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Studies have found funding source, whether public or private, is associated with treatment and services offered in community-based agencies. However, the association of criminal justice funding with community-based treatment and services is unknown. Using a mixed methods case study approach with 34 agencies within one state we assessed administrators’ perspectives of the most important funding source, treatment and services offered. We found that agencies rely on multiple funding sources and the source rated most important was associated with treatment and services offered in the agency. Those agencies citing a criminal justice entity as the most important funder were more likely to offer specific ancillary services and adopt motivational interviewing than those citing private funds. Although client characteristics or training opportunities may determine these services and practices, the agency’s most important funding source may have implications for services offered.
Substance abuse treatment agencies vary in the type of services offered. One source of these differences could be funding source. Ducharme and colleagues (2007) found differences in services offered and use of evidence-based practices by reported majority funding source (private or public source) in treatment agencies. We have previously shown that three levels of funding source (i.e., criminal justice (CJ), other public or private funding) was associated with different staff requirements for education and credentialing (Kubiak & Arfken, in press). To our knowledge, no one has examined if there are differences in services offered across these three sources of funding. This gap in knowledge is critical as CJ population represents one of the most challenging treatment populations for substance abuse clinicians (Taxman, Perdoni & Harrison, 2007) and an increasing number of states’ Department of Corrections (DOC) fund treatment in the community for offenders (Kubiak, 2008). To address if these three funding sources are associated with delivery of care, we examined the differences in treatment and services offered by primary source of funding based on the perspective of treatment agency administrators. The study used a mixed method case study analysis of 34 different agencies within one state.
Michigan’s public funding system of substance abuse treatment through the Single State Authority (SSA) and the DOC provides a case example for examining funder and treatment/services offered while holding state requirements constant. In this state, the SSA is decentralized into 16 coordinating agencies responsible for treatment within their geographic catchments area. Overall, public funding levels for substance abuse treatment were generally lower than insurance reimbursement rates. The DOC reimbursement levels were generally lower than that of Medicaid or block grant funds.
The sample agencies were drawn as part of a larger study of adoption of effective treatment strategies (n=15). To address CJ funding, we supplemented this sample with all agencies funded by the state level DOC in one coordinating agency location (n=7). Agencies not receiving DOC funds but matched on location, ownership, modality and specific population targeted were also recruited (n=11). Of the agencies approached for participation, both in the initial sample and in the supplemental sample, only one declined to participate. One agency was dropped from the analysis because it relied on charity aid only, leaving 34 agencies for analysis. All agencies were located in urban areas with high unemployment rates.
A mixed methods case study approach was used which included interviews and surveys with three staff persons within each agency. For this analysis we use the responses of the Executive Director. This individual was asked about all funding sources and then asked to specify the “most important” funding source. Specific questions for the survey were adopted from the National Survey of Substance Abuse Treatment Services (Substance Abuse and Mental Health Services Administration, 2005) and included: number of admissions, primary focus of service delivery, number of employees, treatment modalities, specialized programs and services offered. For the latter category there were initially 16 different services compared: five tests, four transitional services and six other services. As one coordinating agency requires all clients treated with their funding to be screened for Hepatitis B and C, and to be tested for HIV and TB, the category of tests was not analyzed. Three questions were asked about use of the evidence-based practices of 1) Motivational Interviewing (Miller & Rollnick, 1991), 2) Cognitive-Behavioral Therapy (Beck, Wright, Newman & Liese, 1993) and 3) any pharmacotherapy for substance abuse. These practices were selected as they can be used across modalities. As DOC requires cognitive-behavioral therapy, this practice was not statistically compared.
Private included commercial insurance, foundations and self pay; Public included Medicaid, Medicare, block grant and other sources of state or local funds other than criminal justice; and CJ included the Federal Bureau of Prisons, DOC, county funding from local criminal justice, and court programs. Nearly all (91.2%) of the treatment agencies received funding across at least two of the three categorical groups with 35.3% received funding from all three. Although our sampling strategy included specifically selecting 10 agencies we knew received funding from DOC, an additional six had other types of CJ funding, resulting in 47% (n=16) with some type of CJ funding. The most important funding sources reported by the agencies were Public (50%, n=17), Private (29.4%, n=10), and CJ (20.6%, n=7). On average, agencies had 5.6 funding sources with only one agency having one source of funding.
