Examining Substance Use Disorder Treatment Demand and Provider Capacity in a Changing Health Care System: Final Report. EXECUTIVE SUMMARY

12/05/2017

Despite federal policies enacted within the last decade aimed at promoting insurance coverage for substance use disorders (SUDs), the existing SUD treatment workforce may be insufficient to accommodate the potential increase in demand for care and other factors may be contributing to stagnant treatment utilization rates. To address this concern, in September 2014, the U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation contracted with Mathematica Policy Research to conduct this project to assess current demand for SUD treatment and the state of provider capacity in the SUD treatment field. The key study findings on the demand for and supply of SUD treatment are summarized below.

Demand for SUD Treatment

Uninsured rate among individuals with SUD declined following ACA implementation.

The uninsured rate among individuals 12-64 with an SUD declined to 20 percent in 2014 from an average rate of 25 percent between 2009 and 2013. Most of this decline resulted from an increase in the rate of Medicaid enrollment, from 13 percent between 2009 and 2013 to 18 percent in 2014. This change added about 1 million individuals with SUDs to the Medicaid program.

Nevertheless, the rate of SUD treatment receipt did not increase substantially in the initial years following implementation of the ACA.

Despite the increase in insurance coverage among individuals with SUDs, evidence from multiple data sources indicates there has been no or only a small increase in treatment service use since the beginning of 2014.

Overall treatment use has remained constant, according to the National Survey on Drug Use and Health (NSDUH). According to aggregate estimates from the NSDUH, the number of individuals receiving any SUD treatment in the past year remained constant between 2004 and 2014, at about 4 million individuals (Figure ES.1). About 60 percent of these individuals (2.2-2.6 million individuals per year) received treatment in a specialty setting, which the HHS Substance Abuse and Mental Health Services Administration (SAMHSA) defined as any of the following types of facilities: hospitals (inpatient only), drug or alcohol rehabilitation facilities (inpatient or outpatient), or mental health centers.1 Because of methodological changes in the NSDUH survey implemented in 2015, the survey's estimate of 3.7 million and 2.3 million individuals receiving any and specialty treatment, respectively, in 2015 are not comparable to estimates from earlier years. According to NSDUH, between 2015 and 2016 there was again no significant change in the number of individuals receiving any and specialty treatment in the past year.

FIGURE ES.1. Number of Individuals Who Received Any Treatment or Specialty Treatment, NSDUH 2004-2014
FIGURE ES.1, Line Chart: There are two series displayed. A dark blue line shows the number of individuals receiving any treatment for substance use disorders has remained relatively constant between 2004 and 2014 at about 4 million individuals. A light blue line indicates the number of Individuals receiving specialty treatment has also remained relatively constant between 2004 and 2014, varying slightly between 2.2 and 2.6 million individuals in a given year.
SOURCE: NSDUH 2004-2014.

National Survey of Substance Abuse Treatment Services (N-SSATS) counts of clients in treatment indicate a small increase in the number of clients in care. In contrast to the NSDUH, which measures whether a person had any treatment in the past year based on person-level responses, N-SSATS measures counts of clients in care at a point-in-time as reported by specialty SUD treatment facilities.2

N-SSATS client counts indicate a small increase in the number of clients in care between 2013 and 2015 (4.5 percent over two years), or about 56,000 individuals. About 40 percent of the growth was related to increases in inpatient hospital (which had a change of 65.6 percent) and residential care (which had a change of 11.3 percent) (Table ES.1). The increases in hospital use align with sharp increases in opioid overdoses (Rudd et al. 2016) and opioid-related admissions to intensive care units3 observed in this period. Because NSDUH excludes institutionalized individuals from its sample, N-SSATS is a more accurate source of trends in institutional service use.

The lack of change in the population with service use in the past year based on NSDUH suggests that the increase in point-in-time outpatient clients observed in N-SSATS stems from a longer duration of care. Overall, the estimated increase in SUD treatment use was minimal relative to the increases in insurance coverage and the level of unmet treatment needs.

