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Health Services Utilization by Individuals with Substance Abuse and Mental Disorders |
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Albert Woodward, Ph.D.
This chapter reviews the increasing literature on access to substance abuse treatment and mental health services. The review is focused on the factors critical in shaping access to these services. This knowledge is necessary to help make informed resource allocation decisions that will enhance access for individuals most in need of treatment.
The following sections outline the methods used in the literature review and discuss the determinants of access to substance abuse treatment and mental health services. The chapter concludes with a discussion of the findings.
To develop a body of literature for this review, three online searches of the health care literature covering the years from the mid-1990s to the present were conducted. Articles were obtained from the HealthSTAR, PsycINFO, Sociological Abstracts, and MEDLINE databases using the keywords "access" and "substance abuse treatment." A second search identified literature from the PsycINFO and MEDLINE databases using the keywords "access" and "mental health treatment and services." A third search identified literature from the MEDLINE and PubMed databases using the keywords "access" and "health care," as well as variants of the terms "substance abuse" and "mental health." After a review of the identified articles, a few were eliminated from consideration because they were not directly related to mental health services or substance abuse treatment access. Also, articles that did not present original research were eliminated. The remaining articles were considered for the literature review. Most of the articles came from "field" journals (i.e., journals specializing in mental health or substance abuse). In addition to these online journal article searches, several books, reports, and other documents were added to the review if relevant to the discussion.
Several definitions of treatment access can be applied to both mental health services and substance abuse treatment. Myers (1965) proposed that there had to be four essential elements for "good" medical care, one of which is accessibility. She defined accessibility in terms of three components: personal accessibility, comprehensive services, and quantitative adequacy. Personal accessibility means that there must be defined points of entry into the health care system. A comprehensive range of services is needed because complex problems may require input from a variety of specialties. Quantitative adequacy refers to the supply of a comprehensive range of personal health services sufficient to meet the need.
A widely used definition of access was developed by Aday, Fleming, and Andersen (1984):
...those dimensions which describe the potential and actual entry of a given population group to the health care delivery system. The probability of an individual's entry into the health care system is influenced by the structure of the delivery system itself (the availability and organization of health care resources) and the nature of the wants, resources and needs that potential consumers may bring to the care-seeking process. (p. 13)
Aday et al. (1984) focused on personal characteristics, health behavior, and attributes of the health system. They viewed health services use as a result of a predisposition to use services, factors that facilitate or impede the use and the need for care. Donabedian (1973) developed a similar concept of access, but with a focus on the health system—access "comprises those characteristics of the resource that facilitate or obstruct use by potential clients" (p. 419).
Need, as a key component of treatment access, can be measured in terms of self-perceived health status, number of chronic conditions, or functional limitations. Clinical definitions of treatment need reflect circumstances under which a client seeks or is required to obtain treatment (Jeffers, Bognanno, & Bartlett, 1971). The decision to seek treatment typically is initiated by the patient. Patient choice is affected by need (e.g., incidence of illness), cultural-demographic characteristics, the role of the health care provider (especially in managed care) and/or family as an "agent" for the patient, and external and economic factors. The provider, acting as the patient's agent, determines the patient's demand for treatment.
Myers (1965), Aday and Andersen (1975), and Donabedian (1973) wrote before the advent and explosive growth of managed care and related changes in the health care market. As a result, their discussions of access are somewhat incomplete because they do not account for changes resulting from the growth of managed care or the competition among providers and payers (Gold, 1998; Miller, 1998). Prior to these changes, organization and financing were seen as independent, static variables among a list of system variables that influenced access. At that time, such system variables were of secondary importance to personal variables, including an individual's predisposing characteristics or their need for care (Booth, Staton, & Leukefeld, 2001). However, since the institution of managed care, attitudes have changed, and many researchers now believe that system variables may be even more important than many nonfinancial barriers to access (Berk & Schur, 1997, 1998; Sondik & Hunter, 1998).
The literature regarding access to mental health services and substance abuse treatment generally is consistent with the general health care literature in terms of the determinants of access (Woodward, Dwinell, & Arons, 1992). However, a growing number of researchers suggest that managed care has hindered access to both mental health services and substance abuse treatment (Mechanic, 1996) and to other health care services for vulnerable populations or patients with chronic conditions (Miller, 1998). Moreover, access often is measured by health care utilization data obtained in surveys. These surveys, however, usually do not include persons with mental disorders, who face barriers to access and participation in these surveys. Therefore, it is difficult to evaluate the access of those with mental disorders (Gold, 1998).
