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This column examines whether health plans are adequately identifying adolescents with substance use problems. Three measures developed by the Washington Circle, a group focused on the development of substance abuse performance measures (1,2) (www.washingtoncircle.org), have been adapted for the 2004 Health Plan Employer Data and Information Set (www.ncqa.org). One measure—the identification rate—can be used to examine the extent to which private health plans are able to identify adolescent enrollees with substance use problems.
We calculated this rate for adolescents using MarketScan, a database of private health plan claims for selected employers maintained by the MEDSTAT Group. About a quarter million adolescents were covered in 1997. The number of adolescents with any primary or secondary substance abuse claims during the year was divided by the member-years for adolescents aged 12 to 18.
For enrolled adolescents, the overall identification rate was .5 percent (F1)—.7 percent for males and .4 percent for females. We compared these results to the 6.8 percent rate of alcohol dependence or drug dependence—or both—obtained from a special analysis of a subset of adolescents covered by commercial insurance who were included in the 1998 National Household Survey on Drug Abuse (Harwood H, personal communication, July 2001). No meaningful variation was observed across health plan type.
Several factors may contribute to the low rate. Primary care or other providers may fail to identify substance abuse because they lack adequate training in or incentives for screening and diagnosis. Stigma associated with the use of drugs or legal issues may make providers reluctant to record adolescents' substance abuse diagnoses.
The low rate points to the urgent need to close the gap between the number of adolescents who need treatment and those who receive it. Steps needed include better training for primary care practitioners in recognition, early intervention, and referral. By making health plans accountable for identifying adolescents and for getting them into treatment quickly, a clear incentive is introduced for greater case finding.
This research was supported by the Substance Abuse and Mental Health Services Administration and grant 5 P50 DA 10233 from the National Institute on Drug Abuse to the Brandeis/Harvard Center for Managed Care and Drug Abuse. The authors thank Mady Chalk, Ph.D., Sarah Wattenberg, L.C.S.W.-C., Frank McCorry, Ph.D., Doreen Cavanaugh, Ph.D., Pat Harrison, Ph.D., and Connie Weisner, Dr.P.H.
Dr. Lee, Dr. Garnick, and Dr. Horgan are affiliated with the Schneider Institute for Health Policy of the Heller School for Social Policy and Management at Brandeis University 415 South Street, MS 035, Waltham, Massachusetts 02454-9110 (e-mail, firstname.lastname@example.org). Ms. Miller is with the MEDSTAT Group in Santa Barbara, California. Harold Alan Pincus, M.D., and Terri L. Tanielian, M.A., are editors of this column.
Identification rate in private health plans for adolescents with substance use disorders compared with the rate derived from data from the NHSDAa
a Respondents were classified as substance dependent if they met three of the six DSM-IV criteria on the 1998 National Household Survey on Drug Abuse (NHSDA) questionnaire. Items included questions about health and emotional problems associated with substance use, attempts to cut down, tolerance, withdrawal, and other symptoms.
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