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					              Oklahoma
          Health Care System
  Costs of Mental Health, Substance Abuse and Domestic Violence




                                       RESEARCH TEAM
                              Michael Lapolla and Kent Olson, PhD
               Kelly Damphousse, PhD; Laura Dempsey-Polan, PhD; Craig Knutson;
    Tabitha Doescher, PhD; Anthony Lo Sasso, PhD; Mark Snead, PhD; and Peter Budetti, MD, JD




              Mental Health, Substance Abuse and Domestic Violence
Oklahoma Governor’s and Attorney General’s Blue Ribbon Task Force
                           $1.5 billion


                     Mental Health              Substance Abuse Domestic Violence
                     $1.06 billion                $398 million    $75 million




Direct Costs: Health Care                                2                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                                              Table of Contents
                                                           Health Care




Executive Summary............................................................................................................................. 4
Costs to Hospitals
   Inpatient Services ........................................................................................................................... 6
   Emergency Room Services............................................................................................................. 7
   Hospital Outpatient Services .......................................................................................................... 8
   Community Hospitals-Psychiatric Sub-Providers ......................................................................... 8
   Psychiatric Specialty Hospitals....................................................................................................... 8

Injuries
Traumatic Brain Injuries........................................................................................................................ 9
Spinal Cord Injuries ............................................................................................................................... 9
Intimate Partner Violence Injuries ...................................................................................................... 10

Costs to State Agencies
   Department of Mental Health and Substance Abuse Services .................................................... 13
   State Health Department ............................................................................................................... 15

Costs to Other Institutions
   Nursing Homes.............................................................................................................................. 17
   Community Mental Health Centers.............................................................................................. 18
   Substance Abuse Treatment Centers ............................................................................................ 18
   Residential Care Centers .............................................................................................................. 18

Costs of Other Health Care Services
   Native American Health Care....................................................................................................... 19
   Physicians...................................................................................................................................... 20
   Specialized Practitioners............................................................................................................... 20
   Prescription Drugs......................................................................................................................... 20
   Health Professions Education ....................................................................................................... 22
   Federally Sponsored Research...................................................................................................... 23

Appendices
Program of Assertive Community Treatment (PACT)....................................................................... 25
Primary Hospital Discharge Diagnoses............................................................................................... 28
Secondary Hospital Discharge Diagnoses .......................................................................................... 29
Costs of Injuries ................................................................................................................................... 30

End Notes ............................................................................................................................................ 32

Direct Costs: Health Care                                3                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                         Executive Summary
Health care is an estimated $13 billion enterprise in Oklahoma.1 Of those outlays, this
analysis has conservatively identified $1.5 billion (11.8% of all expense) associated with
mental illness, substance abuse and domestic violence/sexual assault. This represents one
dollar of every eight expended.

Behaviors, conditions and circumstances associated with mental illness, substance abuse and
domestic violence/sexual assault cause Oklahoma’s health care system to expend over $1.5
billion, much of it either from public funds (Medicaid or direct government appropriations),
private charity, or bad debt as medical bills are unpaid. The impacts of each upon the Oklahoma
the health care system are calculated in this report.

Mental illness, alcohol and substance abuse, and domestic violence/sexual assault require society
to respond from a menu of public policy options. Treatment is the domain of the health care
system; the reconciliation of social damages is borne by the social and human services
infrastructure; and the education and justice systems are required to deal with the consequences of
all of the above. The workplace similarly deals with the consequences, and non-profit
organizations pick up the pieces in our communities.

This analysis offers a narrative of detailed costs related to Health Care services. The complete
Master Cost Table provides great detail and explanation of specific costs and calculations. A
modified explanation will appear here.

This analysis examines hospitals [both general and specialized], state agencies responsible for
health services, the Native American health infrastructure, nursing homes, home health agencies
and pharmaceutical payers.

Multiple data were used sources to determine the relationship between these three problems and
the Oklahoma health care system including state agencies, private hospitals and Native American
systems. Much of the data collected was actual expense. Other costs were estimated based upon
rational and reasonable imputations using local source data to the extent feasible.

Observations
Aside from the sheer size of the $1.5 billion of health care expense attributable to persons with
mental illness, substance abusers and victims of domestic violence/sexual assault, there have been
several key findings. They include:

•   Community hospitals (not including freestanding psychiatric facilities) provide over $600 million in
    health care services to mentally ill, substance abusers and victims of domestic violence/sexual assault.

•   Over $200 million is expended for mental health related pharmaceuticals in Oklahoma; the Oklahoma
    Health Care Authority (Medicaid) expended $90 million.

•   It is estimated that 16% (one in 6) nursing home residents will have a diagnosable mental illness, but
    little is expended on treatment. The taxpayer, through the Medicaid program, provides a significant
    amount of total nursing home revenue.

•   There are a host costs related to special injuries and conditions related to alcohol and substance abuse.
    They include spinal cord injury, traumatic brain injury, domestic violence injury, fetal-alcohol
    syndrome, liver transplants and vehicular crashes. The total expense is an estimated $109 million.


