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DATStats: results from 85 studies using the Drug Abuse Treatment Cost Analysis Program (DATCAP)
Journal of Substance Abuse Treatment 25 (2003) 51 – 57
Regular article
DATStats: results from 85 studies using the Drug Abuse Treatment Cost Analysis Program (DATCAP) M. Christopher Roebuck, M.B.A. a, Michael T. French, Ph.D. b,*, A. Thomas McLellan, Ph.D. c a
AdvancePCS, 11350 McCormick Road, Executive Plaza II, Suite 1000, Hunt Valley, MD 21031, USA b University of Miami, 5202 University Drive, P.O. Box 248162, Coral Gables, FL 33124, USA c Treatment Research Institute, 600 Public Ledger Bldg., 150 S Independence Mall (West), Philadelphia, PA 19106, USA Received 1 November 2002; received in revised form 19 April 2003; accepted 19 April 2003
Abstract The Drug Abuse Treatment Cost Analysis Program (DATCAP) was developed and launched in the early 1990s to help addiction researchers and administrators estimate the economic costs of substance abuse interventions. This paper presents summary results from 85 DATCAPs completed over the past 10 years. After first grouping the DATCAPs into 9 treatment modalities, cost measures (normalized to 2001 dollars) are reported along with client caseload information. Additionally, the distribution of costs across 6 resource categories is presented for each of the treatment modalities. The average weekly economic cost per client ranged from $82 per week for outpatient drug court interventions to $1,138 per week for adolescent residential treatment. As expected, labor was overwhelmingly the most utilized resource across all modalities, ranging from 48% to 88% of total economic cost. Addiction researchers, program administrators, and policymakers now have cost estimates and resource distribution information for various treatment modalities serving diverse populations. D 2003 Elsevier Inc. All rights reserved. Keywords: Drug Abuse Treatment Cost Analysis Program (DATCAP); Substance abuse intervention; Economics of substance abuse treatment
1. Introduction Until recently, analysts had few guidelines for conducting rigorous economic evaluations of substance abuse interventions. This void in the literature has been partially filled over the last five years by several publications (Barnett, Zaric, & Brandeau, 2001; French, Roebuck, McLellan, & Sindelar, 2001; French, Salome´, Sindelar, & McLellan, 2002; Hargraeves, Shumway, Hu, & Cuffel, 1998; Salome´ & French, 2001; Zarkin, Lindrooth, Demiralp, & Wechsberg, 2001). It is important that policymakers, managed care organizations, and treatment providers understand the economics of substance abuse treatment so that they can efficiently manage the financial resources they direct. Furthermore, because many government funded research studies include an economic component, it is important that addiction researchers employ the most sophisticated and appropriate economic evaluation methods.
* Corresponding author. Tel.: +1-305-284-6039; fax: +1-305-284-5310. E-mail address: [email protected] (M.T. French, Ph.D.). 0740-5472/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0740-5472(03)00067-9
In general, economic evaluation methods can be classified into three categories: cost, cost-effectiveness, and benefit-cost. Because this paper is aimed at cost studies, other economic evaluation methods and findings will not be discussed here. However, several useful reference documents are available for interested readers (Drummond, O’Brien, Stoddart, & Torrance, 1997; French, 2000; Gold, Siegel, Russell, & Weinstein, 1996; Hargraeves et al., 1998; Kenkel, 1997). Cost studies in the addiction literature concern the valuation of resources used to deliver a substance abuse intervention. Generally, these studies are conducted from the societal perspective and estimate the economic costs of treatment, which are not necessarily equivalent to the accounting costs paid by the program (i.e., direct expenditures, including depreciation expense). While accounting costs may be of interest to providers in fiscal planning, economic costs are preferred for economic evaluation because society shares in the benefits of substance abuse treatment. Economic or opportunity costs include the full value of all resources used by the program, regardless of who paid for them. Because cost evaluations are a
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prerequisite for cost-effectiveness and benefit-cost analyses, it is important that cost estimates are conceptually accurate and empirically precise. A growing body of research has used the Drug Abuse Treatment Cost Analysis Program (DATCAP) to estimate the costs of substance abuse treatment and other interventions (French, 2002a, 2002b). While cost findings from many of the DATCAP studies have been published elsewhere, some of the cost estimates have not, and many have yet to be published together in a single document (Bray, French, Bowland, & Dunlap, 1996; French, Dunlap, Zarkin, & Karuntzos, 1998; French, Dunlap, Zarkin, McGeary, & McLellan, 1997). One of the benefits of using a standard measure and method to conduct these economic studies is, ultimately, the creation of a common database that could provide common metrics for the cost elements that comprise the larger cost-effectiveness and benefit-cost calculations. The use of standard assessment instruments in clinical applications has reduced measurement variability and helped to determine significant symptoms within complex, broader syndromes. Similarly, the use of common outcome measures in different treatment modalities and in the treatment of different types of substance abuse has helped to define expected outcomes and to indicate unexpected ‘‘outliers.’’ The creation of a common database will also help economists and policy makers to agree on operational definitions for the various cost components, to compare economic outcomes from different interventions, and to create a plausible range of economic values for the types of treatments evaluated with the instrument. To initiate the sharing and development of the proposed common database for researchers, administrators, and policy analysts within the substance abuse field, we present economic cost data from 85 DATCAPs completed by the authors and their colleagues in recent years. By classifying programs into treatment modalities, mean values of cost measures, client caseflows, and distribution of costs across resource categories are calculated and presented as summary data. As results from new economic cost studies are added to this initial database, the mean estimates will become more precise and increasingly valuable to the substance abuse treatment field.
2. Methods 2.1. Drug Abuse Treatment Cost Analysis Program The DATCAP was created and launched in the early 1990s (Bradley, French, & Rachal, 1994; French, Bradley, Calingaert, Dennis, & Karuntzos, 1994) and has since undergone extensive revisions. Currently, the eighth edition of both the DATCAP Program (French, 2002a) and the DATCAP User’s Manual (French, 2002b) can be downloaded in Adobe Acrobat format (.pdf ) from www.DATCAP.com or requested by mail. Other derivatives of the DATCAP
have been created to address needs for brevity (Brief DATCAP) and to calculate the cost of treatment incurred by clients (Client DATCAP; Salome´, French, Miller, & McLellan, in press). Preliminary versions of these instruments are also available on the website or by written request. The DATCAP instruments are in the public domain, but it is recommended that an experienced economist administer them. The DATCAP is a data collection instrument and interview guide designed to estimate the costs of a substance abuse treatment program, defined as a single intervention (i.e., a facility offering both outpatient and inpatient treatment services would require the completion of multiple DATCAPs). Based upon standard accounting and economic principles, the instrument measures both accounting and economic costs. Accounting costs represent the actual expenditures of a treatment program and the depreciation of its resources. Economic costs represent the full value of all resources (i.e., opportunity costs), regardless of whether a direct expenditure is involved. In general, economic costs are equal to accounting costs plus the incremental value of those resources that are either partially subsidized or used free of charge by the treatment program (French, 2002b). The DATCAP is appropriate for the economic cost evaluation of most treatment modalities in most social service settings. The instrument is intended to collect and organize detailed information on resources used in service delivery and their associated costs. Resource categories include personnel, supplies and materials, contracted services, buildings and facilities, equipment, and miscellaneous items. Additionally, the DATCAP gathers data on program revenues and client caseflows. 2.2. DATCAP administration Administration of the DATCAP is generally a collaborative effort involving an economist and various members of the treatment program’s staff (e.g., administrators, therapist coordinators, and accounting/finance personnel). The process begins by issuing DATCAP materials to program personnel who are most familiar with the operations and financing of the facility. After these personnel have had adequate time to review the materials, several conference calls are conducted between them and the DATCAP-trained health economists to formulate strategies for preliminary data collection and to answer questions regarding the completion of the DATCAP. Generally, program personnel are offered guidance about the type and source of information to gather for administration of the DATCAP. A site visit to tour the treatment program is then conducted by the DATCAP administrator, during which face-to-face meetings are held and the instrument is completed. The purpose of the site visit is to ensure that important elements associated with the operation and financing of a treatment program are not inadvertently overlooked by either the provider or the researchers.
