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Treatment Financing and Trends in Health Insurance The financing of treatment is often cited by the pharmaceutical industry as yet another deterrent to the development of anti-addiction medications. Prominent reasons for industry hesitancy are the fact that few patients have private insurance and there is a concomitant need to rely on direct public subsidies to pay for treatment (Chapter 4; IOM Workshop, June 13, 1994~. This chapter examines the financing of treatment in greater depth to uncover the full range of financing disincentives and incentives to the development of anti-addiction medications. It highlights the difficulties companies face in launching a new medication with regard to securing treatment financing as presented by a case study on the financing of levo-alpha-acetylmethadol (LAAM). The financing of treatment for opiate and cocaine dependencies are described separately in this chapter despite the overlap in the clinical populations (Condelli et al., 1991; Batten et al., 19921. From the perspective of pharmaceutical development, the markets for medications are distinct; for example, the size of the market for cocaine treatment is considered larger because there are more cocaine-dependent than opiate-dependent individuals (Chapter 1~; also there is the possibility that a cocaine medication will not be a narcotic and not subject to the panoply of federal and state regulations (Chapters 7 and 81. Narcotic medications for the treatment of narcotic addictions are regulated even more severely under the Controlled Substances Act and state statutes than are other narcotics prescribed for the treatment of pain (Figure 5.1; Chapter 7~. 120

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TREATMENT FINANCING //(icinog; - - - - Controll ~\ Substances /? N~rn~tin~ \ ( Cannabis \ N~ \ , ~ ~J | ~Narcot cs 10r the \ ( Treatment d \ \ Narcolk Addict on 121 IN - FIGURE 5.1 Narcotics for the treatment of narcotic addiction are a legally-defined subset of narcotics and controlled substances. FINANCING OF TREATMENT Financing is generally defined as payment or reimbursement for the cost of treatment made by private insurance, Medicaid, the patients themselves, or other sources. Financing is important to pharmaceutical investment because it has a critical effect on treatment supply and demand for treatment (Rogowski, 1993~. Insurance or publicly subsidized coverage increases demand because it improves patients' ability to pay for services. For example, research has shown that people with more generous health insurance buy more prescription drugs and visit doctors more frequently than do those with poorer coverage (Leibowitz et al., 1985; Manning et al., 1988~. Likewise, providers who supply treatment tailor facilities and services to maximize their prospects for private, third-party reimbursement or public financing. The financing of treatment is in a state of transition as a result of the barrage of market forces irrespective, or in anticipation, of future health care reform legislation. A whole new industry of pharmaceutical benefit management, for example, is contributing to immense competitive pressures in the pharmaceutical marketplace for medications to be cost-effective. Benefits also are under increasing scrutiny by insurers who seek to contain costs.

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122 DEVELOPMENT OF MEDICATIONS Financing the Treatment of Opiate Addiction The annual payments for methadone maintenance treatment were estimated at $480 million in fiscal year (FY) 1993. There are an estimated 1 17,000 patients for whom annual expenditures are about $4,100 each. Those estimates by Harwood and colleagues (1994) are based on extrapolations from the 1991 National Drug and Alcoholism Treatment Survey (NDA1~US), which is described in Chapter 4. The vast majority of expenditures are for counseling, medical care, administration, and record keeping. The expenditures for actual medication (methadone or LAAM) are likely to be no more than 10 percent of treatment expenditures, but there is no direct breakdown of treatment financing data to give direct information about the financing of medication as such. Treatment financing data are available only in the aggregate. Despite the lack of available data on the financing of medication, there is information on its retail price. Based on the retail price to clinics, the cost of methadone can be estimated at about $30 million, or about 7 percent of the total cost of treatment (P. Coulis, National Institute on Drug Abuse, personal communication, 1994~. Methadone treatment is financed from a combination of federal, state, local, and