Examining Substance Use Disorder Treatment Demand and Provider Capacity in a Changing Health Care System: Initial Findings Report. IV. Comparison of Demand for and Supply of Substance Use Disorder Treatment

09/30/2015

In this section, we first review indicators of supply adequacy to assess the current supply of SUD treatment providers. Then, we compare trends in supply and demand noted above and assess the implications of these trends for supply adequacy within the next five years.

A. Indicators of a Current Shortage

Below, we review multiple indicators of supply adequacy and assess their implications for a current shortage of SUD treatment professionals.

1. Facility Operating Capacity

According to SAMHSA (2014a) analysis of N-SSATS data, 8.8 percent and 18.2 percent of residential and inpatient facilities, respectively, were operating above capacity in 2013 (Table IV.1).20 Similarly, 6.2 percent of outpatient facilities were operating at 6 percent or more above capacity. An additional one-third of outpatient facilities were operating at 95-105 percent of capacity. Likewise, 21 percent of facility directors reported in 2012 that the caseloads for direct care staff at their facilities were too large (Ryan et al. 2012). These data indicate there was a substantial subset of facilities operating at or above capacity prior to implementation of the ACA.

2. Wages

In an efficient market, a shortage of qualified workers in a given profession is commonly associated with increasing wages. BLS data on trends in mean hourly wages for behavioral health professionals in the categories including SUD treatment providers have been stable (Table IV.2), suggesting an equilibrium between supply and demand given the current level of funding provided for SUD treatment services. However, there is the possibility that SUD provider wages are determined in a monopsony market. State and local governments control approximate 63 percent of resources supporting SUD treatment allowing them market power that may not allow wages to increase. Increases in insurance-related funding associated with the ACA and MHPAEA may induce increases in wages in 2014 and beyond if reimbursement rates rise or there is an insufficient number of professionals to meet the increases in demand. In contrast, efforts to increase the supply of individuals seeking employment in the SUD treatment field with no commensurate increase in funding may further reduce wages. In turn, this may result in increased turnover as individuals in the SUD treatment field leave the profession to seek professional opportunities with greater compensation.

Currently, the field's high turnover rate is commonly attributed to inadequate compensation. Compensation for behavioral health professionals is significantly lower than for other health and non-health professions requiring similar levels of training (Hyde 2013). The clinical directors interviewed as part of the Vital Signs survey noted that low compensation makes hiring and retaining qualified staff a challenge (Ryan et al. 2012). Efforts to increase the supply of individuals seeking work in the SUD treatment field 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.

3. Recruiting and Retaining Qualified Staff

The Vital Signs survey of clinical directors of SUD facilities conducted by ATTCs in 2011-2012 included several questions on recruiting and retaining staff (Ryan et al. 2012).

With regard to recruiting, 49 percent of clinical directors reported difficulty filling open positions. The most common reasons cited for these difficulties (respondents could mark more than one) were insufficient number of applicants who met minimum qualifications (63 percent), insufficient funding for open positions (43 percent), lack of interest in positions due to salary (41 percent), and small applicant pool due to geographic area surrounding work setting (36 percent). The most common reasons cited for applicants not having the minimum requirements for the job were little or no experience in substance abuse treatment (50 percent), insufficient or inadequate training and education (49 percent), and lack of appropriate certification (43 percent).

In terms of staff retention, the surveyed facilities reported an 18.5 percent turnover rate each year. This rate is substantially higher than the median turnover rate for primary care physicians in managed care organizations (7.1 percent) and nurse practitioners and physician assistants (12 percent) (Hyde 2013). Clinical directors responding to the Vital Signs survey indicated their ability to retain employees may be hindered by lack of paid educational assistance for employees (44 percent) and lack of available retirement plans (24 percent).

