Factors Associated With The Receipt Of Treatment Following Detoxification Tami L. Mark, Ph.D., Joan D. Dilonardo, Ph.D., Mady Chalk, Ph.D., Rosanna M. Coffey, Ph.D. Tami Mark (Tami.Mark@thomson.com) and Rosanna Coffey are with Thomson Medstat. Joan Dilonardo and Mady Chal k are with the Office of Quality Improvement and Financing, Center for Substance Abuse Trea tment, Substance Abuse and Mental Health Services Administration. Introduction More than 18 million people who use alcohol and almost 5 million who use illicit drugs need substance abuse treatment, while, overall , less than one fourth of those needing treatment actually get it (Schneider Institute for Health Policy, 2001). Substance abuse treatment usually proceeds in three st ages (Institute of Medicine, 1990): acute intervention (including emergency treatme nt and detoxification), rehabilitation (outpatient, residential or inpatient primary and extended care), and maintenance (aftercare, relapse preven tion, or domicile care). Each year at least 300,000 patient s obtain inpatient detoxifica tion in general hospitals and additional numbers obtain detoxi fication in other settings. De toxification is the medical management or monitoring of acute alcohol or illicit drug intoxi cation and withdrawal. While detoxification may offer a gateway for patients into a substance abuse treatment program, detoxification alone will not lead to lasting improvements (Institute of Medicine, 1990; Gerstein & Harwood, 1990; Wesson, 1995). The receipt of continuing treatment/rehabilitation services following subs tance abuse detoxification is considered to be essential for successful recovery. Research has shown that patie nts who receive such services after detoxification have better outcomes in terms of drug abstinence (McCusker, Bigelow, Luippold, Zorn, & Lewis, 1995) and re-admission rates (Daley, Argeriou, & McCarty, 1998) than those who do not enter treatment. Because the need for detoxification identifies persons who are substance dependent, detoxification presents an opportunity to link such persons to continuing substance abuse treatment services so that they may be able to attain sobriety and recover. Yet little is known about the extent to which these linka ges are occurring. Large databases that follow individuals across systems of care are needed to answer the question of whether persons who enter detoxification subseque ntly receive continuing substance abuse treatment/rehabilitation services. Insurance claims are one type of data that allow tracking of services across large patient populations over time and thus, tracking of tr eatment utilization rates. In addition, such data may contain information about health plan type and benefits that relate to the receipt of health care services. For example, managed care plans offer the promise of greater integration and coordination of services th an may occur under a fee-for-service system. Patients in health maintenance organization plans are typically assigned a primary care physician to coordinate their care. In c ontrast, under a carve-out arrangement for Factors Associated With The Receipt Of Treatment Following Detoxification 1 behavioral health care, a separate compa ny manages just that treatment provided by mental health and substance abuse providers . Typically under such a carve-out, enrollees wishing to use behavioral health care benef its must dial a toll-free number to receive a referral to a mental health or substance a buse specialist. Utiliza tion review is often employed to determine treatment length and placement options. To our knowledge, there are no studies of the effect of plan type on the receipt of continuing treatment/rehabilitation services following detoxification. Cost-sharing is another aspect of insura nce benefit design that may influence the probability of receiving continuing treatment/r ehabilitation services after detoxification. Stein, Orlando, & Sturm (2000) examined the effect of co-payments on the probability of receiving such services following alcohol detoxification. They used data from 14 employer groups whose behavioral health care benefits were managed by United Behavioral Health. Their analyses predicte d that waiving all outpatient co-payments would have resulted in 24% more patients receiving continuing substance abuse treatment and rehabilitation serv ices following detoxification. Demographic and clinical factors may also pl ay a role in determining whether someone receives additional treatment/ rehabilitation services. Analyses of inpatient data have found that being female, younger in age, having private insurance, ha ving higher income, having a longer length of stay, and not be ing admitted through the emergency room were positively associated with receiving inpatient rehabilitation following inpatient detoxification (Mark, Dilonardo, Chalk, & Coffey, 2002a). This paper