Financing and Diffusion of Substance Abuse Treatment

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Financing and Diffusion of Substance Abuse
Treatment

• Cynthia L. Arfken, Ph.D.
• Wayne State University
• Sheryl Pimlott Kubiak, Ph.D.
• Michigan State University

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Background

• Essential to understanding the financing of
  substance abuse services are the substantial
  changes by both public and private payers in the
  methods of paying providers, altering the way
  substance abuse services are delivered (Horgan
  Merrick, 2001 emphasis added)
• Resource Dependency Theory (Pfeffer Salancik,
  1978) procurement of external resources essential
  to organizations and they will respond to those
  demands
• other theories posit organizations constantly
  negotiating, interacting with changing
  environment consisting of multiple competing
  interests.

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In the providers words

• Our treatment philosophy is almost entirely
  dictated by economics.
• Its wise to not only have a funding source
  coming from one direction but from other
  directions as well. So if you lose one aspect,
  you at least have one or two others.
• Funding is critical. What were trying to do is
  diversify.

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Hypothesis

• Funding source and volatility influence the
  adoption of services and treatment by substance
  abuse treatment programs

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Mixed Case Approach

• 35 community-based treatment programs within one
  state (hold constant state-level regulations)
• Oversampling for programs funded by Department of
  Corrections
• Questionnaires and qualitative interviews with
  executive directors, clinical directors, and
  clinical supervisors.

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Categories of Funders

• Which funding source do you consider the most
  important source?
• Public (n17)
• Private (n10)
• Criminal Justice (n7)
• 16 receive some CJ funding
• Excluded one program with 100 funded by charity

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Excluded program

• I can run my organization with six people and
  have a caseload of six clients per counselor.
  That gives us a lot of latitude to do extra
  work...

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Funding Volatility - Decrease
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Anything you had to do that you didnt want to
do because of funding restrictions?

• 86 of programs who experienced an overall
  funding decrease in the last 5 years had to do
  something they didnt want to.
• 60 of programs who did not experience an overall
  funding decrease had to do something they didnt
  want to.

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What they did -

• Restrict services
• Decreased support services, decreased length of
  stay, have supervisors work more hours, and not
  give raises for three years.
• We are doing a hell of a lot more groups.
• Weve reorganized the system completely. Weve
  reviewed every positive component. Weve
  trimmed off everything.

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What they did - more responses

• Forced to do more group education than therapy.
• Lay-offs
• Discharge clients earlier than wed like to.
• Terminate clients.
• Compromises in hiringget people I wouldnt
  normally hire.

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Provision of specific evidence-based practices by
major funder
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Providers perspective on treatment

• Half the guys have been shot or lost someone to
  a shooting, and it really impacts their thinking
  and behavior but you cant address that. (CJ
  program)
• We know what effective treatment is but funder
  has us in a situation - you can treat everyone,
  but you cant use empirically validated
  treatment. (Public program)

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Do any of these funding sources affect
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Services provided where private funders diverge
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Private program perspectives

• Certain insurances dont think of it as an
  ongoing problem they think of it like an
  accident like a car accident.
• The insurance company name says they dont
  qualify because they quit drinking already - they
  dont need therapyso I might need to give a
  mental health diagnosis

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Services provided where public funders diverge
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Services provided where CJ funders diverge
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Provision of Gender-specific Groups

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Conclusions

• Results suggest that funders whether public,
  private or criminal justice, play an important
  role in structure and provision of services and
  treatment.
• Funding levels also affect services

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Implications

• Training clinicians to perform services may be
  ineffective unless funders support the services
• Example of program where education was eliminated
  from budget
• Now I go online or read magazines that staff
  bring to me, magazines they find importantWe
  have had to get creativeOverall, we got slick.

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Acknowledgements

• NIDA (R01 DA-014483) and the state of Michigan
  (Joe Young, Sr.)
• Alison Spork, Elizabeth Agius, and Damon Drown