The use of therapeutic resources is related to factors other than the morbid condition affecting the patient. Patients’ needs, the sociocultural background of patients and providers of services, therapeutic philosophies, and financial incentives in the deliuep of seruices all play a role.

Resource Use and Community Impact

Alfonso Paredes

The decision concerning which therapeutic services best fit a patient’s needs is influenced by factors other than the condition afflicting the patient. It is impor- tant that these factors be identified and examined so that programs may be planned and managed more effectively. Our discussion will use illustrations from services delivery research outside the field of alcoholism. Data from the alcoholism services system will be used in instances in which appropriate infor- mation is available.

Public visibility is a factor that determines which services are used. Thus, campaigns to familiarize the community with the availability of mental health services promote their use (Spiro, Siassi, Crocetti, 1975). Social class is also a factor. Although low use of therapeutic resources is observed among the poor, when public programs are made easily available, resource use increases (Bergner and Yerby, 1968; Bombardier and others, 1977). However, even with the greater availability of resources, the poor do not use therapeutic re- sources as often as do higher economic groups (Sparer and Anderson, 1973).

The ethnicity of the client is an important factor affecting the type of provider who will deliver services to that client. For example, a study demon- strated that, compared with whites, blacks were two to four times more likely to be under the care of surgeons in training than under the responsibility of experienced surgeons. Incidentally, this pattern of care remained unchanged

New Directions for Mental Health Services, 10, 1981 19

20

after the method of payment shifted to individual reimbursement through pri- vate insurance (Egbert and Rothman, 1977). In the case of alcoholism ser- vices, people of low economic status are overrepresented among the recipients of care in federal government supported programs. Unemployed people are also overrepresented; those in the program who were employed, however, re- ported incomes above the poverty level (Ruggels and others, 1975).

The vicissitudes o f the economy have a significant impact on the use of residential mental health services. The poor, as well as the privileged, are affected by economic stress. Members of the most economically insecure groups show a greater risk of hospitalization during periods of economic adversity. The probability of using residential care is affected by social posi- tion factors such as education, occupation, and income. Sex and age also have an impact. Those factors most significantly contributing to the individual’s use of services are changes in career patterns, retirement, death in the family, marriage, responsibility for the care and education of the young, separation and divorce, as well as physical or mental illness (Brenner, 1969). Economic adjustments result in life changes; a considerable proportion of those individu- als faced with greater change and need to adapt will experience behavioral syniptoms. Many will receive treatment, thus affecting demand for services (Dooley and Catalano, 1980).

Data collected statewide through an information system have helped the author and associates to identify factors that may operate in the selection of patients for alcoholism treatment. Although the findings cannot be extrapo- lated to other settings, it is apparent that there is an increasing need to subject data derived from large delivery systems to inquiries. Sociodemographic and clinical descriptors of patients who were taken in for treatment were compared with those of clients who appeared at the agencies seeking help but did not become involved in the treatment programs. Those reporting more years of heavy drinking were more likely to be accepted for treatment. Sobriety reported at admission decreased the probability of remaining in treatment. As we may expect, those who were intoxicated at the time of initial contact were more likely to be admitted to the programs. A significantly larger proportion of court-referred patients were admitted to treatment, thus reflecting the coer- cive nature of these referrals.

In one study, we categorized the programs into groups according to the number of treatment modalities offered. Five groups offering from four to eight services to each pattern were identified. Three of the groups offered resi- dential care among the services available. The sociodemographic characteris- tics of the clients serviced by the various groups were found to be comparable, except that the programs providing residential care had an overrepresentation of nonwhites. Agencies offering residential care and a broad range of services showed larger proportions of unemployed and family-disaffiliated people (Div- ision on Alcoholism, 1978).

21

The rate of use of such services as inpatient, outpatient, and individual or group counseling by programs belonging to the same group category appeared haphazard. Certain agencies relied heavily on a given type of service, while others seldom used it. The service utilization patterns appeared to be a func- tion of the administrative orientation of the program rather than a response to particular characteristics or needs of the clients.

