%), did not know where to go for treatment (12%), or had barriers to accessing treatment (13%), such as transportation, no openings, waiting lists, or unavailable services.
The people who thought that they needed treatment but had cost and insurance barriers fell into groups of those who had no health coverage and could not afford the cost of insurance (28%), and those who had health insurance that did not cover the cost of treatment (7%).
Among those who had no health insurance and could not afford the cost of the treatment, 32% still made an effort to get treatment. “This says something about access issues and the need for public payment,” Dr. Horgan said.
In the past year, individuals paid for their last substance use treatment at a specialty facility most often with their own money (43%), with funds from their family (21%), or with private insurance (38%). Some patients also reported paying for their last treatment with Medicaid (29%), Medicare (23%), or another public sector payer (22%). People typically think that most of these patients use public sector payers and do not have much out-of-pocket expense, Dr. Horgan said at the conference sponsored by the Brown Medical School.
In 2001, most of the $18.3 billion spent on the direct treatment costs of substance abuse in any medical setting—1.8% of all health care expenditures—came from public sector payers: Medicaid (19%), Medicare (5%), and other state and local (38%) or federal (14%) means. The bulk of expenditures for substance abuse were distributed to inpatient (30%) and residential (24%) settings of care. Only 40% of expenditures went to outpatient services, although most patients receive care in that setting, she said. Insurance administration collected 6% of the expenditures.
In a survey of U.S. managed care health plans that Dr. Horgan and her colleagues conducted in 1999 and 2003, the percentage of plans that contracted behavioral health services out to specialty vendors grew from 58% in 1999 to 71% in 2003. The percentage of plans in which network providers were internal to the plan declined in the same period from 28% to 15%.