Forecasting the Cost of Chemical Dependency Treatment Under Managed Care: The Washington State Study
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Linda Grant, M.S., Executive Director, Washington Association of Alcoholism and Addictions Programs - Chair
Over 80 individuals were involved either as advisors or participants in the meetings. They represented health insurance plans, managed care companies, chemical dependency providers, advocacy groups, physicians, and county and state government. This report reflects the conclusions of the group, in which there was a high level of consensus throughout A list of participants and description of process is outlined in Appendix A.
The Issues Investigation Group, in developing its recommendations, followed the seven criteria developed by the Health Services Effectiveness Committee: (1) equity, (2) access, (3) personal choice, (4) medical necessity, (5) preventive, (6) cost benefit, and (7) based on services not providers. Encompassing these considerations as well as keeping in mind the language of the Health Services Act and current mandates, the Group set forth the following objectives:
To meet the challenges of providing universal access to health care at an affordable price, health plans will need flexibility and benefits that can be efficiently administered. Case management should be a tool to assist health plans to accomplish these goals, not add new layers of administration. Because treatment episodes for chemical dependency tend to be relatively short in duration, case management with chemical dependency services is primarily concerned with determining appropriate level of care and ongoing clinical review and does not imply added casework activity:
It is expected that case-management will take place at the last level of contracted risk. Staff model HMOs and capitated providers will perform case-management at the service level. Preferred provider plans will either employ internal utilization review, contract with third-parties to conduct case management independent of ongoing case management at the service level, or contract with providers on a capitated basis. Regardless of administrative structure, the role of case-management is to apply uniform clinical criteria in making decisions around access and coverage.
A small minority of individuals with severe and persistent alcohol and drug addiction may require more intensive casework in relation to long-term care services. This is different from managed care and case-management and would be an additional service, apart from case management, and most likely performed in conjunction with long-term care benefits.
Chemical dependency, alcoholism, other drug addiction: Research often refers to these diseases as "substance abuse." However, "substance abuse," "alcohol abuse" or "drug abuse," as clinically defined in the American Psychiatric Association Diagnostic and Statistical Manual (DSMIIIR or DSMV), are not intended to be covered under the chemical dependency treatment benefit.
"Nicotine dependence" is a substance use disorder under the DSM but the benefit developed herein has not been designed with specific nicotine services in mind. For purposes of pricing this benefit, nicotine dependence will be excluded. However, it would seem appropriate to include smoking cessation services somewhere in the UBP, and it might best fit under the chemical dependency benefit.
It was agreed that the Uniform Benefit Package (UBP) should not offer less than the coverage for chemical dependency that has been mandated in Washington law for 20 years. RCW 48.21, originally enacted in 1974, mandates treating chemical dependency with parity:
In 1986 the Insurance Commissioner adopted WAC 284-53-010 to clarify that intent by defining the comprehensive continuum of services which health plans in Washington State must cover, within medical necessity. These regulations also established a minimum coverage per person of $5,000 every two years; $10,000 lifetime (1986 dollars that have not been adjusted for inflation).
Among the chemical dependency treatment services WAC 284-53-010 requires be covered are medically necessary treatment and supporting services, including medical evaluations, psychiatric evaluations, room and board (inpatient only), psychotherapy (individual and group), counseling (individual and group), behavior therapy, recreation therapy, family therapy (individual and group), and prescription drugs and supplies prescribed by a treatment facility.