The mental health services literature has examined a wide range of personal and environmental attributes that influence access to mental health services. These include demographics, health status and functional limitations, severity of condition, socioeconomic status and employment, patient view of mental illness, acculturation, ethnicity, community support, church participation, provider sensitivity, structural and operating aspects of providers, and a variety of economic and financial barriers (Woodward et al., 1992). Both financial and nonfinancial determinants or barriers to access to substance abuse treatment and mental health services are discussed in this chapter.
Severity of Illness
Research has found that patients with more serious mental illness experience difficulty in obtaining treatment for this illness (Gonzalez & Rosenheck, 2002; Wang, Demler, & Kessler, 2002). Perhaps those with more serious mental illness encounter more barriers to access than the general population because successful treatment may be more expensive due to the severity of the disorder. For example, veterans with co-occurring mental and substance use disorders incur higher overall treatment costs in Department of Veterans Affairs (VA) facilities, largely because of the severity of their conditions (Hoff & Rosenheck, 1998). Homeless persons and others with the human immunodeficiency virus (HIV) who have mental and substance use disorders have better outcomes if they are able to receive extensive services, especially substance abuse treatment (Burnam et al., 2001; Gonzales & Rosenheck, 2002). Substance abuse treatment clients who do not complete treatment appear to have more health problems at both the beginning and termination of treatment. Specifically, clients in outpatient nonmethadone treatment who do not complete treatment have a significantly greater number of diagnoses per client at both intake and discharge than those completing treatment (Woodward, Raskin, & Blacklow, 2004).
Demographics
Children and adolescents face significant obstacles in accessing mental health services and substance abuse treatment. One estimate suggests that approximately half of the children experiencing depression are not receiving care (Glied & Neufeld, 2001). Parental perceptions of children's mental illness and resulting parenting difficulties can act as a barrier to mental health services (Owens et al., 2002). Moreover, parental illness, including mental and substance use disorders, can further impede a child's access to treatment (Cornelius, Pringle, Jernigan, Kirisci, & Clark, 2001).
Race and ethnicity are attributes or predisposing factors that also can affect access to mental health services or substance abuse treatment (Snowden, 2001; Wang et al., 2002). Racial and ethnic differences in perceptions about mental illness, treatment system biases, and reliance on voluntary support networks act in ways that hamper treatment access (Dana, 2002; Kales et al., 2000; Snowden, 2001). As a result, African Americans and Hispanics are likely to receive fewer mental health services or less substance abuse treatment than needed (Wells, Klap, Koike, & Sherbourne, 2001). African Americans use proportionately fewer outpatient mental health services than white patients (Kales et al., 2000), regardless of access to private health insurance (Thomas & Snowden, 2001).
Delivery System
The mental health services system also can act as a barrier to access, even more so than can patient attributes or environmental issues. The delivery system for such care has been characterized by the President's New Freedom Commission on Mental Health (2002) as
... incapable of efficiently delivering and financing effective treatments—such as medications, psychotherapies, and other services—that have taken decades to develop. Responsibility for these services is scattered among agencies, programs, and levels of government. There are so many programs operating under such different rules that it is often impossible for families and consumers to find the care that they urgently need. The efforts of countless skilled and caring professionals are frustrated by the system's fragmentation. ("Letter to the President," October 29, 2002).
This message is not new. Many researchers have called for comprehensive systems of integrated care for people with mental illness, especially for those who are homeless (Dennis, Steadman, & Cocozza, 2000).
Treatment access is determined largely at the local level, where most mental health services are offered. Local market area studies of mental health services and substance abuse treatment (Condelli, Bonito, Ennett, & Fairbank, 1996; Goldsmith, Wagenfeld, Manderscheid, & Stiles, 1996) have indicated that specialty services are concentrated in more urbanized areas, providing urban populations with better access. Capacity or the availability of supply is crucial to understand access (and meet treatment need); both are influenced by the composition of treatment ownership, organization, and services and specialty mix (Schlesinger & Dorwart, 1992).