Direct Costs: Health Care                                4                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                        Oklahoma Health Care
       FY 2003 Costs of Mental Health, Substance Abuse and Domestic Violence/Sexual Assault

                                                          Mental      Substance         Domestic              Total
                                                          Health          Abuse          Violence         SFY 2003
HEALTH CARE SERVICES                              $1,057,617,172    $398,369,618      $74,797,096    $1,530,783,886

OKLAHOMA DMHSAS                                      143,989,491       50,439,962       5,553,680      199,983,133
Central Administration                                 7,306,948        4,800,381         332,811       12,440,140
Inpatient Hospitals                                   45,656,045                0               0       45,656,045
Community Based Programs                              87,609,539        1,211,331               0       88,820,870
Substance Abuse Programs                                       0       44,428,250               0       44,428,250
Domestic Violence Programs                                     0                0       5,220,869        5,220,869
Residential Care Program                               3,416,959                0               0        3,416,959

COMMUNITY MENTAL HEALTH CENTERS                       70,340,782        4,205,556               0       74,546,339
CHILD ABUSE PROGRAMS                                           0                0       2,638,773        2,638,773
DOMESTIC VIOLENCE PROGRAMS                               204,183        1,812,845      16,930,460       18,947,488
SUBSTANCE ABUSE TREATMENT                                      0       48,871,865               0       48,871,865

STATE HEALTH DEPARTMENT                                3,170,738        2,976,765      20,846,312       26,993,815
Administrative and Support                               264,442          248,265       1,738,599        2,251,306
Disease and Prevention                                         0        2,728,500         309,448        3,037,948
Family Health Services                                 1,064,400                0       9,377,000       10,441,400
Community Health Services                              1,841,896                0       9,421,265       11,263,161

NATIVE AMERICAN HEALTH CARE                           36,077,470       24,081,969       2,550,000       62,709,439
IHS Operating Expense                                 29,400,000       12,900,000       2,550,000       44,850,000
IHS Contracts-Federal Facilities                       2,069,831          678,752               0        2,748,583
IHS Contracts-Tribal                                   4,607,639       10,503,217               0       15,110,856

HOSPITALS                                            337,424,716     142,285,569        1,029,162      480,739,447
Inpatient-Principal Diagnosis                        105,526,100      46,575,130          733,695      152,834,926
Inpatient-Secondary Diagnosis                         75,550,599      82,279,737          295,468      158,125,803
Community Hospital Outpatient                         74,382,022               0                0       74,382,022
Community Hospital ER                                  8,754,116       2,504,245                0       11,258,361
Hospitals-Private Psychiatric                         73,211,879       6,232,930                0       79,444,809

SPECIAL INJURIES/CONDITIONS                                    0     109,080,923       25,248,709      214,418,866
Injuries-Spinal Cord                                           0      15,889,963                0       15,889,963
Injuries-Traumatic Brain                                       0      65,772,871                0       65,772,871
Injuries-IPV Related                                           0               0       25,248,709       25,248,709
Fetal Alcohol Syndrome                                         0      16,447,866                0       92,526,187
Liver Transplants                                              0       1,336,971                0        5,347,885
Vehicular Accidents                                            0       9,633,252                0        9,633,252

PHYSICIANS                                            67,438,982                0                0      67,438,982
OTHER HEALTH PROFESSIONALS                            31,129,655                0                0      31,129,655
NURSING HOMES                                        126,066,340                0                0     126,066,340

PRESCRIPTION DRUGS                                   200,097,541                0                0     200,097,541
Health Care Authority                                 90,363,463                0                0      90,363,463
State Employees Plan                                  20,489,646                0                0      20,489,646
Private Insurance                                     69,106,099                0                0      69,106,099
DMHSAS CMHC Pharma Donations                          20,138,334                0                0      20,138,334
Self-Purchase (Not estimated)                                  0                0                0               0

EDUCATION/TRAINING WORKFORCE                          37,880,934       12,626,978                0      50,507,912
FEDERALLY SPONSORED RESEARCH                             499,575        1,987,186                0       2,486,761




Direct Costs: Health Care                                5                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                         Oklahoma Health Care System
                                       Costs to Hospitals
The State of Oklahoma licenses 126 community hospitals,
47 Ambulatory Surgery Centers, 2 Birthing Centers, 11
Psychiatric Hospitals and 10 Rehabilitation Hospitals 2

It is estimated that the 126 community and 11
psychiatric hospitals expended $615 million in treating
the consequences of mental illness, substance abuse and
domestic violence/sexual assault. This includes $480
million as described in the table below; plus an
additional $134 million caring for major injuries
related to spinal cord and traumatic brain injury, fetal-
alcohol syndrome, liver transplants, motor vehicle
crashes, as well as special services for victims of domestic violence. These injury expenses
are described in the special interest section of this report..

These amounts were factored to include (without double-counting) the following services:

•    General inpatient services
•    Specialized psychiatric inpatient services
•    Hospital outpatient care
•    Hospital emergency room services.


                                         Oklahoma Hospitals
       FY 2003 Costs of Mental Health, Substance Abuse and Domestic Violence/Sexual Assault

                                        Mental Health   Substance Abuse Domestic Violence          Total SFY 2003
HOSPITALS                               $337,424,716         $142,285,569           $1,029,162       $480,739,447
Inpatient-Principal Diagnosis             105,526,100          46,575,130             733,695          152,834,926
Inpatient-Secondary Diagnosis              75,550,599          82,279,737             295,468          158,125,803
Community Hospital Outpatient              74,382,022                    0                   0          74,382,022
Community Hospital ER                       8,754,116           2,504,245                    0          11,258,361
Hospitals-Private Psychiatric              73,211,879           6,232,930                    0          79,444,809


Inpatient Services
The preferred primary data source should be the Inpatient Hospitalization - Oklahoma Public Use
Data File that gathers discharge information from every licensed hospital in Oklahoma. The data
used in this analysis is 2002 data, which are incomplete but are the most recent available. 3 The
2003 data is to have a 98% compliance rate but will not be available until Spring 2005. This
annually collected data file offers a record per discharge and includes the discharge diagnosis
code for each discharge.