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2.3. Data assembly procedures As DATCAP interviews are completed, the data are entered into a supplementary Microsoft Excel spreadsheet template that mirrors the hard copy version of the instrument. This spreadsheet generates a 2-page Results Summary Report, which provides the analysts and the program director with key metrics from the cost evaluation, including total annual economic cost for the program, weekly economic cost per client, and total economic cost per treatment episode. To assemble the data for this paper, these key metrics and other selected results from 85 DATCAPs were linked to a master spreadsheet, which normalized all cost information to 2001 dollars using the Consumer Price Index (CPI). The master spreadsheet also calculated summary statistics (mean and standard deviation) for all DATCAPs by treatment modality. 2.4. Data management From 1993 to 2002, the authors and their colleagues completed approximately 85 DATCAPs on a wide variety of substance abuse treatment programs. It is important to emphasize that these programs were not selected randomly for the present study. Rather, the sample includes a collection of disparate programs that participated in research projects directed by the authors and their colleagues throughout this period. These treatment programs were based in communities, hospitals, VA clinics, workplaces, prisons, and public housing. Moreover, DATCAPs were conducted at programs with different types of clients, including male veterans, pregnant women, adolescents, prison inmates, and drug court participants. Due to this diversity in programs, settings, and clients, it was challenging to develop standardized and objective criteria for categorizing programs and presenting the summary statistics. To enhance the interpretation and value of the cost estimates, these 85 DATCAPs were classified into common groups, despite specific differences in services provided, intensity of services provided, and duration of treatment. Thus, in compiling these results, certain assumptions were necessary. It should be noted that a ‘‘program,’’ as used below, refers to a service delivery unit providing a specific treatment intervention or identified by a particular modality, not necessarily an entire agency or organization. First, programs in which clients did not reside at the treatment site were regarded as outpatient treatment programs and sub-divided into five distinct modalities: methadone maintenance, regular outpatient, intensive outpatient, adolescent outpatient, and drug court programs. Methadone maintenance programs mostly provided methadone medication and counseling services. Abstinence-oriented substance abuse treatment programs were classified through self-identification as either regular or intensive outpatient. Regular outpatient programs largely included those labeled ‘‘outpatient drug free,’’ whereas intensive
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outpatient included programs described as such or as ‘‘day treatment,’’ in which clients were typically expected to attend for 4 –8 h per day at least 4 times per week. Adolescent outpatient treatment programs were assumed to be in a class of their own because adolescents bring unique needs into treatment (i.e., treatment providers employ different resources with younger clients than they do when treating adults). Finally, drug courts were the most varied ‘‘modality.’’ Most drug court patients actually attended traditional outpatient or intensive outpatient care, but because of the unique needs of court-referred clients, these programs often involved a much wider array and greater number of services than are typically seen in traditional outpatient treatment. In addition, drug court programs also included linkages with the criminal justice system. Therefore, these programs were assigned their own treatment category. Programs in which clients regularly stayed overnight during treatment were classified as residential treatment. One exception was self-identified therapeutic communities (TC), which were classified separately due to their unique staffing patterns (extensive use of patients and volunteers in the therapeutic process). It should be noted that the programs categorized as adult residential varied widely in length of stay. Typically, length of stay in treatment can dramatically affect weekly costs, because more resources are employed during the early stages of treatment. For example, shorter duration residential programs will likely have a higher weekly cost than longer duration residential programs because the higher cost weeks often occur at the outset of the treatment regimen (e.g., front-loading of intake and assessment services). A final note concerns the DATCAPs administered at in-prison treatment programs. These in-prison programs were evaluated on an incremental basis; that is, the reported costs pertain to the additional resources added to the standard incarceration costs. Results from these DATCAPs cannot be directly compared to similar programs in the community because the ‘‘residential’’ component of the full cost of treatment (i.e., room and board) is included in standard incarceration costs. Therefore, in-prison substance abuse treatment programs are reported separately.
3. Results Table 1 presents the results from DATCAPs conducted at 53 outpatient substance abuse treatment programs. In addition to length-of-stay and average daily census figures, total, weekly, and episodic economic costs are reported in 2001 dollars. Listed first are 11 methadone maintenance programs, which together showed a mean length of stay of 99 weeks and an average caseload of 388 clients (note that 5 of the 11 programs did not have data available on length of stay). Although the mean (median) weekly cost per client was only $91 ($86), the total cost per treatment episode was $7,358 ($6,153 median) due to the almost 2-year average duration of treatment.
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Table 1 Caseflows and costs of 53 outpatient substance abuse treatment programs
Program
Average length of stay (weeks)
Average daily census
Methadone maintenance 1 140 450 2 65 650 3 52 123 4 150 559 5 150 578 6 N/A 573 7 N/A 400 8 N/A 210 9 N/A 250 10 N/A 300 11 39 178 Mean (SD) 99 388 (53) (186) Median 103 400 Standard outpatient 1 16 823 2 15 71 3 29 200 4 22 200 5 16 80 6 16 165 7 17 280 8 16 165 9 10 170 10 16 254 11 40 128 12 4 80 13 5 232 14 18 117 Mean (SD) 17 212 (9) (188) Median 16 168 Intensive Outpatient 1 N/A 17 2 6 12 3 4 8 4 3 6 5 3 5 6 21 30 Mean (SD) 7 13 (8) (9) Median 4 10 Adolescent Outpatient 1 13 8 2 14 10 3 13 8 4 7 6 5 13 10 6 7 7 7 12 10 8 6 4 9 13 10 10 14 8 11 14 9 12 6 5 13 30 10 Mean (SD) 13 8 (6) (2) Median 13 8
Total annual economic cost
Weekly economic cost per clienta
Economic cost per treatment episodeb
$982,128 $1,953,640 $472,365 $2,280,208 $2,500,355 $2,563,530 $1,959,291 $1,033,641 $1,312,134 $1,931,849 $1,537,655 $1,684,254 ($674,444) $1,931,849
$42 $58 $74 $78 $83 $86 $94 $95 $101 $124 $166 $91 ($33) $86
$5,876 $3,757 $3,840 $11,767 $12,478 N/A N/A N/A N/A N/A $6,429 $7,358 ($3,849) $6,153
$1,533,244 $241,303 $671,263 $686,643 $304,753 $636,498 $1,093,600 $700,754 $760,208 $1,260,233 $1,288,535 $1,033,359 $3,264,174 $1,655,090 $1,080,690 ($757,227) $896,784
$36 $65 $65 $66 $73 $74 $75 $82 $86 $95 $194 $248 $270 $272 $121 ($85) $78
$573 $989 $1,844 $1,472 $1,172 $1,187 $1,247 $1,307 $894 $1,552 $7,744 $994 $1,349 $4,897 $1,944 ($1,960) $1,277
$158,912 $179 $157,779 $252 $130,855 $314 $193,459 $598 $160,317 $683 $1,166,719 $748 $328,007 $462 ($411,364) ($243) $159,614 $456
N/A $1,513 $1,255 $1,700 $2,050 $15,706 $4,445 ($6,302) $1,700
$19,872 $26,438 $25,359 $17,263 $30,721 $26,803 $41,810 $18,311 $55,437 $50,270 $60,598 $44,052 $209,275 $48,170 ($50,518) $30,721
$96 $106 $119 $121 $124 $156 $161 $190 $220 $254 $262 $332 $384 $194 ($91) $161
$1,276 $1,453 $1,555 $793 $1,652 $1,160 $1,930 $1,183 $2,920 $3,671 $3,666 $2,136 $11,422 $2,678 ($2,787) $1,652
Table 1. (continued )
Program Drug court 1 2 3 4 5 6 7 8 9 Mean (SD) Median
Average length of stay (weeks) 80 37 55 64 26 45 61 17 33 46 (20) 45
Average daily census 450 450 450 84 84 84 81 81 81 205 (184) 84
Total annual economic cost $696,104 $696,104 $696,104 $380,416 $380,416 $380,416 $542,459 $542,459 $542,459 $539,660 ($136,713) $542,459
Weekly economic cost per clienta
Economic cost per treatment episodeb
$30 $30 $30 $87 $87 $87 $128 $128 $128 $82 ($43) $87
$2,361 $1,110 $1,620 $5,584 $2,232 $3,892 $7,890 $2,184 $4,294 $3,463 ($2,187) $2,361
Notes: All costs are reported in 2001 dollars. N/A = not available. Some numbers may not add, divide, or multiply exactly due to rounding. a Weekly Economic Cost per Client = Total Annual Economic Cost/ Average Daily Census H 52.14 weeks. b Economic Cost per Treatment Episode = Weekly Economic Cost per Client Average Length of Stay (weeks).
