ESTIMATING the COST of PREVENTIVE SERVICES
in Mental Health and Substance Abuse Under Managed Care
Model Six: Brief Counseling to Reduce Alcohol Use
This model was designed on the basis of four research publications-Bien, Miller, and Tonigan (1993); Fleming, Barry, Manwell, Johnson, and London (1997); World Health Organization (1996); and Fleming, Barry, Manwell, Adams, and Stauffacher (1999)-and reviewed by Dorfman (2000) in references respectively numbered 33, 39, 50, and 53. As with all the other models, this model was designed to estimate PMPM costs for a managed care plan with 100,000 members that implements a screening and brief intervention to reduce excessive alcohol use by its adult members (ages 18 to 65) as well as its older members (ages 66 and older), male and female.
Results
PMPM Cost
The median PMPM cost for the Least Expensive Scenario was only $0.36. The median PMPM cost for the Most Expensive Scenario was $0.82, with a midpoint range of $0.59.
Design and Input Values Used in the Model
Membership, Target Audience Screened for Alcohol Use, and Participation
Based on 1998 numbers from the U.S. Census Bureau, the model assumed that male and female adults, including persons older than 65, represented a range of 70 to 73 percent (in increments of 1 percent for each scenario) of the 100,000 members.
Based on the research reported by Fleming et al. (1997) and epidemiological household surveys of drug and alcohol use by the Office of Applied Studies, Substance Abuse and Mental Health Administration (1998), the model assumed that 14 to 17 percent (in increments of 1 percent for each scenario) would screen positive for excessive alcohol use or dependency on a self-administered health screening instrument distributed by a receptionist. This percentage excludes female adults who were pregnant and all adults (ages 19 to 64) known to be drug or alcohol abusers or having a history of treatment for drug or alcohol abuse.
The model assumed that 68 to 71 percent (in increments of 1 percent for each scenario) of those screening positive would agree to go through the initial 30-minute interview with a nurse to further screen participants and collect baseline data on health-related behaviors (e.g., smoking, exercise).
Based on data reported by Fleming et al. (1997), the model assumed that 42 to 45 percent (in increments of 1 percent for each scenario) of those completing this interview would go on to start participation in the intervention. The model assumed that 95 to 98 percent (in increments of 1 percent for each scenario) of those who started the intervention would complete it.
Materials and Staff Time
The model assumed that the average time for distribution and scoring of the self-administered health screening instrument by a receptionist was 5 minutes. The model assumed that the health screening instrument would cost $0.75, $1, $1.50, and $2 in the four scenarios.
Each participant was given a workbook. The workbook used by the participant and the physician "contained feedback regarding current health behaviors, a review of the prevalence of problem drinking, a list of the adverse effects of alcohol, a worksheet on drinking cues, a drinking agreement in the form of a prescription, and drinking diary cards" (Dorfman, 2000, p. 61). The model assumed this workbook was provided to 100 percent of the participants. The model assumed the cost per workbook for each of the four scenarios was $5, $6, $7, and $8.
Service Interventions
As described by Fleming et al. (1997), the model assumed that participants would receive two brief counseling sessions with their primary care physician, each lasting 15 minutes. This time includes the few minutes required for the physician to enter brief documentation in the medical record.
The model assumed that 100 percent of participants would receive a followup phone call by a nurse following each of the two sessions with the physician. Each followup call was assumed to last an average of 5 minutes.
The cost of these interventions by clerical staff, nurses, and physicians was determined by multiplying the cost of a productive staff hour (based on salary, fringe benefits, and nonproductive time) by the time required of the trainers. The annual salaries of each category of staff were assumed to be clerical, $20,000 with $500 increments for each scenario and 80-percent productivity; nurses, $50,000 with $1,000 increments and 70-percent productivity; and physicians, $100,000 with $2,000 increments and 70-percent productivity.
Fringe-benefit costs were assumed at 29 percent for all personnel. The model assumed that no expenses were associated with the need for additional supervisory or management staff, because such an intervention could blend into the ongoing clinical operations of each physician's office.
Physician Recruitment and Staff Training
Based on ratios reported by Fleming et al. (1997) of participants to physicians, the number of physicians who would have to be invited to participate was estimated. Assuming a rate of agreement to participate at 80 to 95 percent in 5-percent increments for each scenario, the number of physicians to invite and the number needed to participate in order to handle the number of expected participants could be calculated. Invitation costs were estimated at $35 to $50 in $5 increments. For each scenario, the model assumed there would be 4, 3, 2, or 1 doctor per office site. That way, the number of office sites where personnel and physicians would need to be trained could be calculated.
The model assumed that all involved office personnel would require some training on the use of the protocol. For each office site, the model assumed a 20-minute (SD = 5 minutes) training for clerical personnel who distributed and scored the health screening instrument, and a 60-minute (SD = 5 minutes) training session for the nurses who would administer the interview and make the followup phone calls. The model assumed an initial training session of 60 minutes (SD = 10 minutes) for all physicians working at a single site. The model also assumed two "booster" training sessions for physicians of 15 minutes each (SD = 10 minutes).
The training costs were determined by multiplying the average salary and fringe-benefit costs of a trainer ($40,000 in $1,000 increments for each scenario, 70 percent productivity and 29 percent fringe-benefit cost) by the time required of trainers. The model assumed that no expenses were associated with the need for additional supervisory or management staff, because such an intervention could blend into ongoing office operations.
Because the original research by Fleming et al. (1997) reported a $300 payment to the physicians, the model assumed payments to each participating physician of $300, $500, $700, and $900 for each scenario. This payment would be made to compensate the physician for "lost patient revenue" related to the need for staff and physician to participate in the training.
Finally, the model assumed that some percentage should be added for G&A expenses plus profit. The model assumed a minimum of 10 percent, increasing by 1 percent for each of the four scenarios.
Discussion
Of all the interventions, this one may be most problematic for traditional IPA-model HMOs or preferred provider organizations to implement, largely because of the extensive logistical effort required to train the physicians and their office staff (clerical workers and nurses) to carry out the protocol, and some physicians' likely resistance to confront problem drinking by a patient.
At least one of the four published studies reviewed by Dorfman (2000) was carried out across a number of countries (World Health Organization Brief Intervention Group, 1996) in college or health screening clinics where the stigma associated with alcohol abuse may be lower or the resistance to confronting problem drinkers may be lower. And while all the studies reported success in reducing drinking, there was no explicit analysis of the likely long-term benefits and cost savings associated with reduced use of medical services.
In a review of the medical cost-offset literature, however, Mumford, Schlesinger, and Glass (1981) reviewed 12 studies, 3 in HMOs and 9 in employee-based work settings, that reported significant effectiveness of alcoholism treatment in reducing medical and surgical costs, lost workdays, and injuries and disabilities. A risk-bearing MCO would clearly have an incentive to incur the costs of training personnel to identify and reduce excessive or problem drinking among its membership, on the assumption that the membership would remain with the MCO long enough for the investment to yield long-term benefits and cost savings.
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