private sources. Public sources account for most of the financing, yet there is wide variation from state to state and program to program. The contribution from each of those sources can be estimated from two separate data bas- es--NDATUS and SADAP, the State Alcohol and Drug Abuse Profile.' Financing for methadone treatment falls into 3 categories: public funding, out-of- pocket payments by patients, alla private insurance. Public sources together accounted for $384 million, or about 80 percent of the total payments for methadone treatment in 1993. The federal component, in the fond of block grants2, was about 30 percent of the total. The state compo- nent, in the form of direct outlays from the state alcohol and drug agencies, was about 31 percent of the total. The Medicaid component was about 12 percent of the total. The local component, in the form of county or local agency funds, was about 7 percent of the total (Butynski et al., 1994~. Medicare plays a negligible 'SADAP is a voluntary annual survey of funding of publicly supported alcohol and other drug treatment services. VIith the focus of the survey on programs that receive some state funding, there are virtually no data on private, for-profit programs. SADAP has the advantage of offering trend information because the survey has been collected annually since 1987 by He National Association of State Alcohol and Drug Abuse Directors, Inc. (NASADAD). 21h' Substance Abuse Prevention and Treatment Block Grant, renamed from the Alcohol, L)rug Abuse, and Mental Health Block Grant under the ADAMHA Reorganiza- tion Act of 1992 is the source of federal funding.

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TREATMENT FINANCING 123 role primarily because of the younger age and poorer employment history of the drug-dependent population. Out-of-pocket payments by patients account for 17 percent of the total, or $81.6 million. Private insurance, either in the form of fee-for-service plans or other private plarls, such as health maintenance organizations, pays for 2.5 percent of the total, or $12 million. The estimates for the client-paid and private insurance sources are extrapolated from the 1991 NDATUS (H. Harwood, Lewin-VHI, unpublished estimates, 1994~. The financing of methadone treatment is quite different from the financing of other types of medical treatment (Figure 5.2~. Public outlays are responsible for 80 percent of payments. Public Finding of methadone treatment is far greater tears that for all health expenditures, towards which public payments contribute 45.8 percent of the total (CBO, 1993~. The composition of the public payers for methadone treatment is quite unusual as most of the public outlays are in the form of direct payments from federal block grants and state alcohol and drug agencies. The only exception is Medicaid which contributes 12 percent of methadone treatment payments, a share similar to Medicaid's contribution of 15.5 percent to all national health expenditures (CBO, 19931. It is counterintuitive that the Medicaid share is not higher for methadone treatment because marry methadone patients are indigent (Chapter 4~. There are two reasons for that apparent misperception: first, state Medicaid programs are not required to cover drug abuse treatment, and if they do elect to cover it, the coverage is often limited (GAO, 1991; CRS, 1993b); and second, many drug- dependent patients are ineligible for Medicaid they meet the low-income criteria, but they do not meet the categorical criteria for Aid to Families with Dependent Children (AFDC) and Supplemental Security Income (SSI).3 AFDC is targeted to women with dependent children, and SSI is targeted to aged, blind, and disabled persons. Most opiate-dependent persons are young, male, and single (Batten et al., 1992; Price et al., 1991), which usually disqualifies them from AFDC, arid they are unlikely to meet the demanding disability criteria for SSI (IOM, 1995~. In fact, restrictive Medicaid eligibility is partly responsible for the evolution of the large role for federal block grant and state alcohol and drug agency funding. The ratio of federal block grant to state agency funds for drug abuse treatment (approximately 50:50) is about the ratio of federal to state Medicaid funds in many states, such as New York arid California. Thus, the . 3AFI)C and SSI are income support programs that confer automatic Medicaid eligibility. At the state's option, Medicaid coverage can be provided for the "medically needy," those individuals who are near poverty but do not qualify as categorically needy because their income is above the mandatory level. For further elaboration on these programs, refer to IOM (1995~.

