Today, substance use disorders (SUDs) among people ages 18 to 25 far exceeds that of adults 26 and older. Substance use disorder encompasses abuse of alcohol and drugs, the use of illegal substances such as heroin, as well as legal substances such as prescription medications not prescribed or recommended by a physician.
While the overall number of young adults seeking treatment is increasing, their choice in care is driving higher treatment costs for health plans. Many enroll in out-of-network residential treatment centers in states outside their residency, instead of choosing a provider in their plan’s network.
These “destination” providers, like those in Florida, California or other desirable locations, can cost, on average, three times higher than in-network facilities. Beyond higher treatment costs, the quality of care at out-of-network centers may not necessarily be at the level offered by in-network providers. Members returning from out of state centers may also lack the built-in support system that comes with local treatment options. There is a real risk of member relapse and subsequent readmission.
Recovery in local treatment settings promotes quality of care
Early identification and outreach to members seeking SUD treatment at out-of-network providers is important to controlling costs and improving quality of care. Optum® created the Facility Benefit Inquiry program to address these challenges. Designated care coordinators – independently licensed mental health clinicians who are trained in addiction services – reach out to members to:
- Offer assistance in finding in-network services in the member’s home area
- Provide education about SUDs and treatment options
- Assist the member in accessing treatment services
Analyzing its claims data, Optum has found SUD treatment costs to be significantly lower at network facilities than at non-network facilities. Additionally, members receiving treatment at local, in-network facilities, or through network non-inpatient providers, have lower readmission rates than when treated at “destination” providers.
Even at this early stage of the Facility Benefit Inquiry program, Optum projects 2015 savings of $19,985 per episode of care on average by using network inpatient services, and $20,942 per care episode on average using network non-inpatient providers.*
When individuals can be treated for SUDs in or near their home communities, they often have a better chance of long-term recovery. Their families and friends can be part of their recovery, and the individuals learn how to be sober in the surroundings where they will continue their lives.
To learn more about the risks associated with out-of-network SUD treatment centers and the efforts of the Facility Benefit Inquiry program, please download our white paper, “Facility Benefit Inquiry: How health plans can tame the rising cost of substance use disorders.”
–Martin Rosenzweig, MD
*Savings projections based upon Optum comparative analysis of in-network and out-of-network behavioral health care costs for members with an authorization to a SUD program and discharged in 2014. Episode defined as claims between 3 days prior to admission start through 30 days after the discharge. Data includes membership in all age cohorts from the fully insured Payer book of business. Bolstrom, June 2015.
About the Author:
Martin Rosenzweig, MD, is regional medical director for behavioral solutions at Optum, and the head of the substance use disorder treatment initiative across the behavioral health business. He received his medical degree from the University of the Witwatersrand and has been in practice for 30 years.