The base data set was a report totaling the hospital discharges and associated charges for patients
with problems associated with specific diagnosis codes related to mental health, substance abuse
or domestic violence/sexual assault. A complete listing of these codes, descriptions, frequencies
and charges may be found in Appendices. That Appendix also depicts the conversions from the

Direct Costs: Health Care                                6                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
partial data set to a statewide estimate, and the conversion of the hospital charges to hospital
expense using the statewide hospital cost-to-charge ratio of 44.9%. 4

There were an estimated 592,000 discharges from Oklahoma community hospitals in FY 2001.
An estimated 7% had a principal discharge diagnosis related to mental illness, substance abuse or
domestic violence/sexual assault. See appendices for detail, and accompanying master cost
summary tables for all calculations.
                        Community Hospital Discharges with Primary Diagnosis
                   Mental Health, Substance Abuse and Domestic Violence/Sexual Assault

                             Primary Diagnosis           Discharges          Expense
                             Mental Health                   29,189     $105,526,100
                             Substance Abuse                   9,288       46,575,130
                             Domestic Violence                    65          733,695
                             State of Oklahoma               38,542     $152,834,926


Even more strikingly, an estimated 35% of all discharged patients had a secondary discharge
diagnosis related to mental illness, substance abuse and/or domestic violence/sexual assault. The
associated expense was almost $1.6 billion and accounted for 39% of all reported hospital
inpatient expense. The presence of a secondary diagnosis marginally extends a hospital stay and
cost. The amount is imprecise but assumed to be 10%.5 The presence of related secondary
diagnoses will add an estimated $158 million to total inpatient costs.


                      Community Hospital Discharges with Secondary Diagnosis
                   Mental Health, Substance Abuse and Domestic Violence/Sexual Assault

                            Secondary Diagnosis          Discharges          Expense
                            Mental Health                   104,255      $755,505,988
                            Substance Abuse                   93,513      822,797,368
                            Domestic Violence                    235        2,954,676
                            TOTAL                            198,003    1,581,258,032
                            Added Expense (10%)                          $158,125,803


Emergency Room Services
The 1987 federal EMTALA (Emergency Medicine Treatment and Labor Act) requires hospital
emergency rooms (ERs) to screen all people regardless of their ability to pay, which leads to their
providing care much like walk-in clinics as well as true emergency care. It is estimated that in
2001, Oklahoma hospitals provided more than 1.2 million ER visits. The total outpatient and ER
revenue was adjusted by a .449 hospital cost to charge ratio, then divided into visits. This yields
an average expense (to the hospital) of $278 per patient for ER (or OPD) care, or a total of $341
million in ER expense. 6

Of that amount, an estimated 3.3% 7 is related to mental disorders (ICD-9 codes 290-319). These
cases include substance abuse related visits. In order to isolate the substance abuse costs, a
utilization rate of 261 visits per 100,000 people was used. 8

Using these calculations, it is estimated that ER expense related to mental illness was $8.8 million
and substance abuse accounted for another $2.5 million. The total ER expense is an estimated
$11.2 million.

Direct Costs: Health Care                                7                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
Hospital Outpatient Services
It is estimated that in 2001, Oklahoma hospitals provided more than 3.3 million outpatient visits.9
Assuming an average cost of $278 (see Emergency Room above), this yields $930 million in
outpatient expense. Of that amount, an estimated 8% 10 is related to mental disorders (ICD-9
codes 290-319). These cases include substance abuse related visits. Using these calculations, it is
estimated that statewide outpatient expense related to mental illness was over $74 million.

Community Hospitals-Psychiatric Sub-Providers
There were 24 community hospitals that have licensed psychiatric care services. The total SFY
2003 expense for these psychiatric services was an estimated $49 million. It is presumed that
these units are totally oriented towards mental health care. While it is stipulated that some
patients carry a “dual diagnosis” of mental illness and substance abuse, the expense devoted to
substance abuse cannot be determined in the absence of a viable Oklahoma Inpatient
Hospitalization - Oklahoma Public Use Data File data set. As an alternative methodology, the
proportions of service reported by the private psychiatric facilities in Oklahoma were applied,
Therefore, it is estimated these general hospitals provided $44 million of mental health services
and an additional $5 million of co-occurring substance abuse treatment.

Psychiatric Specialty Hospitals
There are 10 public and private psychiatric hospitals in Oklahoma. The three state hospitals
[Oklahoma Youth Center, Griffin Memorial and Oklahoma Forensic Center (formerly Eastern
State Hospital)] are presumed to focus solely on mental health services. These hospitals expended
$46 million in providing mental health inpatient services.