Local treatment can be restrictive and bureaucratic, making it difficult for persons with mental illness to obtain care. For example, one study found that persons with mental illness who are homeless in New York City received less Medicaid, food stamps, and other relief services than other persons who are homeless (Nuttbrock, Rosenblum, Magura, & McQuistion, 2002). Further, some rural areas have insufficient services to meet the needs of their population (Fox, Blank, Rovnyak, & Barnett, 2001; Hartley, Britain, & Sulzbacher, 2002).
Not all the changes in government programs have lessened access. The restructuring of California's public mental health system, for example, promoted access to treatment by patients with more serious mental illness (Snowden, Scheffler, & Zhang, 2002). Homeless persons with mental illnesses who receive coordinated and intensive mental health and support services have been discharged from treatment to community support services without loss of mental health status and social functioning (Rosenheck & Dennis, 2001).
Financing
Once persons with mental illnesses decide to seek treatment, they are confronted not only with the challenges of the health care system, but also with the challenge of paying for that care. Financial access to treatment is a function of ability to pay (either out-of-pocket or through private coverage or through public funding sources). In contrast, funding for most other health care is heavily dependent on private health insurance financing (Frank, McGuire, Regier, Manderscheid, & Woodward, 1994). The literature on health care demand has focused principally on the relationship between health care demand and the demand for health insurance, as well as on the relationships between the type of health insurance package and health care utilization (Feldstein, 1973). In general, this literature includes mental illness but excludes substance use as determinants of health care utilization or health insurance choice (Frank & Manning, 1992; Keeler, Wells, Manning, Rumpel, & Hanley, 1986; Wells, Manning, Duan, Ware, & Newhouse, 1982).
Health insurance affects demand and access in two ways: Insured individuals may choose to demand more treatment services (moral hazard, in the conventional sense), or they may select specific coverage in anticipation of using services for themselves or dependents (adverse selection) (Larsen, Horgan, Marsden, & Tompkins, 1996; Steinberg, 1992). These two factors contribute to increased utilization over some optimal social welfare norm, which may be a "good thing" for those who avoid treatment (Steinberg, 1992, p. 275). Manning and Frank (1992) expressed the same idea: "As long as the incremental risk-pooling gains from reduced cost sharing more than offset the incremental increases in costs from demand response, we should expand mental health coverage" (p. 214).
Most persons seeking mental health services rely on public financing, which substitutes for health insurance and funds most mental health care (McKusick et al., 1998). This funding, however, is often inadequate to meet the needs of those with mental illness (Wang et al., 2002). Most mental health care is available through publicly funded programs that are part of the group of "safety net providers." These providers, who have been adversely affected by the changes in public financing, treat patients who might otherwise not have access to medical care (Baxter & Mechanic, 1997). Although the growth of Medicaid managed care made payments available to safety net providers, many States provide only limited mental health coverage and no methadone maintenance under Medicaid (McCarty, Frank, & Denmead, 1999).
Some public financing and private health insurance have moved from coverage of more costly inpatient hospital treatment to lower cost, but equally effective, residential care (Fenton, Hoch, Herrell, Mosher, & Dixon, 2002). Persons with mental illness often come to rely on more than one program for care. Changes in the financing of one type of program can affect other programs and access. A study of veterans with mental illnesses who used the VA mental health systems and non-VA State hospitals is illustrative (Desai & Rosenheck, 2000). In the eight States analyzed in the study, the use of State hospitals by veterans was correlated with VA funding:
A 50% increase in VA per capita mental health spending was associated with a 30% decrease in veterans' use of state hospitals (elasticity of -0.6). Conversely, a 50% increase in state hospital per capita funding was associated with only an 11% increase in veterans' use of state hospitals (elasticity of 0.06). (p. 61)
Per capita funding of State hospitals and VA mental health systems directly affects access, as measured by utilization. The VA system has recently improved access and quality of care in comparison with that of privately insured populations (Leslie & Rosenheck, 2000).