HMOs must additionally comply with the federal HMO Act of 1973. Under this law (P.L. 93-222 and its subsequent amendments) HMOs are required to provide medical treatment and referral services for abuse and/or addiction to alcohol and drugs. HMOs typically cover inpatient and outpatient treatment, but virtually all exclude methadone and long-term inpatient chemical dependency treatment.1
A survey of case-managed chemical dependency and mental health benefits conducted by William M. Mercer2 revealed plans now typically provide comprehensive coverage for chemical dependency treatment. Table 1 outlines their findings:
| Chemical Dependency Benefit Residential treatment (CD) Structured outpatient Individual/group outpatient Lifetime maximum (combined CD/MH) |
Plan Coverage $15,000-$20,000/35-40 days $ 4,000 to $9,000* $ 1,300 to $1,500 $45,000-$50,000**/2 episodes |
| *
recommended raising to $6,000 to $12,000 ** recommended raising to at least $125,000. |
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Chemical dependency treatment makes up a very small portion of the overall health care premium. Prior to case management, 80% of employees were able to access their inpatient chemical dependency treatment benefit with no limitations.34 In a study of over 3,000,000 lives, MEDSTAT found that chemical dependency payments were under 3.8% of inpatient medical payments, even at its peak of utilization:5
In a 1990 study, MEDSTAT6 found over a single year a 22.59% reduction in admissions to inpatient chemical dependency treatment and a 20.34% decrease in payments per capita on those treatments. Table 3 shows these changes in relation to other medical benefits.
Within the publicly funded sector, services are broader in range of intensity and duration than those common to private treatment. In addition to intensive outpatient and short-term intensive inpatient, public treatment includes transitional care (recovery houses) of 30–60 days, and long-term treatment of 90 days or longer. In addition, hospital stabilization programs for pregnant addicted women provide hospital inpatient care for several weeks, and some residential programs designed to take women with their infant or young children are also available. DSHS also funds a residential facility to provide treatment for persons involuntarily committed. Finally, "ADATSA," a public program utilized by all persons initially needing residential treatment, provides up to three months residential treatment and three months outpatient.
The National Academy of Sciences' Institute of Medicine has recommended alcoholism and drug addiction be treated as other chronic, relapsing problems such as diabetes and hypertension, with no prespecified day or visit limits. 7 8, 9 Members of the Institute of Medicine, in a subsequent meeting to address health reform, took the position:
Case-management has become the preferred method for controlling behavioral health care costs.11 Managed behavioral healthcare companies, generally operating under capitated carve-out contracts, have reported savings to health plans from 23-50% in the first year.12 One large employer reduced costs for chemical dependency coverage from $85 to $19 per capita per year.13 Once established, claims increases have been held to 1% for HMO/PPO coverages and 9.5% for indemnity plans.14 15,16
State health reform is moving to case-management and uniform clinical criteria in place of restrictive limits. Table 4 outlines the chemical dependency benefit structures in five states undergoing reform:
The Washington State Board of Health is among those locally that have recommended against placing limits on chemical dependency treatment under health reform.17
Minnesota's basic health plan for low income, Medicaid and uninsured, Minnesota Care, has a $10,000 a year limit on combined mental health and chemical dependency intensive inpatient treatment. and no limit on outpatient. The actual cost per episode of treatment has been held to $3,000 through use of uniform criteria to make individual case decisions about level of care and duration of treatment. After five years of experience, Minnesota's data provide strong support for using case management in lieu of traditional benefit limits:18
No studies or research were found that showed limits on benefits to be superior to case management for cost control.
Local chemical dependency case management firms working with the Issues Investigation Group indicated that utilization for inpatient and residential treatment under case management can be kept to a small portion of the total population served.
Lewin-VHI, Inc. recently completed a national actuarial study on four different chemical dependency benefits.19 The estimate for a plan similar to the one conceived by the Issues Investigation Group of limited residential and short-term, was around $2 per person per month, which would be less than 2% of the premium of the Uniform Benefit Package. The highest estimated cost in this study was $3.75 per person per month for a benefit that included long-term residential, unlimited outpatient, higher utilization and longer duration residential/inpatient, and full drug prevention and education activities.
Based on current market contracts in the Puget Sound area, and on existing data, it would appear that the proposed benefit will capitate under $2 per person per month. The Department of Social and Health Services is working with the Health Services Commission to obtain an actuarial analysis of this proposal, and this data will be available after June 10, 1994.
Appendix B provides more information on Minnesota and the executive summary of the Lewin-VHI analysis.