Relationships among the types of services delivered and demographic and clinical characteristics of the patients were investigated. Our findings indi- cated that females were overrepresented among clients assigned to residential treatment. Patients in the residential care group were more likely to be family disaffiliated, reported greater A.A. attendance, were more likely to be intoxi- cated on admission, and were less likely to have a permanent home and employment. Clients receiving outpatient care appeared less severely ill on measures of drinking behavior and social performance (Division on Alcohol- ism, 1978). It is apparent that further research needs to be done to determine if alcoholism programs are used mainly as therapeutic resources or as commu- nity life support systems for people occupying a vulnerable position in the job market.

The use of health services varies considerably in different geographic areas. Even in the case of conditions accompanied by objective signs, such as surgical conditions, treatment varies greatly according to the geographic region. These variations cannot be explained on the basis of disease preva- lence. For example, elective and discretionary surgical operations are per- formed almost twice as often in Canada as in England (Vayda, 193). Such dif- ferences in therapeutic resource use cannot be explained on the basis of preva- lence of disease. The existence of such variability may deserve investigation in the alcoholism area.

Methods in the payment for health services, the number of practition- ers in the area, and treatment slots influence resource use considerably. Use is often determined by the coverage available for costs of care and dramatically increases after prepaid health plans are instituted (Fullerton, Lohrenz, and Nyca, 1976). In a study of the Blue Cross/Blue Shield Plan, the benefits paid for the care of mental conditions increased progressively as a percentage of the health dollar (Reed, 1974). Thus, once an instrumentality of payment for mental health services became available, utilization increased progressively. This phenomenon seems to have also occurred in the case of treatment for alcoholics. Alcoholism programs proliferate as a greater number of prepaid plans include alcoholism coverage. However, review procedures have been shown to reduce costs per mental health incident by reducing the rate of use and lowering the cost of psychiatric hospitalization. Use may also be affected when controls such as previous approval for estimated days of stay in a hospi- tal are required (Brian, 1972).

It is assumed that prepaid group practice promotes more efficient use

22

of therapeutic resources (Hughes and others, 1974). In keeping with this model, financial incentives result from keeping larger numbers of healthy and socially productive individuals in the community, while other models, such as fee-for-service, presumably reward greater numbers of therapeutic interven- tions. Prepaid plans allegedly encourage preventive health measures, duplica- tion of services is eliminated, and through early intervention, the patient is returned to optimal levels of social adaptability (Burnell, 1971). However, the waiting common in prepaid plans may also be an important factor in discour- aging utilization.

The need for monitoring the delivery of health services has been dra- matized in several studies. Even in health centers with personnel possessing a high level of expertise, inappropriate therapeutic procedures are common. For example, in a well known and reputable university-operated health care center as much as 54 percent of the total antibiotic therapy was found not to be indi- rated, or inappropriately administered, in terms of drug or dosage (Castle and others, 1977). A study conducted in Saskatchewan demonstrated a dramatic decrease in the number of the hysterectomies performed after introducing a mechanism of surveillance that defined the criteria under which the operation was justified (Dyck and others, 1977). It is generally accepted that an adequate volume of activity is essential in order to maintain an acceptable level of skills of both individuals and teams responsible for complex therapeutic maneuvers. Monitoring and a reasonable volume of activity to maintain good skills may also be important in alcoholism programs.

Many problems emerge when an adequate monitoring system is not in place. For example, an investigation failed to show significant correlations between respiratory morbidity, criteria for selection of operations, and surgi- cal resources available with the rates of elective surgery, in this case, tonsillec- tomies, observed across geographic areas. In the same study, few practitioners accounted for the majority of the operations (Roos, Roos, and Henteleff, 1977). Another interesting feature in the delivery of services is that the heavi- est patient caseloads are not necessarily assumed by the practitioners that have more skills. An excessive number of general physicians perform surgical oper- ations, while a rather large proportion of surgical specialists who have more training and the greatest commitment to surgery carry only modest work loads (Nickerson and others, 1976). The possibility of using resources either unnec- essarily or without justification has been raised by various studies. In a study of cases in which surgery was recommended, 24 percent of all surgical proce- dures were found not to be indicated when the opinion of a second expert was requested (McCarthy and Widmer, 1974). Many of the problems mentioned could be corrected with the use of an efficient surveillance system.

