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Alcohol and Drug Treatment Access Project Principal Investigators: Gloria Krahn, Ph.D., MPH, Quick Links: Nearly a fifth of all Americans report a disability that limits their activity, many being “hidden disabilities” such as cognitive and emotional disabilities that go unrecognized and undiagnosed. When considered as a group, people with disabilities have access to and use alcohol and other drugs on a regular basis. A number of studies have demonstrated that the presence of a physical, mental, or psychological disability can place an individual at higher risk for drug abuse than the general population (Rasmussen & Deboer, 1980/1981; Stern et al., 1987; Heinemann et al, 1989; Moore & Polsgrove, 1991; Moore, et al., 1994; Moore & Li, 1998; Moore, 1998). In the general population, the prevalence rate of substance abuse disorders is estimated to be 10% (Robert Wood Johnson Foundation, 1994). Reliable data are limited, but the prevalence rate of substance use disorders is thought to be at least twice as high among people with disabilities as in the general population—20-30% (Center for Substance Abuse Treatment, 1999; Moore, Greer, & Li, 1994). Moreover, 20% or more of all persons qualifying for State Vocational Rehabilitation services display symptoms qualifying them for a diagnosis of substance abuse or substance dependence (Moore & Li, 1994; Schwab & DiNitto, 1993; ). This higher rate of substance use and abuse includes both illicit (e.g. heroin) and licit (e.g. alcohol) drugs. When the incidence of alcoholism for persons with disabilities was compared to the general population, disabled respondents experienced higher rates of heavy drinking and alcoholism, and in some cases these rates were more than double those for the general population (Buss & Cramer, 1989 as cited in Moore, Greer, & Li, 1994). Additionally, younger adults who self-reported a disability (identified selves as “disabled, unable to work”) used illicit drugs (i.e., crack or heroin) more than a nondisabled group; while older adults (35 and older) with disabilities abused prescription medication more often than their nondisabled counterparts (Gilson, Chilcoat, & Stapleton, 1996). Given the greater rates of substance use and abuse, persons with disabilities could be expected to access chemical dependency treatment services at greater rates as well. However, early studies indicate that this is not the case. Instead, persons with disabilities may be less likely to participate in treatment than those without such a coexisting disability (de Miranda & Cherry, 1989; Kirubakaran et al., 1986; Helwig & Holicky, 1994; Schaschl & Straw, 1989). When participating in treatment, it is not known whether current treatment modalities are equally effective for persons with disabilities as the general population. RESEARCH OBJECTIVE/RESEARCH QUESTION The purpose of the present investigation was to conduct a population-based study in one state (Oregon) to examine substance abuse treatment services for Medicaid-eligible persons with disabilities. More specifically, we intended to examine whether persons with disabilities differed from other Medicaid-eligible groups in their access, utilization, and success rates in publicly funded outpatient alcohol and drug treatment programs. This study is built on previous work by the authors examining the effect of managed care payment systems on substance use treatment access and utilization. In an earlier report, Deck, et. al. (2000) examined access to substance abuse treatment services in general for all Medicaid-eligible persons in Oregon and identified managed care plan characteristics following a capitated chemical dependency benefit. The present study is a population-based cross-sectional study examining data from January 1992 to July 1998 in Oregon, comparing the disabled population to other Medicaid eligibility groups for rates of treatment access, service use (utilization), and outcomes (success) for outpatient substance abuse treatment services. Data Sources: The data for this study were drawn from two databases, the Client Process Monitoring System (CPMS) managed by Oregon’s Office of Alcohol and Drug Abuse Programs and administrative dataset on Medicaid eligibility and enrollment files from Oregon’s Office of Medical Assistance Programs. The population studies represented all Medicaid-eligible persons aged 18 to 64 excluding persons dually eligible for Medicare and Medicaid. The CPMS is a publicly funded treatment utilization system that identifies treatment users. Each record in the CPMS represents an occurrence of care with an admission date, discharge date, and the modality of service. It also includes several indices of treatment success. The Medicaid database provides eligibility codes (including disability codes) and enrollment files for all Medicaid recipients. Merging the CPMS and Medicaid databases verified each member’s eligibility category and enrollment status within the first 30 days of each treatment occurrence. Duplicate records and services other than treatment were removed by quality control processes. Imputations were made for missing or outlier data. Study Population: The state Medicaid program defined categories of assistance for
which adults were eligible, and these were classified into 5 mutually
exclusive groups: disabled (e.g., Supplemental Security Income recipients),
welfare (Aid for Families with Dependent Children or Temporary Aid
for Needy Families recipients), other poverty programs, expansion
(single individuals and childless couples newly eligible under the
section 1115 waiver), and all other programs. Persons dually eligible
for Medicare and Medicaid were excluded. A treatment user was defined
as a person aged 18 to 64 years entering publicly funded outpatient
substance abused treatment who was Medicaid-eligible within 30 days
of the admission date. Data Analysis: Substance abuse treatments were grouped into five different modalities:
outpatient drug free, residential, inpatient, methadone maintenance,
and detoxification. The present study focuses primarily on outpatient
drug free treatment which was the most commonly used modality and
included a wide variety of services (education, group counseling)
for varying lengths of time. Measurement limitations of the study include the fact that data were based on treatment records that reflect dates enrolled in service rather than claims/encounter data that would reflect dates participating in service and service intensity. Treatment access data is insensitive to changes in length of stay and is difficult to interpret for clients who were unstable in eligibility and enrollment. Utilization data measure use on a monthly data and their findings supported and bolstered those of treatment access, while demonstrating the effect of slightly poorer retention rates for persons with disabilities. A Medicaid identifier was missing for some clients believed to be Medicaid eligible, thus the rate of service utilization was likely underestimated. Finally, discharge dates were occasionally missing or were longer than was reasonable for the modality of services. To avoid inflated service counts, a date was imputed using the main length of stay for all groups. Access and Utilization: Access. A population-based, 12-month prevalence rate of access to treatment was established for each year and each eligible group between July 1992 and July 1998. The present study calculated the treatment access prevalence rate as the number of admissions per thousand eligible members. An admission was determined by an individual being admitted to treatment at least once during the calendar year. Eligible members were determined by an average of the number of members eligible on the first day of each month in a calendar year. Access percent rate was defined as the number of adults admitted to treatment during a year as a percentage of average number of eligible members. Figure 1 (Oregon Adult Access Rates) below depicts the percent of eligible members from the three largest Medicaid groups who participated in treatment during that calendar year. Several findings are evident relative to treatment access for the Medicaid-eligible subpopulations. First, access percentages increased for all three groups from 1992 through 1998, and notably following the implementation of managed care in 1994. Second and relevant to this study, however, is the finding that persons with disabilities consistently demonstrated lower access rates to treatment, and the gap in access rates increased from 1992 to 1998. The Disability population increased from about 2% in 1992 to about 4% in 1998, the comparison subpopulations increased from about 4% (AFDC/TANF) and 7% (in 1994 for Expansion) to about 8.5% and 10% respectively.
