The Relevance of Drug Policy to Health Care Administration

1
The Relevance of Drug Policy to Health Care
Administration

• John B. White, David Duncan1,
• Patricia Minors, Tom Nicholson

1Brown University School of Medicine
2
Budget Crisis Impacts

• A recent estimate of state budget shortfalls for
  the 2003 fiscal year is approximately 70 billion
  dollars.
• Many states have targeted reimbursement for child
  health insurance programs, mental health
  services, and substance abuse treatment programs
  for cuts
• Resources for substance abuse treatment and
  prevention are likely to shrink rather than grow.

3
Substance Abuse Treatment

• In 1995, there were 114 billion dollars spent on
  all health care costs associated with substance
  abuse
• Almost 20 of all Medicaid hospital costs, and
  nearly 1 of every 4 Medicare spends on
  inpatient hospital care, is associated with
  substance abuse. (RWJ, 2001)

4
Location of Drug Treatment

• Drug users make more than 527,000 visits to
  emergency rooms each year for drug-related
  problems
• Community based centers account for 22 of
  alcohol and 31 of drug direct health care costs.

5
Drug Policy Influences

• Funding
• Organization of treatment resources
• Epidemiology of drug-related behavior

6
Funding

• As reimbursement for substance abuse care
  decreases, demand for alternative treatment will
  increase (e.g., inappropriate use of emergency
  room)
• Episodic treatment is not effective in reducing
  the number of abusers and results in greater
  numbers of drug-related infections, injuries, and
  deaths

7
Funding Institutional Costs

• Unreimbursed treatment for substance abuse
• Inappropriate use of
• Emergency
• Admissions
• Social services
• Medical information systems
• Administration
• Increased mortality and morbidity as an indicator
  of quality

8
Funding Health System Costs

• Continued emphasis on acute episodic treatment
  rather than long-term prevention and care
  management
• Increased sequelae such as gangrene, HIV,
  syphilis, Hepatitis-C, and others
• Thus, increased costs to the health care system
  longitudinally over the life of an abuser treated
  episodically

9
Organization

• Employee drug testing
• EAP
• Control Systems
• Security
• Shrinkage
• MAR/Documentation of treatment
• Capital Costs (e.g., PIXIS, pharmacy information
  systems)

10
Organization Staffing

• More patients, less net revenue, nursing
  shortage
• provider/patient ratio
• increased turnover rates
• increased stress (employees and system)
• Trained/Certified in substance abuse screening
  and treatment

11
Organization Confidentiality

• HIPPA 42 CFR (Part 2)
• Identification of drug seekers
• Stringent protection on medical records related
  to treatment
• Compliance

12
Organization Delivery or Enforcement?

• Patient consent to testing (Ferguson v. City of
  Charleston)
• Avoid seeking treatment for illicit substance
  abuse

13
Epidemiology

• Prohibition policy limits range of responses to
  substance abuse problems
• Policies disproportionately impact lower SES and
  persons of color
• Prohibition policy has created the most
  profitable black market in the world (150 to 400
  Billion US)

14
Epidemiology Limited Responses

• Controversy over needle exchange programs
• Inadequate pain management for nursing home
  residents and chronically ill patients
• No Heroin maintenance
• Emphasis on Abstinence Only programs
• Medicalization of normal drug experimentation

15
Epidemiology Minorities

• Treatment for the rich, jail for the poor
• More black males in prison than in college
• US represents 3 of the worlds population but we
  account for 25 of all incarcerated people in the
  world

16
Epidemiology Black Market

• Cocaine is more profitable than gold
• Black market creates institutionalized violence
  (protection of territory, robbery, etc)
• Black market bypasses governments ability to
  regulate (such as quality), tax, and control
  (e.g., age limits)

17
HCA Education Finance

• Financial models based on classic cost accounting
  (e.g., Cleverly or Gapenskis texts) lack
  emphasis on collecting societal costs
• Activity based cost accounting (e.g., Baker)
  allows capture but is costly to implement and
  maintain

18
HCA Education Legal

• Emphasis in many texts on the delivery of care
  and contractual obligations
• HIPPA and 42 CFR part 2 are not sufficiently
  covered in extant texts

19
HCA Education Management

• Presentation of classic management theory
  dominates texts with little exploration of
  innovative alternatives
• Human Resources/Staffing
• Planning/Marketing
• Supervisory Training

20
HCA Education Suggestions

• Look at other successful models
• Industry (e.g., Lean management)
• Public administration
• Governance
• Incorporation of drug policy cases into
  management curricula

21
HCA Education Suggestions

• Recognition of importance of organizational
  cultures and their interactions
• Using epidemiological information in planning
  (e.g., rates of abuse in community)
• Recognition of diverse risks associated with
  different subpopulations, including the
  population of health care providers

22
HCA Education Suggestions

• Greater creativity in assets management and funds
  allocation to support drug treatment
• Statesmanship addressing needs of patients,
  providers, and society for appropriate drug
  treatment as opposed to episodic, fragmented
  encounters

23
Drug policy formulation, implementation, and
impact provide an excellent case study of how
funding, organization, and delivery of health
care services interrelate with social, political,
and economic forces.