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124 DEVELOPMENT OF MEDICATIONS burden of financing of methadone treatment ultimately remains a shared responsibility between the federal and state governments. 80.0% lo.s~ _e _. - 17.0% 2.5% Methadone Treatment 70.6% :~.~1b 11.8% AI' Drug Abuse Treatment 45.~% AI! Health Care 4.0% | Public funds O Private insurance [01 Patient fees [3 Other | FIGURE 5.2 Payments for methadone treatment, all types of drug abuse treatment, and all types of health care. NOTE: Methadone treatment: Total payments, 1993: $480 million. Public funds are divided asfollows: federal block "rants (30%), state agency(33%), Medicaid (12%), local (5%). Adapted from He 1991 NDATUS by Lewin-VHI. SOURCES: Bu~nski et al., 1994; Harwood et al., 1994; Lewin-VHI, unpublished estimates, 1994. All types of drug abuse treatment: Total payments, 1991: $1.2 billion. Public funds are divided as follows: federal (31.4%, including Medicaid, Medicare, and other federal), state and local (39.2%~. SOURCE: U.S. DHHS, 1993. All types of health care: Total payments, 1993: $898 billion. Public funds are divided as follows: Medicaid (15.5%), Medicare (16.8%), other public (13.5%~. SOURCE: CBO, 1 993. Federa] and state funding has shifted dramatically over the past 20 years. In the 1970s, the federal government had a central role in managing and financing treatment. During the 1980s, the responsibility shifted back to the states, and the federal government created block grants in 1981 to help the states with their new responsibility. In 1987, however, only 15 percent of treatment funding came from block grants. Since then, the block grant contribution has risen substan- tially, to 30.2 percent, and the state contribution, 45 percent in 1987, has declined to 32.8 percent (Table 5.1~. The trends in treatment funding from federal, state, and other sources are mixed. After adjusting for medical inflation, total funding from all sources was greatest in 1976. Thereafter, it declined

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TREATMENT FINANCING 125 significantly until 1982, and then began to increase to 1987; the total funding for 1987 was still about 15 percent below that in 1976 (IOM, 1990~. TABLE 5.1 Trends in Financing of State-Supported Alcohol and Other Drug Abuse Services by Largest Funding Sources Private Medicaid - Federal State Alcohol Insurance, and Other Fiscal Block and Drug Client and Public Year Grant Agency Patient Fees' Sources2 Total 1987 15% 45% 22% 9% 91% 1988 17% 43% 20% 11% 91% 1989 20% 42% 18% 12% 92% 1990 22.2% 37.8% 15.7% 16.6% 92.3% 1991 29.2% 34.7% 15.5% 13.7% 93.1% 1992 30.2% 32.8% 18.1% 12.3% 93.4% 'Also includes court fines. This column renames, but contains the same information as, the SADAP category called "Other Sources." 2This column combines the following SADAP categories, "Other State Agency" and "Other Federal Government," in order to capture the federal and state shares of Medicaid, which constitute most of these two categories. There are other state and federal funds included in this column, but they do not come MOM the federal block grant or from state substance abuse agencies. NOTE: l he percentages in this table do not add up to 100% because this table focuses only on the largest funding sources. SOURCE: U.S. DHlIS, 1987-1992. Despite the huge public role in financing, the state agencies and the federal government have been unable to exert market leverage to exact manufacturer discounts. Federal block grant funds flow to state alcohol and drug agencies, which administer the funds directly to providers who make pharmaceutical purchases solely for their clinics. Given this funding chain, public agencies do not act the same way that private-sector pharmaceutical benefit managers do when they use collective purchasing strength to negotiate directly with pharmaceutical companies to acquire volume discounts. However, it may well be that pharmaceutical companies even now are deterred from investing because of the perception of potentially strong purchasing power that could be exerted by public agencies in the future.

