هزینه های اقتصادی درمان سوء استفاده از داروی مسکن برای زنان باردار و والدین و فرزندانشان

This paper provides basic information about the economic cost of substance abuse treatment provided in 39 demonstration projects funded by the Center for Substance Abuse Treatment, in the Substance Abuse and Mental Health Services Administration, under its Residential Women and Children and Pregnant and Postpartum Women (RWC/PPW) programs. It integrates data assembled in two studies, a study of annual project implementation costs based on the CSAT-developed Substance Abuse Treatment Cost Analysis and Allocation Template (SATCAAT) and a cross-site study of other project and client characteristics. Findings indicate that the average economic cost of treating a woman and her infants and young children in this type of long-term residential program, in fiscal 1997 dollars, was $25,744. This cost had three components of roughly equal size: services for clients, services for clients' children, and housing. Clinical services were found to be highly front-loaded, being more intensive in the initial weeks of treatment than in later stabilization phases. Considerable project-to-project variation in average episode cost was observed, linked primarily to project differences in size/occupancy and in average client length of stay.

In 1993, the Center for Substance Abuse Treatment (CSAT), in the Substance Abuse and Mental Health Services Administration, began funding grants under its Residential Women and Children and Pregnant and Postpartum Women (RWC/PPW) program (Clark, 2001). This initiative funded the development of long-term (6–12 months) residential substance abuse treatment projects at 50 geographically dispersed sites. The RWC/PPW program was a unique undertaking, since the projects provided on-site residential care for the mothers' infants and young children, as well as unusually long-term and comprehensive services for the mothers. The projects that focused on pregnant women were especially distinctive since, until that point, many alcohol and other drug treatment programs did not accept pregnant clients because of liability issues and other concerns (Mitchell, 1993). In addition to expanding the availability of residential treatment for pregnant and parenting women, CSAT's objective was to assess the cost and the effectiveness of such long-term treatment. To support the latter objective, CSAT awarded contracts for two separate studies. One provided for the collection of detailed information about the economic costs of the projects, and the second supported a wide-ranging cross-site evaluation of project activities and impacts. These data provide a unique opportunity to develop integrated assessments of both the costs and the impacts of a particular type of program. The cross-site study collected data from fall 1996 to summer 2001, gathering longitudinal information about RWC/PPW clients at several time periods: admission into a RWC/PPW facility, at quarterly intervals during treatment, at discharge, and 6 months following discharge. Contemporaneous data concerning the costs of each RWC/PPW project were obtained using a system known as the Substance Abuse Treatment Cost Analysis and Allocation Template (SATCAAT). The SATCAAT was developed for CSAT to provide a standardized, comprehensive picture of the economic opportunity costs (in general, economists define the opportunity cost of any good or service as the market value of the good or service) of treatment resources used at a given treatment project during a specified fiscal year. The system uses generally accepted accounting practices to assemble and allocate cost data into conventional expense categories (administration, facility and grounds, laboratory, etc.), which are then reconfigured into a series of 18 service categories that, in aggregate, encompass the full range of services provided (intake assessments, individual counseling, group counseling, housing, etc.). The system results in the development, for each service category, of a cost figure that is fully ‘loaded’ to represent all relevant costs, whether direct or indirect, expensed or donated. The SATCAAT template also provides for the collection of information about the quantities of services delivered during the reference year, from which service-specific unit cost statistics can be calculated (e.g. cost per intake assessment, or cost per hour of group counseling). The template was designed to be applicable across a wide range of treatment modalities and has been used to develop cost information for several-hundred treatment programs.1 The SATCAAT uses a service-focused, cost-of-resources methodology that has been widely recommended in concept (French, Dunlap, Zarkin, McGeary, & McLelland, 1997). Several recent studies have reported illustrative findings for residential SAT programs based on economic costing methods, but they generally involved small samples of providers and unspecified service packages (Anderson, Bowland, Cartwright, & Bassin, 1998). To our knowledge, this analysis involves the first large-scale application of standardized economic costing methods in a study of the costs of one distinctive form of residential SAT. In this paper, we report the results of the SATCAAT data collection and examine the correlates of cost variation among RWC/PPW projects. We combined information from cross-site and SATCAAT data to produce a rich set of data that contains detailed project costs, characteristics of each project, and summary measures about clients served at each project.