TABLE ES.1. Number of Clients by Setting of Care, N-SSATS 2013 and 2015
Type of Care Within Setting 2013 2015 % Change
Total 1,249,629 1,305,647 4.5%
Outpatient 1,127,235 1,161,456 3.0%
Residential (non-hospital) 107,727 119,900 11.3%
Hospital inpatient 14,667 24,291 65.6%
SOURCE: N-SSATS 2013 and 2015.
NOTE: N-SSATS surveys the universe of specialty SUD treatment facilities. In 2013 and 2015, respectively, the survey had a 94% and 92% response rate. Estimates are not adjusted for facility or item non-response. For inpatient and residential services counts indicate the number of clients in treatment on the last working day in March of each survey year. For outpatient services counts indicate the number of clients receiving services during March who are still enrolled in treatment on the last working day in March.

Lack of perceived need for treatment presents challenges in providing treatment services to those with SUDs.

Increasing treatment use for individuals with SUDs has the potential to substantially improve their welfare and that of their families as well as reduce societal and economic losses associated with SUDs, such as criminal justice costs, productivity loss, and mortality and morbidity due to accidents. The increased insurance coverage provided through recent federal policy initiatives resulted in, at most, small increases in treatment use. An important reason insurance coverage did not result in a significant expansion in treatment use is that, according to the 2015 NSDUH (Lipari et al. 2016), 95.4 percent of individuals who met criteria for an SUD but who did not receive specialty treatment (19.3 million people) did not feel they needed treatment. Among the remaining small percentage (4.6 percent, or 880,000 people) who felt they needed treatment but did not get it, 64.4 percent (about 567,000 people) reported making no effort to get treatment. Thus, expanding treatment use will require a multifaceted approach including changing attitudes about alcohol misuse and illicit drug use, increasing public awareness of treatment effectiveness, reducing stigma associated with SUD treatment, addressing financial barriers, and increasing primary care physicians' role in screening, treatment and referral.

Supply of SUD Treatment

The SUD treatment workforce comprises counselors, medical professionals, and support staff.

The 2016 N-SSATS survey found 197,559 full-time equivalent (FTE)4 paid staff and 6,726 unpaid staff in specialty SUD treatment facilities in 2016.5 About two-fifths of the FTE paid staff were counseling staff (that is, no-degree or degreed counselors); the other three-fifths were about evenly divided between medical staff (that is, physicians, nurses, pharmacists, and mid-level professionals), other support staff (that is, peer support staff, care managers, care navigators, other recovery support staff, other clinical staff and interns, pharmacy assistants, contractors/per diem staff, and intake coordinators), and administrative staff. A substantial majority of counseling staff FTEs (57 percent) had a graduate degree, but most counseling staff members with a graduate education were not certified in addiction treatment (60 percent).

FIGURE ES.2. Hours of Care per 100 Outpatient Clients per Week, by Facility Characteristics, N-SSATS 2016
FIGURE ES.2, Bar Chart: Each bar represents the number of hours of care provided by non-administrative staff per 100 outpatient clients per week for a subgroup of facilities. There are three sets of bars. The first set shows the distinction between urban and rural facilities, with urban facilities administering 278 hours of care per 100 outpatient clients per week, and rural facilities administering 370 hours of care per 100 outpatient clients per week. The second set shows the distinction between facilities that provide recovery support services and those that do not, with facilities providing recovery support services administering 373 hours of care per 100 outpatient clients per week, and facilities that do not provide recovery support services administering 269 hours of care per 100 outpatient clients per week. The final set shows the distinction between facilities that focus on substance use disorder treatment, mental health treatment, or both. Facilities that focus on substance use disorder treatment administer 193 hours of care per 100 outpatient clients per week, facilities that focus on mental health treatment administer 1,000 hours of care per 100 outpatient clients per week, and facilities that focus on both administer 405 hours of care per 100 outpatient clients per week.
SOURCE: N-SSATS 2016.
NOTE: Hours of care include only non-administrative staff time.