In summary, the use of therapeutic resources is related to factors other than the morbid condition that affects the patient. In clinical practice, the complex interaction of patients’ needs, therapeutic philosophies, training, and

23

the sociocultural background of service providers, as well as the financial incentives in the delivery of services all significantly influence how therapeutic resources are used (Paredes, 1977).

Community Impact of Alcoholism Services

Only a few studies have attempted to assess the therapeutic impact of systems or aggregates of alcoholism programs on large numbers of patients (Polich, 1980). Most investigations of therapeutic outcome have been con- ducted with groups of patients processed in one program. Occasionally, three to four programs have been evaluated simultaneously. Studies conducted with patients from a large network of programs have been monitored through the information system of the National Institute on Alcohol Abuse and Alcohol- ism. According to these investigations, the impact of alcoholism programs appears to be favorable along several dimensions. In one study, outcome was assessed using variables, such as alcohol consumption, behavioral impair- ment, and social adjustment. Measures closely related to the alcoholism syn- drome, such as alcohol consumption and behavioral impairment, showed rates of improvement in males as high as 70 percent. Social adjustment indices, such as gains in employment and income, are also favorably influenced. On the other hand, marital status does not appear to be affected by participation in alcoholism programs (Armor, Polich, and Stambul, 1976). The findings of these studies are congruent with the results reported by comprehensive reviews of treatment studies (Baeckland, Lundwall, and Kissin, 1975; Emrick, 1975).

Regarding the stability of the gains obtained, it was found that remis- sion rates among the clients of the system at six months follow-up compared favorably with results of assessments at eighteen months. However, a recent study indicates that drinking status at eighteen months is a better predictor of the outcome observed four years after treatment (Polich, Armor, and Braiker, 1980). In the group of agencies investigated by Armor, Polich, and Stambul (1976), very few differences in treatment outcome were observed between inpatient and outpatient treatment modalities. Combinations of modalities, such as outpatient treatment following inpatient care, do not yield more favor- able results than inpatient care alone. Amount of exposure to treatment has a positive correlation with improvement, but therapeutic effects level off once the amount of exposure to treatment has reached a certain point (Jones and others, 1980).

Alcoholics in treatment experience comparable remission rates regard- less of the form of treatment administered. Regular attendance at Alcoholics Anonymous meetings may be as effective as formal treatment provided by alcoholism programs, but the effect of self-selection in A.A. membership has not been assessed. Remission of symptoms is observed in patients treated at alcoholism programs even when minimal amounts of treatment are provided.

24

However, these rates are better than among patients who received little or no treatment. Remission obtained, to a great extent, seems to be a function of the patient’s clinical status and level of social functioning on admission, rather than a response to a treatment modality or to the amount of treatment admin- istered (Armor, Polich, and Stambul, 1976).

Two colleagues and I studied outcome data from a statewide network of alcoholism programs, including twenty-six alcoholism agencies (Paredes, Gregory, and Rundell, 1979). The results of this study differ in a few impor- tant respects from the study by Armor, Polich, and Stambul(l976). The over- all rate of remission at six months follow-up was considerably lower (54 per- cent) than in Armor’s study. The stability of remission at the six and eighteen months follow-up was also documented. Reduction of drinking correlated pos- itively with social performance variables such as stability of employment. Work-earned income increased, loss of work due to drinking was reduced, and use of institutional resources was less in treated patients. An important finding of our study was that a significant portion of patients (17 percent) were classi- fied as being in remission at the time of admittance to treatment. For these people, the intervention seemed to have operated as a secondary prevention measure. Another possibility is that these people were using treatment services to justify their sick role and participate in its inherent benefits. Alcohol treat- ment programs may have provided life supports for a significant number of those labeled as alcoholic who are in fact middle-aged, in a weak position to compete in the labor market, family disaffiliated, and probably lonely but who may have not needed treatment for alcoholism. Interestingly, the amount of therapeutic services provided to these patients, as measured by the amount of money reimbursed for services, was not less than that spent on active alcohol- ics coming for treatment. Since only a small proportion of people seriously troubled by alcohol enter into the treatment system, it is necessary to make a strong case for the treatment of these alcoholics in remission.

