Title: Cost Effectiveness and Cost Benefit Analysis of Substance Abuse Treatment: Literature Review and Ann
1Cost Effectiveness and Cost Benefit Analysis of
Substance Abuse TreatmentLiterature Review and
Annotated Bibliography
- Presented by Henrick Harwood, The Lewin Group
- Prepared For the Center for Substance Abuse
Treatment - Document available at
- http//neds.calib.com/products/pdfs/litrvw/cost_li
t_review/index.cfm
2Major Conclusions
- Treatment is effective!
- Treatment pays for itself!
- Some treatment approaches are more cost effective
. . .
3Major Progress in Substance Abuse Treatment
- Quality of research better
- Continuum of care
- Patient placement criteria operationalized
- Need for composition of comprehensive services
better understood - Some Guidelines and Manuals published
- ASAM
- also AACAP NIH CSAT CSAT grantees
4Purpose
- The goals of the literature review and
bibliography were to - Develop a comprehensive list of the literature
available - Identify trends in the literature in terms of
topics studied and areas in need of work - Broadly characterize and summarize findings and
conclusions of cost effectiveness and cost
benefit studies.
5Citations by Type of Study
- The largest number of studies have been cost
benefit studies (49). - There have been fewer studies with a primary
focus on cost effectiveness (29) or cost of
treatment (20).
6Perspectives of Economic Analysis
- Is some/any treatment better than no treatment?
- Are some types of treatment more economical than
others? - What makes treatment more cost effective?
- Treatment and Distinct Client Populations
- Females
- Adolescents
- Co-Occurring Mental Illness and Substance Abuse
- Prisoners/Offenders
- Opiate Substitution Therapy
7Conclusions
- Cost benefit studies
- Recent cost benefit studies consistently find
that benefits (i.e., improvements in crime,
health, and social functioning) are greater than
the costs of substance abuse treatment. - Cost benefit studies examining benefits in terms
of reduced health care utilization and costs
(cost offsets) find that health costs and
utilization sharply increase prior to treatment
initiation, then fall dramatically following the
treatment period. - Cost effectiveness studies
- A handful of cost effectiveness studies conclude
that less expensive treatment modalities or
levels of care are more cost effective or cost
beneficial than more expensive approaches.
8Comprehensive Cost-Offset StudiesFind Major
Returns per Dollar Spent on Treatment
- French et al. (2000)
- 10 and 23, in two Washington State clinics.
- Gerstein, Harwood, and Suter (1994)
- 7 in the California public system
- Finigan (1995)
- 7 in the Oregon public system
- Koenig, Harwood, Sullivan, and Sen (2000b)
- 4 in federally-funded programs
9Health Costs of Substance Abusing Populations
are Higher than non-Abusers
- Studies of insured populations compare those
treated for alcohol and drug abuse with
non-abusing populations. - Those getting treatment have total health costs
several times higher than the non-abusing
population before treatment initiation. - Holder and Hallan (1986)
- Tracked abusing and non-abusing populations for
up to 4 years and found that health costs were
nearly identical at the end of that period. - Goodman et al. (2000)
- Found a reduction of the gap in costs between
comparable treated and non-abusing populations
over time. - Found cost offsets for treatment of alcohol
abuse but probably not for dependence or
those with mental comorbidities
10Health Expenditures Decline Following Substance
Abuse Treatment
- Analyze changes in health care utilization and
costs before and after treatment cost offsets
- Holder and Blose (1992)
- health care costs declined by 23 to 55 from
their highest pretreatment levels - Holder Schachtman (1987)
- offsets made up for the cost of the treatment
within 2 years
11Cost-Offsets for Treated versus Untreated
Substance Abusers
- Reiff, Griffiths, Forsythe, and Sherman (1981)
HMO - treated population had about 500 per year lower
post-referral insured health costs treatment
refusers - Holder and Blose (1992) privately insured
- after treatment treated alcoholics had 24 percent
lower health costs than similar untreated
alcoholics. Tracked 3 years. - Gerson et al., (2001) Ohio Medicaid
- treated substance abusers had annual insured
health costs of about 500 less than diagnosed
but untreated individuals.
12Some Types of Treatment Are More Cost-Effective
than Others (for Some Clients)
- Hospital inpatient treatment versus intensive
outpatient (IOP) - Alterman et al., 1994 Bachman et al., 1992
Longabaugh et al., 1983 Schneider, Mittelmeier,
Gadish, 1996) - No significant difference in outcomes. Various
client populations male and coed adults cocaine
addicts, poly substance abusers and alcoholics.