Standard outpatient treatment was offered at 14 of the programs studied. The mean caseload for these programs was 212 clients with an average length of stay of about 17 weeks. The mean weekly economic cost per client was $121 ($78 median), and the mean cost per treatment episode was $1,944 ($1,277 median). As expected, results from 6 intensive outpatient programs showed much higher costs, but with smaller caseloads for shorter stays in treatment. The mean intensive outpatient program treated 13 clients at a time for 7 weeks at a cost of $462 per week or $4,445 per episode (note that 1 of the 6 programs did not have data available on length of stay). Adolescent outpatient treatment is represented in Table 1 by 13 programs. As one would expect, treatment of this unique population was more costly than that of adults. The average adolescent in these programs attended treatment for 13 weeks at a mean (median) cost of $194 ($161) per week and $2,678 ($1,652) per episode. Finally, results from 9 DATCAPs completed on drug court programs are reported at the end of Table 1. The cost of these programs, though lower on a weekly basis ($82 mean, $87 median) than standard outpatient treatment, is greater in terms of cost per treatment episode ($3,463 mean, $2,361 median) due to a relatively long length of stay (46 weeks mean, 45 weeks median). Table 2 presents the DATCAP results from 32 residential substance abuse treatment programs. Adult residential treatment was delivered at 18 of these sites. The mean caseload was 34 clients, and the mean length of stay was 13 weeks, resulting in a mean (median) economic cost of $700 ($680) per week per client or $9,426 ($4,686) per treatment episode (note that 1 of the 18 programs did not have data available on length of stay). One residential treatment program for
M.C. Roebuck et al. / Journal of Substance Abuse Treatment 25 (2003) 51–57 Table 2 Caseflows and costs of 32 residential substance abuse treatment programs
Program
Average Total length Average annual of stay daily economic (weeks) census cost
Weekly economic cost per clienta
Adult Residential 1 17 93 $907,721 $187 2 N/A 33 $409,958 $238 3 3 25 $633,103 $486 4 4 14 $349,588 $489 5 28 30 $837,408 $535 6 3 16 $455,417 $558 7 11 30 $925,066 $591 8 3 33 $1,088,614 $633 9 3 27 $939,746 $671 10 4 60 $2,147,645 $688 11 16 22 $846,849 $738 12 50 34 $1,362,946 $769 13 44 74 $3,015,561 $784 14 15 28 $1,160,062 $797 15 12 28 $1,175,758 $808 16 5 30 $1,388,548 $890 17 5 30 $1,433,322 $919 18 4 8 $798,094 $1,818 Mean (SD) 13 34 $1,104,189 $700 (14) (21) ($643,053) ($343) Median 5 30 $932,406 $680 Adolescent Residential 1 8 22 $1,307,064 $1,138 Therapeutic Community 1c 36 625 $11,751,840 $362 2 65 53 $1,377,481 $500 3 3 8 $235,442 $564 4 30 13 $421,775 $622 5 32 62 $2,864,146 $888 Mean (SD) 33 152 $3,330,137 $587 (22) (265) ($4,821,587) ($194) Median 32 53 $1,377,481 $564 In-Prison Therapeutic Communityd 1 28 129 $263,534 $39 2 26 109 $248,377 $44 3 36 715 $1,920,980 $52 4 26 734 $4,731,386 $52 5 N/A 32 $91,479 $55 6 24 90 $273,175 $58 7 7 107 $368,345 $66 8 47 200 $766,862 $74 Mean (SD) 28 265 $1,083,017 $55 (12) (288) ($1,587,030) ($11) Median 26 119 $320,760 $53
Economic cost per treatment episodeb $3,119 N/A $1,457 $2,055 $14,915 $1,575 $6,505 $1,898 $1,945 $3,098 $11,812 $38,441 $34,481 $12,230 $9,892 $4,504 $4,686 $7,635 $9,426 ($11,023) $4,686 $9,347 $13,017 $32,488 $1,411 $18,668 $28,428 $18,802 ($12,409) $18,668 $1,097 $1,139 $1,855 $1,349 N/A $1,397 $447 $3,456 $1,534 ($947) $1,349
Notes: All costs are reported in 2001 dollars. N/A = not available. Some numbers may not add, divide, or multiply exactly due to rounding. a Weekly Economic Cost per Client = Total Annual Economic Cost H Average Daily Census H 52.14 weeks. b Economic Cost per Treatment Episode = Weekly Economic Cost per Client Average Length of Stay (weeks). c This TC had several treatment sites operating in close geographical proximity, hence the relatively large values for Average Daily Census and Total Annual Economic Cost. d Reported costs for in-prison therapeutic communities are incremental (i.e., in addition to standard incarceration).
adolescents was included in Table 2. As with outpatient services, residential services for adolescents (at least at this
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program) were more expensive than for adults on a weekly basis ($1,138), but not in terms of episode costs ($9,347). DATCAPs were conducted for two types of therapeutic communities: community-based and prison-based. Because in-prison TCs provide services that are ancillary to standard incarceration, these DATCAPs measured the incremental cost of the TC program. Community-based TCs, on the other hand, are stand-alone programs, and the associated results pertain to full economic costs. Therefore, the cost estimates for community-based TCs can be directly compared to the other types of residential programs listed in Table 2. The mean length of stay for clients in communitybased TCs was 33 weeks at a mean (median) cost of $587 ($564) per week. This translates to a mean (median) cost per treatment episode of $18,802 ($18,668). In-prison therapeutic communities added $55 per week to the cost of incarceration for a typical inmate, and the mean length of stay in these programs was 28 weeks (note that 1 of the 8 programs did not have data available on length of stay). As previously described, the DATCAP organizes cost information into 6 main resource categories: labor, supplies and materials, buildings and facilities, contracted services, major equipment, and miscellaneous. Tables 3 and 4 report the average distribution of costs across these resource categories by modality. In Table 3, methadone maintenance shows a relatively low level of labor utilization compared to other modalities (55.26%) and a high level of supplies and materials use (12.52%). This is likely due to the cost of the methadone itself and to the relatively low frequency of counseling services provided at such programs. Comparing standard outpatient with intensive outpatient treatment reveals that intensive had a much higher utilization of building and facilities (20.84% vs. 10.24%). This distribution is expected as intensive outpatient clients attend treatment for most or all of some days. Among adolescent outpatient treatment programs, labor is the overwhelming resource employed in the therapeutic process, representing
Table 3 Mean distribution of costs for 53 outpatient substance abuse treatment programs Methadone Standard Intensive Adolescent Drug maintenance outpatient outpatient outpatient court Cost category (n = 11) (n = 14) (n = 6) (n = 13) (n = 9) Labor
0.5526 (0.1998) Supplies & 0.1252 materials (0.0990) Buildings & 0.1327 facilities (0.0742) Contracted 0.1298 services (0.1064) Major 0.0045 equipment (0.0057) Miscellaneous 0.0547 (0.0733)
0.6793 (0.1114) 0.0552 (0.0416) 0.1024 (0.1106) 0.0743 (0.0701) 0.0122 (0.0067) 0.0771 (0.0526)
0.5550 (0.1654) 0.0737 (0.0640) 0.2084 (0.1218) 0.0572 (0.0630) 0.0101 (0.0066) 0.0956 (0.0286)
Note: Standard deviations reported in parentheses.
