¹FY 1996 Actuals will be available in Spring 1997.

II. METHODOLOGY

• "Treatment Costs" represent the cost for all inpatient and outpatient care of veterans with a primary or associated diagnosis of drug abuse. These figures include the cost of care for these patients in the following: specialized drug abuse treatment programs; specialized substance abuse programs treating veterans with alcohol and/or drug abuse problems; and all other medical programs (e.g., medicine, surgery, psychiatry, etc.).



• For specialized drug abuse treatment programs, 100% of the costs are included. However, the majority of patients receiving specialized treatment for drug abuse problems receive their care in substance abuse treatment programs. Substance abuse treatment programs provide services to drug abusers, alcohol abusers and poly-substance abusers. The costs allocated for the treatment of veterans with drug abuse problems in these programs are based upon an analysis of the proportion of drug abuse diagnoses within the total substance abuse population treated in the specialized programs. In determining the treatment costs for drug use disorders in specialized substance abuse treatment programs, 62.9% of the total costs of these programs is allocated.



• The other related medical costs for drug abuse patients (i.e., costs for care other than specialized drug treatment in dedicated drug or substance abuse programs) is comprised of five general components: 100% of the other related medical costs for patients with a drug diagnosis and treated in a specialized drug program; 100% of the other related medical costs for patients with a primary drug diagnosis and treated in a specialized substance abuse treatment program; 100% of the other related medical costs for patients with a primary drug diagnosis and treated in programs other than specialized drug or substance programs; 50% of the other related medical costs for patients with a second diagnosis (not primary) involving drug abuse and treated in programs other than specialized drug or substance abuse programs; 25% of other related medical costs for patients with an associated (not first or second) drug diagnosis and treated in programs other than specialized drug or substance abuse program.

III. PROGRAM SUMMARY

• The Department of Veterans Affairs, through its Veterans Health Administration, operates a network of substance abuse treatment programs located in the Department's medical centers, domiciliaries and outpatient clinics. VA plays a major role in the provision of services to veterans who are "service connected" or indigent. (The term "service connected" refers to veterans who have injuries sustained while in military service). All of the drug-related resources support Goal 3 of the National Drug Control Strategy.



• The investment in healthcare and specialized treatment of veterans with drug abuse problems identified as funded by the resources in Medical Care helps avoid future health, welfare and crime costs associated with illegal drug use.



• In coordination with NIDA on how to best employ outreach models, VA has been a participant in the Treatment Improvement Protocol (TIP) initiative developed by the Center for Substance Abuse Treatment of SAMHSA in HHS. A component of this project is the specific development of a TIP relating to case management and the associated facilitation of access to treatment.



• The dollars expended in research help to acquire new knowledge to improve the prevention, diagnosis and treatment of disease, and acquire new knowledge to improve the effectiveness, efficiency, accessibility and quality of veterans health care.



• The Department of Veterans Affairs, in keeping with modern medical practice, continues to improve service delivery by expanding primary care and shifting treatment services to lower cost settings when clinically appropriate. Initial data suggest these shifts in care delivery may impact budgets in future years. The exact nature of the impact, if any, cannot be determined until additional trend data becomes available.

IV. BUDGET SUMMARY

1997 Base Program

• The 1997 base program includes $1,121.5 million for medical care. This program consists of $591.3 million for inpatient drug abuse care and treatment, $529.8 million for outpatient treatment and $0.5 million for prevention activities. Evaluation of substance abuse treatment programs will continue in 1998.



• The FY 1997 base program also contains $7.3 million for research and development to be applied towards drug abuse related research.



• Funding levels in the Medical Care decision unit in FY 1997 will maintain current service levels.

• The total FY 1998 drug control budget request is $1,177.6 million, an increase of $48.9 million over the FY 1997 enacted level.



• The total drug control request for Goal 3 activities for FY 1998 is $1,177.6 million, a net increase of $48.9 million over FY 1997. This constitutes an adjustment in overall funding which reflects increases projected for the medical consumer price and payroll indices.

