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    Rethink treatment models for substance dependence

    Gary Ingenito, MD, PhD
    Despite advances in behavioral health management, managed care persistently incurs significant costs for members with a diagnosis of substance dependence. Better identification and engagement into treatment has been shown to reduce emergency room, inpatient and total cost for the substance-dependent individual. The chronic nature of addiction further suggests that we examine a different management and treatment paradigm.

    National data based on 20 million commercial plan lives shows that substance-dependent members average $8,290 in annual paid claims, compared to $3,250 for those without substance dependence. Based on 2007 statistics, the federal Healthcare Cost and Utilization Project presents an even worse picture for those with substance dependence as a principal diagnosis. The average length of a hospital stay was five days at a cost of approximately $13,000, with a range of $11,000 to $26,000.

    According to the report, examples of related medical conditions included: hypertension, asthma, diabetes, esophageal disorders, anemia and hepatitis. High-utilizing substance dependent (HUSD) members—defined as those with total annual claims greater than $7,500—average $25,500 in annual claims costs. Within the commercial population, the incidence of substance dependence is 1.93%, and approximately 26% of these are HUSD members.

    Even with these figures, the size of the issue is probably underestimated since identification of substance-dependent members relies on an appropriate diagnosis code being entered into the claim. Prevalence of substance dependence is significant, with some estimates indicating nearly 10% of a commercial population is likely dealing with a substance-dependence issue. HUSD members have 5,000 more inpatient days per 1,000 members compared to non-substance-dependent members.


    Exacerbating the problem, relatively few members with a substance-dependence diagnosis receive treatment. The National Survey on Drug Use and Health states that only about 10% of individuals who need treatment receive it. Further claims analysis of HUSD members found that only 28% had claims for substance-dependence treatment.

    However, there were significant claims incurred under the medical classification for these members. Substance dependence is not a condition that occurs in isolation. Twenty-five percent of individuals with substance dependence also have a serious mental illness, and substance dependence complicates other chronic illnesses. In each case, a comorbid condition in a HUSD member increases costs between 75% and 360%, compared to those without substance dependence.

    Mental health, substance abuse and medical health treatment systems have traditionally developed independently and today's treatment approach is fragmented. The absence of a coordinated care continuum results in poor compliance. There is a need for behavioral/medical care integration in the substance dependence and mental health area, as well as a need for accountability of total member healthcare costs rather than compartmentalizing claims into behavioral versus medical costs. The new paradigm must respect the chronic nature of the disease and account for the intensity required to enhance compliance for the substance-dependent individual.

    Gary Ingenito, MD, PhD, is a healthcare researcher and scientist with Catasys, a specialty provider of services in the area of substance dependence.

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