Figure 1: Oregon Adult Access Rates; Adults admitted to treatment during year as percentage of average eligible members. Utilization. Treatment utilization rates were calculated for each month from January 1993 through July 1998 based on the number of users in a month divided by number of members at the first of the month. While treatment access rates count all unique individuals admitted into treatment during a calendar year, treatment utilization rates count treatment users on a monthly basis and are more sensitive to ongoing participation in treatment. Figure 2 (Oregon Outpatient Utilization) shows the treatment utilization data for a comparable period of time. Findings again reveal a significant gap between the Disability subpopulation and the AFDC/TANF and Expansion subpopulations. These data reveal, however, that while treatment utilization doubles for the other two groups (from about 15 users per thousand to about 30), a similar increase is not noted for the Disability group.
Figure 2: Oregon Outpatient Utilization; Adults in treatment per thousand eligible adults on first of month. Treatment Success: While this data set does not hold a single measure of treatment success, information on success is available through consideration of four separate indicators: treatment retention for at least 90 days, treatment completion, abstaining from the primary drug for at least 30 days prior to discharge, and treatment completion as reported by the drug counselor. Treatment Retention. Figure 3 below depicts the percent of adults from the three subpopulations who, on entering treatment, stayed for at least 90 days. These data suggest that over the 6 years, persons with disabilities stayed in treatment generally at the same rates as the other populations.
Figure 3: Retention in Outpatient Treatment; Percent of Oregon adults retained in treatment at least 90 days by eligibility Treatment Completion: Drug counselors are required to assess and report whether individual treatment participants complete their treatment program. This rating can be fairly subjective. As shown in Figure 4, the disabled subpopulation rates for treatment completion were generally comparable but slightly lower than the other subpopulations.
Figure 4: Outpatient Treatment Completion; Percent of Oregon adults completing treatment. Treatment Readmission. This measure indicates the percent of adults who are readmitted to treatment within one year of outpatient discharge. This excludes readmissions within two weeks of discharge which was interpreted to mean transfer to another program. While readmission was historically regarded as a treatment failure, more recently relapse and readmission are regarded as typical occurrences in the substance abuse recovery process. Figure 5 shows that persons with disabilities are comparable to or slightly less likely to be readmitted to treatment programs than the other groups.
Figure 5: Outpatient Treatment Readmissions; Percent of Oregon adults readmitted to treatment within year of outpatient discharge. Abstain from primary drug. Figure 6 illustrates that persons with disabilities are slightly more likely to abstain from their primary drug during the last 30 days prior to discharge than their counterparts in other groups.
Figure 6: Abstain from Primary Drug; Percent of Oregon adults abstaining from primary drug in 30 days prior to outpatient discharge. The present study compared access, use and success of outpatient substance abuse treatment services and outcomes between the disabled and other Medicaid-eligible subpopulations over the years 1992 through 1998. Despite presumed higher rates of substance use and abuse by persons with disabilities, findings indicate that over the time period studied, those participants with Medicaid disability codes are only about half as likely as other Medicaid enrollees to enter treatment during any one year. While all groups increased in rates of access, the disability subpopulation consistently accessed treatment at only about one-half the rate of other Medicaid groups. While implementation of managed care in Oregon marked an increase in utilization (sustained use) by the AFDC/TANF and Expansion subgroups, a similar marked increase in utilization was not evident for the disability subpopulation. At the same time, treatment effectiveness when considered across four indicators suggests that persons with disabilities generally fare as well and benefit as much from substance abuse treatment as other Medicaid subpopulations. Slight increases in access and service utilization were observed for the disabled group under managed care but lagged dramatically behind that of other eligibility groups. Further research should be done to determine factors that contributed to this disparity. Outpatient service utilization was lower for persons with disabilities due to slightly worse retention. Special attention should be given to factors contributing to retention of outpatient participants with disabilities. Persons with disabilities might be more likely than persons without disabilities to have experience with illicit drug use, and that the type of drug used could vary with age Both disability and chemical dependence service providers report increases in substance use disorders among people with disabilities. State directors of alcohol and drug departments and directors of State VR agencies reported increases in coexisting disability and substance use disorders among recent referrals to their programs. Directors of both agencies predicted that these numbers would continue rising in the future (RRTC, 1996). Since many people with disabilities are not currently receiving the treatment for substance use disorder they require, the number of people with disabilities seeking treatment can only be expected to grow. Research
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