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126 DEVELOPMENT OF MEDICATIONS Private insurance coverage of methadone treatment, at 2.5 percent of the total, is almost insignificant. In contrast, private insurance payments represent 33 percent of all national health expenditures (CRS, 1993a). Upon entering treatment, 5.2 percent of patients list private insurance as the primary source of payment (SAMHSA, 1994~. However, because most private policies have restrictions that limit coverage for treatment, most benefits are exhausted after 1 month (Harwood et al., 19941. The group of patients who use insurance (about 11 percent) is largest at private, not-for-profit programs; the greatest percentage of patients paying out-of-pocket (77 percent) is at for-profit facilities (Batten et al., 1992~. Patient fees pay for 17 percent of total methadone treatment costs, a share similar to that for all national health expenditures (CBO, 1993~. This contradicts the perception that patients are unwilling to pay for treatment. Financing the Treatment of Cocaine Addiction There is little data on the financing of treatment specifically for cocaine addiction. NDATUS, the best source, presents data in the aggregate, and with the exception of opiates does not stratify the data by primary drug of abuse. Figure 5.2 provides the most recent published data from 1991 NDATUS on the treatment financing for all drugs of abuse. As stated in Chapter 4, an estimated 30~0 percent of all patients in treatment use cocaine (Batten et al., 1992~. Treatment for cocaine addiction is financed by the same combination of sources as is methadone treatment, but in different proportions. Of the total payments of $1.2 billion for all drug abuse treatment, state and local agencies contributed 39.2 percent, federal block grants contributed 31.4 percent, private insurance contributed 1 1.8 percent, client and patient fees contributed 9.6 percent, and other sources including private donations and public welfare contributed 8 percent (U.S. DHHS, 19931. Combining all public sources yields a contribution of 70.6 percent, a share that is lower than that for methadone treatment (80 percent, Figure 5.2) but still much higher than that for all health care expendi- tures (45.S percent). Similarly, the amount of private insurance payments (11.8 percent) is greater than that for methadone treatment (2.5 percent), but much lower than that for all health care expenditures (33 percent). FINANCING OF LAAM FOR THE TREATMENT OF OPIATE ADDICTION LAAM was introduced into clinical practice so recently that its financial profile is somewhat tenuous, mostly because of state financing and regulatory practices. Information in this section is based on interviews with clinic operators,

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TREATMENT FINANCING 127 state authorities, arid representatives of BioDevelopment Corporation, which manufactures and markets LAAM. The first sales took place in selected states in April 1994, even though LAAM received Food and Drug Administration (FDA) approval in July 1993. BioDevelopment Corporation officials reports that clinics did not begin to buy the medication arty earlier because of state scheduling requirements arid state and federal approvals needed for narcotics used in the treatment of narcotic addiction (Chapters 7 and 8~. BioDevelopment's monthly revenues since the introduction of LAAM, its only product, began at $3,000 in April and rose to $14,000 by May. Revenues were projected to reach $16,000 by June 1994. Of the 737 dispensing units nationwide4 already approved by FDA to dispense methadone by June 1994, only 23 had received the separate approval necessary to dispense LAAM. BioDevelopment set the price for LAAM at about double that for metha- done. The average patient can be maintained on LAAM for about $8-$12 for three weekly doses, in comparison with about $5-$8 for seven weekly doses of methadone (irrespective of the number of take-home doses). Some private for- profit clinics in Texas charge LAAM patients an additional $5 per week. LAAM's higher price is warranted, according to BioDevelopment, for several reasons: first, it is more expensive to manufacture than methadone; second, some patients prefer LAAM because it produces fewer narcotic effects (less sedation, less euphoria); and finally some patients can visit their clinics less often, thereby saving transportation and opportunity costs, because LAAM is administered three times a week. The reduction in dosing frequency is presented as an important advantage to public health, because clinics could increase their patient load. Another advantage promoted by BioDevelopment is that a clinic that uses LAAM exclusively can operate more efficiently because of an estimated 15-20 percent reduction in dispensing and pharmacy services. That is especially important for publicly funded clinics, which generally operate on fixed, sometimes dwindling, budgets. For instance, a clinic that only dispenses LAAM could close on Sunday, when wages are higher. Thus, the higher cost of LAAM relative to methadone might be offset by lower overhead. State financing has been and is expected to be a major impediment to the sale of LAAM, according to BioDevelopment and clinic operators. State financing practices can be so rigid that they effectively block the introduction arid adoption of a new medication. The flow of funds to clinics is dictated by the policies and regulations of two separate state agencies: the state alcohol and drug 4This figure is the number of dispensing units rather than the number of clinics. FDA licenses dispensing units, and a large clinic with more than one dispensing site, usually on different floors, will be counted more than once. Therefore, this is an overestimate of the number of methadone clinics nationwide (IOM, 1995~.

