Although a spike in drug use among teen-agers is tripping alarms along the presidential campaign trail, drug-treatment specialists contend the slogan of "just say no" also applies to coverage of drug-abuse treatment.
Addiction specialists say that despite the increase in drug use, their ability to help drug abusers recover has been limited by the same forces that have swept through the rest of medicine: managed care, less-generous employee benefit packages, a rising number of uninsured patients and public-sector cutbacks.
"You're seeing an increasing number of young people coming in for treatment at the same time there has been a reduction in treatment capabilities," said David Smith, M.D., founder and medical director of Haight-Ashbury Free Clinic in San Francisco and president of the 3,000-member American Society of Addiction Medicine.
"Addiction and mental health services tend to be marginalized," Smith said. "If anything's going to be cut down, it's that."
Federal government statistics show that the percentage of Americans between 12 and 17 who are current users of illegal drugs has risen to 10.9% in 1995 from a 13-year low of 5.3% in 1992. Drug use among all Americans 12 and older has increased to 6.1% in 1995 from a 13-year low of 5.8% in 1992, although use among people 26 and older for the most part still is flat or falling.
Hospital emergency rooms have reported a 22.7% increase in drug-related episodes over the same period, according to figures from the Substance Abuse and Mental Health Services Administration.
Smith's clinic acutely illustrates the pressures facing addiction medicine providers. Even though the clinic's drug-treatment center now treats about 350 to 400 patients at a time, as many as 400 more want to receive treatment there, said Greg Hayner, chief pharmacist at the treatment center.
But the center can take in, at most, only 32 new patients a week, meaning some drug users could wait up to a month to get in, he said.
"We know what happens to those people: They put off getting treatment because of frustration," Hayner said. "It's a problem of not having available treatment resources to meet the need.
"Only a small fraction of the treatment center's patients have any coverage through private insurance, state Medicaid or federal funds, Hayner said. Most of the clinic's addiction-treatment coverage comes from local government, he said.
Hayner said an average patient visits the clinic's outpatient drug-treatment clinic about 15 times over three weeks. Local government pays $100 a visit, he said.
Driven by employers to reduce healthcare costs, meanwhile, insurers and managed-care firms have limited the amount of drug-abuse recovery treatment they will cover. Insurers contend they're willing to offer policies that cover substance-abuse treatment-as long as employers and purchasers are willing to buy such services in their policies.
Addiction-medicine specialists are saying goodbye to the days when employers and insurers would pay for as much as three months of inpatient substance-abuse treatment and greeting a future in which some plans cover only 23 hours of inpatient care.
"There's no way, with a couple days in a hospital and a couple weeks in a day program, we're going to turn around a drug-abusing teen-ager," said Steven Jaffe, M.D., director of child and adolescent psychiatric services at Charter Behavioral Health System at Peachford in Atlanta and a professor of psychiatry at Emory University.
According to Bureau of Labor Statistics data, the percentage of companies with 100 or more employees that gave the same coverage for inpatient detoxification treatment as they did for other illnesses has remained roughly the same in recent years, rising to 29% in 1993 from 28% in 1988. But the percentage of large employers that placed dollar limits on such treatment rose to 35% from 21% over the same period.
Physicians and other drug-treatment specialists should expect only further tightening of inpatient substance-abuse coverage.
According to an analysis by Evanston, Ill.-based Sachs Group, the nearly 4.2 million inpatient days nationwide related to substance-abuse treatment in 1995 would be cut to 2.5 million days by 2000 if the rest of the country were to resemble the managed-care-intensive Seattle healthcare market by then. Under the same scenario, inpatient discharges for such services would shrink to 314,900 from 503,300.
Drug-treatment specialists haven't gotten any help from the federal government.
