Transcript Racial minorities, managed care and substance abuse

The costs and effectiveness of
substance abuse treatment programs
for pregnant women
Marilyn Daley, Ph.D.
Conference on Harm Reduction Strategies in Uzbekistan
Brandeis University
August 18, 2004
MOTHERS Project was funded through HCFA Cooperative
Agreement #HC-05-111-PC/004
Background: Drug, alcohol and tobacco
use among pregnant women is a serious
public health problem in the United States
 According to national epidemiological studies:
 5% of U.S. women use illicit drugs during
pregnancy
 20% use alcohol
 20% use tobacco
 In 1996, 647 pregnant women were admitted
to publicly funded drug treatment programs in
Massachusetts
 About 40% of these women are heroin users
Background
 Drug and alcohol use among pregnant
women is associated with adverse birth
outcomes and is very expensive to society
Leading preventable cause of low birth weight
HIV transmission/pediatric AIDS
Hepatitis C and other infections
Neonatal abstinence syndrome
Growth, learning and behavioral problems which
can persist into adulthood
 Increased use of neonatal intensive care units,
lengthy hospital stays, abandoned infants
 Cost Medicaid program over $1 Billion in 1991
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Expansion of treatment programs
during the 1990s – 2000s
 Reports of a shortage of treatment slots that could
accommodate the physiological needs of pregnant
women, particularly those under Medicaid
 Led to increased federal, state and private funding for
specialized treatment for pregnant women
 NIDA, NIAAA, CSAP, CSAT and HCFA all funded
demonstration projects
 Led to 250% increase in publicly funded treatment
services available for pregnant women in
Massachusetts between 1989 and 1995
Description of the MOTHERS Project
 Funded by the Health Care Financing Administration
between 1992-1996
 Part of a five site research and demonstration
project to explore new ways to increase access to
prenatal care and substance abuse treatment for
pregnant women
 Interviewed 627 pregnant women who were
receiving treatment in Massachusetts publicly
funded detoxification programs
 Followed these women for a year and a half using
face to face follow-up interviews at 3, 6, 9 and
months, birth records, Medicaid claims and
substance abuse treatment records
Compared the costs and effectiveness
of the following treatment programs:
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Methadone (n=56)
Residential (n=63)
Outpatient (n=79)
Residential/outpatient (n=77)
Detoxification only (used as a no
treatment comparison group) (n=170)
Methadone programs
 Accepted protocol was to maintain pregnant
women on methadone and withdraw the child
after delivery
 12 methadone programs in Massachusetts
 Transportation provided to and from the
programs
 Total cost: $20 day plus transportation
 Pregnant women on methadone were accepted
at a few of the residential treatment programs
 Numbers of pregnant women served by
methadone programs remained stable between
1992 and 1996 at 72
Outpatient programs
 Day treatment programs
 Linkages to prenatal care, WIC, early
intervention, local welfare offices
 Individual and group counseling
 Case management
 4 hours per day for six days per week
 Total cost: $55/day
 The number of pregnant women in day
treatment programs increased from
 46 in 1988
 100 in 1996
Detoxification programs
 8 specialized detoxification programs that could
serve pregnant women up to their 3rd trimester
 Needed to be associated with a hospital, a
prenatal care provider, an early intervention
program, DPW, WIC
 Had a full time OB/GYN nurse on staff to
provide medical care and case management
 Total cost: $160/day
 Number of women using these services
increased from
 10 in 1988 to
 377 in 1996
Residential programs
 200 residential beds
 11 recovery homes
 4 therapeutic communities
 9 family shelters
 Many allowed other children to live on site
 Individual & group counseling, parenting skills training,
housing assistance, etc.