V. PROGRAM STATISTICS

	1996 Estimate	1997 Estimate	1998 Projected
Drug and Drug-Related Diagnosis (Medical Related Costs)
- Inpatients treated
Specialized treatment programs	$390.534	$410.061	$430.564
All other patients	$271.388	$284.957	$299.205
Drug and Drug-Related Diagnosis
Inpatients treated	70,930	70,930	70,930
Outpatient visits	3,242,983	3,242,983	3,242,983
Halfway house placements (Estimate)	5,830	5,830	5,830
Compensated work therapy patient visits (Subset of Outpatient visits)	23,184	23,184	23,184

VI. PROGRAM ACCOMPLISHMENTS

• Specialized substance abuse treatment services are available at 126 VA medical facilities.



• VA continues to provide inpatient treatment services to veterans with significant substance abuse and psychosocial problems: 36% are 50 and older, 75% are not married, 39% are members of an ethnic minority, and 64% are unemployed or low income. Among patients with drug diagnoses treated in specialized inpatient substance abuse units, 65% abuse cocaine, 19% abuse opiates, and 35% have co-existing psychiatric diagnoses.



• VA has expanded access to care for veterans with substance abuse disorders. Since FY 91, the number of substance abuse treatment components (i.e., outpatient, detoxification, residential rehabilitation, etc.) has increased 19%. To meet the needs of increasingly difficult-to-treat populations, many VA programs offer specialized treatment services. For example, 151 program components target veterans with concomitant psychiatric or medical disorders, 72 offer specialized services to patients with HIV/AIDS and 133 tailor some aspects of treatment to homeless veterans.



• VA continues to promote care in lower cost settings as clinically indicated. The majority of newly established program components are outpatient and day hospital programs. The number of patients with outpatient substance abuse care, but with no inpatient substance abuse treatment within the year, has dramatically increased between FY 88 and FY 95 by 30,000 for a 78% increase. Although the number of patients treated in substance abuse units remained relatively constant between FY 88 and 95, the total number of VA patients receiving specialized substance abuse outpatient care increased.



• Efforts to promote continuity of care for substance abusing veterans are yielding positive results. The number of substance abuse inpatients and extended care patients who received one or more specialized substance abuse outpatient visits increased between FY 88 and FY 95 by 11,400 for a 28% increase.



• The Program Evaluation and Resource Center (PERC), Palo Alto VAMC, is conducting a major process-outcome evaluation of substance abuse treatment programs. PERC is focusing on substance abuse treatment programs at 13 VAMCs that follow a traditional 12-step and/or a cognitive behavioral treatment approach. These are the two most prevalent treatment orientations in VA programs. Intake and discharge data have been collected on over 3,000 patients; one- and two-year follow-ups are being conducted. Treatment outcome will be assessed in terms of drug and alcohol use, problems related to use, depression, employment, and readmission for treatment. The project will also examine the processes underlying the two treatment approaches and whether certain types of patients fare better in each type of treatment.



• A second outcome-oriented evaluation focuses on the VA's Contract Residential Facilities (CRF) Program that provides residential care which serves as a bridge between inpatient treatment and independent life in the community for selected substance abuse patients. Four-year follow-up findings for patients referred to CRFs in FY 87 indicate that those who had longer episodes of residential care were less likely to be readmitted for substance abuse treatment or psychiatric care. A survey of CRFs identified three models of care in such facilities (psychosocial model, supportive rehabilitation model, and intensive treatment model.) A prospective follow-up study of patients admitted to CRFs is being conducted to estimate more accurately the effects of such care, to determine the processes that account for those effects, and to identify characteristics of patients who are the best candidates for placement in different models of CRF care.



• The Program Evaluation and Resource Center is working with Mental Health and Behavioral Sciences Service to develop a system of indicators to monitor the provision of services to veterans with substance use disorders. The first phase of development will test monitors designed to assess the effectiveness of early intervention as well as monitors measuring access to treatment and continuity of services. Later phases will evaluate treatment outcome using indicators such as changes in substance use, medical and psychiatric status, economic status and social conditions after receipt of services.