Such diverse groups as the American Society of Addiction Medicine, President Clinton's Commission on Model State Drug Laws, the Legal Action Center, the American Managed Behavioral Healthcare Association, and the Washington Business Group (190 of the nation's largest employers) have all called for comprehensive coverage for chemical dependency in health reform, managed like any other medical condition.20 The elements common to all proposals for chemical dependency coverage are:
A cornerstone of this benefit recommendation is to use less restrictive alternatives as the mainstay of delivery. However, it is essential that those few who need more intense forms of treatment also are able to receive appropriate, effective care.
Chemical dependency benefits must address the needs of a wide range of individuals of all ages, receiving treatment at different points in the progression, and experiencing different levels of physical, mental, or social impairment as a result of the disease.
Severity of addiction plays a great role in placement determinations: 60% of inpatients are at the high end of severity of addiction, and 60% of outpatients are at the low end of severity21 (see Appendix C for full research summary from CATOR). A 21-day residential intensive inpatient treatment in Washington State can be obtained for as little as $2520 for adults, and a 28-day residential adolescent program can cost as little as $3920. If unable to receive effective levels of treatment, individuals only end up revolving in an out of detox, emergency rooms, mental health facilities, and physicians' offices at far greater expense than the cost of appropriate chemical dependency treatment.
Some individuals cannot be treated in outpatient settings. For example, a pregnant addicted woman may require medically managed chemical dependency treatment to complete safe withdrawal from drugs for herself and the unborn baby.
Making the coverage available does not imply that patients will utilize each coverage, or have unlimited access to that modality of care. Intensity of care and duration will be determined on a case by case basis, based on clinical indicators and examination of "appropriate" and "effective" in the case management process. Increasingly services are "blending" inpatient and outpatient programs for patients who live in areas where inpatient facilities are available.
Since the Uniform Benefit Package is intended to provide a benefit floor, basic and affordable while meeting the health needs of most citizens of this state, the benefit herein is also a basic one that will effectively treat the disease. The long-term services needed by the minority may either be provided within the scope of long-term care benefits or funded through another service system altogether.
For consistency, the Issues Investigation Group required that every included service must be medically necessary and directly linked to treating the disease of chemical dependency. It also treats chemical dependency as a primary disease, consistent with research that has identified that chemically dependent persons have no greater incidence of mental disorder than the population in general.22, 23, 24
In the context of chemical dependency, medical necessity is used in a broader sense, as defined by the Health Services Commission, to mean "clinical necessity" as well. References to "medical necessity" herein include "clinical necessity."
This UBP recommendation deliberately does not attempt to cover all the psycho-socio-economic needs of individuals and their families presenting for treatment. However, this exclusion should not be interpreted as a denial of the value of support services or the role they may play in facilitating access, outcome, or prevention. As is stated throughout this paper, it is possible that some of these services will be covered under other benefits; if not, they will need continuation under supplemental systems. The group simply determined early that this must be a conservative package that does not create concerns for cost that might lead to excluding chemical dependency treatment altogether.
Likewise, the Issues Investigation Group conceded that it was not realistic to expect that health plans to cover the cost of a full two-year court-ordered chemical dependency treatment program, regardless of the initial medical need of the patient. Therefore, the Uniform Benefit Package would not cover monitoring or treatment required after the person no longer meets clinical criteria for medical necessity. The reverse of this is also important: Individuals should not be denied access to treatment by virtue of court involvement. Medical necessity determinations should be based on clinical criteria, regardless of legal involvements, as regulations now require.
As case management has become the preferred mode for administering chemical dependency benefits, health policy experts are moving toward national adoption of uniform criteria to guide the medical necessity decisions of case managers.25, 26, 27, 28, 29
President Clinton's Commission on Drug Laws has prepared the Model Managed Care Consumer Protection Act, based on adoption of uniform clinical criteria, to provide reasonable protections to policyholders that they can access the benefits they have paid for. Oregon, Minnesota, Texas, Colorado, New Mexico, Vermont, Iowa, and Massachusetts are among those that have adopted, or are in the process of adopting, standard practice guidelines for chemical dependency.