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128 DEVELOPMENT OF MEDICATIONS agency, which administers state funds and federal block grants, and the state Medicaid agency, which administers state and federal Medicaid dollars. There is widespread variation in funding practices (IOM, 1995), but either state agency can erect financial barriers to the adoption of a new medication. New York sets a flat daily or weekly fee per patient (which usually includes all services without specifying the amount for medication and dispensing); other states set a flat fee for a "dosing visit," the dispensing of one dose of medication. California authorizes ceilings on the number of publicly funded patients that can be treated at each clinic (Goldstein, 1989~. Under these finding practices, LAAM is at a disadvantage because it is more expensive than methadone, the medication for which reimbursement rates have been structured over the past 20 years. To obtain better reimbursement, clinics must petition the appropriate agency for more favorable rates. The alcohol and drug agency in Texas, for example, is not planning to increase reimbursements for LAAM, despite requests from clinic operators (S. Garza, Texas Commission on Alcohol and Drug Abuse, personal communication, 1994~. When Medicaid reimbursements fall short, clinics are not generally permitted to bill the patient, and patients are not required to pay the difference. Financing obstacles are contributing to the stalled market penetration of LAAM. Its higher price might have exacerbated the problem, but the rigidity of the financing structure antedates its introduction. Even one of LAAM's selling points for public health the prospect of increasing clinic patient loads has become a disincentive for state alcohol and drug authorities struggling to find additional funding not just for LAAM, but for the higher costs of counseling and comprehensive treatment for possibly more patients. If BioDevelopment Corporation succeeds in securing adequate financing, that will serve as an incentive to other pharmaceutical companies. If not, the future for other opiate medications does not appear encouraging. Therefore, the committee strongly urges state and federal agencies to work together, in the interest of public health and to provide an incentive to pharmaceutical companies, to facilitate the availability of newly approved anti-addiction medications. Possible mechanisms that the states and federal government might consider include requiring all Substance Abuse Block Grant recipients to offer those medications to patients and assuring appropriate financing of new medications by state alcohol and drug agencies and their counterpart Medicaid agencies. Those actions would have the additional benefit of sending a strong signal to the pharmaceutical companies, demonstrating state and federal commitment to the development of anti-addiction medications. One of the ironies about LAAM's financing is that insured patients, those most likely to afford LAAM, are generally the more stable patients who qualify for the greatest number of methadone take-homes permitted by state and federal regulations (often 6 per week). Those patients appear to have the least incentive

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TREATMENT FINANCING 129 to switch to LAAM because they would have to visit the clinic more frequently (M. Parrino, American Methadone Treatment Association, personal communica- tion, 1994) as Federal regulations prohibit LAAM take-home dosing [21 CFR 291.505(k)~1~(iii)~. In light ofthe published data, however, that strongly suggests less of an abuse potential with LAAM than methadone (Blaine and Renault, 1976), the committee urges that the FDA and the Drug Enforcement Administra- tion (DEA) reconsider the regulations that prohibit LAAM take-home dosing to permit take-home privileges of LAAM. While the committee realizes that LAAM could be harmful to uninformed, nontolerant, or new patients because of its delayed effect, LAAM take-home privileges could require restrictions similar to methadone take-home privileges. The prohibition on take-homes has been a significant barrier to patient and provider interest in LAAM (Chapter 8~. In conclusion, financing and regulatory obstacles continue to stall the market penetration of LAAM. LAAM's higher price may have exacerbated the problem, but the rigidity of the financing and regulatory structure antedate the introduction of LAAM. If BioDevelopment eventually