0.8109 (0.0948) 0.0302 (0.0136) 0.0438 (0.0212) 0.0834 (0.1129) 0.0050 (0.0034) 0.0268 (0.0153)
0.6950 (0.0689) 0.0220 (0.0177) 0.0344 (0.0157) 0.2103 (0.0605) 0.0086 (0.0065) 0.0297 (0.0083)
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Table 4 Average distribution of costs for 32 residential substance abuse treatment programs
Cost category Labor Supplies & materials Buildings & facilities Contracted services Major equipment Miscellaneous
Adult residential (n = 18)
Adolescent residential (n = 1)
Therapeutic community (n = 5)
In-prison therapeutic community (n = 8)
0.5546 (0.0967) 0.1034 (0.0447) 0.1264 (0.0624) 0.0423 (0.0463) 0.0096 (0.0101) 0.1642 (0.1035)
0.6156
0.4758 (0.1879) 0.1181 (0.0471) 0.1820 (0.2384) 0.1331 (0.2595) 0.0029 (0.0027) 0.0850 (0.0750)
0.8765 (0.0828) 0.0172 (0.0084) 0.0040 (0.0113) 0.0309 (0.0481) 0.0173 (0.0089) 0.0541 (0.0651)
0.0642 0.0797 0.1002 0.0071 0.1333
Note: Standard deviations reported in parentheses.
more than 81% of the total economic cost. Finally, the drug court modality differed from the standard outpatient modality only in its use of contracted services. Table 4 provides the resource distribution of costs for the 32 residential programs. As with outpatient substance abuse treatment programs, labor is the primary resource used in residential substance abuse treatment. However, except in the case of in-prison therapeutic community modality, where the cost of treatment was estimated incremental to standard incarceration, the range of labor proportions for residential (47.58% to 61.56%) was lower than that of outpatient (55.26% to 81.09%). The differential was spread throughout the remaining cost categories with no unusual patterns.
4. Discussion This summary article is unique in that it presents a large amount of research resulting from multi-year administration of the DATCAP, a standard economic cost instrument used in the evaluation of substance abuse treatment. In all, 85 case studies (i.e., treatment programs) were assembled and categorized into 9 common substance abuse treatment modalities. This allows for program-to-program comparisons within treatment modalities and for the calculation of modality-specific descriptive statistics. Furthermore, because the DATCAP organizes data into 6 cost categories, the allocation of treatment resources can be analyzed by modality as well. Addiction researchers, policymakers, and treatment providers can use this reference document to better understand the range of costs for different treatment modalities and how those costs are distributed. In addition, although these programs were not selected randomly and the coverage is not full or deep within all categories, as new programs complete the DATCAP they will now have a basis for comparison of their program-specific cost estimates. In
turn, these new case studies will be added to the existing database, thus creating a larger sample of programs and more reliable summary statistics. To facilitate swift and widespread dissemination of the modality-specific summary statistics, these estimates will be accessible on the DATCAP webpage (www.DATCAP.com) and updated when new DATCAPs are completed. Despite these advantages, some caution should be exercised in the interpretation of these findings due to several limitations of the study. First, as noted earlier, these programs were not selected randomly, and some of the modality-specific summary statistics apply to a small number of programs. A small number of programs contributes to the greater variation in mean values and the uncertain generalizability to the broader population of substance abuse treatment programs in the U.S. Second, the distinctiveness of the 85 programs is both a strength and a limitation of the study. Although their classification into treatment modalities was through self-identification or simple criteria, it was not without assumptions, because all programs offered somewhat different services in different doses. Every effort was made to classify treatment programs into widely accepted modalities found not just among these programs, but also in practice. Third, the study is also somewhat limited in that it does not normalize cost estimates geographically. To preserve the anonymity of the treatment programs, program names, cities, and state identifiers were not reported. Some of the programs were in rural areas, others in metropolitan areas. Cost-of-living differences likely affected the cost of treatment resources across the 85 studies. As the DATCAP and its associated instruments and spreadsheets evolve, the economic evaluation of substance abuse treatment will become increasingly well organized and reliable. As new studies are conducted using the DATCAP, additional cost data will be added to this collection of estimates to strengthen the findings (e.g., to reduce the variance in mean cost estimates and mean distributions among resource categories). Eventually, we hope to regularly update the summary statistics on the DATCAP website (www.DATCAP.com) to disseminate information in the timeliest manner possible (i.e., via the Internet). Finally, to control for geographical differences, cost-of-living indices by city, state, and year of data collection will be built into the cost estimates to ‘‘geo-normalize’’ the data.
Acknowledgments Financial assistance for this study was provided by grants (P50 DA07705, R01 DA11506, and R01 AA13167) from the National Institute on Drug Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA), Public Health Service, U.S. Department of Health and Human Services. We are grateful to Michelle Peart and William Russell for their suggestions and editorial assistance, and to
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all of our colleagues who contributed to the DATCAP and related studies. The authors are entirely responsible for the research conducted in this paper and their positions or opinions do not necessarily represent those of NIDA, NIAAA, AdvancePCS, University of Miami, or Treatment Research Institute.
References Barnett, P. G., Zaric, G. S., & Brandeau, M. L. (2001). The cost-effectiveness of buprenorphine maintenance therapy for opiate addiction in the US. Addiction, 96 (9), 1267 – 1278. Bradley, C. J., French, M. T., & Rachal, J. V. (1994). Financing and cost of standard and enhanced methadone treatment. Journal of Substance Abuse Treatment, 11 (5), 433 – 442. Bray, J. W., French, M. T., Bowland, B. J., & Dunlap, L. J. (1996). The cost of Employee Assistance Programs (EAPs): findings from seven case studies. Employee Assistance Quarterly, 11 (4), 1 – 19. Drummond, M. F., O’Brien, C. P., Stoddart, G. L., & Torrance, G. W. (1997). Methods for the economic evaluation of health care programmes. New York: Oxford University Press. French, M. T. (2000). Economic evaluation of alcohol treatment services. Evaluation and Program Planning, 23 (1), 27 – 39. French, M. T. (2002a). Drug Abuse Treatment Cost Analysis Program (DATCAP): Program version (8th ed.). Coral Gables: University of Miami (Available at www.DATCAP.com). French, M. T. (2002b). Drug Abuse Treatment Cost Analysis Program (DATCAP): User’s manual (8th ed.). Coral Gables: University of Miami (Available at www.DATCAP.com). French, M. T., Bradley, C. J., Calingaert, B., Dennis, M. L., & Karuntzos, G. T. (1994). Cost analysis of training and employment services in methadone treatment. Evaluation and Program Planning, 17 (2), 107 – 120.
