Nursing home patients with substance use disorders: Implications for cost of care

Smith MW, Lemke S, Schaefer JA, Chow A, Ananth L. Nursing home patients with substance use disorders: Implications for cost of care. Presented at: VA HSR&D National Meeting; 2009 Feb 11; Baltimore, MD.

Objectives: Substance abuse and dependence represent a hidden epidemic among older veterans. The long-term impact on cost of care is uncertain: patients with substance use disorders (SUDs) are sicker than average and have fewer home resources, but they also experience higher mortality rates. This study used a large national sample of newly admitted VA nursing home patients to determine how the presence of SUD affects the use and cost of care over a subsequent four-year period. Methods: The sample consisted of persons age 45+ starting a VA nursing home stay in FY2000. Of 30,001 usable observations, about 20% were identified as having a SUD based on diagnosis codes during FY1998-FY2000. VA costs were extracted from the HERC Average Cost datasets. Fee Basis files provided information on VA-paid, non-VA care costs, e.g., community nursing homes and home-based care. We developed descriptive statistics on demographics, diagnoses, care patterns, and cost of care. To improve comparability we developed adjusted cost figures for SUD patients using non-SUD patients' distribution of age (5 categories), race (White vs. other), and marital status. Results: Adjusting for demographics, we found that SUD patients used similar amounts of nursing home, residential, and non-MHSA (mental health/substance abuse) care. SUD patients used more acute inpatient care (MHSA and all other) as well as more MHSA outpatient care. Over 4 years, total care costs for (adjusted) SUD patients was $89,110, almost 8% greater than for non-SUD patients. Only one-fifth of the total cost differential between SUD and non-SUD patients can be attributed to the three demographic adjustment factors. Implications: Substance use disorders are relatively common among residents of VA nursing homes. SUD patients are more costly over time even after controlling for substantial differences in age, race, and marital status distributions. Impacts: The lower marriage rates and higher mental health comorbidities among people with SUDs may contribute to earlier nursing home placement. Tailoring SUD treatment programs to late middle-aged adults and incorporating SUD treatment into psychiatric care could be cost-effective if it leads to delays in nursing home placement and less expensive care after placement.