starts with the pr emise that persons receiving inpa tient detoxification, alone or with inpatient rehabilitation, should receive continuing rehabi litation treatment services after they are discharged. Da ta from both efficacy and eff ectiveness studies have shown that patients who participate in continui ng specialized outpatient substance abuse treatment after being discharged from treatm ent for substance abuse tend to have better long-term outcomes (Miller, Ninoneuvo, Kl amen, Hoffman, & Smith, 1997; Miller and Hoffman, 1995; Moos, Finney, Federman, & Suchinsky, 2000; Moos, Schaefer, Andrassy, & Moos, 2001; Patterson, Macphe rson, & Brady, 1997; Ritsher, Moos, & Finney, 2002; Swindle, Phibbs, Paradise, Recine, & Moos, 1995). The paper examines the extent to which this follow-up care is be ing received and what fa ctors are associated with receiving it after disc harge from detoxification. Materials and Methods Data for this study come from Medstat222s 1997, 1998, and 1999 MarketScan256 database, which compiles claims information from pr ivate health insurance plans of large employers. The covered individuals include employees, their depende nts, and retirees with employer-sponsored health insurance. Me dstat collects the claims and standardizes them. These claims are collected from over 200 different insurance plans, including fee- for-service (FFS), preferred provider orga nization (PPO), health maintenance organization (HMO), and point of service (POS) plans. Both capitated and non-capitated plans are included. In 1999, about 40 large em ployers participated. Detailed information about the firms is unavailable for reasons of confidentiality. There were 4.1 million covered lives in 1999. Factors Associated With The Receipt Of Treatment Following Detoxification 2 Hospitalizations for detoxification were identified using proc edure codes of the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9- CM), the system used uniformly for coding clinical diagnoses and procedures by the hospital industry. ICD-9-CM incorporates c odes of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) for mental health and substance abuse conditions. A hospitalization with a det oxification procedure code was considered an 221221index discharge222222 in this study for determining whether or not continuing treatment/ rehabilitation services were received. Persons were considered to have had detoxification and rehabilitation while inpatients if they had ICD-9-CM procedure codes 94.63 (alcohol rehabilitation and detoxification), 94.66 (dr ug rehabilitation and detoxification), or 94.69 (combined alcohol and drug rehabilitation a nd detoxification); othe rwise patients were considered to have detoxification only if th ey had the following ICD-9-CM codes: 94.62 (alcohol detoxification), 94.65 (drug detoxifi cation), 94.68 (combined alcohol and drug detoxification). Outpatient detoxifications ma de up a small portion of total detoxification (about 10%) and were excluded from the an alyses to simplify interpretation. A broad definition of continuing treatment or rehabilitation services post-discharge was used in this study. The operational defin ition of receiving continuing substance abuse treatment/rehabilitation services was a claim ( outpatient or subsequent inpatient claim) with an ICD-9-CM diagnosis or procedure co de related to mental illness or substance abuse, or a CPT psychiatric procedure code, or a claim indicating tr eatment in a mental health or chemical dependency specialty facil ity within 30 days afte r the index discharge. Those persons who had only additional detoxification procedure codes within 30 days after an index detoxification discharge were not considered to have received continuing treatment/rehabilitation services. Enrollment records indicated the length of time of persons in the claims database. Persons who were not enrolled for 30 days after the index discharge were excluded from the analyses. A benefit simulation model was developed to determine the amount a patient would have to pay out-of-pocket for one outpatient subs tance abuse visit following detoxification. Approximately 60% of beneficiaries in the MarketScan256 database had benefit information to permit this calculation. This information had been abstracted from the beneficiary plan description booklets using primary data co llection for the MarketScan256 database. For example, the plan booklet may indicate that a covered member would pay a $20 co-payment for each substance abuse vis it. Then the simulation model would assign a $20 value to persons with that benefit p ackage indicating the e xpected out-of-pocket cost to them of a substance abuse visit. Some benefit plans were more complicated than others. For example, a covered member might be required to pay 50% cost-sharing for the first 10 visits and 25% for the next 10 vi sits. The simulation