Outpatient treatment intensity varies based on facility characteristics.

On average, non-administrative staff provided 292 hours of care per 100 clients in outpatient treatment per week. The intensity of treatment varied substantially based on facility characteristics and services offered (Figure ES.2). Statutes and regulations for SUD treatment facilities vary by state and commonly allow facilities substantial flexibility in the professional credentials and intensity of services provided by staff (National Association of State Alcohol and Drug Abuse Directors 2013). There is little research on how staffing affects care quality.

The availability of evidence-based pharmacotherapy has increased, but challenges to further expansion remain.

Pharmacotherapy has been demonstrated to be clinically effective and cost effective for alcohol and opioid disorders (Baser et al. 2011; Mann et al. 2015). Although strong evidence suggests that the use of pharmacotherapy in managing SUDs provides substantial cost savings, the approach has not been widely adopted. The proportion of facilities offering pharmacotherapy has expanded in recent years, but still only 43 percent of facilities offered any pharmacotherapies in 2016.

FIGURE ES.3. Staff Hours of Care per 100 Outpatient Clients per Week, by Whether Facility Provided Pharmacotherapy, N-SSATS 2016
FIGURE ES.3, Stacked Bar Charts: Providing Pharmacotherpy includes Recovery support and other (39), Counselors (147), Nurses (32), and Prescribers (24).  Not Providing Pharmacotherpy includes Recovery support and other (74), Counselors (284), Nurses (14), and Prescribers (22).
SOURCE: N-SSATS 2016.
NOTE: Hours of care include only non-administrative staff time. Counselors include no-degree and degreed counselors. Nurses include registered and licensed practice nurses. Prescribers include physicians and mid-level medical staff.

Many of the barriers to expansion of pharmacotherapy are related to the workforce. The number of medical staff qualified to provide pharmacotherapy services and the staff supporting them needs to increase for provision of pharmacotherapy to expand. Training primary care providers to provide pharmacotherapy in primary care or other integrated care settings such as HIV or mental health treatment settings can improve treatment access and abstinence at six months (NIDA 2017; Korthuis et al. 2017). Primary care providers can act independently or work collaboratively with SUD treatment specialist in these models. In addition to increasing the number of qualified providers, workforce attitudes preferring behavioral therapies may need to change to attain more widespread adoption. Consistent credentialing and licensure requirements across states and insurers for professionals providing pharmacotherapy services are also needed. The HHS Opioid Strategy announced in April 2017 aims to continue the department's efforts to improve access to "treatment, and recovery services, including the full range of medication-assisted treatments" (HHS 2017); also, despite the barriers, the ACA has resulted in expansions in the number of physicians waivered to prescribe buprenorphine (Knudsen et al. 2015).

There were substantial differences in staffing patterns for outpatient treatment based on whether facilities offered pharmacotherapy (Figure ES.3). Facilities that did not offer pharmacotherapy provided nearly twice as many counselor and recovery support staff hours and about half as many nursing staff hours per 100 outpatient clients. Facilities provided a similar number of prescriber hours (including physician and mid-level medical staff) regardless of whether they provided pharmacotherapy.

Residential and inpatient hospital capacity for SUD treatment is insufficient in many states.

Despite increases in designated beds for residential and inpatient hospital SUD treatment between 2013 and 2015, utilization rates rose in these care settings. Nationally, the utilization rate for residential beds increased from 97 percent to 106 percent; that for inpatient hospital beds increased from 97 percent to 109 percent.6 In 18 states, residential bed utilization rates across all facilities were over 100 percent in 2015; the same number of states had inpatient bed utilization rates of over 100 percent.

