Chairman SIMPSON. The panel consists of Dr. Leonard Saxe of the Office of Technology Assessment, accompanied by Ms. Denise Dougherty; Ms. Sandra K. Hill of the Baltimore Alcoholism Treatment Center; and Leo Ruffing, Association of Halfway House Alcoholism Programs of North America, Inc. We do have a time constraint rushing in on us, but each of you, Dr. Saxe, Ms. Hill and Mr. Ruffing, have 5 minutes to summarize your testimony. We appreciate receiving your testimony in the order as set up in the agenda. Thank you. TESTIMONY OF A PANEL CONSISTING OF LEONARD SAXE, PH.D., PSYCHOLOGIST, BOSTON UNIVERSITY, ACCOMPANIED BY DENISE DOUGHERTY, OFFICE OF TECHNOLOGY ASSESSMENT; SANDRA K. HILL, R.N., C.A.C., M.B.A., DIRECTOR, SUBURBAN HOSPITALS' ALCOHOLISM TREATMENT SERVICES, BETHESDA, MD, AND PRESIDENT, BOARD OF TRUSTEES, BALTIMORE ALCOHOLISM TREATMENT CENTER, BALTIMORE, MD; AND LEO RUFFING, MEMBER OF THE BOARD OF DIRECTORS, ASSOCIATION OF HALFWAY HOUSE ALCOHOLISM PROGRAMS OF NORTH AMERICA, INC., ST. PAUL, MN, ACCOMPANIED BY DONALD ANDERSON, DIRECTOR, SERENITY HOUSE ALCOHOLISM RECOVERY PROGRAM, NEWPORT NEWS, VA Dr. SAXE. Thank you, Mr. Chairman, we are pleased to appear this morning to discuss the implications of recent scientific research for the provision of alcoholism treatment by the VA. I am a psychologist on the faculty of Boston University and senior author of the Congressional Office of Technology Assessment's report on the "Effectiveness and Costs of Alcoholism Treatment." With me is Denise Dougherty who was coauthor of the report and is a staff member at OTA. Our testimony today is drawn directly from the OTA report and I request that a copy of my statement be a part of the record, along with a copy of the report. Chairman SIMPSON. Without objection, it is so ordered. Dr. SAXE. I would like to make three sets of comments very briefly. First, about the alcoholism problem, and, second, about current research on alcoholism treatment, and, third, on some specific comments on S. 2514. Let me turn to the problem. Alcoholism, I think, is only beginning to be understood, but one thing is very, very clear and that is that the cost of not treating alcoholism is tremendous. We estimated the overall cost to society of alcoholism in 1982 dollars could have been as high as $120 billion, amounting to at least $10,000 a year for every alcoholic. Alcohol abusers cost the VA over $121 million in 1982 in direct alcohol treatment costs. This figure, however, dramatically underestimates the actual cost to the VA because it neglects the increased costs of treating any illness of an alcoholic. The VA estimates that between 20 and 50 percent of all patients are alcohol abusers. Because many patients' health problems are associated with alcohol abuse, the VA's alcohol-related health-care costs are substantially greater than those of its treatment programs alone. Attention to patients' prob 37-524 0-84--17 lems with alcohol should save the VA a substantial amount in reduced health-care utilization over the long term. Economic findings about alcoholism are related to the growing evidence that alcohol abuse is implicated in a wide range of problems, including cardiovascular disease, neurological disorders, and cancer. The recently published "Encyclopedic Handbook of Alcoholism" includes 19 separate chapters on the medical problems associated with alcohol abuse along with a dozen more on the social problems associated with alcohol abuse. The central question that is particularly relevant to the VA is which of the many treatments available for alcoholism are most effective and the least costly in terms of benefits generated. Treatments for alcoholism range from the use of drugs which make it unpleasant to ingest alcohol to psychological treatments based on changing individuals' patterns of behavior. Alcoholics Anonymous, perhaps the most frequently discussed, is not really a treatment, but is designed to serve as a resource and support system for alcoholics. Treatment can take place in general hospitals, in psychiatric hospitals as well as in specialized alcoholism treatment facilities. Inpatient treatment is usually differentiated from outpatient treatment, which can take place in physicians' offices or other health provider facilities. Some place between inpatient and outpatient are what are called intermediate care facilities, such as halfway houses. Most research which has looked at alcoholism treatment effectiveness has determined that it is difficult to know which is the most effective treatment. Available research does, however, suggest the direction that policy and research should take. Very briefly, it appears that any treatment for alcoholism is better than no treatment. From 45 to 63 percent of patients in the studies we reviewed showed significant improvement although few maintained abstinence for very long. This was much greater than what we would expect without treatment. Perhaps the most controversial research and treatment issue concerns the necessity for hospitalizing alcoholics, that is, providing treatment on an inpatient basis, other than that necessary for detoxification or dealing with other medical complications versus providing treatment on an outpatient basis. Several studies have found that inpatient treatment does not seem superior to outpatient treatment. I think an important finding, however, is that the inpatient/outpatient distinction is probably not very useful. Efforts to distinguish systematically the characteristics of studies reporting good and bad outcomes have indicated that inpatient treatment was valuable. However, it also suggests that an