The American Society of Addiction Medicine, a national group of physicians with specialized education and experience in chemical dependency, over the past decade developed, tested and refined placement and discharge criteria for chemical dependency treatment services, referred to as "ASAM Criteria."30 These criteria are employed across Washington State and the nation, and are a component of the Model Managed Care Consumer Protection Act.
ASAM Criteria identify six primary problem areas for evaluation when making placement decisions: acute intoxication and/or withdrawal potential; biomedical conditions and complications (such as psychiatric conditions, psychological or emotional/behavioral complications of known or unknown origin, transient neuropsychiatric conditions); emotional/behavioral conditions or complications; treatment acceptance or resistance; relapse potential; and recovery environment.
Assessment of the individual's medical status and functioning in each of these areas will determine the appropriate level of care and length of time needed in treatment. Appendix D contains an overview of the ASAM placement criteria for adults and adolescents as well as their glossary of terms, including "medical necessity."
Alcohol and drug problems in 1990 cost Washington State $1.81 billion--$215.8 million in medical care and over $500 million from accidents and deaths related to alcohol and drug abuse.31
At least 13.5% of all adults will experience alcohol abuse or dependence in their lifetimes and 6.1% will experience a drug problem, exclusive of nicotine.32 Over 72 illnesses and health conditions have been directly linked to alcohol and other drug abuse (see Appendix E).33
Between 20% and 40% of all hospital admissions are for conditions related to alcoholism.34, 35, 36, 37 As many as 40% of all patients seen by physicians have alcohol problems.38 Alcohol-related hospitalizations among elderly are as common as myocardial infarction.39 Table 5 shows the use of hospitals for medical, psychiatric, and for detoxification before and after treatment for chemical dependency:40
Twenty percent of Medicaid admissions in 1990 were for conditions caused by substance abuse,41 and 38% of all Medicare admissions were alcohol-related.42 Substance abusers required twice the length of stay in hospitals when admitted for other conditions.43
Over two decades of data consistently show that the cost of chemical dependency treatment is recouped within two to three years of treatment through reductions in other health care services.48 49, 50
Families' use of health care has been found to drop by more than 50% after treatment,57, 58 with one Blue Cross/Blue Shield plan showing a reduction from S100 a month in the two years prior to treatment to $13.34 in the fifth year post-treatment.59
When savings from reduction in workplace absenteeism and accidents and increases in productivity are factored in, as well as reductions in crime and violence, dollars spent on treatment are offset even more rapidly.60
Appendix F contains more information on cost offsets, including the executive summary of the review of all the research on treatment effectiveness and cost offsets conducted by Rutgers University for President Clinton's Commission on Drugs.
Courts are the primary intervention agent with chemically dependent persons, and social service agencies the next. Although chemical dependency has been recognized as a medical health problem since the 1 960's, the health care system has not confronted chemical dependency as a primary problem. Washington State health reform provides an opportunity to integrate preventive efforts with health care to identify and treat persons with chemical dependency and "reduce inappropriate utilization of more intensive or less efficacious medical services" (HSA of 1993).
Primary Care Provider Screening and Assessment: Only 32% of primary care physicians in a University of Washington study could effectively diagnose patients with alcoholism; one-third erroneously made psychiatric diagnoses, chiefly anxiety or depression61 (full article is in Appendix G). In order to reduce the inappropriate use of medical services by chemically dependent persons, it is essential that greater attention be given by health plans to screening and referral to case management.
Screening can be as simple as the four-question CAGE questionnaire62, which takes 30 seconds to administer. Group Health of Puget Sound has implemented full protocols for primary care providers to screen and refer patients with chemical dependency. The Chemical Dependency Issues Investigation Group recommends the Health Services Commission, perhaps through the Quality Improvement Committee, recommend systems to improve screening for chemical dependency by primary care providers and other gatekeepers.