                                         Public Psychiatric Hospitals

                               Totals                                  $45,656,045
                               Griffin Memorial Hospital                22,819,234
                               Oklahoma Forensic Center                 16,480,212
                               Oklahoma Youth Center                     5,436,345
                               Other                                       920,254


The other seven private facilities offer predominantly mental health services, but also provide
some substance abuse treatment. Each private institution provided their proportions of service via
interview. See the Master Cost Table for amounts and data sources. There are seven (7)
specialized private psychiatric hospitals in Oklahoma. In FY 2003, these hospitals expended an
estimated $73 million on mental health services and $6 million to provide substance abuse related
services. Costs related to domestic violence/sexual assault are very difficult to precisely identify.
Although some related costs appear as abuse-related coded encounters, most are masked under
other definitions.
                                         Private Psychiatric Hospitals

                                    Totals                        $79,444,809
                                    Mental Health                 $73,211,879
                                    Substance Abuse                $6,232,930




Direct Costs: Health Care                                8                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
    Traumatic Brain Injuries
    There were 2,874 cases in FY 2002 yielding a total hospital expense of $212 million
    ($212,170,176). An estimated 31% of this expense is attributable to alcohol and drugs. 11
    Multiplying these factors will yield an overall FY2003 TBI cost of over $66 million.

•   The direct and indirect costs of traumatic brain injury in the U. S. have been estimated to be $48.3
    billion annually. Survivor costs account for $31.7 billion and fatal brain injuries cost another
    $16.6 billion (1991 dollars).12

•   The lifetime costs for one person surviving a severe TBI can reach $4 million. 13

•   An estimate of medical and non-medical (e.g., home modifications, vocational rehabilitation,
    health insurance) per TBI survivor averages $151,587. 14

•   Average costs rise dramatically for those individuals who undergo rehabilitation. In one study,
    after a 4-year follow-up, average costs for medical and long-term care services averaged
    $196,460 for survivors receiving rehabilitation services, compared to $17,893 for those receiving
    no rehabilitation. 15

•   Acute rehabilitation costs for survivors of a severe TBI have been shown to average $110,891 per
    person, or about $1,000 per day. The average length of stay for these severely injured persons in
    acute rehab is about 55 days. 16

•   Medical costs are the highest for those who do not survive, an average of $454,717 per brain
    injury fatality. 17

•   One study showed that supported employment for helping TBI survivors return to work costs an
    average of $10,198 for the first year of service. 18

    The FY2003 mean charges per TBI case were $120,426 for inpatient hospital care and $43,993
    for inpatient rehabilitation, per Ken Wood, PhD (The Traumatic Brain Injury National Data
    Center). 19 Converting these charges to hospital expense yielded an estimated FY2003 total
    Oklahoma hospital expense of $73,824 per case.

    Spinal Cord Injuries
    There were 134 accident survivors with spinal cord injuries in Oklahoma in 2002. Data has been
    collected since 1988 and can account for a cohort of 1,925 survivors with SCI. 20 Using the lowest
    average first year cost of $184,662, and a subsequent year cost of $12,941 (see table below), one
    may conservatively conclude that this cohort consumed $50 million in medical services in FY
    2002. It is estimated that alcohol was a contributing factor in 32% of these injuries. 21Aside from
    the human tragedy, one may conservatively presume $16 million in FY 2002 cost attributable to
    substance abuse.




    Direct Costs: Health Care                                9                                        February 17, 2005
    Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                                                                  22
                                      Estimated Costs of Spinal Cord Injuries
                                    Annual (first table) and Lifetime (second table)

         Severity of Injury                                      First Year            Each Subsequent Year
         High Tetraplegia (C1-C4)                                 $626,588                    $112,237
         Low Tetraplegia (C5-C8)                                  $404,653                     $45,975
         Paraplegia                                               $228,955                     $23,297
         Incomplete Motor Functional at any Level                 $184,662                     $12,941


                                                                          Age at Time of Injury
         Severity of Injury                                     25 years old                50 years old
         High Tetraplegia (C1-C4)                                $2,393,507                  $1,409,070
         Low Tetraplegia (C5-C8)                                 $1,353,360                   $857,050
         Paraplegia                                               $799,721                    $545,460
         Incomplete Motor Function at any Level                   $533,474                    $386,619


         All costs are expressed in 2000 dollars. Lifetime costs: Average yearly health care and living
         expenses and the estimated lifetime costs that are directly attributable to SCI vary greatly according
         to severity of injury. These figures do not include any indirect costs such as losses in wages, fringe
         benefits and productivity but vary substantially based on education, severity of injury and pre-injury
         employment history.


Intimate Partner Violence
The FY 2003 cost attributed to domestic violence (within the Oklahoma health care system was
over $25 million. This cost included expenditures related to Hospitals (Inpatient, Outpatient and
Emergency Room), Physician and Dental Offices, Ambulance/Paramedic, Physical Therapy and
Mental Health Services for individuals who were victims of domestic violence.

The estimated costs of domestic violence injuries are limited by the following realities. Health
care coding systems are designed to capture encounter data by clinical need or diagnosis, not by
the social parameters of the event. Incident coding and reporting systems do not accurately
capture the involvement of “domestic violence” in medical care episodes.

Therefore standard health care databases are not useful in estimating domestic violence related
medical costs. Only recently has the Oklahoma State Bureau of Investigation (OSBI) begun to
isolate domestic violence related crimes, and victims of unreported domestic violence crimes may
now begin to seek treatment more predictably.

The table below depicts three different projections of the prevalence of domestic violence
incidents in Oklahoma. The intent of displaying this table is to show the uncertainty involved in
estimating the number of occurrences of measurable domestic violence. In most cases, statistical
estimates cite the limitations of sample sizes and response rates.