TABLE IV.1. Percentage Capacity at Which Facilities are Operating, by Care Setting, N-SSATS 2013
  Outpatient
(percentage)
Residential
(percentage)
Inpatient
(percentage)
Over
120
106
to 120
95
to 105
80
to 94
Less
Than 80
More
Than 100
91
to 100
50
to 90
50 or
Less
More
Than 100
91
to 100
50
to 90
50 or
Less
Total 1.3 4.9 34.2 35.9 23.8 8.8 47.9 34.4 8.9 18.2 27.3 34.6 19.9
Private non-profit 1.7 6.1 39.0 34.6 18.6 8.0 49.6 34.1 8.4 12.2 27.8 36.5 23.5
Private for-profit 0.4 2.1 25.3 38.8 33.4 11.9 41.1 35.5 11.5 27.3 23.4 33.1 16.2
Local, county, or community government 1.3 7.7 40.0 34.5 16.4 3.8 41.8 41.8 12.7 25.0 25.0 29.2 20.8
State government 3.2 8.3 38.1 33.5 17.0 11.3 48.5 35.1 5.2 12.1 45.5 36.4 6.1
Federal Government 4.3 8.6 48.5 27.3 11.3 15.4 50.0 28.2 6.4 21.4 21.4 28.6 28.6
   Department of Veterans Affairs 5.6 9.7 53.6 26.0 5.1 14.9 49.3 31.3 4.5 25.0 16.7 25.0 33.3
   Department of Defense 3.6 6.0 40.5 34.5 15.5 - - 66.7 33.3 - - - - 100.0 - - - -
   Indian Health Service - - 8.8 41.2 17.6 32.4 25.0 50.0 - - 25.0 - - - - - - - -
   Other - - 8.3 41.7 25.0 25.0 - - - - - - - - - - - - 100.0 - -
Tribal government 2.8 7.6 33.1 33.5 23.1 12.8 35.9 38.5 12.8 66.7 33.3 - - - -
SOURCE: Estimates obtained from SAMHSA 2014a, Tables 4.5-4.7.

 

TABLE IV.2. Trends in Mean Hourly Wages for Behavioral Health Professionals, in Dollars
Type of Professional 2007 2008 2009 2010 2011 2012 2013
Mental health and substance abuse social workers 19
(0.6)
19
(0.8)
20
(0.5)
20
(0.5)
21
(0.5)
21
(0.5)
21
(0.6)
Substance abuse and behavioral disorder counselor 18
(0.6)
19
(1.3)
19
(1.2)
20
(1.2)
20
(0.5)
20
(0.5)
20
(0.5)
SOURCE: BLS Occupational and Employment Wage Estimates, 2007-2014.

4. Concern About Training Adequacy

In 2004, SAMHSA convened a panel of stakeholders who developed a number of recommendations for strengthening the SUD treatment workforce. A number of these recommendations focused on training, including recommendations to create career paths for the treatment and recovery workforce and adopt national core competency standards, support the development and adoption of national accreditation standards for addictions education programs, and increase training of primary care health professionals in addiction treatment.

Concerns about training adequacy were also raised during our interviews with experts from IC&RC and NAADAC. For example, a one state board representative indicated that providers are skeptical of hiring individuals with online training. Similarly, the NAADAC respondent revealed that there is concern that more highly educated workers, most of whom graduate from programs that are not specifically focused on addiction, may not have necessary addiction-specific training. A state board representative indicated that treatment degree programs at the graduate level are commonly classes built into a social work, counseling, or psychology degree and that the bulk of addiction-specific treatment degree programs are at the associate level. Another state board representative estimated they test about as many people a year as the number of people who drop out of the workforce, and they believe that a lack of minimum competencies and standards results in an unprepared and transient workforce. The IC&RC expert interviewee noted that boards handle the recertification process, so they are not certain of the reasons some individuals do not recertify, but they believe that some people have had problems finding adequate continuing education to meet recertification requirements.

Similar concerns about training adequacy were expressed by clinical directors responding to the Vital Signs survey. Clinical directors reported that their facilities face significant challenges in filling open positions due to a lack of qualified applicants (Ryan et al. 2012).

5. Inability to Accept Insurance Coverage

Because providers have traditionally relied on grant funding, there is concern that providers are not prepared to accept the Medicaid and private insurance coverage that potential clients may obtain as a result of ACA insurance expansions. In 2013, over one-third of facilities did not accept private insurance, and a larger percentage (41 percent) did not accept Medicaid. Many facilities may find it challenging to take advantage of new payment sources without support.

