Appropriate placement is key to cost-effective care

by Gary Hestness

With health care costs continuing to outpace inflation, a prime target of the managed care
industry has been inpatient chemical dependency treatment. No doubt some providers of
residential treatment have abused the third-party payer system, thus arming managed
care groups with some cause to scrutinize inpatient care.

But is there justification for the strong trend toward outpatient care, which is perceived to
be (but isn’t always) a less- expensive form of treatment? Is it cost-effective? Is it in the
best interests of patients and employers? Some evidence suggests that it is not.
The fact is both inpatient and outpatient programs work for the appropriate patient.
Inpatient care works well for most patients. But not all addicted persons need intensive
inpatient care. Hazelden offers a full continuum of care, including both inpatient and
outpatient care. For many patients the continuum begins appropriately with outpatient
therapy.

Treatment for chemical dependency is not unlike that for any other disease. Like other
diseases, chemical dependency comes in various degrees and needs a range of treatment
modalities. And like the cancer patient who may require multiple surgeries and
chemotherapy, the chemically dependent person may require intensive inpatient care and
aftercare services in order to arrest and control the disease.

Several studies report no overall advantage for inpatient treatment over outpatient care.
However, several experts in the addiction field contend that it’s rare to find good controlled
studies that compare the effectiveness of the two types of treatment. Most of the studies
that attempt to compare the two types of treatment look at chronic recidivist populations, a
group that traditionally yields poor results for both types of treatment.

Unless researchers can control the many variables (such as patient population) and look
at similar models of treatment that use similar outcome measures, then studies that
attempt to compare the two types of treatment are like comparing apples to oranges.
Placing patients in the appropriate treatment program, or achieving the appropriate case
mix, is the real key to providing cost-effective chemical dependency treatment. In talking
with three managed care companies, each said they are sending about 10 percent of their
patients who need chemical dependency care to inpatient treatment. On the other hand,
according to data collected by the Drug and Alcohol Abuse Normative Evaluation System
(DAANES) of Minnesota, independent assessment specialists who make evaluations
based on patient needs said they recommend that one third of patients go to inpatient, one
third to outpatient, and the rest to a combination model. So, according to the DAANES
data, about 23 percent of chemically dependent persons (covered by those three managed
care companies) probably are not receiving appropriate treatment, or inpatient care as
prescribed by objective assessors.

Says Dan Smith, who directs the McDonnell Douglas Corporation Employee Assistance
Program: "Over a four-year period of time, we saved $6 million through the use of our
employee assistance program as a gatekeeper for our mental health and chemical
dependency care. The emphasis was on appropriate placement, not just limited stays at
inpatient programs or outpatient-only care. We feel that appropriate case mix is the
important factor."
Inpatient chemical dependency treatment provides a therapeutic environment in which the
patient can learn how important a support system can be in the recovery process. It offers
support and expectation for change 24 hours a day, as well as frequent interactions with a
multidisciplinary staff. One of the great recovery tools, especially in inpatient settings, is
learning to use the peer group as a support system. It is not so much the treatment center,
but the peers who provide the therapeutic nurturing in recovery. The peer group is an
important component of outpatient care as well, but it can be developed even more
effectively in the safe, supportive environment of inpatient care.

The bottom line is both types of treatment work. Correct assessment and placement will
ultimately save an organization the greatest amount of money over the long term. The
costs for appropriate treatment will be recouped within two to three years in reduced
medical costs for the individual.

As the McDonnell Douglas study indicates, the employee assistance program (EAP) may
be in the best position to clinically assess the severity of chemical use problems and
develop treatment options. The EAP is connected with all parts of the continuum of care,
from employee benefit design, to supervisory referral involvement, and to clinical case
management and the ability to follow up with an aftercare plan. It is well positioned to
measure how well people do in different levels of care. EAP will likely provide the cost-
containment answers for the 1990s.