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French, M. T., Dunlap, L. J., Zarkin, G. A., & Karuntzos, G. T. (1998). The costs of an enhanced Employee Assistance Program (EAP) intervention. Evaluation and Program Planning, 21, 227 – 236. French, M. T., Dunlap, L. J., Zarkin, G. A., McGeary, K. A., & McLellan, A. T. (1997). A structured instrument for estimating the economic cost of drug abuse treatment: the Drug Abuse Treatment Cost Analysis Program (DATCAP). Journal of Substance Abuse Treatment, 14 (5), 445 – 455. French, M. T., Roebuck, M. C., McLellan, A. T., & Sindelar, J. L. (2001). Can the Treatment Services Review (TSR) be used to estimate the costs of addiction and ancillary services. Journal of Substance Abuse, 12 (4), 341 – 361. French, M. T., Salome´, H. J., Sindelar, J. L., & McLellan, A. T. (2002). Benefit-cost analysis of addiction treatment: methodological guidelines and application using the DATCAP and ASI. Health Services Research, 37 (2), 433 – 455. Gold, M. R., Siegel, J. E., Russell, L. B., & Weinstein, M. C. (1996). Costeffectiveness in health and medicine. New York: Oxford University Press. Hargraeves, W. A., Shumway, M. T., Hu, W., & Cuffel, B. (1998). Costoutcome methods for mental health. San Diego, CA: Academic Press. Kenkel, D. (1997). On valuing morbidity, cost-effectiveness analysis, and being rude. Journal of Health Economics, 16, 749 – 757. Salome´, H. J., & French, M. T. (2001). Using cost and financing instruments for economic evaluation of substance abuse treatment services. In M. Galanter (Ed.), Recent Developments in Alcoholism, Volume 15: Services Research in the Era of Managed Care ( pp. 253 – 269). New York: Kluwer Academic/Plenum Publishers (Section III, Chapter 11). Salome´, H. J., French, M. T., Miller, M., & McLellan, A. T. (in press). Estimating the client costs of addiction treatment: First findings from the Client Drug Abuse Treatment Cost Analysis Program (Client DATCAP). Drug and Alcohol Dependence. Zarkin, G. A., Lindrooth, R. C., Demiralp, B., & Wechsberg, W. (2001). The cost and cost-effectiveness of an enhanced intervention for people with substance abuse problems at risk for HIV. Health Services Research, 36 (2), 335 – 356.
Regular article
DATStats: results from 85 studies using the Drug Abuse Treatment Cost Analysis Program (DATCAP) M. Christopher Roebuck, M.B.A. a, Michael T. French, Ph.D. b,*, A. Thomas McLellan, Ph.D. c a
AdvancePCS, 11350 McCormick Road, Executive Plaza II, Suite 1000, Hunt Valley, MD 21031, USA b University of Miami, 5202 University Drive, P.O. Box 248162, Coral Gables, FL 33124, USA c Treatment Research Institute, 600 Public Ledger Bldg., 150 S Independence Mall (West), Philadelphia, PA 19106, USA Received 1 November 2002; received in revised form 19 April 2003; accepted 19 April 2003
Abstract The Drug Abuse Treatment Cost Analysis Program (DATCAP) was developed and launched in the early 1990s to help addiction researchers and administrators estimate the economic costs of substance abuse interventions. This paper presents summary results from 85 DATCAPs completed over the past 10 years. After first grouping the DATCAPs into 9 treatment modalities, cost measures (normalized to 2001 dollars) are reported along with client caseload information. Additionally, the distribution of costs across 6 resource categories is presented for each of the treatment modalities. The average weekly economic cost per client ranged from $82 per week for outpatient drug court interventions to $1,138 per week for adolescent residential treatment. As expected, labor was overwhelmingly the most utilized resource across all modalities, ranging from 48% to 88% of total economic cost. Addiction researchers, program administrators, and policymakers now have cost estimates and resource distribution information for various treatment modalities serving diverse populations. D 2003 Elsevier Inc. All rights reserved. Keywords: Drug Abuse Treatment Cost Analysis Program (DATCAP); Substance abuse intervention; Economics of substance abuse treatment
1. Introduction Until recently, analysts had few guidelines for conducting rigorous economic evaluations of substance abuse interventions. This void in the literature has been partially filled over the last five years by several publications (Barnett, Zaric, & Brandeau, 2001; French, Roebuck, McLellan, & Sindelar, 2001; French, Salome´, Sindelar, & McLellan, 2002; Hargraeves, Shumway, Hu, & Cuffel, 1998; Salome´ & French, 2001; Zarkin, Lindrooth, Demiralp, & Wechsberg, 2001). It is important that policymakers, managed care organizations, and treatment providers understand the economics of substance abuse treatment so that they can efficiently manage the financial resources they direct. Furthermore, because many government funded research studies include an economic component, it is important that addiction researchers employ the most sophisticated and appropriate economic evaluation methods.
* Corresponding author. Tel.: +1-305-284-6039; fax: +1-305-284-5310. E-mail address: [email protected] (M.T. French, Ph.D.). 0740-5472/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0740-5472(03)00067-9
In general, economic evaluation methods can be classified into three categories: cost, cost-effectiveness, and benefit-cost. Because this paper is aimed at cost studies, other economic evaluation methods and findings will not be discussed here. However, several useful reference documents are available for interested readers (Drummond, O’Brien, Stoddart, & Torrance, 1997; French, 2000; Gold, Siegel, Russell, & Weinstein, 1996; Hargraeves et al., 1998; Kenkel, 1997). Cost studies in the addiction literature concern the valuation of resources used to deliver a substance abuse intervention. Generally, these studies are conducted from the societal perspective and estimate the economic costs of treatment, which are not necessarily equivalent to the accounting costs paid by the program (i.e., direct expenditures, including depreciation expense). While accounting costs may be of interest to providers in fiscal planning, economic costs are preferred for economic evaluation because society shares in the benefits of substance abuse treatment. Economic or opportunity costs include the full value of all resources used by the program, regardless of who paid for them. Because cost evaluations are a
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prerequisite for cost-effectiveness and benefit-cost analyses, it is important that cost estimates are conceptually accurate and empirically precise. A growing body of research has used the Drug Abuse Treatment Cost Analysis Program (DATCAP) to estimate the costs of substance abuse treatment and other interventions (French, 2002a, 2002b). While cost findings from many of the DATCAP studies have been published elsewhere, some of the cost estimates have not, and many have yet to be published together in a single document (Bray, French, Bowland, & Dunlap, 1996; French, Dunlap, Zarkin, & Karuntzos, 1998; French, Dunlap, Zarkin, McGeary, & McLellan, 1997). One of the benefits of using a standard measure and method to conduct these economic studies is, ultimately, the creation of a common database that could provide common metrics for the cost elements that comprise the larger cost-effectiveness and benefit-cost calculations. The use of standard assessment instruments in clinical applications has reduced measurement variability and helped to determine significant symptoms within complex, broader syndromes. Similarly, the use of common outcome measures in different treatment modalities and in the treatment of different types of substance abuse has helped to define expected outcomes and to indicate unexpected ‘‘outliers.’’ The creation of a common database will also help economists and policy makers to agree on operational definitions for the various cost components, to compare economic outcomes from different interventions, and to create a plausible range of economic values for the types of treatments evaluated with the instrument. To initiate the sharing and development of the proposed common database for researchers, administrators, and policy analysts within the substance abuse field, we present economic cost data from 85 DATCAPs completed by the authors and their colleagues in recent years. By classifying programs into treatment modalities, mean values of cost measures, client caseflows, and distribution of costs across resource categories are calculated and presented as summary data. As results from new economic cost studies are added to this initial database, the mean estimates will become more precise and increasingly valuable to the substance abuse treatment field.