model would then assign an out-of-pocket value to th e person based on the number of visits they had prior to discharge for detoxification and the average co st of the visit. Becau se encounter records for capitated plans do not have dollar values, the benefit simulation model was estimated only for persons with cl aims for payment. We used logistic regression analysis to a ssess factors associated with whether or not continuing treatment/rehabilitation services were received within thirty days of an index hospital discharge for detoxi fication. Two regression models were estimated. One model included measures of plan type and was estim ated using discharges with encounter and Factors Associated With The Receipt Of Treatment Following Detoxification 3 claims data. The other model included meas ures of out-of-pocket payments and was estimated only for persons with claims. Other variables in both models included: the presence of a behavioral carve-out arrangement, whether patients received detoxification plus rehabilitation while an inpatient or detoxification-on ly, age, age-squared, gender, type of diagnosis, and year in which the index inpatient deto xification occurred. Results A total of 1577 detoxification discharges from the 1997226 1999 MarketScan256 data met the inclusion criteria. Of these, 1394 discha rges and 1108 unique patients could be linked to benefit information and were enrolled in a plan in the Ma rketScan256 database at least 30 days after the index disc harge. Of these 1394 discharg es, 966 had claims data as opposed to encounter data. The smaller subset with claims data were only used in the analyses of out-of-pocket payments. Demogr aphic and clinical characteristics of the sample are shown in Table 1. Almost 70% of the sample was male, the average age was 42.4 years, 62.1% were employees, 30.7% were spouses, and 7.3% were dependents. The most common diagnosis was alcohol psychoses or alcohol dependence syndrome (58.4%), followed by drug psychoses or drug dependence (23.9%), other diagnoses (16.4%), and nondependent drug abuse (1.3%). We calculated the total payments made for a visit for substance abuse treatment (defined as a visit where substance abuse was the diagnosis) in 1997 using the Market- Scan database of approximately 4 million covered lives. The average total payment for a substance-abuse-related visit was $97 (SD = 129). The average out-of-pocket cost for an outpatient substance abuse visit was $16.10 (abo ut 17% of the average total payment of $97). Of the subset of covered persons, 37.4% would pay nothing for an outpatient substance abuse visit and 6.7% would pay the full $97 (not shown in tables). All of the individuals included in the study had benefits that were diffe rent for behavioral health than for general health treatment. Individua ls were spread fairly evenly among FFS, HMO, and PPO plans, with the smallest group in POS plans. About 57.2% of the sample received alcoho l-only detoxification, 19.9% received drug- only detoxification, and 23.1% received co mbined alcohol-and-drug detoxification. Overall, 48.0% of the discharges received a detoxification only procedure, and the other 52.0% received detoxification plus rehabil itation procedures while inpatients. The average length of stay for an index detoxi fication index was 6.3 days (SD = 6.6 days). Ninety percent of the index discharges had less than 14 days of inpatient care. Only 49.4% of the discharges had continuing treatment/rehabilitation services within 30 days after being discharged from the inde x detoxification. Of those with continuing treatment, 57% had outpatient-only treatment within 30 days, 22% had inpatient-only treatment, and 21% had both inpatient and outpa tient treatment (not shown in tables). The average number of visits among persons who did receive con tinuing rehabilitation treatment was 3.5 visits after discharge, wh ich included all of th eir remaining observed time in the database (i.e., a maximum of 3 years). Factors Associated With The Receipt Of Treatment Following Detoxification 4 Table1. Characteristics of inpatient detoxification episodes (N = 1394) Mean (SD) Male gender 68.8% Average age 42.4 (11.1) Employee relationship Employee 62.1% Spouse 30.7% Dependent 7.3% Price for a substance abuse treatment visit $97 ($129) Out-of-pocket costs under benefit package $16.10 ($19.89) Plan Type FFS 30.9% HMO 26.1% POS 7.8% PPO 35.2% Percent in behavioral carve-out plan 30.5% Percent with detoxification procedure 94.62 Alcohol detoxification 30.9% 94.63 Alcohol rehab and detoxification 26.3% 94.65 Drug detoxification 8.0% 94.66 Drug rehab and detox ification 11.9% 94.68 Combined alcohol and drug detoxification 9.2% 94.69 Combined alcohol and drug rehab and detoxification 13.9% Percent with detoxification only procedure 48.0% Primary ICD-9-CM diagnosis Alcohol psychoses or alcohol dependence syndrome 