Why have admissions to state-funded drug treatment declined?
(Editor's note: Embargoed until week of June 26.)
Even amid an apparent epidemic of cheap heroin and prescription pill abuse in Massachusetts, admissions to drug and alcohol treatment programs paid for or contracted by the state dipped about 12 percent over the last decade.
A state official said the decline probably does not mean that fewer addicts are receiving treatment they need – quite the opposite.
After Massachusetts passed its landmark health care reform law in 2006, more people are insured and likely able to access treatment funded by sources other than the state, said Michael Botticelli, director of the Bureau of Substance Abuse Services at the Mass. Department of Public Health.
“As more and more clients are insured, our dollars are being used increasingly for other kinds of support services other than treatment admissions,” Botticelli said.
Some treatment program directors were initially surprised to hear of any decline in state-funded admissions, saying they are as busy as ever.
“We’re not seeing any diminution of demand,” said Ray Tamasi, CEO of Gosnold on Cape Cod, which runs treatment programs on the Cape and in Brockton and North Dartmouth.
Some providers agreed that more clients may be using Medicaid-funded plans or other means to access treatment, but they also pointed to sharp budget cuts to state treatment services in fiscal 2003 as another possible reason for an overall decline. Others said there might be fewer state-funded providers of outpatient treatment programs today.
Some program directors also said while more people are insured, that’s not an automatic guarantee a carrier will cover certain types of substance abuse treatment. They described managed care companies for some Medicaid-funded plans as declining certain services.
“I need to turn away a lot of people because their insurance company has essentially disagreed with us and decided that the person does not need treatment,” said Mark Anderson, director of inpatient services for Spectrum Health Systems, which has offices in Worcester, Westborough, Framingham, Milford, Marlborough, Weymouth and Southbridge. Anderson said he has seen this problem in two of the six programs he runs.
Providers said overall demand for substance abuse treatment remains high, particularly as the number of people struggling with heroin and other opiates has soared.
“It’s an equal opportunity destroyer,” said Vic DiGravio, president of the Association for Behavioral Healthcare, which represents nearly 100 organizations in the state that treat mental illness and substance abuse disorders. “It doesn’t discriminate against race or socioeconomics or geography. It’s an epidemic.”
Bureau of Substance Abuse Services-funded programs saw 122,709 admissions in 2001, according to figures provided by the bureau. People treated more than once in a year were counted each time they were admitted.
State-funded admissions peaked for the decade the following year, with 124,343 admissions in 2002. Just two years later, that number plunged to the lowest point in the decade – 103,383 – in the wake of severe budget cuts.
In fiscal 2003, the number of publicly funded detox beds alone dropped by half. In part, those cuts may still account for lower admissions today, treatment providers said.
Since then, state-funded admissions gradually rose along with restored funding, Botticelli said. But after reaching 115,178 in 2007, admissions slid to 107,963 as of last year.
Patients likely have more options for treatment after health care reform, Botticelli said, using either Medicaid-funded coverage or private insurance to pay for services. The number of uninsured people in Massachusetts has dropped from upward of 10 percent to less than 2 percent since the law went into effect, according to state officials.
People who still lack insurance remain a significant number of those who seek treatment from state-funded substance abuse programs, Botticelli said – particularly young men.
Most declines have come in state-funded outpatient therapy, according to Botticelli.
“We’re not paying for nearly the admissions to outpatient programs,” he said. Detox admissions and other forms of more acute treatment remain steady, he said.
It’s difficult to say for sure what role health care reform has played in the recent dip because only programs that receive state funding report admission data to the Bureau of Substance Abuse Services, offering a limited snapshot of available treatment services.
The Division of Health Care Finance and Policy is working on a database with admission information from all providers, which could help pin down an answer.
“We’ll be able to look at, in a health care reform environment, did more people get treatment?” Botticelli said.
Treatment providers described state funding as inadequate for certain outpatient programs, and said that may discourage some providers from continuing to participate. DiGravio also noted that a Tewksbury detox program was forced to close late last year amid financial problems.
“Ultimately, providers get to a point where they cannot continue to deal with significant financial losses,” DiGravio said.
At Gosnold, Tamasi said his seven outpatient clinics operate at a loss.
“They lose money,” he said. “But it’s a very important piece in the continuum of care for patients.”
Whatever the cause of the dip in state-funded admissions, it has contributed to changes in the state’s approach to substance abuse. Botticelli said his bureau has focused more on services that identify and help people with substance abuse problems before they reach an acute stage, and providing support services that people need to continue in recovery.
For example, the state received a five-year federal grant totaling $14 million to work with primary care physicians to include substance abuse screenings and intervention during routine visits, Botticelli said. The grant wraps up this year.
For $2.3 million a year, the state also now runs six peer recovery support centers in Brockton, Marlborough, Worcester, Boston, Lawrence and Greenfield, meant to give recovering addicts a safe place to socialize and get help finding jobs and housing, he said.
The state also secured funding to open three high schools specifically for teens recovering from addiction in Beverly, Boston and Springfield.
In the changing treatment landscape, needs are also shifting. State admission figures show more people between 21 and 29 are seeking treatment, as are people over 50.
The number of people seeking treatment for crack and cocaine is on the decline, while heroin is encroaching on alcohol as the most common problem.
At Spectrum, Anderson said more people have also gone from abusing prescription opiates to heroin, which is often cheaper.
In light of these problems, DiGravio said his group hopes to stave off budget cuts to substance abuse programs. Studies have shown that treatment and prevention cost society less than drug-related costs for criminal justice, health care and lost time at work, he said.
“It’s not just the right thing to do, to provide treatment, it’s the smart thing to do economically,” DiGravio said.
(David Riley can be reached at 508-626-3919 or firstname.lastname@example.org.)