The scenario that often is depicted when characterizing addiction treatment centers in the health reform era involves a steady stream of patients newly eligible for services and a provider community ready and eager to serve them. Yet the reality offers a more complex picture.

 

Judging from some of the results of Addiction Professional‘s 2010 Treatment Center Survey, a substantial number of treatment centers are predicting no increase in census over the short term as a result of provisions in the Affordable Care Act. While addiction treatment administrators foresee eligibility being enhanced for people in need, access still might be difficult to come by because of funding constraints and workforce shortages. 

 

“There will be fewer sources to pay, and services will be reimbursed at lower rates,” says survey respondent William LaBine, executive director of the Jackie Nitschke Center in Green Bay, Wis. Having seen most of its county funding support disappear earlier this year, the Wisconsin center has taken to more aggressive outreach to employers, hospitals and other entities in an effort to make its services more broadly appealing in the community. 

“We have to get more of an employed client with health insurance,” says LaBine. (Two-thirds of the respondents to this year’s survey do some work in the insurance market, while one-third exclude third-party payers.)

In its second year, the Treatment Center Survey this year attracted 363 respondents who identified themselves as working in an addiction treatment facility (as opposed to a private counseling practice or other health and human services organization). Respondents completed a 27-item online questionnaire in the months of September and October, with the survey covering centers’ treatment populations and their substance-using trends, the types of services the facilities offer, and some of their census and business trends and projections.

Population trends

The survey results offered a compelling juxtaposition of recent and projected census trends for the responding facilities, 61 percent of which reported serving mainly a client base receiving publicly funded services such as Medicaid.

More than half of facility-based respondents (55 percent) said their patient census as it relates to total capacity had increased in the past year compared with previous years’ averages, with 28 percent reporting no change and 17 percent reporting a relative decrease in census. Yet when asked about the projected impact of health reform on their patient numbers over the next three years, a slightly smaller number of respondents said they expected the increases to continue. Just under half (47 percent) said they expect an increase in the number of patients they see in the program, with 43 percent expecting no change and less than 10 percent expecting a decrease.

LaBine of the Jackie Nitschke Center does not see an influx of patients to his facility because of health reform. Although he says no one is talking about the storm clouds yet, he foresees a situation in which employers might not be able to afford the cost of providing behavioral health benefits, at the same time that his cash-strapped state and others struggle to fund Medicaid at needed levels and to deliver reimbursement in a timely fashion.

Jim Curtin, senior vice president of the Daytop Village adolescent treatment facility in New Jersey, agrees that this is an uncertain time for providers, saying it reminds him of the period of managed care’s arrival in substance use treatment. While the push among providers to stay ahead of the reform curve and be creative has generated some excitement, it has come with the realization that some trusted forms of public funding support-particularly the federal substance abuse block grant-might significantly erode or disappear altogether.

 

“I see an increase in outpatient slots and a movement away from residential treatment,” says Curtin, whose organization primarily offers residential care now, taking many of its referrals from the criminal justice system. “We’re going to have to treat individuals more intensively with fewer bed days.” 

Patient characteristics

In other findings regarding the patient population, just under half of respondents said alcohol was the primary substance of abuse for the largest number of patients they see. Stimulants ranked a distant second on this list, with marijuana placing low in the survey as the primary substance of abuse in the patient population.

However, slightly more than half of respondents did say that they have seen an increase in the number of patients presenting with marijuana dependence in the past couple of years. In Curtin’s New Jersey program, marijuana is the primary drug of abuse in the adolescent population served, and its effects still are not taken seriously enough by youths and by society, he says. “I don’t think we’ve seen an appreciation of the problem of dependence,” Curtin says.

This year’s survey for the first time asked about the presence of autism spectrum disorders in centers’ patient population, and found that 27 percent of respondents’ programs encounter clients on the autism spectrum.

 

Also, 78 percent of respondents reported that they have seen a more difficult-to-treat patient population in the past two years, stating that their clinicians’ everyday work has grown more difficult. In the inaugural Treatment Center Survey last year, 69 percent of respondents answered this question the same way. (Direct year-to-year comparisons in this survey are not emphasized because the survey is open to all treatment center participants, and therefore the sample of respondents changes significantly from year to year.) 

Other results

Several of the Treatment Center Survey questions yielded a fairly even split among respondents. For example, just over half of respondents said mind-body/wellness treatments were not currently a formal part of their treatment program (58 percent of respondents last year said these services were part of their program).

In addition, a slight majority of respondents said they offered medication treatments as part of their program. The three most widely used dependence medications among respondents were buprenorphine, acamprosate and oral naltrexone.

On a question related to technology, only 4 in 10 respondents said their facility has an electronic health record (EHR) system. Daytop Village’s Curtin says he has looked at several system options for the center, but the task of acquiring and implementing one remains daunting for an organization such as his. “We’ll need some [financial] assistance,” he says.

 

As the introduction of health reform begins to shake up the traditional assumptions about how care is delivered and who pays for it, the Jackie Nitschke Center’s LaBine believes facilities such as his will grapple with the question of how much they are willing to change in order to survive. 

 

LaBine emphasizes that for his center, its eight years of work with the quality improvement collaborative NIATx has been pivotal in its ability to adapt to changing funding streams and community needs. Having seen success in improving client access and engagement through NIATx initiatives, the Wisconsin center now is working through NIATx on mentoring activity to assist other centers, as a learning community develops to help ease provider agencies into a new era in healthcare. 

Addiction Professional 2010 November-December;8(6):12-15