Direct Costs: Health Care                               10                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                 Varying Estimates of IPV Crimes in Oklahoma

                       Method                                             Sex Crime     Assault
                                                              23
                       Centers for Disease Control (1995)                     2,649      17,217
                                         24
                       Bardwell (2001)                                        4,238      58,540
                                                        25
                       State Health Department (1999)                                    30,754
                       OSBI Annual Crime Report (2002)                         540       24,572


                     There were an estimated 1,324,441 OK women over 18 in 2003. Using the
                     2003 estimate of women over 18:

                     (1) The CDC projection for rape is 0.2% of women 18 years and older; the
                     CDC projection for assault is 1.3% of women 18 years and older; and, the
                     CDC projection for Stalking is 0.5% of women 18 years and older. (2) Using
                     a different method of projection, Oklahoma’s State Health Department
                     (OSDH) estimate for statewide totals projected from a study sample
                     includes all forms of physical abuse whether or not classified as “assault.”
                     (3) The OSBI data represents reported domestic violence crimes. (4) The
                     Bardwell Victimization rate (incidents per 1,000 women) was rape (3.2),
                     assault (44.2), and stalking (5.0).


In order to maintain standardization, the research team used the incidents officially reported and
tracked in the state’s annual crime report published by the OSBI. Here, it is almost certain that an
incident occurred because it was officially claimed. The OSBI data is used knowing that it may
be under-estimating actual utilization of health care services, because using other estimates would
be little more than an educated guess.

                                Estimated Average Health Care Costs per
                      Nonfatal Intimate Partner Rape, Physical Assault and Stalking
                                                                                  26
                      Victimization (Occurrence) Against U.S. Adult Women, 1995

                    Service                                    Rape          Assault      Stalking
                    Emergency Room                            $30.19           35.69
                    Outpatient                                 15.30           23.90
                    Inpatient                                 382.76          429.19
                    Physician                                  38.76           21.69
                    Dental                                     14.67           15.06
                    Ambulance/Paramedic                            3.60         2.32
                    Physical Therapy                           30.23           19.65
                    Mental Health                             322.70          268.57        293.92
                    Total                                    $838.21         $816.07       $293.92


The research team used the following method to calculate these costs: Multiply the number of
IPV incidents times the average cost per incident. To that end the team:

•   Identified the number of Oklahoma incidents from the OSBI Annual Crime Report 27 which
    catalogs the number of reported domestic violence rapes and physical assaults and

•   Used the CDC 28 data reporting the estimated medical costs “per victimization,” and

•   1995 dollars are inflated to 2003 dollars using traditional conversions. 29



Direct Costs: Health Care                               11                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
This method may confuse the casual reader. The table above (Estimated Average Health Care
Costs per Nonfatal Intimate Partner Rape, Physical Assault and Stalking Victimization
(Occurrence) Against U.S. Adult Women, 1995) contains the per victimization costs (whether or
not they were reported) for each health care component. It is the average costs for all incidents.

Multiplying the costs per victimization above times the 2003 IPV offenses in Oklahoma (540
rapes, 24,572 assaults and 2,777 stalking) 30 yields the estimates arrayed in the table below:


                    Estimated Medical Costs of IPV (Intimate Partner Violence) Injuries
                           For Reported Incidents, State of Oklahoma, FY 2003

                                                Rapes      Assaults    Stalking
                                                                              31
                                                  540       24,572     2,777                  Total
               Hospital-Inpatient               $244,763   $12,488,640    0             $12,733,403
               Hospital-Outpatient                 9,784       695,446      0               705,230
               Hospital Emergency Room            19,306     1,038,513      0             1,057,819
               Physician Office                   24,786       631,139      0               655,925
               Dental Office                       9,381       438,218      0               447,599
               Ambulance/Paramedic                 2,302        66,926      0                69,228
               Physical Therapy                   19,331       571,779      0               591,110
               Mental Health Services            206,356     7,814,893   966,563          8,987,813
               State of Oklahoma                $536,008   $23,745,555 $966,563         $25,248,127


Limitations of Data
To remedy reporting problems, the American Medical Association (AMA), the Joint Commission
on the Accreditation of Health Care Organizations (JCAHCO) and other organizations endorse
routinely screening adult and teenage women for IPV. By asking simple and direct questions
regarding abuse and sexual assault, trained health care providers can more accurately identify the
extent of such assaults. This also allows them to engage in prevention and early intervention. 32

Some health care facilities accomplish this through in-house staff providing victims with
resources and support, such as safety planning. Others partner with local domestic violence and
sexual assault programs to provide patients with appropriate referrals. On the other hand, the
National Advisory Council on Violence Against Women and the Violence Against Women
Office reminds that, while documentation is important, medical records must remain confidential.
Abused women have legitimate concerns about inappropriate access to and use of medical record
information by insurance companies, employers, and law enforcement agencies. Victims of
domestic violence have the additional concern of perpetrator access, since few laws prevent
spousal access to medical records. 33




Direct Costs: Health Care                               12                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                         Oklahoma Health Care System
                                 Costs to State Agencies




State health agencies will expend $227 million to provide health care services to the
mentally ill, substance abusers and victims of domestic violence/sexual assault. This amount
does not include spending by the Oklahoma Health Care Authority as those revenue flows
are accounted for in other portions of this report.

There are two state agencies directly involved with the delivery of these health care services. The
primary agency is the Department of Mental Health and Substance Abuse Services with an annual
expense budget of $200 million. However, the State Health Department also houses several
programs targeting this population and will expend another $27 million. Actual delivery of the
health care services for this population is primarily by community hospitals in Oklahoma, and in
many outpatient settings that are contracted with the Department of Mental Health and Substance
Abuse Services.