58.4% Drug psychoses or drug dependence 23.9% Nondependent drug abuse 1.3% Other diagnosis 16.4% Average length of stay 6.3 (6.6) Percent with treatment within 30 days of inpatient detoxification 49.4% Average number of visits post discharge 3.5 (3.8) Source: Analysis of MarketScan database, 1997 -1999 To determine what type of treatment patie nts were receiving following discharge from the index detoxification event, the primary procedure codes on inpatient and outpatient claims were examined (not shown in tables). For outpatient treatment , the majority of the procedures on the claims were for various types of psychotherapy (about 55% of the claims) or for other psychiatric services su ch as pharmacological management (18% of the claims). About 12% of the outpatient clai ms were missing a procedure code, 7% were Factors Associated With The Receipt Of Treatment Following Detoxification 5 for 221221evaluation and management222222 or 221221office co nsultation.222222 Four per cent of the claims were for alcohol or drug rehabilitation w ith or without detoxification. The remaining claims (making up less than 5% of the total) were for a wide variety of procedures including 221221team conference222222, 221221routine veni puncture222222, and 221221hematology.222222 For inpatient treatment within the index stay or within 30 days of the index discharge, the most common primary procedure code was 221221evaluation and management222222 (about 25% of the claims). Alcohol or drug rehabilitation made up about 10% of the primary procedure codes. A variety of other codes including 221221c onsultation222222, 221221drug a ddiction counseling222222, and 221221other psychiatric drug therapy222222 made up the remainder of the primary procedure codes. Ten inpatient claims had a detoxificati on and rehabilitation code within 30 days of the index discharge. Although these claims ma y indicate the start of a new episode of treatment, half of them occu rred within 5 days of discharge suggesting th at the patient may have merely been transferred or discharg ed for a short period prior to continuing to receive detoxification and re habilitation treatment. The distribution of each explanatory variable was examined as a function of whether they received continuing treatment/rehabilitation se rvices within 30 days after the index inpatient detoxification episode (Table 2). Ag e, plan type, and length of stay were the only variables not statistical ly related to the probabil ity of receiving continuing treatment/rehabilitation services. Males were less likely than females to receive continuing treatment/rehabilitation after disc harge. Spouses and dependents were less likely than employees to receive continuing treatment/rehabilitation services. The average out-of-pocket payments for persons without continuing treatment was $25 (SD = $24) and the average out-of-pocket payment for persons with additional treatment was about $13 (SD = $21). Clients in a behavioral health carve-out were more likely than those in other plans to receive continuing treatment/reh abilitation services. Patients admitted with drug psychoses or drug dependence diagnoses were less likely than those with other diagnoses to receive continuing treatment after detoxification. Those with 221221other diagnoses222222 (other than alcohol or drug-relate d diagnoses) were the most likely of the diagnostic categories to receive c ontinuing treatment/rehabilitation. Clients with an index detoxi fication plus rehabilitation treatment in the hospital (as opposed to an index detoxification- only i npatient episode) were more likely to have continuing treatment (usually outpatient) follo wing discharge. The average length of stay in the index inpatient detoxi fication episode (6.3 days) was the same for persons who did and did not receive continuing treatment within 30 days after discharge. However, persons whose index detoxification episode incl uded rehabilitation stayed an average of 7.8 days while persons with detoxification- only episodes stayed for only 4.6 days (not shown in tables). Factors Associated With The Receipt Of Treatment Following Detoxification 6 Table2. Receiving continuing treatment 226 as a function of patient and index di scharge characteristics (N = 1394) No treatment (N=706) Treatment (N=688) Gender** Female 44.6% 55.4% Male 53.4% 46.6% Average age 42.3 (11.6) 42.6 (10.7) Employee relationship*** Employee 47.1% 53.0% Spouse 56.5% 43.5% Dependent 56.4% 43.6% Out-of-pocket costs for one substance abuse visit*** $25.4 (23.8) $12.9 (20.7) Plan Type FFS 46.4% 53.6% HMO 54.7% 45.3% POS 47.7% 52.3% PPO 52.0% 48.0% Presence of behavioral carve-out*** No carve-out 55.4% 44.6% Carve-out 39.8% 60.2% Type of inpatient detoxification*** 94.62 Alcohol detoxification 56.3% 43.7% 94.63 Alcohol rehab and detoxification 42.4% 57.7% 94.65 Drug detoxification 55.9% 44.1% 94.66 Drug rehab