 Needed to be affiliated with a physician, a hospital, a
prenatal care provider, WIC, early intervention, local
welfare office
 Total cost: $80/day
 Admissions increased from
 18 in 1988 to
 115 in 1996
Emerson House in Falmouth, Massachusetts
10 beds for pregnant women
Steppingstone women’s program in Fall
River: 6 beds for pregnant women
MOTHERS Project clients
 Average age = 28
 41% black, 41% white, 18% hispanic
 83% had other children, but 77% did not have
custody of their children
 33% said heroin was their drug of choice, 26%
cocaine, 26% crack, 8% alcohol
 90% were unmarried
 45% had been homeless in the last 3 years
 60% had been physically abused
 50% had not graduated from high school
Costs of treatment and health care during
pregnancy to six months postpartum
Thousands
$20
$15
$10
$5
$0
Treatment
Health care
detox
out
meth
res
r&o
2723
4009
6812
9882
17720
12850
13059
16717
19563
15163
Birth weight for 445 infants
(singleton live births)
3100
3072
3050
3026
3000
2955
2963
2950
2900
2864
2850
2800
2750
dtx
out
meth
resd
r&o
Percent low birth weight
(445 singleton live births)
26
30
18
25
18
16
13
20
15
10
5
0
dtx
meth
op
res
r&o
dtx
meth
op
res
r&o
According to regression analysis, the following
variables were also associated with higher or lower
birth weight
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Mothers age (-13 g year)
Male infants (+ 115 g)
Previous preterm delivery (-142 g)
Gravidity (+127 g)
Weight gain (+110 g)
Readmissions to detoxification during pregnancy (-121 )
The following variables increased costs:
 Previous preterm delivery (+ $2,140)
 Age (-$168)
 Infections (+ $5,001)
#Cigarettes per day, polydrug use, race, #prenatal care
visits, #grades completed had no effect
Discussion: cost-effectiveness
 There was a near linear relationship between the
amount of treatment received and birth outcomes
 Mothers who received the most treatment (130 days) in
residential/outpatient delivered infants who weighed 190
grams more than the women who received only
detoxification, who spent only 17 days in treatment
 The infants whose mothers received detox only had
twice the rate of low birth weight (13% vs. 26%)
compared to women in residential/outpatient
 However, the residential/outpatient programs also cost
$16,323 more than the detoxification programs
 Outpatient programs were the most efficient option.
Infants weighed 139 g more than in detox for a cost of
only $1788 or $13 gram
 Methadone programs cost $7,920 more than detox and
increased birth weight by 107 grams, or $75 per gram
Treatment programs for pregnant
women benefit society
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Produce healthier children
Improve health and quality of life for mothers
Decrease drug use for mothers
Reduce crime to society
Reduce health care expenditures
Reduce criminal activity and attendant costs
Promote family reunification
Reduce the spread of HIV and other infections
Since they produce more benefits than costs, an
investment in treatment programs for pregnant
women produces a net return to society
Reductions in the cost of crime
 High rate of criminal involvement in
mothers project sample:
 68% had been arrested
 40% had spent time in jail
 Women commit different crimes from men
 Shoplifting
 Prostitution
 Drug sales
 Did treatment reduce the costs of crime?
Background
 Since crack epidemic more women have
entered retail drug trade
 Between 1986 and 1991 there was a 433%
increase in the number of women in state
prisons for drug offenses
 All treatment programs reduced the costs
of criminal activity even after accounting
for treatment costs, representing a net gain
to society
Annualized savings due to reductions
in crime (net gain to society)
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Detoxification ($3,072)
Methadone ($7,884)
Outpatient ($8,508)
Residential/Outpatient ($18,060)
Residential ($32,772)
Benefits (net of costs) of treatment
programs due to reductions in crime
$32,772
35000
30000
25000
20000
15000
$7,884
10000
5000
0
dtx
MM
out
res
resop
$18,060
$8,508
$3,072
dtx
MM
out
res
resop
For every dollar spent on treatment
programs for pregnant women, society
receives a return of :
$2.50
$2.10 $2.11
$2.00
$1.50
$1.54
$1.72
dtx
mm
out
res
r&o
$1.14
$1.00
$0.50
$0.00
dtx
mm
out
res
r&o