Treatment provision at publicly operated facilities declined while care at privately operated facilities increased.

Between 2013 and 2015 clients served in public facilities declined substantially for outpatient care (13.7 percent) and somewhat for residential care (4.3 percent). Meanwhile clients served in private for-profit and private non-profit facilities expanded in these settings. This shift may be related to increased rates of insurance coverage. Inpatient clients increased substantially for facilities of all operation types.

The number of clients served in rural areas declined substantially although the population in rural areas was constant.

The number of clients receiving treatment in rural areas declined substantially (31.8 percent) and increased in urban areas (15.6 percent) between 2013 and 2015, the latest period of data available. Meanwhile, the population living in rural areas was fairly constant in this period while the population living in urban areas increased modestly (U.S. Department of Agriculture 2016). Given the treatment access barriers for individuals living in rural areas that pre-date this period, the substantial declines in treatment use in rural areas warrant further investigation.

Low wages for SUD treatment providers present challenges in expanding the workforce.

Although most SUD counselors and social workers providing SUD treatment hold post-graduate degrees, analyses of data from the Bureau of Labor Statistics show that average hourly wages for SUD treatment professionals are substantially below the average wage across all occupations and the difference between the average wage for all occupations and that for counselors has widened over the last decade, from $1.56 per hour in 2006 to $2.63 per hour in 2016. Looking at two health care professions requiring similar or fewer years of education mean hourly wages for SUD counselors were $5 and $13 lower, respectively, than those for marriage and family therapists and registered nurses.

Currently, high turnover and difficulty in hiring qualified SUD treatment staff are attributed by facility administrators to low compensation (Hyde 2013; Ryan et al. 2012; Bukach et al. 2017). Efforts to increase the supply of individuals seeking work in the SUD treatment field by increasing training program output without an associated increase in reimbursement for services or increases in funding sources are likely to result in reduced wage levels and lower retention as individuals in the SUD treatment field recognize the potential to increase their earnings by shifting to other professions.

Discussion

Policymakers at all levels of government have targeted increasing SUD treatment to address escalating drug overdose deaths related to the opioid epidemic and improve societal welfare. Meanwhile, rates of SUD treatment use generally have been constant for more than a decade despite the substantial recent increase in insurance coverage for SUD treatment. Individuals with SUD treatment needs overwhelmingly indicate that they do not feel a need for treatment and, even among the small minority who believe that they might benefit from treatment, most make no effort to obtain it. Increasing treatment penetration will require a multifaceted approach to identify and refer individuals in need to treatment, reduce treatment access barriers, and reduce stigma and change attitudes about SUDs and treatment efficacy.

Overall, the role of Medicaid in funding SUD treatment services has expanded since the beginning of 2014. There is concern that low reimbursement rates and restrictive treatment coverage under Medicaid may be a barrier to expanding treatment in some states (Dickson 2015). State Medicaid programs have the potential to play an important role in transforming the SUD treatment system and the HHS Centers for Medicare and Medicaid Services (CMS) is taking an active role encouraging states to make reforms. CMS is conducting an Innovation Accelerator Program (IAP) to support state efforts to improve care quality and continuity, enhance performance monitoring capacity, identify beneficiaries in need of treatment, develop a continuum of care that addresses the variety treatment needs and the chronic nature of SUDs, and target reimbursement models to incentivize better outcomes (CMS 2017). In addition, CMS has been working with states to improve access to and quality of SUD treatment through Medicaid Section 1115 demonstrations (CMS 2017b).

The impact of a number of recent federal efforts to increase SUD treatment use and the quality of SUD treatment services is not fully captured in the data available for this study. The initiatives include the CMS IAP as well as several SAMHSA grant programs intended to expand access to SUD treatment (McCance-Katz et al. 2017). There are also a number of federally-funded efforts to expand access to SUD screening and treatment in primary care settings and rural areas. Future years of data should be monitored to assess the impact of these initiatives.