Department of Mental Health and Substance Abuse Services
DMHSAS is Oklahoma’s lead public agency to provide and coordinate health services for the
mentally ill, substance abusers and victims of domestic violence/sexual assault. “During the
Fiscal Year 2003, the State of Oklahoma expenditures amounted to approximately $199 million
dollars. An unduplicated total of approximately 90,468 recipients were served system-wide in FY
2003. The unduplicated total of 90,468 recipients consists of 57,993 recipients that were admitted
and served and 39,976 recipients that were contacts.” 34 The SFY 2003 expenses were almost
$200 million. Mental health services consumed $144 million (72%); substance abuse services
$50.5 million (25%) and domestic violence/sexual assault programs $5.5 million (3%).


                            The ODMHSAS was established through the Mental Health Law of
                            1953, although publicly supported services to Oklahomans with mental
                            illness date back to early statehood. Today, ODMHSAS delivers
                            services in the areas of mental health, substance abuse, and domestic
violence and sexual assault. A governing board provides oversight regarding Department
functions and activity related to the care, treatment, and recovery of persons suffering from
mental illness, substance abuse, and victimization related to domestic violence/sexual assault.
The Board is responsible for appointing the Commissioner of Mental Health and Substance
Abuse Services.

For individuals with mental illness, ODMHSAS supports a continuum of programs from
community-based treatment and case management to acute inpatient care. Programs for
individuals dependent on alcohol or other drugs range from outpatient counseling to extended
residential treatment. Community-based programs for victims of domestic violence/sexual assault
provide safe shelter, advocacy, and other services. The Department also actively supports

Direct Costs: Health Care                               13                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
prevention programs to reduce the occurrence of substance abuse, violence, and other harmful
behaviors among young people.

The ODMHSAS delivers programs and services in the areas of mental health, substance abuse,
and domestic violence/sexual assault. A brief description of each follows:

Mental Health Services 35
Oklahoma is divided geographically into 17 mental health service areas. Located within each is a
publicly supported community mental health center. In addition, most community mental health
centers operate satellite offices. Five of the community mental health centers are operated by
ODMHSAS, while the others are private non-profit organizations that contract with ODMHSAS.
These centers provide therapeutic and community support services designed to assist clients in
living as independently as possible. To provide inpatient treatment, the Department operates a
psychiatric hospital for adults and one for children under age 18. The Department also operates a
specialty center devoted to forensic services. Contracts with approximately 30 residential care
homes provide ODMHSAS mental health clients with social and recreational experiences.

Substance Abuse Services
The Department operates or contracts with more than 40 substance abuse treatment programs
offering a range of outpatient, residential, and aftercare services. In addition, substance abuse
treatment is available at the community mental health centers. ODMHSAS also funds a network
of 18 Area Prevention Resource Centers offering substance abuse prevention education and
community project development.

Domestic Violence/Sexual Assault Services
The Department's activities in the area of domestic violence/sexual assault services are conducted
through contracts with more than two dozen locally operated community programs which offer
shelter, advocacy and other services to individuals affected by family violence or rape.

SFY 2003 Expense
The table below provides an overview of expense allocation of the SFY 2003 expenditures. There
is a significant amount of services that are contracted to private, non-profit entities in the areas of
Community Based Programs, Substance Abuse Programs and Domestic Violence Programs. The
operating expenses of those contracted programs will appear later in this section.


                             Department of Mental Health and Substance Abuse Services
                           Mental Illness, Substance Abuse or Domestic Violence/Sexual Assault

                                        Mental Health     Substance Abuse     Domestic Violence      Total SFY 2003
OKLAHOMA DMHSAS                          $143,989,491           $50,439,962           $5,553,680      $199,983,133
Central Administration                       7,306,948            4,800,381              332,811         12,440,140
Inpatient Hospitals                         45,656,045                    0                      0       45,656,045
Community Based Programs                    87,609,539            1,211,331                      0       88,820,870
Substance Abuse Programs                             0           44,428,250                      0       44,428,250
Domestic Violence Programs                           0                    0            5,220,869          5,220,869
Residential Care Program                     3,416,959                    0                      0        3,416,959




Direct Costs: Health Care                               14                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
State Health Department
In comparison with the Department of Mental Health and Substance Abuse Services, the State
Department of Health has little involvement in service provision for programs related to mental
health, substance abuse and domestic violence/sexual assault. Nevertheless, the Department of
Health provides $27 million to address these issues. There is $3 million each for mental health
and substance abuse and $21 million for domestic violence/sexual assault. The bulk of the
domestic violence/sexual assault expense ($16 million) is for child abuse prevention services and
related expense.


                                            State Health Department
                         Mental Illness, Substance Abuse or Domestic Violence/Sexual Assault


                                  Mental Health      Substance Abuse      Domestic Violence        Total SFY 2003
STATE HEALTH DEPT                    $3,170,738             $2,976,765           $20,846,312          $26,993,815
Administrative and Support              264,442                248,265              1,738,599            2,251,306
Disease and Prevention                         0             2,728,500                309,448            3,037,948
Family Health Services                1,064,400                       0             9,377,000          10,441,400
Community Health Services             1,841,896                       0             9,421,265          11,263,161


HIV/STD Service
The service plans, develops and implements statewide programs for the prevention and
intervention in the spread of HIV/AIDS and sexually transmitted diseases. Activities include
disease surveillance and the development of community partnerships for broad-based initiatives.
It also manages specific programs designed to provide pharmaceutical assistance and other vital
services to people living with HIV and AIDS. This program expended an estimated $2,728,500 to
provide substance abuse related services in FY 2003.