Responses to the survey were analyzed using Kruskall-Wallis, correlations and chi-square tests.
Most of the agencies (57.6%) offered outpatient treatment with the remainder as residential or a combination of residential and outpatient. The size of the agencies varied greatly (see Table 1) but there was no association between size of agency and funding source. There were differences in the percentages of agencies offering specific treatment and services by funding sources (Table 2). Specifically, agencies that reported Private sources of funding as most important were least likely to offer ancillary services of housing assistance (p<.001), case management (p=.006), or discharge planning (p=.02). They were also least likely to offer Motivational Interviewing (p=.03). Agencies that reported CJ sources of funding as most important provided services to address domestic violence (83.3% or six of the seven). Agencies that reported CJ sources of funding as most important did not offer pharmacotherapy at all (p=.096). As larger agencies may be able to offer more services, we examined the associations of services offered and number of clients enrolled; agencies offering housing assistance had fewer clients (p=.01).
This analysis expands previous studies by including criminal justice funding in the comparison of agencies funded by private and public revenue (Ducharme et al, 2007). Those administrators who considered Private funds to be their most important funding source were less likely to offer some ancillary services and report that their counselors are less likely to use Motivational Interviewing than other agencies. Conversely, all the directors who considered CJ funding sources as most important did not offer any pharmacotherapy but all of them did offer case management. The services of screening and testing for infectious diseases were not statistically compared because one public funder demanded it for all agencies receiving its funds. Similarly, using cognitive-behavioral therapy was not statistically compared because DOC requires it for all treatment using their funds. Both of these requirements demonstrate one way in which funding influences services offered.
The observed differences in treatment and services offered may reflect a mixture of funding requirements, underlying differences in client populations and, for Motivational Interviewing, training opportunities. Approximately half of the agencies reported that funding did influence ancillary services offered. As private insurance companies usually only reimburse for medically necessary treatment, the agencies that rated private funds as most important may feel their clients do not need the services; they also may not need to offer social services as a means to attract clients. In contrast some public funders, most notably one coordinating agency, may require certain ancillary services to be offered, such as the above-mentioned screening and testing for infectious diseases. With this approach they are responding to the public health need to address infectious diseases. Nonetheless, it is important to emphasize that the service question was directed to the agency as a whole and not to particular clients funded by specific revenue streams. It is possible that agencies may search for funding streams that fit into the treatment philosophy and services already offered. This possibility is supported by at least one administrator: “When we consider using a funding source it is a process of looking at what the funding source requires and seeing if it is a good fit for us.” These decisions were made within a context of multiple funding sources for all except one agency.
The analysis is limited by the small number and nonrandom selection of agencies in the sample. The self-report data does not allow us to review objective evidence to determine funding sources and services offered. In addition, we cannot confirm that the treatments were being used appropriately at the clinician-level. Notwithstanding, this study should be understood as exploratory to determine the relative impact of three different funding sources on treatment and services offered and to encourage others to examine it more definitively.
This study assessed multiple treatment agencies within one state to examine the possible influence of three different funding sources on treatment and services. As substance abuse treatment agencies struggle to respond to increasing demands for economic efficiency and evidence of treatment effectiveness (McLellan, Carise, & Kleber, 2003), they must be responsive to both internal and external demands for change (Fuller, Rieckmann, Nunes, Miller, Arfken, et al, 2008). One strategy may be to diversify funding streams, but this means balancing often competing demands of funding sources or seeking out sources with compatible requirements. We found that the administrators’ perception of the agency’s most important funding source is associated with services offered and may point to gaps in the adoption of evidence-based treatment.
This study was supported in part by a grant from the National Institute of Drug Abuse (RO1 DA014483). The authors would like to acknowledge and thank all the administrators and staff who participated in the survey.
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An earlier version of this paper was presented at the 2007 annual convention of the American Psychology Association in San Francisco.