Highlights

This volume is a compendium of health services analyses on a variety of behavioral health care issues conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies (OAS). First, a literature review traces recent trends in access to treatment for substance use and mental disorders. Then results from analyses based on large, representative datasets and economic modeling approaches provide new insights into access, treatment choice, retention in treatment, and costs associated with treatment for substance use and mental disorders.

The in-depth review of current research findings on access to treatment for substance use and mental disorders (Chapter 2) encompasses the wider area of health care utilization and places special emphasis on financial factors impacting access to care. Key highlights from Chapter 2 include the following.

Financing and Access to Substance Use and Mental Disorder Treatment

There is a growing awareness of the effects of financing and costs on access to treatment. Managed care and financing issues appear to be as important as nonfinancial barriers, such as the severity of the substance use disorder, in influencing access to care. Homeless people with substance use and mental disorders may have the most difficulty in accessing treatment, even if they have public health insurance.
Managed care for substance abuse treatment not only has shifted treatment from inpatient care to outpatient care, but also has shifted the risk to providers, thus constraining provider treatment options.

Substance Use Disorder Severity and Access to Treatment

Those with more serious behavioral illnesses may encounter more barriers to access because successful treatment for them may be more expensive and because redundant and bureaucratic procedures may pose insurmountable obstacles. However, changes in government-sponsored systems can promote access for clients with more serious disorders.
To better understand the issues of access to services, researchers should study the entire universe of persons with substance use and mental disorders, not just those who seek treatment.

Subsequent chapters in this compendium provide insight into the organization, financing, management, and delivery of behavioral health services for substance use and mental disorders by exploring such issues as utilization, quality, cost, cost-effectiveness, and outcomes. The authors examine how the demographic characteristics of an individual affect how, when, where, and if a person will seek care, what types of care are chosen or provided, and what happens during the delivery of care. Key highlights include:

Community Hospitalizations of Those with Substance Use and Mental Disorders

Discharges from community hospitals of those with substance use and mental disorder diagnoses grew substantially between 1990 and 1995, a time of stability in overall hospital discharges (Chapter 3).
Although the complexity of substance use and mental disorders increased over time, the length of stay (LOS) decreased in community hospitals. The decrease was most pronounced for those with disorders related to substance use (Chapter 3).
Patients with substance use and mental disorder diagnoses were more likely to receive uncompensated care or have Medicaid coverage than other community hospital patients (Chapter 3).
The Federal Government's role in paying for the care of patients with substance use and/or mental disorders in community hospitals increased between 1990 and 1995, with Medicare and Medicaid paying for the treatment of more than half of discharges with such diagnoses (Chapter 3).

Admissions to Substance Abuse Treatment

The criminal justice system was the most common source of treatment referral for adult males with alcohol as the primary substance of abuse in most States examined (Chapter 4).
Greater disorder severity increased the likelihood of inpatient admission. In addition, daily alcohol users were significantly more likely to receive inpatient treatment than clients who did not drink in the 30 days prior to admission. Moreover, using cocaine as a secondary substance increased the likelihood of inpatient admission in most States (Chapter 4).
Referral by an alcohol or drug treatment provider generally increased the likelihood of inpatient admission, but in many of the States examined, co-occurring mental disorders did not consistently increase the odds of inpatient admission (Chapter 4).
Clients who were employed were less likely to have an inpatient admission; clients who paid for their own care had a lower likelihood of entering inpatient treatment (Chapter 4).
An examination of the choice among five types of treatment (standard outpatient, intensive outpatient, long-term residential, short-term residential, and inpatient hospital) in two States revealed that those admitted to standard outpatient treatment appeared to have less severe alcohol use disorders and were more likely to be employed than those admitted to any other treatment setting. Furthermore, analyses that allowed for only two choices, inpatient and outpatient, obscured the relationships between client characteristics and treatment-setting choice (Chapter 5).

Retention of Women in Substance Abuse Treatment

Substance abuse treatment for women at facilities offering child care services and treatment at women-only facilities were associated with a longer LOS (Chapter 6).
Lower educational levels (fewer than 8 years) were associated with a shorter LOS among female clients (Chapter 6).
Among adult female clients at outpatient nonmethadone facilities:

LOS was shorter among those aged 55 to 64 than among those aged 18 to 54.
The average LOS differed by race.
The LOS was longer among those whose primary source of payment was no payment or self-payment (Chapter 6).

Among adult female clients at nonhospital residential facilities, the LOS was longer among women with a criminal justice system referral.
Adult female clients in facilities offering combined mental health and substance abuse treatment services stayed in treatment longer than in those facilities not offering these services.
Adult female clients receiving care at facilities offering prenatal care or transportation services had shorter LOS.

Costs of Substance Abuse Treatment

Average cost per admission declined as facilities became larger, which suggests that larger facilities may be able to provide care at a lower price than smaller facilities (Chapter 7).
Facilities with a greater proportion of clients who received Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) had higher costs (Chapter 7).

Selection Bias in Analyses of Client Data

Analyses of data collected by States only from facilities that receive public funds earmarked for substance abuse treatment may be biased. States may want to pursue reporting client data by all facilities, regardless of their funding status, to get a more accurate understanding of the substance use problems in their State (Chapter 8).
Clients admitted to facilities receiving public funds earmarked for treatment of substance use disorders generally were younger, less likely to be employed, less likely to be married, less likely to have postsecondary education, and less likely to have private insurance pay for their treatment than those entering other facilities. However, variations among States were found between clients who entered facilities that accepted earmarked funds and those who entered facilities that did not accept earmarked funds (Chapter 8).