and detoxification 51.2% 48.8% 94.68 Combined alcohol and drug detoxification 58.6% 41.4% 94.69 Combined alcohol and drug rehab and detoxification 45.1% 54.9% Inpatient detoxificati on only procedure*** Detoxification only procedure 56.7% 43.4% Detoxification plus rehabilitation 45.1% 54.9% Primary ICD-9-CM diagnosis at index detoxification*** Alcohol psychoses or alcohol dependence syndrome 48.9% 51.1% Drug psychoses or drug dependence 60.4% 39.6% Nondependent drug abuse 44.4% 55.6% Other diagnosis 43.2% 56.8% Average length of stay in index detoxification 6.3 (6.8) 6.3 (6.4) Source: Analysis of MarketScan256 database, 1997 -1999 *p < .1. **p < .05. ***p < .01. Factors Associated With The Receipt Of Treatment Following Detoxification 7 In a predictive analysis, two separate logistic regression models were estimated to determine the factors associated with r eceipt of continuing treatment/rehabilitation services in the 30 days following the inde x detoxification. One model had plan type measures and the other model had cost-sha ring measures. The variables that were statistically significant at p < .05 levels in bo th models and that were positively related to receiving continuing substance abuse treatmen t/rehabilitation were: (1) being in a carve- out plan; (2) receiving rehabil itation during an inpatient deto xification stay as opposed to detoxification-only; (3) having a diagnosis of alcohol abuse or other diagnosis as opposed to drug psychosis or dependence; and (4) be ing discharged for detoxification in 1997 as opposed to year 1999. Age was also positively associated with receiving additional treatment in the model with out-of-pocket sp ending but not in the model with the plan variables. Factors that were negatively associated with a dditional treatment were being male and higher out-of-pocket spending. In terms of magnitudes, the probability of receiving continuing treatment/rehabilitation for persons in a carve-out plan was between 13% and 21% higher th an for those in a non carve-out. Persons receiving rehabilitation a nd detoxification while inpatients as opposed to detoxification-only duri ng an index admission had a 13% higher probability of receiving continuing treatment/rehabilitati on after discharge. A $1 increase in out-of- pocket spending would lead to a decrease of 0.004% in the probability of receiving additional treatment/rehabil itation. The mean value of out-of-pocket spending was $16.10. Eliminating cost-sharing would lead to a 0.06% increase in the probability of having additional treatment/rehabilitation. Discussion This paper starts from the premise that persons who receive i npatient detoxification should receive continuing treatment/rehabilitation once discharged. In this observational study we found that most patients discharged from inpatient detoxifi cation did not receive any continuing substance abuse treatment/rehabilitation services and thus were missing opportunities for sustaining treatment gains a nd sobriety. In this study, only 49.4% of index episodes of inpatient detoxification received additional substance abuse treatment/ rehabilitation services within 30 days after discharge. The receipt of additional subs tance abuse treatment/ rehabilit ation services was broadly defined to include any encounter that resulted in a mental illness or substance abuse diagnosis and most often comprised some form of outpatient psychotherapy or rehabilitation. However, it also included inpatient rehabilitation treatment received following the index detoxification, but exclud ed detoxification only procedures. This measurement of continuing treatment is perhap s too simple in that it does not take into account the quality or intensity of continuing treatment. It included some forms of mental health and substance abuse treatment, such as 221221consultation,222222 that may not significantly affect substance abuse usage. Thus, it is quite likely that an even larger proportion of patients than the reported 49.4% did not receive optimal treatment following detoxification. The fact that patients who r eceived continuing treatment of some type received, on average, only 3 to 4 outpatient visits, also supports this view. On the other hand, the study does not account for services th at are not reimbursed by private insurance such as Alcoholics Anonymous, Narcotic s Anonymous, and similar support groups. Factors Associated With The Receipt Of Treatment Following Detoxification 8 The rate of receiving continuing post-detoxi fication treatment/rehabilitation services found in this study of persons with private insurance falls in between those found in prior research. Stein and colleague s (2000) used data from a be havioral carve-out and found that 79% of patients received continuing treatment within 30 days of hospital discharge. A study of Medicaid claims and data from public mental health and substance