Analysis by Andrews and colleagues (2015a) on a survey of SSA activities related to supporting treatment facility ability to meet requirements of the ACA, suggests that SSAs are providing limited support to treatment facilities. The survey included representatives from the 50 states and the District of Columbia and was conducted between November 2013 and July 2014, achieving a 98 percent response rate. The findings indicate only about one in four SSAs was providing technical assistance to help treatment programs with insurance enrollment and outreach to individuals newly eligible for insurance coverage under the ACA. Likewise, one in four SSAs reported providing technical assistance to help treatment facilities join private insurance provider networks and only 6 percent of SSAs reported providing funding to help treatment programs prepare for ACA implementation.

6. Lack of Evidenced-Based Treatment

According to research by the CASA (2012), the services currently provided to SUD treatment clients are inconsistent with the scientific findings on evidence-based treatment. Specific discrepancies between current treatment practice and science include the following:

  • Patient Education, Screening, Brief Interventions, and Treatment Referrals. Despite the documented benefits and endorsements of these activities, few primary care health professionals educate, screen, treat, or refer patients who have SUDs. Only 6 percent of referrals to SUD treatment come from general health care providers.

  • Treatment Often Ends with Detoxification. In 2008, only 12.6 percent of discharges from a detoxification program were transferred to a treatment facility, despite evidence that additional treatment following detoxification is a medical necessity.

  • Pharmaceutical Treatments are Underutilized. Only half of both privately and publicly funded treatment programs use one or more pharmaceutical treatments. There are many reasons for the limited adoption of these treatments, including lack of qualified medical staff in treatment programs, negative attitudes toward pharmaceutical treatments in abstinence-based treatment approaches, and insufficient knowledge about pharmaceutical treatments among prescribers.

  • Treatment Plans are not Tailored to Disease Severity, Co-occurring Conditions, or Chronic Nature of Disease. The standard treatment for addiction is non-intensive outpatient treatment or a brief acute intervention. Relapse is common with these approaches because there is little evidence that addiction remits in a brief period of time. Although addiction is understood to be a chronic disease, treatment approaches do not address this aspect of the illness.

Addressing the disparity between treatment practice and scientific evidence will require more integration of SUD treatment with general health treatment, re-shaping the SUD treatment workforce to incorporate more medical professionals, and improved training for SUD treatment professionals.

7. Summary

Overall, the available evidence suggests that prior to ACA implementation, the SUD treatment workforce was strained to effectively meet the existing level of treatment demand. A substantial number of facilities were operating at or above capacity. Insufficient funding resulted in low wages, which made hiring and retaining qualified staff a challenge. Clinical directors and representatives of certification organizations expressed concerns about training adequacy, and a review of the services provided to clients indicated that current practice was often inconsistent with the scientific findings on evidence-based treatment. Finally, many facilities may not accept or be included in the insurance networks associated with coverage obtained under the ACA.

B. Comparison of Trends in Demand and Supply

Although trends in SUD prevalence and treatment receipt have been relatively constant for the last decade, a substantial shift in demand may be observed between 2014 and 2018. While federal, state, and local funding for SUD treatment are likely to remain relatively stable, the ACA may result in a substantial increase in demand for SUD treatment. Additional increases related to the impact of MHPAEA, the opioid epidemic and changing perspectives about the validity of SUDs as a health condition could further increase demand.

In contrast, on the supply side, we find a workforce that is challenged to meet the existing demand prior to ACA implementation. Although no data are available regarding trends in training program output, interviews with experts suggest, at most, a small increase in training programs in recent years. Meanwhile, credentialing experts and clinical directors express concern about training adequacy specifically noting that more highly educated workers, most of whom graduate from programs not specifically focused on addiction, may not have necessary addiction-specific training and experience. Overall, the best available evidence suggests that the supply side does not have sufficient capacity to address the expected short-run increase in demand that is projected.

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