Drug policy issues for health services research

1
Drug policy issues for health services research

• John White, PhD and Thomas Nicholson, PhD
• Western Kentucky University
• David F. Duncan
• Duncan and Associates

2
Major Alternative Policy Schemes

• Medicalization would allow currently illegal
  drugs to be prescribed by a physician for use by
  addicts (or perhaps even by recreational users)
• Decriminalization would reduce the penalties for
  possession and use of illegal drugs to an offense
  (comparable to a traffic violation) rather than a
  felony or misdemeanor

3
Schemes contd

• Depenalization would eliminate all penalties for
  possession or use of illegal drugs but would
  retain penalties for production and trafficking
  in them
• Legalization would permit the currently illegal
  drugs to be sold and used like any other
  commodity, subject to such limits as the
  legislature might apply for instance, age
  limits.
• Any of these alternative approaches might be
  taken with any one or all of the currently
  illegal drugs.

4
Impact of Schemes

• The current prohibition scheme has an important
  impact on the patient populations served by drug
  abuse treatment programs. The adoption of any of
  the alternative schemes would have major
  implications for the number of admissions, payer
  mix and case mix for treatment programs.

5
Data Source

• To explore impact of these various schemes on
  drug treatment services we analyze data from the
  TEDS data set
• We focus on referral patterns, payer mix, and
  other operational data.

6
Treatment Episode Data System

• Is a continuation of the former Client Data
  System (CDS) that was originally developed by the
  Alcohol, Drug Abuse and Mental Health Services
  Administration
• The TEDS data collection effort began in 1989
  with three-year development grants to states.
• Treatment providers that receive any state agency
  funding are expected to provide TEDS data for all
  clients admitted to treatment, regardless of the
  source of funding for individual clients.
• http//webapp.icpsr.umich.edu/cocoon/ICPSR-SERIES/
  00056.xml

7
TEDS Data

• 20.5 million
• 1992-2003
• Concatenated dataset
• Covers all 50 States and Puerto Rico

8
Principal Source of Referral
9
Impact on Admissions

• One-third of all treatment admissions are
  generated directly by the criminal justice
  system. If all of the currently illegal drugs
  were to be decriminalized, depenalized or
  legalized, then all or most of these criminal
  justice system referrals would cease.
• Furthermore, it is likely that some substantial
  portion of the patients entering the system as
  self-referrals is actually motivated by a desire
  to avoid prosecution for a drug offense. The same
  is likely to be true of some referrals by
  healthcare providers or other community sources.
• Thus, drug policy reform could reduce patient
  numbers by more than one-third.

10
Increased Admissions?

• On the other hand, the prohibitionist approach of
  the current war on drugs stigmatizes drug users
  and abusers as criminals. This may be
  discouraging many persons in need of treatment
  from seeking it.
• It is conceivable that taking a new approach
  might produce an increase in self-referral
  patients as large as or larger than the decrease
  in coerced patients.

11
Living Arrangements
12
Income Source
13
Impact on SES

• Elimination of all criminal justice referrals
  would have very little effect on the distribution
  of either income sources or living arrangements
  in the patient care population. The greatest
  change would be an increase of roughly three
  percent in the proportion of patients who were
  homeless and of about two percent in the
  proportion who were receiving public assistance.
  These estimates are again hampered by a large
  amount of missing data on the variables.

14
Health Insurance
15
Payment Source
16
SES of Clients

• Health Insurance coverage and Payment Source
  demonstrate the potential impact of a change in
  drug policy schemes on the payer mix for patients
  undergoing treatment for drug abuse. The large
  amount of missing data on these variables in the
  T.E.D.S. database limits our ability to draw any
  conclusions
• Elimination of criminal justice referrals would
  result in an increase in the proportion of
  patients whose care is paid for by Medicaid and a
  decrease in the proportion of self payment and of
  payment by government programs other than
  Medicaid or Medicare.
• Such shifts in source of payment for care would
  have major impacts on the administration of
  treatment services, including changes in the
  types and amounts of treatment provided.

17
Case Mix
18
Case Mix Impacts

• The case mix in terms of primary drug of abuse
  would be effected in a number of small but
  potentially important ways by drug policy reform.
• If all criminal justice referrals were
  eliminated, then the proportion whose primary
  problem was heroin addiction would increase by
  five percent (from 14.1 to 19.2)
• Those reporting a primary problem with marijuana
  would decrease by more that three percent (from
  11.9 to 8.3).
• Alcohol remains the primary substance abuse
  problem at admission.

19
Marijuana Impacts

• Decriminalization, depenalization or legalization
  is most likely to come first for marijuana.
  Patients with a primary problem with marijuana
  constituted 2,454,902 patients during the period
  1992 thru 2003, or about a quarter of a million
  per year.
• Elimination of criminal justice referrals would
  mean that about 136,000 fewer patients would
  enter care for marijuana abuse annually.

20
Revenue Implications

• Using costs estimates from the ADSS Cost Study
  the lowest cost per admission reported was for
  outpatient treatment without methadone (1,433)
• This suggests an annual loss of 194,888,000 in
  revenue per year if marijuana initiatives are
  successful

Source http//www.oas.samhsa.gov/2k4/costs/costs
.htm
21
Prior Admissions
22
First Time Admissions

• Criminal justice referrals are more often persons
  who are entering treatment for the first time.
• Eliminating criminal justice referrals would
  reduce the proportion of patients who were first
  time patients from 36.6 to 31.1 (3,213,316
  fewer first time patients).

23
Impact of Scheme Changes

• Drug policy reforms could be expected to result
  in a patient population that
• Is smaller by one-third
• Includes a larger proportion of patients on
  Medicaid
• Includes a larger proportion of patients who are
  homeless or on welfare
• Includes a larger proportion of heroin addicts
• Includes a smaller proportion of marijuana
  abusers
• Includes a larger proportion of patients with a
  history of relapse
• Such changes in patient population would present
  treatment agencies with greater clinical
  challenges than the current state of the system.