succeeds in securing adequate financing, that will serve as an incentive to other pharmaceutical companies. If not, the future for other opiate medications does not appear encouraging. IMPACT OF HEALTH INSURANCE TRENDS ON MEDICATIONS DEVELOPMENT Changes in health insurance have been occurring in the marketplace long before legislative remedies were proposed. Market-based and legislatively driven reforms, together or in isolation, are important determinants of pharmaceutical investment in the development of medications for opiate or cocaine addiction. The section below presents an analysis of marketplace trends, in an attempt to forecast their effect on pharmaceutical development. In Appendix G. the committee presents an analysis of possible legislative trends in health care reform. Trends in Drug Abuse Treatment Benefits There are three related trends in benefits offered under private insurance; an increase in the number of employer health plans that cover drug dependence treatment; a reduction in the coverage for inpatient treatment; and growth in the management of benefits. Employers have added drug abuse treatment as an employee benefit-either voluntarily or as a result of state law because of the recognition that depen- dence on heroin, cocaine, and alcohol reduces worker productivity and

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130 DEVELOPMENT OF MEDICATIONS contributes to absenteeism, health problems, theft, and accidents. Through annual surveys, the Bureau of Labor Statistics (BLS) has monitored the growth of such benefits. In 1983, benefits were contained in 43 percent of enrollees' medical plans offered by medium and large employers. By 1989, 96 percent offered them (Kronson, 1991~. However, across all types of employers, the BLS found greater limitations placed on drug abuse benefits than were placed on other types of medical benefits. Limitations are used to curtail use and to reduce uncertainty about costs to the employer (IOM, 19901. The most common limitations were in the annual number of days of inpatient hospitalization, the number of annual outpatient visits, and separate maximum dollar amounts per year or per lifetime (BLS, 1992~. A typical policy restricted inpatient care to 30 days per year, outpatient care to 20 or 30 visits per year, and contained maximum dollar amounts of $25,000 to $50,000 per lifetime for inpatient and outpatient care combined. The second trend, driven mostly by cost-containment, is a reduction in coverage for inpatient treatment (IOM, 1990~. The cost of inpatient drug abuse treatment escalated dramatically during the 1980s, forcing insurers to impose limits on coverage. For example, before the imposition of limits, one study of private insurance claims for about 1 million enrollees (Frank et al., 1991) revealed that inpatient charges per enrollee climbed 32.4 percent between 1986 and 1988, an increase that was almost three times that for all types of medical treatment. After an inpatient limit of 30 days was established, charges increased only 2.2% over a 1-year period. Consistent with this trend, Rawson and co- workers (1991) observed that by the end of the 1980s, cocaine-dependent individuals faced insurance restrictions on the use of hospital-based chemical dependency programs, which often cost $25,000 for a treatment episode. Those programs had been the treatment of choice for those with insurance in the mid- 1980s, the peak of the middle-class cocaine epidemic. Reductions in hospital coverage are more likely to have been felt by cocaine rather than opiate-dependent patients, because methadone treatment has long been delivered in the outpatient setting. Cocaine-dependent patients who previously sought hospital care in chemical dependency programs are now often treated in 24-hour residential programs. Hospital treatment is typically reserved for drug abuse patients who have concomitant medical and psychiatric problems of a serious nature. According to Rawson and co-workers (1991) the shifting of cocaine-dependent patients to the outpatient setting was motivated principally by the cost concerns of insurers. More recently, Alterman and co-workers (1994) have shown that patients randomly assigned to intensive day hospital treatment for cocaine addiction had as much improvement at less cost than did those assigned to inpatient treatment. The cost of the intensive day hospital (27 hours per week) was only 40~0 percent of inpatient treatment costs (48 hours per week).