Child Abuse Prevention Service
The Child Abuse Prevention Service's responsibilities include provision of statewide
multidisciplinary and discipline-specific training, assessment and monitoring of prevention
programs and child abuse teams, funding of community programs and other capacity building
efforts to ensure quality services that effectively prevent child abuse and neglect; improvement of
the system that intervenes in cases of child abuse and neglect; and promotion of the identification
and reporting of domestic violence/sexual assault.

Children First
This OSDH program develops and provides voluntarily requested home visitation services to
first-time parents in order to reduce the maternal and child health problems that often emerge
early in the life cycle and that may be prevented with improvements in maternal health habits,
parenting skills and the psychosocial and material contexts in which the family is functioning.
Trained public health nurses follow tested program protocols that focus on five domains of
functioning: personal health, environmental health, maternal role, and material life-course
development and family and friend support.




Direct Costs: Health Care                               15                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
Children First
Average Actual Expenditures per Family in 2003
A Children First public health nurse visited a total of 7,527 families at least once during FY 2003. A total
of $12,862,825 was expended during SF 2003 to prevent child abuse, including state appropriations and
Medicaid reimbursement.36 The average actual expenditure per family for Children First (C-1) was $1,709
per family in FY 2003.

The OSDH Project on Violence Against Women 37 describes Children First as a preventive abuse
program. Beyond nurse home visitation services to families with little financial or social supports,
families who are expecting to deliver and/or parent their first child, and pregnant women who are
less than 28 weeks gestation, Children First offers:

•   Health assessments of mother and child
•   Child development assessments
•   Education in parenting
•   Nutrition
•   Health and safety; and
•   Referrals including domestic violence and sexual assault services

The OSDH Project found that nurse home visitation programs have been a component of public
health for over 100 years with the goal of improving maternal and child health, child development
and pregnancy outcomes. Important findings cited include:

•   Follow-up studies indicate that nurse home visitations reduce antisocial behaviors associated
    with poor maternal health during pregnancy, dysfunctional care giving and maternal life
    course.38

•   Nurse home visitations also made a significant impact on antisocial behaviors in adolescents
    of high-risk families, including fewer arrests and convictions, lower rates of substance abuse,
    fewer sexual partners, and fewer behavioral problems related to drugs and alcohol when
    compared to controls.39

Maternal and Child Health (MCH) Service
MCH is comprised of Child and Adolescent Health, Women's Health, and MCH Assessment.
Child and Adolescent Health Division provides preventive and primary care services for infants,
children, adolescents and their families through SAFE KIDS Injury Prevention, Healthy Child
Care Oklahoma and Early Childhood Comprehensive Systems activities. MCH provides
leadership for Sudden Infant Death Syndrome (SIDS), Fetal and Infant Mortality Review,
Maternal Mortality Review, and participates in Child Death Review.

OSDH Services are delivered locally through organized county health departments in 69 of 77 counties.
Each county health department consists of a core of public health professionals (e.g., administration,
nursing, environmental, health promotion and clerical support staff.) Administrative, technical and fiscal
support, including supervision of all local personnel, is provided via Community Health Services Local
Services Support.




Direct Costs: Health Care                               16                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                       Oklahoma Health Care System
                                    Costs to Other Institutions

Nursing Homes
Nursing home residents have significant mental health needs. Little is expended to address these
needs. This creates a cost-finding research dilemma. Does one simply find actual treatment costs
that are small ($1 million)? Or does one measure unmet needs in terms of proportional nursing
home costs ($126 million)? And there is no method to know how many nursing home residents
are clients because their mental conditions preclude self-care.

Direct Mental Health Expense
Oklahoma nursing homes will have an estimated expense of $769 million. Of that amount, the
Oklahoma Health Care Authority will pay $534 million, or 69.4%.40 The payments indicate
$738,000 paid for behavioral health services for Medicaid patients. Adjusting by 69.4% yields an
estimated $1 million ($1,063,232) expended for mental health services from all sources.

Cost of Related Nursing Home Expense (Unmet Need)
The National Nursing Home Survey (NNHS) is a continuing series of national sample surveys of
nursing homes, their residents and their staff. Nursing home surveys have been conducted in
1973-74, 1977, 1985, 1995, 1997 and 1999. These surveys were preceded by a series of surveys
from 1963 through 1969, called the "residents places" surveys. Although each of these surveys
emphasized different topics, they all provided some common, basic information about nursing
homes, their residents and their staff. The most recent NNHS was conducted in 1999.