The examination of the previous areas, led to the following conclusions:
| Case-managed Chemical Dependency
Treatment Services: Medically necessary hospital, residential, outpatient primary chemical dependency treatment and collateral services (includes triage, assessment, case management, concurrent family education and counseling services) which are case-managed in accordance with state-recognized uniform chemical dependency placement, continuing stay and discharge criteria. Deductibles and Copayments: Consistent with those applied to medical inpatient and outpatient services. Benefit Limit: No specific limit, except mat all services must be deemed medically necessary and approved by me Certified Health Plan through their chemical dependency case management process. Proposal does not include long-term residential and outpatient chemical dependency services except as covered under long-term care benefits. |
In addition to the specific case-managed chemical dependency benefit, other sections of the UBP appear to cover necessary services for persons with alcohol and other drug problems, and the group makes the following recommendations in this regard:
Chemical Dependency Services
Covered under Other Sections of the UBP:
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Both clinicians and health plans wish to see detox case-managed, but it must also be immediately accessible, apart from case management, on an emergency basis. The group has recommended that:
Collateral services under the case-managed chemical dependency benefit of the UBP should be covered only when provided as part of an intensive treatment program, and as medically necessary. Among services needed by some patients are urinalysis and other laboratory tests, medical consultation, medications prescribed by the physician of the chemical dependency treatment facility, psychological evaluation/consultation, and acupuncture.
Preventive Counseling and Intervention: It is far less costly to provide limited counseling to chemically dependent persons feeling at risk of using drugs or alcohol than to serve them after they have relapsed. To encourage preventive intervention the Preventive Services section of the UBP should specifically identify relapse prevention counseling.
Brief Intervention: One of major tools for families to deal with a chemically dependent relative is "chemical dependency intervention." This consists of a several structured sessions designed to assist families in designing a strategy to confront the dependent person and break the cycle of denial. It often results in treatment for the dependent person and usually provides strong support for the family in crisis. The Issues Investigation Group presumes this fits under "Preventive Services" and raises the issue for clarification and perhaps specification.
Inclusion into the "Case-managed chemical dependency services" benefit was based on direct relationship to treating the person with the addictive disease, and direct relation to the addiction itself. It was also narrowed to exclude some publicly funded social, rehabilitative, and support services. This is not to say these services are not essential and do not need continued funding. It is simply an attempt by the Issues Investigation Group to provide the Health Services Commission with a clinically-based, consistent approach to drawing the boundaries around a service that in the public sector has become quite blurred.
Long Term Care: These recommendations have not attempted to incorporate the full range of individual and community-wide services required by a small group of chemically dependent persons who repeatedly access detoxification centers as well as emergency rooms, hospitals, and primary care physician's offices. It is important, however, to note that special long-term services must continue to be funded, whether through long-term care benefits or through supplemental delivery systems.
Support Services: Publicly funded services have encompassed an array of supportive services, such as housing, living assistance, child care, transportation, and vocational rehabilitation, which enhance the total rehabilitation of individuals with needs beyond primary chemical dependency treatment. These support and habilitative services would be funded independent of the health care system. Therapeutic child care, provided in conjunction with a parent in treatment, would also be a separately funded activity.
Chemical Dependency Family Counseling: When the chemically dependent person enters treatment, family members and other significant persons (including employers) are given ancillary education and counseling, and this is included in the UBP recommendation. However, family members often seek out counseling prior to the dependent person entering treatment. As pointed out earlier, family members are as great a source of health care utilization as the alcoholic/addict, but in order to keep a minimal service package, this was not incorporated into the "Case-Managed Chemical Dependency Services" benefit. It is possible that these services might be covered under mental health benefits and, to a limited extent, under Preventive Services.
Child Care: Neither therapeutic child care nor day care are included in this benefit recommendation. When therapy is provided to children of chemically dependent persons as an adjunct to that treatment, it is assumed that the child will have mental health benefits to cover their services. Other forms of child care would be funded by the Department of Social and Health Services or other supplemental systems.
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2Anderson D.F., and Berlant, J.L. Managed mental health and substance abuse services. In Kongstvedt, P.R. (Ed), The Managed Health Care Handbook, 2nd Edition. Aspen Publishers: Gaithersburg, MD, 1993, pp 130-141.