2. Methods 2.1. Drug Abuse Treatment Cost Analysis Program The DATCAP was created and launched in the early 1990s (Bradley, French, & Rachal, 1994; French, Bradley, Calingaert, Dennis, & Karuntzos, 1994) and has since undergone extensive revisions. Currently, the eighth edition of both the DATCAP Program (French, 2002a) and the DATCAP User’s Manual (French, 2002b) can be downloaded in Adobe Acrobat format (.pdf ) from www.DATCAP.com or requested by mail. Other derivatives of the DATCAP
have been created to address needs for brevity (Brief DATCAP) and to calculate the cost of treatment incurred by clients (Client DATCAP; Salome´, French, Miller, & McLellan, in press). Preliminary versions of these instruments are also available on the website or by written request. The DATCAP instruments are in the public domain, but it is recommended that an experienced economist administer them. The DATCAP is a data collection instrument and interview guide designed to estimate the costs of a substance abuse treatment program, defined as a single intervention (i.e., a facility offering both outpatient and inpatient treatment services would require the completion of multiple DATCAPs). Based upon standard accounting and economic principles, the instrument measures both accounting and economic costs. Accounting costs represent the actual expenditures of a treatment program and the depreciation of its resources. Economic costs represent the full value of all resources (i.e., opportunity costs), regardless of whether a direct expenditure is involved. In general, economic costs are equal to accounting costs plus the incremental value of those resources that are either partially subsidized or used free of charge by the treatment program (French, 2002b). The DATCAP is appropriate for the economic cost evaluation of most treatment modalities in most social service settings. The instrument is intended to collect and organize detailed information on resources used in service delivery and their associated costs. Resource categories include personnel, supplies and materials, contracted services, buildings and facilities, equipment, and miscellaneous items. Additionally, the DATCAP gathers data on program revenues and client caseflows. 2.2. DATCAP administration Administration of the DATCAP is generally a collaborative effort involving an economist and various members of the treatment program’s staff (e.g., administrators, therapist coordinators, and accounting/finance personnel). The process begins by issuing DATCAP materials to program personnel who are most familiar with the operations and financing of the facility. After these personnel have had adequate time to review the materials, several conference calls are conducted between them and the DATCAP-trained health economists to formulate strategies for preliminary data collection and to answer questions regarding the completion of the DATCAP. Generally, program personnel are offered guidance about the type and source of information to gather for administration of the DATCAP. A site visit to tour the treatment program is then conducted by the DATCAP administrator, during which face-to-face meetings are held and the instrument is completed. The purpose of the site visit is to ensure that important elements associated with the operation and financing of a treatment program are not inadvertently overlooked by either the provider or the researchers.
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2.3. Data assembly procedures As DATCAP interviews are completed, the data are entered into a supplementary Microsoft Excel spreadsheet template that mirrors the hard copy version of the instrument. This spreadsheet generates a 2-page Results Summary Report, which provides the analysts and the program director with key metrics from the cost evaluation, including total annual economic cost for the program, weekly economic cost per client, and total economic cost per treatment episode. To assemble the data for this paper, these key metrics and other selected results from 85 DATCAPs were linked to a master spreadsheet, which normalized all cost information to 2001 dollars using the Consumer Price Index (CPI). The master spreadsheet also calculated summary statistics (mean and standard deviation) for all DATCAPs by treatment modality. 2.4. Data management From 1993 to 2002, the authors and their colleagues completed approximately 85 DATCAPs on a wide variety of substance abuse treatment programs. It is important to emphasize that these programs were not selected randomly for the present study. Rather, the sample includes a collection of disparate programs that participated in research projects directed by the authors and their colleagues throughout this period. These treatment programs were based in communities, hospitals, VA clinics, workplaces, prisons, and public housing. Moreover, DATCAPs were conducted at programs with different types of clients, including male veterans, pregnant women, adolescents, prison inmates, and drug court participants. Due to this diversity in programs, settings, and clients, it was challenging to develop standardized and objective criteria for categorizing programs and presenting the summary statistics. To enhance the interpretation and value of the cost estimates, these 85 DATCAPs were classified into common groups, despite specific differences in services provided, intensity of services provided, and duration of treatment. Thus, in compiling these results, certain assumptions were necessary. It should be noted that a ‘‘program,’’ as used below, refers to a service delivery unit providing a specific treatment intervention or identified by a particular modality, not necessarily an entire agency or organization. First, programs in which clients did not reside at the treatment site were regarded as outpatient treatment programs and sub-divided into five distinct modalities: methadone maintenance, regular outpatient, intensive outpatient, adolescent outpatient, and drug court programs. Methadone maintenance programs mostly provided methadone medication and counseling services. Abstinence-oriented substance abuse treatment programs were classified through self-identification as either regular or intensive outpatient. Regular outpatient programs largely included those labeled ‘‘outpatient drug free,’’ whereas intensive
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outpatient included programs described as such or as ‘‘day treatment,’’ in which clients were typically expected to attend for 4 –8 h per day at least 4 times per week. Adolescent outpatient treatment programs were assumed to be in a class of their own because adolescents bring unique needs into treatment (i.e., treatment providers employ different resources with younger clients than they do when treating adults). Finally, drug courts were the most varied ‘‘modality.’’ Most drug court patients actually attended traditional outpatient or intensive outpatient care, but because of the unique needs of court-referred clients, these programs often involved a much wider array and greater number of services than are typically seen in traditional outpatient treatment. In addition, drug court programs also included linkages with the criminal justice system. Therefore, these programs were assigned their own treatment category. Programs in which clients regularly stayed overnight during treatment were classified as residential treatment. One exception was self-identified therapeutic communities (TC), which were classified separately due to their unique staffing patterns (extensive use of patients and volunteers in the therapeutic process). It should be noted that the programs categorized as adult residential varied widely in length of stay. Typically, length of stay in treatment can dramatically affect weekly costs, because more resources are employed during the early stages of treatment. For example, shorter duration residential programs will likely have a higher weekly cost than longer duration residential programs because the higher cost weeks often occur at the outset of the treatment regimen (e.g., front-loading of intake and assessment services). A final note concerns the DATCAPs administered at in-prison treatment programs. These in-prison programs were evaluated on an incremental basis; that is, the reported costs pertain to the additional resources added to the standard incarceration costs. Results from these DATCAPs cannot be directly compared to similar programs in the community because the ‘‘residential’’ component of the full cost of treatment (i.e., room and board) is included in standard incarceration costs. Therefore, in-prison substance abuse treatment programs are reported separately.
3. Results Table 1 presents the results from DATCAPs conducted at 53 outpatient substance abuse treatment programs. In addition to length-of-stay and average daily census figures, total, weekly, and episodic economic costs are reported in 2001 dollars. Listed first are 11 methadone maintenance programs, which together showed a mean length of stay of 99 weeks and an average caseload of 388 clients (note that 5 of the 11 programs did not have data available on length of stay). Although the mean (median) weekly cost per client was only $91 ($86), the total cost per treatment episode was $7,358 ($6,153 median) due to the almost 2-year average duration of treatment.