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TREATMENT FINANCING 131 Management of benefits, motivated by insurer cost containment policies, attempts to control costs arid yield greater efficiency by influencing the treatment decisions of practitioners and patients. Benefits can be managed by a fee-for- service policy through a special carve-out of the drug abuse treatment benefit, through a health maintenance organization (HMO), or through a preferred- provider organization. Benefit management is exerted in a variety of ways, most commonly through preadmission review, case management to refer patients to the most appropriate providers and medically necessary services, and utilization review during arid after discharge. Industry claims of cost containment have begun to be buttressed by academic research. Larson and Harvard (1994) state that managed care can sharply reduce treatment expenditures under private and public health insurance. One of the studies they cite focused on the effect of managed care on 375,000 enrollees in the Massachusetts Medicaid program. Callahan and co-workers (1994) found the initiation of Barraged care to reduce treatment expenditures per enrollee by 48 percent. Contributing to this overall reduction was a decrease in inpatient expenditures per enrollee of 67 percent and an increase in outpatient expenditures of 8 percent. Overall, the number of patients who received services increased by 5 percent, although this might reflect a higher share of disabled enrollees. There was a 4.6 percent increase in the use of services, primarily as a result of greater usage of methadone services and freestanding detoxification. No direct comparisons of quality of care were possible between managed care and the prior fee-for-service system because of the lack of baseline data. Providers who were surveyed after managed care had been introduced reported a somewhat improved quality of care, and a pilot survey of patients characterized their impressions as "generally positive." The trend toward expanded benefits should aid pharmaceutical development because of an expected increase in demand for anti-addiction medications. The demand also should increase as a result of the trend in management of benefits, because this approach appears to broaden access to plan members. On balance, the trends in addiction treatment benefits are encouraging. REFERENCES Alterman AI, O'Brien CP, McLellan AT, August DS, Snider EC, Droba M, Cornish JW, Hall CP, Raphaelson AH, Schrade FX. 1994. Effectiveness and costs of inpatient versus day hospital cocaine rehabilitation. Journal of Nervous and Mental Disorders 182:157-163. Batten H. Prottas J. Horgan CM, Simon LJ, Larson MJ, Elliott EA, Marsden ME. 1992. Drug Services Research Survey Final Report: Phase II. Waltham, MA: Bigel Institute for Health Policy, Brandeis University. Contract number 271-90-8319/1. Submitted to the National Institute of Drug Abuse, February 12, 1992.

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132 DEVELOPMENT OF MEDICATIONS Blaine JD, Renault PF. 1976. Rx: 3 Times Per Week LAAM Alternative to Methadone. NIDA Research Monograph 8. Rockville, MD: NIDA. BLS (Bureau of Labor Statistics). 1992. Substance Abuse Provisions in Employee Benefit Plans. Bulletin 2412. Washington, DC: U.S. Department of Labor, BLS. Butynski W. Reda J. Bartosch W. McMullen H. Nelson S. Anderson R. Ciaccio M, Sheehan K, Fitzgerald C. 1994. State Resources and Services Related to Alcohol and Other Drug Problems for Fiscal Year 1992. Washington, DC: National Association of State Alcohol and Drug Abuse Directors, Inc. Callahan JJ, Shepard DS, Beinecke RH, Larson M, Cavanaugh D.1994. Evaluation ofthe Massachusetts Medicaid Mental Health/Substance Abuse Program. Submitted to the Massachusetts Division of Medical Assistance, Mental Health Substance Abuse - Program. NValtham, MA: Institute for Health Policy, Brandeis University. CBO (Congressional Budget Office). 