A significant finding in the study of Paredes and others is the relapse rate observed among patients who engaged in so-called normal drinking at six months follow-up. These people had a higher relapse rate when assessed at the eighteen month follow-up than their counterparts who took a total abstinence stance at six months. This finding is at a variance with the results reported by Armor and his associates (1976) although the same authors (Polich, Armor, and Braiker, 1980) later reported results that confirmed our findings. Recom- mendation of abstinence is a good therapeutic stance and the adoption of this advice by the patient will increase the probability of therapeutic success.

The recent study of Polich and his associates (1980), using data cover- ing follow-up periods of four years, provides further insights into the impact of a system of alcoholism programs. Serious alcohol-related problems were reported in 90 percent of the admissions to alcohol programs. Four years later, 54 percent of this group remained seriously affected by the excessive use of

25

alcohol. Within the four year span, 14 percent of the admissions had died. The causes of death were mostly such alcohol-related events as suicide, accidents, and medical complications. The therapeutic value of follow-up was limited, as contacts with the treatment agencies were found to contribute only modestly to treatment outcome. Furthermore, outcome was only slightly less favorable among patients who received treatment consisting of only one visit as com- pared with those who participated in more than five therapeutic visits.

The adoption of abstinence, as mentioned, is an important factor as a predictor of outcome, particularly if it is maintained for more than eighteen months. The short-term abstainers show a 9 percent mortality at four years against 1 percent for the long-term abstainers. It is interesting to note that alcoholics, even when they abstain, are marginal individuals. Abstinent alco- holics show lower levels of social adjustment and psychological functioning than people from the general population. Modalities of treatment such as expensive residential care are difficult to justify, since this type of treatment shows no better therapeutic advantages than outpatient treatment.

The main areas impacted by participation in treatment programs are alcohol-related illnesses, medical treatment and hospital use, frequency of arrests, employment stability, and extent of interpersonal problems (Polich, Armor, and Braiker, 1980). The benefits observed after treatment, however, cannot be necessarily attributed to the treatment program. Other factors such as self-selection or the characteristics of the patient on admission may account for the improvement observed.

We readily assume that treatment is beneficial for the alcoholic. It is quite possible that unfavorable results may result from our intended therapies. The pattern of frequent reentries and drifting through different treatment pro- grams may suggest that the alcoholic is using the network of services as life supports. The acknowledgment of being an alcoholic, so often considered a requirement for treatment, may have negative consequences (Fox, 1967). The process of labeling may encourage prone persons to adopt or remain identified with the alcoholic life-style, thus becoming beneficiaries of the sick role (Par- sons, 1951). The acknowledgment that one is an alcoholic might not be as important as many have believed. Edwards and others (1977) assigned alco- holics at random to two treatment groups. In the first group, the patients were assigned to only one counseling session in which they were told that the prob- lems presented were their own responsibility and further appointments were not offered. In the second group patients received conventional alcoholism treatment with an introduction to Alcoholics Anonymous. One year later there were no significant differences in outcomes between the two groups. Feeley (1975) has noted that absences for illness in business and industry have been increasing at an average rate of 2.7 percent since 1957. In spite of the increased availability and effectiveness of health resources, including alcohol- ism treatment, some industries report increases in absenteeism as high as 43

26

percent within a period of five years. Labeling oneself an alcoholic might be used as self-justification for taking a passive stance toward life’s responsibilities and thus contribute to the problem. The implications of labeling have been well-documented by recent research. In one study (Haynes and others, 1978), it was found that labeling of patients as hypertensive resulted in an increased absenteeism from work. Patients unaware of having hypertension and those with prior awareness of their problem had lower rates of absenteeism. In the study the level of severity of the disease was statistically controlled.

