Charts 10-14 Charts 10 through 14 highlight the differences in length of stay for Medicaid patients with and without a secondary diagnosis of substance abuse -- by substance, by age and sex, and by selected diseases and conditions. As noted in the methods section, our estimates of the additional days of care required to treat patients with a secondary diagnosis of substance abuse are limited by the medical reporting of these problems. Cigarette smoking is rarely if ever recorded as a secondary diagnosis: yet, for some conditions such as pneumonia continued heavy smoking lengthens the course of recovery. Even for alcohol and drugs, studies show that as much as 60% of cases with secondary substance abuse problems go unrecorded. If true, many patients who have a substance abuse problem are incorrectly placed in the category of patients with no secondary diagnosis; since they have a longer average length of stay (ALOS), they artificially inflate the ALOS for the category without a substance abuse diagnosis, thus reducing the true difference in length of stay. Moreover, the data can demonstrate a longer length of stay for many diseases where substance abuse is a comorbid condition, but they cannot portray the greater intensity of care that many of these patients must receive as a result of a substance abuse problem. As discussed above, many of the additional burn days may be spent in the Intensive Care Unit (ICU) where additional costs per day are much higher than the $750 average daily cost we used to compute cost differences in length of stay. This also understates the cost of substance abuse to Medicaid. Chart 10 shows that the ALOS of the Medicaid patient without a secondary diagnosis of substance abuse is 4.99 days. When a patient has a secondary diagnosis of drug abuse the ALOS jumps to 8.4 days. With a secondary diagnosis of alcohol abuse, the ALOS increases to 8.94. If the patient has a secondary diagnosis of both alcohol and drug abuse, the ALOS jumps to 9.83 days, nearly double the ALOS for the patient without a secondary diagnosis of substance abuse. These figures represent average lengths of stay, but as can be seen from Charts 12-14, some diseases demonstrate much more significant differences. The ALOS was in fact shorter for some patients with a secondary diagnosis of substance abuse. This does not imply that these patients benefitted from the use of alcohol or drugs. Rather, the differences probably result from an aberration in the data due to the small sample of patients within these diagnoses, or from the financial or social undesirability of these patients, which can lead to early discharge or transfer (dumping) to another facility. More research is needed to examine the disposition of such patients with respect to inadequate or incomplete medical care, or a lack of sufficient attention to treating their substance abuse problem. Chart 11 compares the ALOS by sex and age for those with and without a secondary diagnosis of substance abuse. Males stay 4.2 days longer with a substance abuse problem, and females 3.1 days longer. Much of the difference in ALOS in the under 15 age group is accounted for by the effect of substance abuse on newborns (see the next chart). Note that the ALOS is greater for both genders and all age levels for those with a secondary diagnosis of substance abuse with the exception of males in the 15-44 age bracket. Given the fact that Medicaid covers men in much of the age range from 21 to 64 only when they have a serious and permanent disability, the "undesirable" hypothesis described previously may explain this, since this group includes those with chronic alcohol or drinking problems as well as those diagnosed as having both mental illness and chemical dependency problems. Hospitals may stabilize these individuals and then discharge or transfer them quickly to nursing homes or psychiatric facilities, accounting for their shorter length of stay. According to Chart 12, babies born to mothers who abuse substances during pregnancy remain almost three times longer in the hospital than babies born to mothers who did not abuse substances. In utero substance abuse exposure often results in low birth weight, premature delivery, and its sequelae, mental retardation, and congenital malformations. Here again, the difference in ALOS does not include the effect of smoking during pregnancy, which would likely make these differences even more dramatic since smoking is associated with low birth weight and other adverse effects. Chart 13 reveals that AIDS patients with substance abuse as a secondary diagnosis stay about one-third longer than those without this diagnosis. Nationwide, 32% of all adult and 55% of all pediatric AIDS cases are attributable to intravenous drug use. Considering that AIDS is a protracted disease that may take ten years or more to run its course and involves multiple hospital stays, the total impact of even a third longer length of stay has significant cost implications. Medicaid patients with a primary diagnosis of burns, pneumonia, or septicemia and a secondary diagnosis of substance abuse stay more than twice as long in the hospital as Medicaid patients with the same primary diagnosis but no substance abuse (Chart 14). For example, burn patients with a secondary diagnosis of substance abuse have an ALOS of 12.6 days compared to 5.6 days for burn patients without the secondary diagnosis. |