- Day treatment costs about half (or less) as much
as inpatient care of same duration - Day treatment and intensive outpatient compared
to less intensive regimens - Weisner et al., 2000 step-down day treatment
to IOP versus IOP alone for a poly substance
population no differences in outcomes costs
almost twice as much (about 1650 versus 900) - Avants et al. (1999) for a medically indigent
methadone population day treatment was no more
effective than enhanced standard care the more
intensive treatment cost about twice the less
intensive care
13Longer Treatment Yields Better Outcomes
- Harwood, Hubbard, Collins, and Rachal (1988)
- An additional day of treatment retention reduced
crime-related costs during and in the year
following treatment by 2 to 4 times the cost of
the day of care. - French, Zarkin, Hubbard, and Rachal (1991), and
French and Zarkin (1992) - Increased stay in treatment associated with
significant increases in earnings decreases in
illegal earnings, But much less than the cost of
the care. - Koenig et al. (2000b)
- Post-treatment benefits only partially offset
costs of an additional day of treatment. - Barnett Swindle (1997)
- VA inpatient 28 day programs had modestly higher
outcomes than 21 day programs (78 percent success
versus 75 percent) - Improvement judged too small to warrant
operating 28 day programs since the costs are
materially higher.
14 Strong Benefits from Treating Women
- Harwood, Fountain, Carothers, Gerstein, and
Johnson (1998) - Benefits about four times greater than the cost
of treatment - Svikis et al. (1997)
- Successfully treated versus untreated pregnant
women - Treatment cost 6,600 (day treatment)
- Average NICU costs/ birth 900 for treated women
vs 12,200 for untreated - Daley et al. (2000, 2001)
- Pregnant women economic returns from birth
outcomes and criminal activity - Residential and combined residential-outpatient
treatment most cost effective, better than
standard outpatient, methadone and detoxification - Berkowitz, Brindis, Clayson, and Peterson (1996)
- Mandating pregnant and parenting offenders into
treatment saved about 3,000 vs. the nearly
17,000 in expense to incarcerate (and treat them
in prison) for six months
15Adolescents Benefit From Intensive Services
- Schoenwald, Ward, Hennggeler, Pickrel, and Patel
(1996) - Compared multisystemic therapy (MST, an
intensive mix of substance abuse, mental health
and social services) with usual services for
adolescents - MST reduced arrests by 26 and time
incarcerated by 46 - Costs for therapeutic services increased 50
over usual services - The reduction in incarceration from MST offset
the increase in costs
16Marital Therapy is Cost Effective, Some
Approaches More So than Others
- Fals-Stewart, OFarrell, and Birchler (1997)
- combining behavioral couples therapy with
individual counseling more effective than
individual based treatment alone - no more costly
- OFarrell, Choquette, Cutter, Floyd et al.
(1996) - behavioral marital therapy superior to
interactional couples therapy - BMT was also less expensive
17 Treatment for Offenders Pays for Itself
- Hughey and Klemke (1996)
- Offenders completing in-jail program (85) had
lower rates of re-arrest compared to similar
untreated inmates. - Savings after treatment costs were
3,500/offender. - Further (but unestimated) benefits from reduced
victim, police and court costs. - Maddox (1996)
- Based on lit review of drug courts judged
cost-effective - 5,000 in incarceration costs compared to
treatments costs of 900 to 1,600 per defendant.
- Recidivism rates and drug use post-treatment are
also reduced.
18Co-Occurring Substance Abuse and Mental Illness
- Jerrell and Hu (1996)
- supportive, low intensity mental health plus
substance abuse treatment 12 step and case
management models - cost savings of over 40 during the
post-treatment period - French, Sacks, DeLeon, McKendrick, Staines,
(1999) - Mentally ill homeless substance abusers in
modified TC group experienced significantly lower
levels of alcohol intoxication, criminality, and
depression than those in the treatment-as-usual
group, and - Incurred a lower cost of health treatment, offset
costs for TC services
19Opiate Substitution Therapy
- Kraft, Rothbard, Hadley, McLellan, and Asch
(1997) - Low, medium and high levels of counseling and
support services - Medium level was most cost effective, but high
had modestly better results - Barnett (1999)
- One additional life year is saved for each 5,900
spent on methadone treatment Compares very
favorably with results for other health
interventions - Zaric et al. (2000)
- Using methadone to reduce HIV transmission yields
an additional 1 year of quality adjusted life at
a cost of 8,200 - Most of the benefits are with the non-injection
drug using population. - Barnett, Zaric, and Brandeau (2001)
- Buprenorphine for opiate addiction is cost
effective at a price of up to 30 per dose if
applied to clients that would not use methadone - However, methadone is the treatment of choice
for clients that will accept it
20(No Transcript)