Managed care appears to have constrained access to mental health services over the past decade. It has shifted financial risk onto providers and constrained provider treatment options through close oversight, financial incentives, and controls. However, nationally representative data are not available, and results must be interpreted with caution (Rosenbaum, Mauery, Teitelbaum, & Vandivort-Warren, 2002). For example, Cuffel and Regier (2001) observed that increased spending on behavioral health care leads to greater access. Although some studies have found that access is reduced as a consequence of managed care (e.g., Bloom et al., 2002; Leslie, Rosenheck, & Horwitz, 2001), other studies found no impact on health care utilization (e.g., Alegria et al., 2001–2002). Most of these studies have examined private-sector mental health care organizations. Referrals of patients to psychiatrists are constrained by the limits imposed by managed care plans (Grembowski et al., 2002). As mental health managed care becomes more concentrated among fewer firms, providers will have less opportunity to change their delivery systems to promote access (O'Brien, 2000). Korper and Raskin (2002) argued that the delivery system and managed care adversely have affected the treatment of older patients with substance use and mental disorders:
Reduced time for doctor-patient interactions makes it difficult to identify patient problems with substances and drug interactions. The health care system has experienced reduced hospital lengths of stay, increased reliance on primary care physicians, dwindling outpatient resources, and reduced nursing home beds. Older adults...have fewer options as to where they can live and receive care. (p. 10)
In response to managed care, mental health care advocates have supported State and Federal legislation to make mental health benefits comparable with those of general medical care ("parity"). The effects of parity on access to mental health services are ambiguous. Managed care controls utilization by circumventing the benefit-design improvements that parity attempts to achieve (Frank & McGuire, 1998). In one large employer group, access for subgroups subject to a parity mandate was no different from that for subgroups not subject to parity—treatment prevalence rose for both types of subgroups (Zuvekas, Regier, Rae, Rupp, & Narrow, 2002). Parity can lead to improved mental health coverage and, therefore, access for a slightly higher number of people with mental illnesses. However, it also can have negative consequences, including the loss of all health insurance coverage for some people with mental illnesses (Sturm, 2000a). States with parity legislation have not experienced large increases in mental health care utilization, perhaps as a result of reductions in private health insurance coverage for mental health services (Pacula & Sturm, 2000).
Need and Demographics
The need for substance abuse treatment has been estimated at the national and State levels based on responses to questions in the annual National Survey on Drug Use and Health (NSDUH), formerly the National Household Survey on Drug Abuse (NHSDA). This nationally representative survey assesses dependence and abuse of substances and treatment received (Office of Applied Studies [OAS], 2002). Findings based on this survey generally have been consistent with studies using other surveys and frequently agree with anecdotal treatment perceptions. Age at first use of alcohol or illicit drugs is a very important factor in understanding an individual's need for treatment—the earlier the use of marijuana, for example, the greater is the likelihood for substance abuse treatment at a later age (Gfroerer, Wu, & Penne, 2002). Men are more likely to need treatment than women. The likelihood of seeking treatment increases with age up to the mid-30s and then declines; problems of substance use and need for treatment by race and ethnicity are similar to other illness conditions in the U.S. population (Flewelling, Ennett, Rachal, & Theisen, 1993; Gerstein, Foote, & Ghadialy, 1997; OAS, 1998). Family structure, living arrangements, and residential stability influence substance use and treatment need (Bachman, Wadsworth, O'Malley, Johnston, & Schulenberg, 1997; Johnson, Hoffman, & Gerstein, 1996).
The influence of predisposing factors—such as level of educational attainment, income, and employment status—on treatment need is still being evaluated. Because these factors often are interrelated, researchers have found it difficult to explore the separate effects of these variables. Thus, studies have somewhat contradictory findings. One study found no consistent associations among these predisposing variables and heavy or frequent use of substances, which is an indicator of treatment need (Flewelling et al., 1993). However, other studies have found a correlation between lower income and need for treatment among those over 25 years of age, but this correlation could indicate a relationship between different career and education paths and different levels of treatment need (Bachman et al., 1997; Gfroerer et al., 2002). The nature of the relationships observed between race/ethnicity and need for treatment could be confounded by the relationship between race and socioeconomic status (Flewelling et al., 1993).