Economic Efficiency of Alcoholism Services

Resources for medical care are finite and demands on these resources are growing rapidly. There is an increasing need to allocate resources using well-rationalized methodologies. We must consider the cost involved in the provision of services in relation to the benefits obtained. The argument that where human life is involved, the benefits are infinite and the costs, therefore, irrelevant is not tenable. Excessive expenditures in one area of health care ser- vices will limit the resources that will be available in another. The area deprived of resources might be more important in terms of health and social payoffs (Weinstein and Stason, 1977). There is a trend to develop more objective deci- sion-making methods. Attempts have been made to devise methods to decide whether or not to apply diagnostic and therapeutic resources. In one method (McNeil, Keeler, and Adelstein, 1975), a decision tree is constructed. The tree describes possible courses o f action and the consequences of each. Quanti- tative estimates of the probability and utility (value) of each course of action are then made. A mathematical relation is derived between the benefits and costs of the courses of action for a given disease. Beyond certain thresholds, action is indicated; below the threshold, no intervention is in order.

Cost effectiveness analysis indicating the ratio of health care costs to net health benefits may provide indices or criteria to set priorities (Pauker and Kassirer, 1975). The need to assign numerical values to the costs and benefits obtained in the application of therapeutic resources is distressing to some. It is argued that we may have to rely on assessments of questionable numerical reliability. This should not be a deterrent to the use of quantitative assess- ments. Clinicians frequently incorporate subjective data assessments into their decision-making process. In benefit-cost analysis, there are methods available, such as sensitivity analysis, to help give validity to the estimates. Sensitivity analysis is a procedure that substitutes given numerical assessments for values that bound the range. The purpose of the manipulation is to determine appro- priate courses of action for the values assigned. If the decision is not altered through a given rstimated range of variation, the decision is said to be insensi- tive to this variation. If the decision can be altered within the range of varia- tion of the probabilities and utilities, the decision is said to be sensitive to this

27

variation. It therefore becomes necessary to gather additional data (Pauker and Kassirer, 1975). In cost-benefit analyses, quality of life indices and quan- titative estimates of both adverse and beneficial effects of therapy may be incorporated into the calculations along with adjustments to life expectancy.

Decision making based on analysis of cost and benefits is not a new approach. Management and military decisions have been subjected to such analysis for several years. In medicine, cost-benefit analysis has been applied to screening programs and population surveys, rubella vaccinations, strate- gies, management of essential hypertension, hospital costs, mortality attrib- uted to nosocomial bacteremias, and so on (Pauker and Kassirer, 1975; Schoen- baum, Hyde, and others, 1976; Spengler and Greenough, 1978; Stason and Weinstein, 1977).

In the area of mental health, cost-benefit studies have been less com- monly applied. However, one of the few studies has shown that, in the treat- ment of schizophrenia and in terms of cost per patient released and cost per case treated, it is much less expensive to provide the most effective available treatment than to provide merely a good level of care (May, 1971). Among psychiatric patients who have families willing to take care of them, brief hospi- talization followed by either day or outpatient care is less expensive in terms of hospital costs and costs to the family than standard hospitalization.

The relationships that exist between fiscal investment and health bene- fits obtained are particularly important in the field of alcoholism, a field where therapeutic procedures are insufficiently rationalized by scientific data. Armor, Polich, and Stambul (1976) have shown that the severity of alcohol symptomatology bears little relationship to the type or amount of services pro- vided to the clients. Similarly, a colleague and I (Paredes and Gregory, 1978) found little relationship between the magnitude of reimbursement for services, sociodemographic characteristics of the clients, and the level of alcohol impair- ment. Using the same data base but applying better controls and more sensi- tive analysis, Jones and others (1980) found a systematic positive relationship between the amount of dollars reimbursed for treatment and therapeutic out- come measured by remission rate and income earned by patients. However, there was an optimal cutoff for resource investment above which no further treatment gains were achieved. Beyond that point increased application of therapeutic resources does not result in further improvement.