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Table 1 Caseflows and costs of 53 outpatient substance abuse treatment programs
Program
Average length of stay (weeks)
Average daily census
Methadone maintenance 1 140 450 2 65 650 3 52 123 4 150 559 5 150 578 6 N/A 573 7 N/A 400 8 N/A 210 9 N/A 250 10 N/A 300 11 39 178 Mean (SD) 99 388 (53) (186) Median 103 400 Standard outpatient 1 16 823 2 15 71 3 29 200 4 22 200 5 16 80 6 16 165 7 17 280 8 16 165 9 10 170 10 16 254 11 40 128 12 4 80 13 5 232 14 18 117 Mean (SD) 17 212 (9) (188) Median 16 168 Intensive Outpatient 1 N/A 17 2 6 12 3 4 8 4 3 6 5 3 5 6 21 30 Mean (SD) 7 13 (8) (9) Median 4 10 Adolescent Outpatient 1 13 8 2 14 10 3 13 8 4 7 6 5 13 10 6 7 7 7 12 10 8 6 4 9 13 10 10 14 8 11 14 9 12 6 5 13 30 10 Mean (SD) 13 8 (6) (2) Median 13 8
Total annual economic cost
Weekly economic cost per clienta
Economic cost per treatment episodeb
$982,128 $1,953,640 $472,365 $2,280,208 $2,500,355 $2,563,530 $1,959,291 $1,033,641 $1,312,134 $1,931,849 $1,537,655 $1,684,254 ($674,444) $1,931,849
$42 $58 $74 $78 $83 $86 $94 $95 $101 $124 $166 $91 ($33) $86
$5,876 $3,757 $3,840 $11,767 $12,478 N/A N/A N/A N/A N/A $6,429 $7,358 ($3,849) $6,153
$1,533,244 $241,303 $671,263 $686,643 $304,753 $636,498 $1,093,600 $700,754 $760,208 $1,260,233 $1,288,535 $1,033,359 $3,264,174 $1,655,090 $1,080,690 ($757,227) $896,784
$36 $65 $65 $66 $73 $74 $75 $82 $86 $95 $194 $248 $270 $272 $121 ($85) $78
$573 $989 $1,844 $1,472 $1,172 $1,187 $1,247 $1,307 $894 $1,552 $7,744 $994 $1,349 $4,897 $1,944 ($1,960) $1,277
$158,912 $179 $157,779 $252 $130,855 $314 $193,459 $598 $160,317 $683 $1,166,719 $748 $328,007 $462 ($411,364) ($243) $159,614 $456
N/A $1,513 $1,255 $1,700 $2,050 $15,706 $4,445 ($6,302) $1,700
$19,872 $26,438 $25,359 $17,263 $30,721 $26,803 $41,810 $18,311 $55,437 $50,270 $60,598 $44,052 $209,275 $48,170 ($50,518) $30,721
$96 $106 $119 $121 $124 $156 $161 $190 $220 $254 $262 $332 $384 $194 ($91) $161
$1,276 $1,453 $1,555 $793 $1,652 $1,160 $1,930 $1,183 $2,920 $3,671 $3,666 $2,136 $11,422 $2,678 ($2,787) $1,652
Table 1. (continued )
Program Drug court 1 2 3 4 5 6 7 8 9 Mean (SD) Median
Average length of stay (weeks) 80 37 55 64 26 45 61 17 33 46 (20) 45
Average daily census 450 450 450 84 84 84 81 81 81 205 (184) 84
Total annual economic cost $696,104 $696,104 $696,104 $380,416 $380,416 $380,416 $542,459 $542,459 $542,459 $539,660 ($136,713) $542,459
Weekly economic cost per clienta
Economic cost per treatment episodeb
$30 $30 $30 $87 $87 $87 $128 $128 $128 $82 ($43) $87
$2,361 $1,110 $1,620 $5,584 $2,232 $3,892 $7,890 $2,184 $4,294 $3,463 ($2,187) $2,361
Notes: All costs are reported in 2001 dollars. N/A = not available. Some numbers may not add, divide, or multiply exactly due to rounding. a Weekly Economic Cost per Client = Total Annual Economic Cost/ Average Daily Census H 52.14 weeks. b Economic Cost per Treatment Episode = Weekly Economic Cost per Client Average Length of Stay (weeks).
Standard outpatient treatment was offered at 14 of the programs studied. The mean caseload for these programs was 212 clients with an average length of stay of about 17 weeks. The mean weekly economic cost per client was $121 ($78 median), and the mean cost per treatment episode was $1,944 ($1,277 median). As expected, results from 6 intensive outpatient programs showed much higher costs, but with smaller caseloads for shorter stays in treatment. The mean intensive outpatient program treated 13 clients at a time for 7 weeks at a cost of $462 per week or $4,445 per episode (note that 1 of the 6 programs did not have data available on length of stay). Adolescent outpatient treatment is represented in Table 1 by 13 programs. As one would expect, treatment of this unique population was more costly than that of adults. The average adolescent in these programs attended treatment for 13 weeks at a mean (median) cost of $194 ($161) per week and $2,678 ($1,652) per episode. Finally, results from 9 DATCAPs completed on drug court programs are reported at the end of Table 1. The cost of these programs, though lower on a weekly basis ($82 mean, $87 median) than standard outpatient treatment, is greater in terms of cost per treatment episode ($3,463 mean, $2,361 median) due to a relatively long length of stay (46 weeks mean, 45 weeks median). Table 2 presents the DATCAP results from 32 residential substance abuse treatment programs. Adult residential treatment was delivered at 18 of these sites. The mean caseload was 34 clients, and the mean length of stay was 13 weeks, resulting in a mean (median) economic cost of $700 ($680) per week per client or $9,426 ($4,686) per treatment episode (note that 1 of the 18 programs did not have data available on length of stay). One residential treatment program for
M.C. Roebuck et al. / Journal of Substance Abuse Treatment 25 (2003) 51–57 Table 2 Caseflows and costs of 32 residential substance abuse treatment programs
Program
Average Total length Average annual of stay daily economic (weeks) census cost
Weekly economic cost per clienta
Adult Residential 1 17 93 $907,721 $187 2 N/A 33 $409,958 $238 3 3 25 $633,103 $486 4 4 14 $349,588 $489 5 28 30 $837,408 $535 6 3 16 $455,417 $558 7 11 30 $925,066 $591 8 3 33 $1,088,614 $633 9 3 27 $939,746 $671 10 4 60 $2,147,645 $688 11 16 22 $846,849 $738 12 50 34 $1,362,946 $769 13 44 74 $3,015,561 $784 14 15 28 $1,160,062 $797 15 12 28 $1,175,758 $808 16 5 30 $1,388,548 $890 17 5 30 $1,433,322 $919 18 4 8 $798,094 $1,818 Mean (SD) 13 34 $1,104,189 $700 (14) (21) ($643,053) ($343) Median 5 30 $932,406 $680 Adolescent Residential 1 8 22 $1,307,064 $1,138 Therapeutic Community 1c 36 625 $11,751,840 $362 2 65 53 $1,377,481 $500 3 3 8 $235,442 $564 4 30 13 $421,775 $622 5 32 62 $2,864,146 $888 Mean (SD) 33 152 $3,330,137 $587 (22) (265) ($4,821,587) ($194) Median 32 53 $1,377,481 $564 In-Prison Therapeutic Communityd 1 28 129 $263,534 $39 2 26 109 $248,377 $44 3 36 715 $1,920,980 $52 4 26 734 $4,731,386 $52 5 N/A 32 $91,479 $55 6 24 90 $273,175 $58 7 7 107 $368,345 $66 8 47 200 $766,862 $74 Mean (SD) 28 265 $1,083,017 $55 (12) (288) ($1,587,030) ($11) Median 26 119 $320,760 $53
Economic cost per treatment episodeb $3,119 N/A $1,457 $2,055 $14,915 $1,575 $6,505 $1,898 $1,945 $3,098 $11,812 $38,441 $34,481 $12,230 $9,892 $4,504 $4,686 $7,635 $9,426 ($11,023) $4,686 $9,347 $13,017 $32,488 $1,411 $18,668 $28,428 $18,802 ($12,409) $18,668 $1,097 $1,139 $1,855 $1,349 N/A $1,397 $447 $3,456 $1,534 ($947) $1,349
Notes: All costs are reported in 2001 dollars. N/A = not available. Some numbers may not add, divide, or multiply exactly due to rounding. a Weekly Economic Cost per Client = Total Annual Economic Cost H Average Daily Census H 52.14 weeks. b Economic Cost per Treatment Episode = Weekly Economic Cost per Client Average Length of Stay (weeks). c This TC had several treatment sites operating in close geographical proximity, hence the relatively large values for Average Daily Census and Total Annual Economic Cost. d Reported costs for in-prison therapeutic communities are incremental (i.e., in addition to standard incarceration).