3Institute of Medicine, Treating Drug Problems, Vol. 1. Washington, DC: National Academy Press, 1990.
4Ford, M.Q. The incredible shrinking utilization. NAATP Review, 1992:13(3): 2-5
5MEDSTAT Systems, Inc. Unpublished data prepared for the National Association of Addiction Treatment Providers, 1992.
6MEDSTAT Systems, Inc. Unpublished data prepared for the National Association of Addiction Treatment Providers, 1992.
7Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press 1990.
8Institute of Medicine. Treating Drug problems (Vol. I). Washington, DC: National Academy Press, 1990.
9Lewis, D.C. The rationale for including a substance abuse benefit in health care reform: Medical, research, economic and community perspectives. George Washington 10 University, Intergovernmental Health Policy Project, 1994, pp. 3-5.
10Lewis, D.C. Ibid.
11McArdle, FB and Mahoney, JJ. Report prepared by Hewitt Associates, employee benefits consulting firm, for the Subcommittee on Health and the Environment, Committee on Energy and Commerce, United States House of Representatives on Mental Illness and Substance Abuse Benefits, December 3, 1993.
12Geraty, R., Bartlett, J., Hill, E., Lee, F., Shusterman, A., and Waxman, A. The impact of managed behavioral healthcare on chemical dependency treatment. Behavioral Healthcare Tomorrow, 1994: Mar/Apr, 18-30.
13Larson, M.J., and Horgan, C.M. Issues in calculating the cost of a substance abuse benefit under health care reform. Intergovernmental Health Policy Project, The George Washington University, Washington, DC 1994.
14SAMHSA: Effectiveness of managed care delivery of mental health/substance abuse services. Unpublished. Rockville, MD: Substance Abuse and Mental Health Services Administration, DHHS. 1993.
15Geraty, R., et al., op cit.
16SAMHSA, op cit.
17Testimony to the Washington Health Care Commission, September 29, 1992, by Beverly Lingle, Chair of the Washington State Board of Health.
18Research News: Minnesota's chemical dependency efforts influence national health care reform bill. Minnesota Department of Human Resources, 1994.
19Hawood, HJ, Thomsom M, Nesmith T. Healthcare Reform and Substance Abuse Treatment: The cost of financing under alternative approaches. Report of Lewin-VHI, Inc. dated January 19, 1994.
20Lewis, D.C., op cit.
21CATOR. Measurement of Patient Risk: A Critical Element of Care and Management. Research summaries, 1993.
22Schuckit, M.A. Low level of response to alcohol as a predictor of future alcoholism. Am J Psychiatry, 1994: 151, 184-189.
23Brown, S.A ., and Schuckit, M.A. Changes in depression among abstinent alcoholics. Journal of Studies on Alcohol, 1988: 49(5), 412-417.
24Schuckit, M.A. Treatment of anxiety in patients who abuse alcohol and drugs. In R. Noyes, et al (Eds.), Handbook of anxiety, Vol. 4: The treatment of anxiety, 1990.
25McArdle, F.B., and Mahoney, J.J., op cit.
26Langenbucher, J.W., McCrady, B.S., Brick, J., and Esterly, R. Socioeconomic Evaluations of Addictions Treatment: Prepared for the President's Commission on Model State Drug Laws. Piscataway, N.J.: Rutgers University, 1993.
27Legal Action Center. The Need for Specific Coverage for Drug and Alcohol Treatment in National Health Care Reform, unpublished paper dated March 24, 1993.
28Institute of Medicine. Treating Drug Problems, Vol. 1. Washington, DC: National Academy Press, 1990.
29Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press, 1990.
30American Society of Addiction Medicine. Patient Placement Criteria for me Treatment of Substance Abuse Disorders. March 1991.
31Wickizer T., Wagner, T., Atherly, A., and Beck, M.. The Economic Costs of Drug and Alcohol Abuse in Washington State: Olympia, WA: DSHS, 1992.
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33Center for Substance Abuse Treatment at Columbia University. Substance Abuse Services and State Health Care Reform. Unpublished report of meeting September 9-10, 1993.