Recently, several attempts have been made to apply cost-benefit tech- niques to the treatment of alcoholism. Cicchinelli, Binner, and Halpern (1978) developed a method for evaluating the effectiveness of mental health programs. The benefits of the program were determined by estimating the value of the discharged patient. This value consisted of measures of the indi- vidual's response to treatment plus his or her economic productivity. Indices of program efficiency were obtained by dividing treatment costs by value. Apply- ing this method, the alcoholism treatment program returned a favorable out-

28

put value for each dollar invested. This ratio was considerably better than the ratios obtained from mental health programs treating other types of patients in the same community facility. However, the alcoholism program appeared to be more efficient in treating men than women.

.Johns (1976) analyzed data from forty-one NIAAA supported alcohol- ism treatment centers. Of these, twenty-five centers produced estimated bene- fits exceeding the cost of resources invested in their programs. Harrison and others (1979) estimated the economic benefits of alcoholism treatment pro- grams in three selected communities, using data from the National Alcoholism Program Information System. Although only tentative conclusions were reached, the findings suggest that favorable cost-benefit ratios result from alco- holism treatment.

A technique of retrospective benefit-cost analysis was applied by a col- league and me (Rundell and Paredes, 1980) to data from the state-monitored alcoholism treatment programs. The analysis was modeled after Johns’s (1976). One advantage of the available data was that the state reimbursed the alcoholism treatment programs on a fee-for-service basis. Services were docu- mented on a monthly basis and reimbursements made accordingly. Data on the amount and kinds of services given to each client were readily available, as were the reimbursements to each program for providing these services. Using these data, i t was possible to prorate the costs of treating individual clients on the basis of the amount of services received by the client as a proportion of the total services delivered. A quasi-control group who had received less than $14 in actual treatment was identified. Follow-up data were available on the clients at six- and eighteen-month intervals. This group served as the validation sam- ple and was used to verify projected benefits in the first year following six rnonths (or less) of treatment.

The rosts of reimbursement for treatment of clients who entered the system within a three-year period were available (Rundell and Paredes, 1979). Figures at intake and six-months follow-up were compared for earnings, health care costs, motor vehicle accident costs, and law enforcement and legal system costs. Subtracting treatment costs from the first year benefits, the pro- gram yielded net benefits. A net benefit-cost ratio of 2.4 was derived by divid- ing the total benefits figure by the total costs. Without a control group, one cannot be certain what proportion of the benefits should be attributed to treat- ment and what proportion is attributable to other factors that may lead to spontaneous remission. Therefore, the annual benefits computed for the quasicontrol group were subtracted from the benefits projected for the six- month.; sample and the benefit-cost ratio was recomputed. The ratio still indi- cated a return of nearly $1.98 for every dollar invested. Apparently, in spite of the weak empirical basis of the therapies and social intervention methods used by alcoholism programs, their impact is economically very favorable.

Cost-benefit analyses have been applied to preventive plans. The eco-

29

nomic feasibility of preventing Wernicke-Korsakoff syndrome has been stud- ied by Centerwall and Criqui (1978). These investigators calculated the eco- nomic value of fortifying alcoholic beverages with thiamine. The annual inci- dence of institutionalization and the costs of long-term institutionalization were discounted to present value. The costs of adequately fortifying alcoholic beverages with allithiamines or thiamine were also estimated. The authors found cost-benefit ratios ranging from 1.1:2.3 to 1:4, concluding that it may be economically advantageous to fortify alcoholic beverages with thiamine, providing the stability, safety, and marketability of thiamine and the allithia- mines in alcoholic beverages are demonstrated.

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324-333.

294, 306-310.

289, 67-72.

A l f n s o Paredes is regional director for the Los Angeles County Central Mental Health Region and profssor of psychiaty and behavioral sciences at the University of Southern California Medical School.