Substance-abuse treatment is specifically excluded from recent federal legislation that equalizes annual and lifetime expenditure limits on mental health coverage with physical health coverage.Substance-abuse providers decried that exclusion. "Everyone seems so eager to debate who's toughest on the availability of drugs, but equitable treatment of alcoholics and addicts gets specifically ignored," said John Schwarzlose, president of the Betty Ford Center in Rancho Mirage, Calif.
Addiction-medicine specialists contend, however, that coverage of drug-abuse rehabilitation pays off in the long run.
That's particularly true, they say, if such care averts episodes or accidents that result in costly emergency room visits or inpatient stays. For instance, Smith of the Haight-Ashbury clinic cites studies indicating that every dollar spent on drug-abuse treatment saves $7 in health and social costs.
By itself, heroin use may cost the healthcare system hundreds of millions of dollars. Gabor Kelen, M.D., chairman of the emergency medicine department at Johns Hopkins University School of Medicine and chief emergency physician at Johns Hopkins Hospital in Baltimore, has told a congressional panel that, in round numbers, inpatient hospital treatment of heroin users cost $150 million nationwide in 1995.
Meanwhile, in testimony to the House Government Reform and Oversight Committee's criminal justice subcommittee, Kelen said emergency room visits by heroin users cost $17.3 million and physician charges totaled at least $40 million.
Kelen said the percentage of heroin-addicted patients in Maryland without any insurance whatsoever grew to 37% from 10% between 1990 and 1995, while the percentage covered by Medicaid dropped to 41% from 62%.
In an environment in which capitation is becoming more dominant, however, coverage of drug-abuse rehabilitation could pay off for providers and payers.
When physicians are financially at risk for managing and improving the health status of groups of patients enrolled in health plans, failing to avert drug abuse could end up costing them dearly.Some companies say they're thriving in a managed-care environment. Allen Tepper, chief executive officer of PMR Corp., a mental healthcare provider based in San Diego, says the five ambulatory substance-abuse treatment centers it owns in the Los Angeles area serve patients covered exclusively by private managed-care plans.
Yet the company's substance-abuse treatment programs are "positive contributors to the bottom line," Tepper said. Between its Los Angeles clinics and a center serving Medicaid beneficiaries and indigents in Little Rock, Ark., the company's substance-abuse business grosses between $3 million and $4 million a year, he said.
"For niche companies that can create cost-saving products in managed-care and public-sector markets where there is tremendous cost pressure, we think there is opportunity," Tepper said. "That is a product that's in demand today."
Charter Peachford's Jaffe agrees. He sees the future of drug treatment in rapid evaluation of patients' needs in an inpatient setting, followed quickly by treatment in ambulatory and community settings.
For youths, the community or ambulatory setting may involve intensive after-school programs, perhaps in which the students are picked up at their schools and transported to outpatient centers for several hours of treatment in the late afternoon.
"We need less-costly ways to treat teen-agers," Jaffe said. But he added, "Sometimes you need to take them out of that family and neighborhood setting" where substance abuse began.
Some large employers say they've seen benefits from expanded coverage of substance-abuse treatment.
For example, Ellen O'Connor, vice president of the Washington Business Group on Health, cited Federal Express Corp. and Digital Equipment Corp. as companies that have expanded substance-abuse mental health benefits.
Those companies found appropriate substance-abuse treatment is "saving money and doing the trick" in helping employees recover and retaining productive workers, O'Connor said.
But she cautioned that such savings are only occurring in a managed-care environment, where the care provided is appropriate and follows clinical protocols.
" (Employers) want to get out of controlling (cost) through benefit design," O'Connor said. "It's common ground to say you want a productive work force. Then it's a question of, `Does the medical community want to partner, or is it stuck in fee-for-service?"
Physicians and other providers acknowledged that the addiction-medicine specialty once abused more generous benefits and failed to provide the less-expensive outpatient product that managed-care companies and payers wanted.
But now they say payers aren't doing enough.
"There may have been abuses," Jaffe said. "Now, we're moving too much in the opposite direction."