The data summarized here may represent the most intensive documentation ever assembled concerning the economic (resource) costs of a specific form of substance abuse treatment. Hopefully, this information will be informative and useful to those involved in planning, funding, or managing treatment programs similar to RWC/PPW. In many respects, the cost findings reported here reflect programmatically distinctive features of the RWC/PPW demonstration projects and may not be applicable to other forms of intervention. For example, many project administrators noted during the cross-site study that providing needed clinical, educational, and nursery or daycare services for clients' children proved to be more costly and challenging than they had anticipated. This impression, that child service costs constitute a substantial component of total project costs, is confirmed by the finding that projects spent almost as much caring for clients' children (30% of total costs) as for all diagnostic, treatment, and rehabilitative services for their mothers (38% of total costs). Another important finding is that, at an average market value of $51 per family per day (in FY1997 dollars), housing costs also account for a substantial fraction (32%) of total project costs. The study findings confirmed anecdotal information that costly diagnostic and clinical services tend to be highly front-loaded, with the result that clients who stay in treatment for extended periods incur only modest additional costs in these areas once the clinically intensive initial phase of treatment is completed. On the other hand, the findings also show that non-clinical, fixed daily costs (i.e. housing and general child care) constitute a substantial fraction of total project costs (48%), with the result that a client's total number of days in treatment is a major determinant of her total episode cost. Similarly, project-level differences in average client LOS were found to be important in accounting for project differences in average episode cost. Another important factor accounting for between-project cost variation was project size-occupancy, as measured by any of several correlated variables: number of client beds, ADC of in-residence clients, or bed utilization rate (ADC divided by number of beds). All three were strongly, and negatively, associated with average project cost per day and per treatment episode, suggesting an economy of scale phenomenon where larger projects and projects operating closest to full capacity had comparatively low unit costs. The implication seems to be that the smallest RWC/PPW projects (e.g. those in the 10–20 bed range) were not optimally efficient. From our conversations with project administrators, we noted two efficiency factors that may have been particularly problematic for small projects. First, it is difficult for small projects to accommodate diverse child-care needs efficiently. It is difficult to operate efficient nursery, daycare, and preschool programs, and to provide transportation to appropriate off-site child mental health and recreational services when, at any given time, there are only 2–4 (and sometimes fewer) age-appropriate children in residence who need a given service. A second efficiency challenge for small projects emerges when projects with long-term treatment plans are successful in retaining large percentages of their clients beyond the initial phases of treatment. As more and more of a project's beds are filled by long-staying clients in the latter phases of their treatment, fewer and fewer beds are available for entering clients for whom intensive group counseling and other group-based treatment services are needed, leading to clinical service groups of sub-optimal size. In retrospect, our experience of working with the SATCAAT to document the costs of operating RWC/PPW projects has led us to appreciate both the strengths and the limitations of this costing methodology when applied to this form of treatment. The major advantage is in the standardization and rigor of the approach, and in the resulting between-site comparability of cost figures. As compared to an expenditures-based representation of project costs, the SATCAAT emphasis on market-value representation of project facilities and services eliminates major sources of between-project cost variation that would otherwise exist when some—but not all—projects are able to obtain valuable services at little or no cost. The other side of this coin is that SATCAAT market-value adjustments have the effect of representing some projects' costs at levels higher than their actual expenditures. For example, some projects were able to obtain client housing at less than market rates (e.g. using housing donated by the parent organization, or using public housing facilities for which clients would be eligible even if they were not in the program). Their housing costs—and the added costs associated with long-term stays beyond the clinically intensive initial treatment phases—are arguably overstated in our cost figures. Our housing cost figures are best viewed as indicating the market rates providers should expect to pay for client housing, if discounted housing is not available. In another respect, SATCAAT may understate the economic value of project-provided services. The SATCAAT seeks to represent fully the market value of all professional services directly provided by the projects to their clients and families. This includes all on-site services provided by paid staff plus estimates of the market value of any similar ‘donated’ services (e.g. volunteer daycare workers; doctors or nurses who periodically visit the project to provide intake physicals, HIV tests, or the like). However, the cost system does not represent ‘leveraged’ services that are accessed off-site by project case managers. For example, prenatal, pediatric, and other valuable medical services projects access off-site are excluded from SATCAAT service cost estimates, as are any educational or vocational training services clients receive off-site. This exclusion of leveraged services is perhaps more of an issue for the RWC/PPW treatment model than for many other forms of substance abuse treatment. The cost of outpatient treatment, for example, is reasonably represented by a system that looks just at the services provided/received at the treatment site. However, for a program like RWC/PPW, where arranging access and transport to many off-site services is a core feature of the treatment program, exclusion of leveraged services has the effect of substantially understating the value of the services clients and children receive by virtue of being in the program. It also has the effect of creating substantively spurious between-project differences in measured costs. Thus, two projects that provide equivalent daycare services will appear to have very different costs in this area, if one provides on-site daycare and the other obtains the same service off-site. We suspect that this exclusion of leveraged services is the reason our efforts to predict project differences in major cost components were ineffective. For example, we were unable to document that client clinical service costs were higher for projects serving pregnant and postpartum women than for projects serving women not recently pregnant, even though cross-site records show women in PPW projects received much higher levels of medical services than women in RWC projects. The problem is that these project-arranged services were obtained predominately off-site and were therefore excluded from the cost figures. Similarly, measured differences in project clinical services for children reflect differences in project-administered services, but not necessarily in project-arranged services. The take-home lesson here is that the SATCAAT resource cost measurement system provides cost figures that are compatible with conventional accounting rules and procedures and that fully represent the economic value of project-provided services; however, they do not fully represent—and in some cases vastly understate—the economic value of services received by clients and their children by virtue of being in an RWC/PPW project. Finally, while it is apparent that RWC/PPW residential treatment was costly, especially for clients who remained in treatment for extended periods, it remains to be seen whether or not the benefits achieved from this experience are great enough to outweigh, and therefore justify, the costs. Other forms of residential treatment have been shown to produce substantial post-treatment reductions in criminal activity, resulting in cost savings to society greater than the cost of the treatment (Flynn et al., 1999 and Daley et al., 2000). In addition to such savings, it might be anticipated that RWC/PPW treatment might produce further savings in the form of reduced TANF and foster care costs to society. Additionally, insofar as RWC/PPW projects help substance-addicted pregnant women reduce their chances of delivering low birth-weight or premature babies with significant health problems, further cost savings to society could be achieved. Health care savings from averting low birth-weight deliveries can be substantial, ranging from lifetime savings estimated at $427,000 for a moderately low birth-weight child (1501–2500 g) to $853,821 for an extremely low birth-weight child (under 1000 g) (U.S. Environmental Protection Agency, 2002). This paper lays the foundation for such a cost–benefit analysis by describing factors influencing the cost side of the equation.