inpatient setting without an intensive community milieu and aggressive outpatient followup would be of limited value. The studies reporting very good outcomes were also characterized by a variety of other characteristics such as the use of Antabuse, social casework, family therapy, involvement of employers, and behavioral therapy. Let me skip to the completion and I will very briefly summarize the thrust of what we are trying to achieve. Chairman SIMPSON. Thank you. Dr. SAXE. The thrust of S. 2514 generally is consistent with our assessment of research findings. The bill establishes outpatient options and includes development and implementation of treatment plans requiring long-term followup. These elements appear to be cost effective treatment solutions. Their application should assist in providing treatment to those in need of services and reducing the overall burden of health-care treatment and costs within the VA. Intermediate care facilities, such as halfway houses, may be particularly useful for some populations. After detoxification, there may be no need for certain patients to be in medically oriented inpatient facilities. The halfway house may be a cost efficient option. Perhaps the most important feature of the legislation is the requirement that individual treatment plans are developed, implemented and monitored. Recent research and literature on alcoholism treatment has stressed the need to tailor treatment to individual needs. Treatment planning is, thus, critical and should result in different treatment strategies. The provision of the bill that there be 1-year followup is also consistent with our scientific understanding. Let me say that most treatment currently is what I call frontloaded. It occurs upon identification of the disorder but does not follow through. Follow through is essential; particularly in the VA it is difficult. Let me stop my comments there. Chairman SIMPSON. Thank you very much. As in the testimony you just gave, some treatment is better than none and some testimony is better than none. I hate to do it that way. I wish we could do it differently. I appreciate it very much. [The prepared statement of Leonard Saxe, Ph.D., psychologist, Boston University, follows:] PREPARED STATEMENT OF LEONARD SAXE, PH.D., PSYCHOLOGIST, BOSTON UNIVERSITY, BOSTON, MA Mr. Chairman and Members of the Committee: We are pleased to appear this morning to discuss the implications of recent scientific research for the provision of alcoholism treatment by the Veterans Administration. I am Dr. Leonard Saxe, a psychologist on the faculty of Boston University and senior author of the Congressional Office of Technology Assessment's (OTA) case study, The Effectiveness and Costs of Alcoholism Treatment. With me is Denise Dougherty who was co-author of the alcoholism case study and is a staff member at OTA. Our testimony is drawn directly from the OTA assessment of alcoholism treatment. On the basis of the assessment, we will describe the nature of the alcoholism problem, research findings about treatment effectiveness, and the implications of OTA's findings with respect to S.2514, the "Veterans' Administration Health Care Amendments of 1984." Alcoholism Problem OTA's investigation of alcoholism treatment was requested by the Senate Finance Committee. In responding to this request, we conducted an exhaustive review of existing theoretical and empirical research on alcoholism treatment. In addition, we met and talked with experts in medicine, psychology, social work and a number of other disciplines concerned with alcoholism treatment. The resulting OTA paper was carefully reviewed by over 50 clinicians and researchers who represented a broad spectrum of the alcoholism field. One of our principal conclusions can be stated simply: The cost of not Testimony Page 2 treating alcoholism is tremendous. Consequently, treatment, even if limited in impact, may nevertheless be cost-effective. Based on data collected and analyzed by economists, we estimated that the overall cost to society of amounting to at alcoholism, in 1982, could have been as high as $120 billion least $10,000 a year for every alcoholic. These costs include lost productivity as a major component, but also include subtantial health system costs. Alcohol abusers cost the Veterans Administration over $121 million in 1982 in direct alcohol treatment costs. This number, however, drastically underestimates the cost of alcoholism to the Veterans Administration because it neglects the increased costs of treating any illness of an alcoholic. For our nation's population as a whole, it is estimated that 15% of total health care costs are related to alcohol abuse. In the Veterans Administration it is estimated that between 20 and 50% of all incoming patients are alcohol abusers. Because many of these patients' health problems are undoubtedly associated with alcohol abuse, the VA's alcohol-related health care costs are substantially greater than those of its alcohol treatment programs alone, and attention to patients' problems with alcohol should save the Veterans' Administration substantial amounts in reduced health care utilization over the long term. Our findings about the economics of alcoholism are related to the growing evidence that alcohol abuse is implicated in a number of medical problems. Cirrhosis of the liver has, traditionally, been the focus of analyses of morbidity and mortality due to alcohol abuse. It is now clear, however, that many other problems, including cardiovascular disease, neurological disorders and cancer are also related to alcoholism. In addition, a substantial number of |