Access to substance abuse treatment can be affected by such demographic factors as race/ethnicity and urbanization of residence, among others (OAS, 1998). For example, African Americans and Hispanics are less likely to have access to substance abuse treatment than are whites (Wells et al., 2001). Rural residency is a greater barrier to treatment than urban status. Rural at-risk drinkers had more difficulty obtaining care and were sick more often than their urban counterparts (Booth, Kirchner, Fortney, Ross, & Rost, 2000). Homeless persons with substance use disorders may have the most difficulty accessing treatment, even if they have public health insurance (Kushel, Vittinghoff, & Hass, 2001; Wenzel et al., 2001). Persons enrolled in a health maintenance organization (HMO) are more likely to initiate treatment after assessment if they are employed (with pressure from employers or colleagues to enter treatment) and have more serious substance use disorders (Mertens & Weisner, 2002). Persons who inject drugs or have HIV face particular barriers to care. The literature on these groups covers a wide variety of determinants of access to care. However, these studies are lacking, as these groups are difficult to study in a representative manner. Even so, there is agreement that these groups receive suboptimal care, which may be indicative of access constraints and an inability to comply with a prescribed treatment regimen (Burnam et al., 2001; Chitwood, Comerford, & McCoy, 2002; Knowlton et al., 2001; Weissman et al., 1995).
Seeking Treatment
Understanding the demand for substance abuse treatment is more complex than assessing the need for treatment. Demand depends on multiple factors—the person's behavior consequent to substance use, the seriousness of the substance use disorder, the price for treatment, patient income and education, and other market and personal characteristics. It is not uncommon for those with a health problem to delay seeking treatment. Those with substance use disorders also are likely to deny that they need treatment (McCoy, Metsch, Chitwood, & Miles, 2001). Persons with substance use disorders often have an altered perception of their use that may contribute to their avoidance of treatment (Grossman, 1993).
When substance use disorders reach a point where an individual no longer can cope, then individuals will seek or be coerced into treatment. The time between the recognition of the need for treatment and actually seeking treatment may be as long as a decade or more (Kessler et al., 2001). The reasons for seeking treatment are "illuminating, although their logic proves to be unintelligible in some cases, and they may be evasive or deceptive in others" (Institute of Medicine [IOM], 1990, p. 109). Typically, the individual's reluctance to seek treatment has to be overcome. In many cases, the individual may have to be coerced into treatment by court order, family, or employer. The physical consequences of substance use, and subsequent attention to the disorder by health care professionals, motivate some people to seek treatment (Weisner & Matzger, 2002).
Financial Barriers
Multiple factors affect treatment access (Kessler et al., 2001), including financial barriers. As previously noted, a substantive body of literature has examined the relationship between demand for mental health services and health insurance coverage. More research remains to be done regarding the impact of insurance on substance abuse treatment access.
Many of those who seek substance abuse treatment have low incomes, which may hamper their ability to pay out-of-pocket, as well as their ability to acquire adequate health insurance coverage (Larsen et al., 1996; Sturm & Sherbourne, 2001). As a result, they often are forced to rely on subsidized treatment provided by publicly funded programs.
Persons with lower income are not the only group who face difficulties obtaining care. Older persons frequently have undiagnosed substance use disorders and, as a consequence, do not receive necessary treatment (Korper & Council, 2002). Older patients with diagnosed substance use disorders also face difficulty in obtaining needed outpatient mental health care, perhaps because of limits in Medicare benefits coverage (Brennan, Kagay, Geppert, & Moos, 2001).
The effect of managed care on access to substance abuse treatment is comparable with that for access to mental health services. Managed care, in general, shows evidence of systemic reductions in access to inpatient care for both substance use and mental disorders while increasing the reliance on outpatient treatment (Steenrod, Brisson, McCarty, & Hodgkin, 2001). Most substance abuse managed care also is "carved out" of the general health insurance plan or State Medicaid plan (Sosin & D'Aunno, 2001). As is the case with mandated mental health benefits, mandated substance abuse benefits may not increase utilization because managed care constrains that utilization (Sturm, 2000b).
States have introduced changes to welfare programs and Medicaid plans as a result of Federal legislative changes. Most of these changes have not improved access for persons with substance use disorders. For example, under welfare reform, welfare recipients with substance use disorders in the State of Washington face difficulty in obtaining treatment and vocational counseling in their efforts to become self-sufficient (Wickizer, Campbell, Krupski, & Stark, 2000). Although treatment access may be constrained by changes to State programs, two separate studies found that substance abuse treatment access improved as a result of programs in Massachusetts and Oregon (Beinecke, Shepard, Tetreault, Hodgkin, & Marckres, 2001; Deck, McFarland, Titus, Laws, & Gabriel, 2000).