1993. Estimated Projections of National Health Expenditures, 1993 Update. Washington, DC: CBO. Condelli WS, Fairbank JA, Dennis ML, Rachal JV. 1991. Cocaine use by clients in methadone programs: significance, scope, and behavioral interventions. Journal of Substance Abuse Treatment 8 :203-212. CRS (Congressional Research Service). 1993a. Medicaid: An Overview. Washington, DC: Library of Congress, CRS. CRS Report No. 93-144 EPW. CRS (Congressional Research Service). 1993b. Medicaid Services for Substance Abuse Treatment. Washington, DC: Library of Congress, CRS. CRS Report No. 93-764 EPW. Frank RG, Salkever D, SharEstein S. 1991. A new look at rising mental health insurance costs. Health Affairs 10:11 ~23. GAO (General Accounting Office). 1991. Substance Abuse Treatment: Medicaid Allows Some SeIvices But Generally Limits Coverage. Washington, DC: GAO. HRD 91-92. Goldstein HM. 1989. The Availability of Methadone Maintenance in California. Drug Abuse Information and Monitoring Project (DAIMP) White Paper Series 9. Los Angeles: UCLA Drug Abuse Research Center, DAIMP. Prepared for the California Department of Alcohol and Drug Programs. Harwood HJ, Thomsom M, Nesmith T. 1994. Healthcare Reform and Substance Abuse Treatment: The Cost of Financing Under Alternative Approaches. Fairfax, VA: Lewin-VHI. IOM (Institute of Medicine). 1990. Treating Drug Problems. Gerstein DR and Harwood HJ, eds. Washington, DC: National Academy Press. IOM (Institute of Medicine). 1995. Federal Regulation of Methadone Treatment. Rettig R. Yarmolinsky A, eds. Washington, DC: National Academy Press. Kronson ME. 1991. Substance abuse coverage provided by employer medical plans. Monthly Labor Review April:3-10. Larson M, Horgan CM. 1994. Issues in Calculating the Cost of a Substance Abuse Benefit under Health Care Reform. Presentation at the Legislative Leaders Conference on Substance Abuse Benefits in State Health Care Reform, Denver, CO, May 2~21, 1994. Sponsored by Intergovernmental Health Policy Project. Leibowitz A, Manning WG, Newhouse JP. 1985. The Demand for Prescription Drugs as a Function of Cost-Sharing. Santa Monica, CA: RAND. RAND/N-2278-HHS.

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TREATMENT FINANCING 133 Manning WG, Newhouse JP, Duan N. Keeler E, Benjamin B. Leibowitz A, Marquis MS, Zwanziger J. 1988. Health Insurance and the Demand for Medical Care: Evidence from a Randomized Experiment. Santa Monica, CA: RAND. RAND Health Insurance Experiment Series RAND/R-3476-HHS. Price RH, Burke AC, D'Aunno TA, Klingel DM, McCaughrin WC, Rafferty JA, Vaughn TE. 1991. Outpatient drug abuse treatment services, 1988. In: Pickens RW, Leukefeld CG, Schuster CR, eds. Improving Drug Abuse Treatment (NIDA Research Monograph 106: 63-92~. Rockville, MD: NIDA. Rawson RA, Olbert JL, McCann MJ, Castro FG, Ling W. 1991. Cocaine abuse treatment: a review of current strategies. Journal of Substance Abuse 3:457~91. Rogowski JA. 1993. Private Versus Public Sector Insurance Coverage for Drug Abuse. Santa Monica, CA: RAND Drug Policy Research Center. MR-166-DPRC. SAMHSA (Substance Abuse and Mental Health Services Administration). 1994. Client Data System FY 1992: Opiate and Cocaine/Crack Admissions to Treatment. Prepared under contract for the Off;ce of Applied Studies. U.S. DHHS (U.S. Deparunent of Health and Human Services). 1987-1992. State Resources and Services Related to Alcohol and Drug Abuse Problems. Prepared by the National Association of State Alcohol and Drug Abuse Directors, Inc. for the O~ice of Applied Studies, SAMHSA. U.S. DHHS (U.S. Depardnent of Health and Human Services). 1993. National Drug and Alcoholism Treatment Unit Survey (NDATUS) 1991 Main Findings Report. DHHS Publication No. (SMA) 93-2007.