Financing and Diffusion of Substance Abuse Treatment

Cynthia L. Arfken, Ph.D. Wayne State University

Sheryl Pimlott Kubiak, Ph.D.Michigan State University

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.

In the providers’ words…

“Our treatment philosophy is almost entirely dictated by economics.”

“It’s 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 we’re trying to do is diversify.”

Hypothesis

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

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.

Categories of Funders

“Which funding source do you consider the most important source?”• Public (n=17)

• Private (n=10)

• Criminal Justice (n=7) • 16 receive some CJ funding

• Excluded one program with 100% funded by charity

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...”

Funding Volatility - Decrease

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10

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40

50

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%

All Programs CJ Public Private

“Anything you had to do that you didn’t 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 didn’t want to.

60% of programs who did not experience an overall funding decrease had to do something they didn’t want to.

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.” We’ve reorganized the system completely.

We’ve reviewed every positive [component]. We’ve trimmed off everything.”

What they did - more responses

“Forced to do more group education than therapy.”

“Lay-offs” “Discharge clients earlier than we’d like to.” “Terminate clients.” “Compromises in hiring—get people I

wouldn’t normally hire.”

Provision of specific evidence-based practices by major funder

0

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40

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80

100

CBT MI*

%PublicPrivateCJ

Provider’s 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 can’t address that.” (CJ program)

“We know what effective treatment is but [funder] has us in a situation - you can treat everyone, but you can’t use empirically validated treatment.” (Public program)

“Do any of these funding sources affect:…”

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80

100

%

Services provided – where private funders diverge

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20

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80

100

%

Private program perspectives

“Certain insurances don’t think of it as an ongoing problem; they think of it like an accident – like a car accident.”

“The insurance company [name] says they don’t qualify because they quit drinking already - they don’t need therapy…so I might need to give a mental health diagnosis…”

Services provided – where public funders diverge

0

20

40

60

80

100

Hep C screen Hep B screen HIV Test TB Test Follow-up

%

Services provided – where CJ funders diverge

0

20

40

60

80

100

Domestic Viol. Groups Any Rx

%

Provision of Gender-specific Groups

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20

40

60

80

100

Women Men

%

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

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 important…We have had to get creative…Overall, we got slick.”

Acknowledgements

NIDA (R01 DA-014483) and the state of Michigan (Joe Young, Sr.)

Alison Spork, Elizabeth Agius, and Damon Drown