abuse agencies found a rate of 30.3% (Mark et al ., 2002b). McCusker and colleagues (1995) found that only 26% of substance abuse clie nts who received detoxification in a 29-bed, free-standing substance abuse treatment cen ter also received continuing treatment/ rehabilitation services after discharge. The higher rate in the Stei n study may reflect the fact that the data were limited to behavioral carve-out claims. This study presumed that patients who rece ived detoxification and rehabilitation during their index admission could still benefit from additional treatment/rehabilitation following discharge. One reason for this pres umption was that the average length of the index stay was only 7.8 days. Such inpatient detoxification and rehabilitation stays were actually more likely to be detoxification and st abilization as described by the Institute of Medicine (1990), rather than rehabilitation treatment per se. Detoxification and stabilization aims to remove the physiologic a nd emotional instability that impedes direct entry into rehabilitative treatment, but s hould not be considered a substitute for rehabilitation. Another reason to a ssume that patients who received treatment/rehabilitation following their detoxifi cation event would have a better chance of recovery was that studies have consistently found that treatment length was a positive predictor of successful outcomes (Ether idge, Craddock, Dunteman, & Hubbard, 1995; McLellan, Lewis, O222Brien, & Kleb er, 2000; Simpson, 1979; Stark, 1992). This study suggests that financial incentives may be helpful for encouraging treatment following detoxification since thos e with a lower cost-sharing benefit were more likely to receive treatment following detoxification. Perv ious studies have also found that cost- sharing reduces the probabil ity of follow-up. Stein et al . (2000) studying alcoholism treatment within carve-out plans drew such an inference. Another study of financial incentives confirms this suggestion. (Chutuape , Katz, & Stitzer, 2001) looked at three methods for promoting outpatient aftercare following inpatient detoxification. Patients were randomly assigned to (1) standard referr al, (2) standard referral plus a $13 incentive payment, and (3) staff escort from detoxifica tion to aftercare with an incentive payment. They found that more escort incentive partic ipants (76%) than in centive-only (44%) or standard-referral (24%) participants complete d transition to aftercare. Thus, programs to encourage transfers between inpatient detoxi fication and subsequent outpatient treatment may be a more powerful way to encourage treatment than financial incentives. Enrollment in behavioral carve-outs also wa s associated with receipt of continuing treatment following detoxification. One might sp eculate that this is because behavioral carve-outs and some plan types work to coordinate care among the inpatient and outpatient providers although further study is needed to confirm this hypothesis. When individuals enter detoxification the hea lth care system has a unique opportunity to provide linkages to treatment which will offer lasting benefits in terms of reducing substance use. This study indicated that for many patients this opportunity is being squandered. More research and efforts are requi red in order ensure th at detoxification is followed by treatment. Financial incentives may offer one way to increase successful Factors Associated With The Receipt Of Treatment Following Detoxification 9 linkage to additional substance abuse trea tment/rehabilitation services. Coordination among providers that provide detoxification and treatment may offer another promising alternative and is an appro ach that needs more study. Acknowledgments We would like to acknowledge the computer programming support of Jack Li and Yelena Sadkova. A contract from the Center for Substance Abuse Treatment (CSAT) and Center for Mental Health Services (CMHS) of the Substance Abuse and Ment al Health Services Administration (SAMHSA) supported the pre paration of this paper (Contract No. 270-96- 0007). The content is solely the responsibi lity of the authors and does not necessarily reflect the official views of SAMHSA, or its components CSAT or CMHS, or the Department of Health and Human Services. Pa rts of this paper were presented as a poster at the American Public Health A ssociation Meetings in November, 2002. References Chutuape, M. A., Katz, E. C., & Stitzer, M. L. (2001). 223Methods for Enhancing Transition Of Substance Dependent Patients From Inpatient To Outpatient Treatment224. Drug Alcohol Depend , 61, 137226 143. Daley, M., Argeriou, M., & McCarty, D. ( 1998). 223Substance Abuse Treatment For Pregnant Women: A Window Of Opportunity224. Addictive Behaviors, 23, 239226 249. Etheridge, R. M., Craddock, S. G., Dunteman, G. 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