adolescents was included in Table 2. As with outpatient services, residential services for adolescents (at least at this
55
program) were more expensive than for adults on a weekly basis ($1,138), but not in terms of episode costs ($9,347). DATCAPs were conducted for two types of therapeutic communities: community-based and prison-based. Because in-prison TCs provide services that are ancillary to standard incarceration, these DATCAPs measured the incremental cost of the TC program. Community-based TCs, on the other hand, are stand-alone programs, and the associated results pertain to full economic costs. Therefore, the cost estimates for community-based TCs can be directly compared to the other types of residential programs listed in Table 2. The mean length of stay for clients in communitybased TCs was 33 weeks at a mean (median) cost of $587 ($564) per week. This translates to a mean (median) cost per treatment episode of $18,802 ($18,668). In-prison therapeutic communities added $55 per week to the cost of incarceration for a typical inmate, and the mean length of stay in these programs was 28 weeks (note that 1 of the 8 programs did not have data available on length of stay). As previously described, the DATCAP organizes cost information into 6 main resource categories: labor, supplies and materials, buildings and facilities, contracted services, major equipment, and miscellaneous. Tables 3 and 4 report the average distribution of costs across these resource categories by modality. In Table 3, methadone maintenance shows a relatively low level of labor utilization compared to other modalities (55.26%) and a high level of supplies and materials use (12.52%). This is likely due to the cost of the methadone itself and to the relatively low frequency of counseling services provided at such programs. Comparing standard outpatient with intensive outpatient treatment reveals that intensive had a much higher utilization of building and facilities (20.84% vs. 10.24%). This distribution is expected as intensive outpatient clients attend treatment for most or all of some days. Among adolescent outpatient treatment programs, labor is the overwhelming resource employed in the therapeutic process, representing
Table 3 Mean distribution of costs for 53 outpatient substance abuse treatment programs Methadone Standard Intensive Adolescent Drug maintenance outpatient outpatient outpatient court Cost category (n = 11) (n = 14) (n = 6) (n = 13) (n = 9) Labor
0.5526 (0.1998) Supplies & 0.1252 materials (0.0990) Buildings & 0.1327 facilities (0.0742) Contracted 0.1298 services (0.1064) Major 0.0045 equipment (0.0057) Miscellaneous 0.0547 (0.0733)
0.6793 (0.1114) 0.0552 (0.0416) 0.1024 (0.1106) 0.0743 (0.0701) 0.0122 (0.0067) 0.0771 (0.0526)
0.5550 (0.1654) 0.0737 (0.0640) 0.2084 (0.1218) 0.0572 (0.0630) 0.0101 (0.0066) 0.0956 (0.0286)
Note: Standard deviations reported in parentheses.
0.8109 (0.0948) 0.0302 (0.0136) 0.0438 (0.0212) 0.0834 (0.1129) 0.0050 (0.0034) 0.0268 (0.0153)
0.6950 (0.0689) 0.0220 (0.0177) 0.0344 (0.0157) 0.2103 (0.0605) 0.0086 (0.0065) 0.0297 (0.0083)
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Table 4 Average distribution of costs for 32 residential substance abuse treatment programs
Cost category Labor Supplies & materials Buildings & facilities Contracted services Major equipment Miscellaneous
Adult residential (n = 18)
Adolescent residential (n = 1)
Therapeutic community (n = 5)
In-prison therapeutic community (n = 8)
0.5546 (0.0967) 0.1034 (0.0447) 0.1264 (0.0624) 0.0423 (0.0463) 0.0096 (0.0101) 0.1642 (0.1035)
0.6156
0.4758 (0.1879) 0.1181 (0.0471) 0.1820 (0.2384) 0.1331 (0.2595) 0.0029 (0.0027) 0.0850 (0.0750)
0.8765 (0.0828) 0.0172 (0.0084) 0.0040 (0.0113) 0.0309 (0.0481) 0.0173 (0.0089) 0.0541 (0.0651)
0.0642 0.0797 0.1002 0.0071 0.1333
Note: Standard deviations reported in parentheses.
more than 81% of the total economic cost. Finally, the drug court modality differed from the standard outpatient modality only in its use of contracted services. Table 4 provides the resource distribution of costs for the 32 residential programs. As with outpatient substance abuse treatment programs, labor is the primary resource used in residential substance abuse treatment. However, except in the case of in-prison therapeutic community modality, where the cost of treatment was estimated incremental to standard incarceration, the range of labor proportions for residential (47.58% to 61.56%) was lower than that of outpatient (55.26% to 81.09%). The differential was spread throughout the remaining cost categories with no unusual patterns.
4. Discussion This summary article is unique in that it presents a large amount of research resulting from multi-year administration of the DATCAP, a standard economic cost instrument used in the evaluation of substance abuse treatment. In all, 85 case studies (i.e., treatment programs) were assembled and categorized into 9 common substance abuse treatment modalities. This allows for program-to-program comparisons within treatment modalities and for the calculation of modality-specific descriptive statistics. Furthermore, because the DATCAP organizes data into 6 cost categories, the allocation of treatment resources can be analyzed by modality as well. Addiction researchers, policymakers, and treatment providers can use this reference document to better understand the range of costs for different treatment modalities and how those costs are distributed. In addition, although these programs were not selected randomly and the coverage is not full or deep within all categories, as new programs complete the DATCAP they will now have a basis for comparison of their program-specific cost estimates. In
turn, these new case studies will be added to the existing database, thus creating a larger sample of programs and more reliable summary statistics. To facilitate swift and widespread dissemination of the modality-specific summary statistics, these estimates will be accessible on the DATCAP webpage (www.DATCAP.com) and updated when new DATCAPs are completed. Despite these advantages, some caution should be exercised in the interpretation of these findings due to several limitations of the study. First, as noted earlier, these programs were not selected randomly, and some of the modality-specific summary statistics apply to a small number of programs. A small number of programs contributes to the greater variation in mean values and the uncertain generalizability to the broader population of substance abuse treatment programs in the U.S. Second, the distinctiveness of the 85 programs is both a strength and a limitation of the study. Although their classification into treatment modalities was through self-identification or simple criteria, it was not without assumptions, because all programs offered somewhat different services in different doses. Every effort was made to classify treatment programs into widely accepted modalities found not just among these programs, but also in practice. Third, the study is also somewhat limited in that it does not normalize cost estimates geographically. To preserve the anonymity of the treatment programs, program names, cities, and state identifiers were not reported. Some of the programs were in rural areas, others in metropolitan areas. Cost-of-living differences likely affected the cost of treatment resources across the 85 studies. As the DATCAP and its associated instruments and spreadsheets evolve, the economic evaluation of substance abuse treatment will become increasingly well organized and reliable. As new studies are conducted using the DATCAP, additional cost data will be added to this collection of estimates to strengthen the findings (e.g., to reduce the variance in mean cost estimates and mean distributions among resource categories). Eventually, we hope to regularly update the summary statistics on the DATCAP website (www.DATCAP.com) to disseminate information in the timeliest manner possible (i.e., via the Internet). Finally, to control for geographical differences, cost-of-living indices by city, state, and year of data collection will be built into the cost estimates to ‘‘geo-normalize’’ the data.
Acknowledgments Financial assistance for this study was provided by grants (P50 DA07705, R01 DA11506, and R01 AA13167) from the National Institute on Drug Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA), Public Health Service, U.S. Department of Health and Human Services. We are grateful to Michelle Peart and William Russell for their suggestions and editorial assistance, and to
M.C. Roebuck et al. / Journal of Substance Abuse Treatment 25 (2003) 51–57
all of our colleagues who contributed to the DATCAP and related studies. The authors are entirely responsible for the research conducted in this paper and their positions or opinions do not necessarily represent those of NIDA, NIAAA, AdvancePCS, University of Miami, or Treatment Research Institute.
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