34Moore R.D., et al., op cit.
35Holden, C. Alcoholism and the medical cost crunch. Science, 1987: 235(Mar 6), 1132-1133.
36Brandeis University Institute for Health Policy. Substance Abuse: The Nation's No. 1 Health Problem, 1994.
37Economic Costs of Drug and Alcohol Abuse in Washington State, DSHS, 1990, p. 70.
38Brown, R.L., Carter, W.B., and Gordon, M. J. Diagnosis of alcoholism in a simulated patient encounter by primary care physicians. J Family Practice, 1988: 25(3), 259-264.
39Adams W.L., Yuan, Z., Barboriak, J.J., and Rimm, A.A. Alcohol-related hospitalizations of elderly people JAMA 1993: 27(10), 1222-1225.
40Harrison, P.A. and Hoffman, N.G. CATOR Report: Adult inpatient completers one year later St. Paul: Ramsey Clinic 1989.
41Center on Addiction and Substance Abuse at Columbia University. The Cost of Substance Abuse to Arnenca's Health Care System, Report 1: Medicaid Hospital Costs. Columbia University, 1993.
42Adams WL, Yuan Z, Barboriak JJ, and Rimm M. Alcohol-related hospitalizations of elderly people. JAMA, 1993: 270(10), 1222-1225.
43Columbia University Center on Addiction ad Substance Abuse, op cit.
44Langenbucher J.W., et al. op cit.
45Ellwood, M.R., et al. An exploratory analysis of the Medicaid expenditures of substance exposed children under two years of age in California. Unpublished paper, Sept 1993.
46Langenbucher J.W., et al. op cit.
47Children of Alcoholics Foundation, Inc. Children of Alcoholics in the Medical System: Hidden Problems; Hidden Costs. New York: 1990.
48Holder, H. Alcoholism treatment and potential health care cost savings. Medical Care, 1987: 25, 52-71.
49Langenbucher, J.W., et al., op cit.
50U.S. Congress Office of Technology Assessment. Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment, March 1983.
51Holder, H.D., and Blose, J.O. Alcoholism treatment and total health care utilization and costs. JAMA, 1986: 256(11), 1456-1460.
52Holder, H.D., and Blose, J.O. The reduction of health care costs associated with alcoholism treatment: A 14–year longitudinal study. J.Studies on Alcohol, 1992: 53(4), 293-302.
53Hoffman N.G., DeHart, S.S., and Fulkerson, J.A. Medical care utilization as a function of recovery status following chemical addictions treatment. J. Addictive Diseases, 1993: 12(1), 97-108.
54Longhi, D., Brown, M., and Comtois, D. ADATSA Treatment Outcomes: Employment and Cost Avoidance. Department of Social and Health Services, Office of Research and Data Analysis. 1993
55Krohn, M. Preliminary findings for MOMS project. DSHS Focus, Winter/Fall 1993.
56Tabbush V. The effectiveness and efficiency of publicly funded drug abuse treatment and prevention programs in California: A benefit-cost analysis. UCLA, March 1986.
57Spear S.F. and Mason, M. Impact of chemical dependency on family health status. Intl J Addictions, 1991: 26, 179-187.
58Mahoney, J.J. McDonnell Douglas Corporation Employee Assistance Program Financial Offset Study, 1985- 1988. Unpublished paper, 1989.
59Holder, H.D., and Hallan J.B. Impact of alcoholism treatment on total health care costs: A six year study. Advances in Alcoholism and Substance Abuse, 1986: 6, 1 -15.
60Langenbucher J.W., et al., op cit., p. 3-11.
61 Brown, R.L,. Carter, W.B., and Gordon, M.J. Diagnosis of alcoholism in a simulated patient encounter by primary care physicians. Journal of Family Practice, 1987: 25(3), 259264.
62Mayfield, D.B., McLeod, G., and Hall, P. The CAGE questionnaire: Validation of a new alcoholism screening instrument. Am J Psychiatry, 1974: 131, 1121 -1123.
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