The structure and organization of treatment providers can affect access to substance abuse treatment. For-profit treatment programs are more likely to provide treatment to clients with health insurance coverage or the ability to pay—clients who generally are not treated in publicly financed treatment programs (Wheeler & Nahra, 2000). Thus, substance abuse treatment is a "two-tiered" public and private system. Centralized intake assessments prior to treatment initiation serve to place publicly financed clients into treatment programs, thereby promoting treatment access (Guydish, Woods, Davis, Bostrom, & Frazier, 2001). However, one study found lower rates of treatment placement for women after centralized intake assessment (Arfken, Borisova, Klein, di Menza, & Schuster, 2002). Women with special needs (e.g., those who are pregnant) and men and women who injected drugs were given higher priority for treatment. Treatment access can be improved for women by providing the range of social support services they need, especially services for mothers (Marsh, D'Aunno, & Smith, 2000; Nakashian, 2002).
Publicly funded treatment facilities may not have sufficient capacity to provide services to all individuals who request treatment. Changes that increase staff burden, reduce or eliminate certain services, or lessen methadone availability are likely to erode patient access to substance abuse treatment programs (Friedmann, Alexander, & D'Aunno, 1999). Too often, individuals with substance use disorders end up going through short-term detoxification multiple times before beginning more long-term treatment solutions or relying on emergency departments for palliative treatment (McCarty, Capsi, Panas, Krakow, & Mulligan, 2000; McGeary & French, 2000; Wingerson, Russo, Ries, Dagadakis, & Roy-Byrne, 2001). Methadone maintenance programs may offer access to treatment for those addicted to heroin but may have insufficient funding to provide appropriate dosage or sufficient long-term treatment (Brands, Blake, & Marsh, 2002; Joseph, Stancliff, & Langrod, 2000; Sees et al., 2000; Weinrich & Stuart, 2000). The Medicaid program could itself be a barrier to treatment for these patients in the 25 States that do not cover methadone maintenance medication (McCarty et al., 1999).
This literature review has covered a wide variety of the attributes of access to treatment for substance use and mental disorders, with an emphasis on financial impediments. The determinants of treatment access were divided into mental health and substance use topics because much of the literature discusses them separately. Nonetheless, the determinants are similar for both mental health services and substance abuse treatment. The literature shows a growing awareness of the impact of financing and costs as critical determinants of treatment access, reflecting the growth of managed care in the past decade. This growth has affected treatment of both disorders.
Treatment access, of course, is only the first step to successful outcomes. Persons with mental or substance use disorders cannot be treated if they cannot gain access to treatment, nor can they be treated successfully if treatment is not effective. Although treatment effectiveness is beyond the subject of this chapter, effectiveness also depends, to some extent, on access to care. The IOM (1990) report sums up treatment effectiveness:
No single treatment "works" for a majority of the people who seek treatment. Each of the treatment modalities for which there is a baseline of adequate studies can fairly be said to work for many of the people who seek that treatment; and enough of them do find the right treatment, and stay with it long enough, to make the current aggregate of treatment programs worthwhile. (p. 191)
The IOM report points out that access to appropriate treatment frequently is constrained by the lack of capacity in treatment programs, the restrictive costs of treatment, the lack of adequate intake assessment, and the lack of information or transportation. The critical first part of treatment effectiveness is initial assessment and assignment to the appropriate treatment, which often is missing. This is true for both mental health services and substance abuse treatment.
Despite a large number of studies on the topic, the reasons that people with mental or substance use disorders seek treatment are not fully known. Booth et al. (2001) argued that
This broader definition of access can generally only be studied from community samples, where substance using individuals are identified and followed prospectively to see how access influences their use of treatment or other services. We know that relatively few individuals with "substance use disorders" use treatment services, and it is critical to identify the effect size for access, as a potentially modifiable policy-related factor, in increasing treatment-seeking. Additional information is needed to understand more about broad inequities in access, particularly for posited and actual vulnerable and generally powerless populations such as minorities and adolescents. (p. 676)
The authors suggested that the focus of new research should be on persons with substance use disorders in the community, as distinct from those getting substance abuse treatment, if the determinants of "treatment-seeking" are to be understood.
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