Different Sectors, Different Services? Examining variations in treatment program caseloads

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Different Sectors, Different Services? Examining
variations in treatment program caseloads

• Paul M. Roman, Ph.D.
• Lori J. Ducharme, Ph.D.
• Meredith P. Huey, M.A.
• Center for Research on Behavioral Health Human
  Services Delivery
• Institute for Behavioral Research
• With research support from the National Institute
  on Drug Abuse
• (R01-DA13110, R01-DA14482, R01-DA14976)

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Background

• Organizational theorists suggest multiple
  categorizations of public and private
  organizations based on public interest,
  ownership, funding, and profit status (Dahl and
  Lindblom 1953 Wamsley and Zald 1973 Bozeman
  1987 Perry and Rainey 1988).
• Yet, within the substance abuse treatment field
  there has been longstanding attention to the
  notion of a two-tiered system of treatment
  delivery.
• There are two highly contrasting tiers of drug
  treatmentone for the poor under public
  sponsorship and one for those who can pay with
  insurance or out-of-pocket funds (Gerstein and
  Harwood 1990 200)
• Assertions have been made that differences
  between public- and private-sector programs
  translate into significant disparities in the
  scope and quality of services available to
  patients assessing treatment (Yahr 1988 Gerstein
  and Harwood 1990 Wheeler et al. 1992).

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Clarifying the Public-Private Distinction in the
Substance Abuse Treatment Field

• Prior research has distinguished public from
  private centers by ownershipprivate vs.
  government owned (state and federal)and profit
  statusfor profit vs. not for profit.
• Research has confirmed differences in
  characteristics of private for profit and
  government owned centers, however, little
  knowledge has been generated about not for profit
  centers.
• The characteristics of not for profit centers
  fall somewhere between those of private for
  profit and government owned programs.
• Comparisons of private for profit, not for
  profit, and government owned centers suggest a
  system characterized by multiple tiers.

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Alternative Classification Revenue Sources

• In addition to disparities in caseloads, research
  has shown that public and private programs differ
  in sources of revenue
• Private centers receive a majority of funds from
  out-of-pocket payments or from private insurance
  public centers receive revenues mainly from
  government sources (Heinrich Lynn 2002).
• An alternative method for classifying public and
  private centers is based on ownership, profit
  status, and funding resulting in a four tiered
  system
• Privately Funded For Profit, Privately Funded Not
  for Profit, Publicly Funded Not for Profit, and
  Government Owned programs.

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Research Question

• Are there meaningful differences among treatment
  centers differentiated by these four types?
• Specifically, to what extent do these four types
  of treatment centers differ in terms of their
  caseloads characteristics?

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Sample The National Treatment Center Study

• National samples of publicly-funded (N345) and
  privately-funded (N401) substance abuse
  treatment centers
• Eligibility Criteria
• Community-based programs providing treatment for
  substance abuse at a level of care equivalent to
  structured outpatient programming (as defined by
  ASAM Patient Placement Criteria)
• Exclusion Criteria
• Counselors in private practice, DUI / driver
  education programs, halfway houses, and programs
  offering exclusively methadone maintenance
  services were not eligible
• correctional facilities and VA facilities were
  not eligible

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• Definitions
• Private centers receive lt 50 revenues from
  government block grants/contracts
• Public centers receive gt 50 revenues from
  government block grants/contracts
• Data collected via on-site interviews with center
  administrators in 2002-03
• Private center response rate80
• Public center response rate88
• Pooled, unweighted data (N746) are reported in
  all analyses.

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Measures and Analysis

• We used one-way analysis of variance (ANOVAs) to
  identify differences in caseload characteristics
  across the four types of centers
• Referral Sources
• Proportion from EAPs, other workplaces, legal
  system, and social service agencies
• Caseload
• Proportion who are Women, Adolescents,
  Racial/ethnic Minorities, Charity Patients,
  Relapsers, Probationers/Parolees
• Primary Diagnosis
• Proportion with primary dependence on alcohol,
  cocaine, opiates, and methamphetamine

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Distribution of Sample by Center Type
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Findings Referral Sources
For Profit Private NP Public NP Govt
EAP 9.1 6.9 3.2 2.6
Other Workplace 7.0 5.5 4.6 2.7
Legal System 25.2 22.3 39.6 38.0
Social Services 13.9 16.8 23.0 20.8
Shading denotes significant between-group
differences (plt.05)
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Findings Caseload
For Profit Private NP Public NP Govt
Minorities 29.5 31.0 50.6 44.7
Relapsers 50.0 56.2 62.4 61.5
Probation/Parole 35.7 33.3 51.5 51.0
Charity 5.0 8.3 14.6 23.0

• Shading denotes significant between-group
  differences (plt.05)
• No significant differences on women or
  adolescent clients

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Findings Primary Diagnosis
For Profit Private NP Public NP Govt
Alcohol 51.5 49.8 38.8 40.0
Cocaine 17.8 18.9 26.6 21.8
Opiates 16.7 18.7 14.2 14.7
Methamphetamine 9.1 6.8 11.9 13.2
Shading denotes significant between-group
differences (plt.05)
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Summary of Findings

• These data show significant variation among
  treatment centers classified by a combination of
  revenue source and profit status.
• Several of these findings are consistent with
  previous research describing a two-tiered
  system (i.e., privately funded programs differ
  from publicly funded programs).
• However, these data show significant contrasts
  within nonprofit programs when considering the
  centers primary funding source.
• Differences between publicly-funded non-profits
  and privately-funded non-profits deserve further
  research
• Are there differences in organizational structure
  and staffing?
• Are there differences in service provision?
• Are there differences in innovative behavior?
• Implications for patient retention and outcomes.