All nursing homes included in this survey had at least three beds and were either certified (by
Medicare or Medicaid) or had a State license to operate as a nursing home, The National Nursing
Home Survey provides information on nursing homes from two perspectives - that of the provider
of services and that of the recipient. Data about the facilities include characteristics such as size,
ownership, Medicare/Medicaid certification, occupancy rate, number of days of care provided
and expenses. For recipients, data are obtained on demographic characteristics, health status and
services received. Data for the survey has been obtained through personal interviews with
administrators and staff, and occasionally with self-administered questionnaires in a sample of
about 1,500 facilities. 41

The private nursing home data is FY2003; the Veterans data is FY2002. The total expenses were
multiplied by 16.4% prevalence rate of nursing home residents with a mental health condition. 42

                                         Nursing Homes in Oklahoma

                                                                FY2003 Expense             Mental Health
         Totals                                                     $768,697,195            $126,066,340
         Private Nursing Homes                                       746,376,000             122,405,664
         Veterans State Nursing Home Care                             22,321,195               3,660,676




Direct Costs: Health Care                               17                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
Community Mental Health Centers
Oklahoma is divided geographically into 17 mental health service areas. Located within each is a
publicly supported community mental health center. In addition, most community mental health
centers operate satellite offices. Five of the community mental health centers are operated by
ODMHSAS, while the others are private, non-profit organizations that contract with ODMHSAS.
These centers provide therapeutic and community support services designed to assist clients in
living as independently as possible. 43

Services build on individual strengths to promote consumer empowerment and recovery. Core
services include crisis intervention, screening and referral, counseling, case management,
medication therapy and psychosocial rehabilitation. Specialty services (not yet available
statewide) can include integrated treatment for persons with co-occurring mental illness and
substance abuse, assertive community treatment, systems of care for children, crisis stabilization,
short-term inpatient treatment and housing programs. Due to resource limitations, the primary
target populations are adults with a serious mental illness and children with a serious emotional
disturbance. 44

The Oklahoma CMHCs expended an estimated $112 million to provide services in FY 2003.
Most of the services ($104 million) were for mental health; and the remainder for co-occurring
substance abuse services ($9 million).

There are 12 private, non-profit facilities. They received an aggregated $21.8 million contract
from DMHSAS and generated an additional $51.7 million in fees and other revenue for a total
expense of over $73 million. The state centers received an appropriation of $30 million and
generated an additional $8 million of revenue for a total expense of $38 million.

Substance Abuse Treatment Centers
There are 116 certified alcohol and/or drug treatment centers in Oklahoma. The DMHSAS
contracts with 68 centers, and 48 centers operate with non-DMHSAS funding. The Oklahoma
SATCs expended an estimated $49 million (including DMHSAS contracts) to provide services in
FY 2003. The DMHSAS contracts totaled $15 million in FY 2003.

Residential Care Centers 45
These centers have an estimated 1,302 beds and had an aggregate FY2003 expense of almost $9
million, including $3.4 million in FY2003 DMHSAS contracts. These contracts cover 31 certified
residential care centers in Oklahoma (an estimated 984 beds – or 75.6% of the total statewide
complement). The contracts were to provide ODMHSAS mental health clients with social and
recreational experiences.

Other sources of revenue include Supplemental Security Income and Medicaid. For cost finding
purposes, it is conservatively estimated that 75.6% of total expenses of these care facilities are
attributable to individuals who require mental health treatment and/or services.




Direct Costs: Health Care                               18                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                            Oklahoma Health Care System
                              Costs of Other Health Care Services

Native American Health Care
Oklahoma is home to 39 federally recognized tribal governments. The health care services
provided by and/or for Native Americans are at arms-length from other health care services in the
state. The Native American health services are a hybrid of services provided by tribal government
using large appropriations from the federal government and those services operated by the federal
government for the sole use of Native American clients.

                                   There is no central source of expense data for Oklahoma tribal
                                   governments. Securing similar data from each tribe is neither practical
                                   nor likely to be accurate, since the tribes do not use common accounting
                                   systems, nor are they all able to apportion expenses uniformly.

                            Therefore the primary source of FY 2003 health care expense data is the
                            federal appropriation to the Indian Health Service to the Oklahoma
facilities, and Oklahoma City Area office of the Indian Health Service. That office provides the
mental health/substance abuse contracts operational with each tribe and tribal operation. Although
the tribes may supplement these funds with others, it is likely that the contract funds provide the
vast majority of expenses. It is presumed that the Native American services would be embedded
into their hospital and clinic system as they are into Oklahoma’s community hospitals. These
multipliers would be 9.8% of expense related to mental health; 4.3% to substance abuse and
0.85% related to domestic violence/sexual assault. These multipliers were used against total NA
expense of $300 million. The contracts for direct mental health and substance abuse contracts
were added to these numbers. 46

The Indian Health Service and tribal health care organizations in Oklahoma were provided an
estimated $18 million to apply to health care expenses related to mental illness and substance
abuse. Domestic violence/sexual assault grants/contracts appear in the Social Services section of
this report. 47


                                            FY2003 Health Care Expense
                                        Native American Health Care Services

                                                   Mental       Substance          Domestic              Totals
                                                   Health           Abuse           Violence          SFY 2003
NATIVE AMERICAN HEALTH CARE                   $36,077,470      $24,081,969        $2,550,000        $62,709,439
IHS Operating Expense                          29,400,000       12,900,000          2,550,000         44,850,000
IHS Contracts-Federal Facilities                2,069,831         678,752                   0          2,748,583
IHS Contracts-Tribal                            4,607,639       10,503,217                  0         15,110,856




Direct Costs: Health Care                               19                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
Physicians
There were an estimated 880 million office visits in the United States. The Oklahoma population
represents 1.2% of the U.S. population, suggesting approximately 10.8 million visits in
Oklahoma. Assuming a cost of $114.65 per visit, that yields an Oklahoma expense of $1.3 billion.
Of that amount, an estimated 5.1% are related to mental disorders (ICD-9 codes 290-319). Using
these calculations, it is estimated that physician office expense related to mental illness was
almost $68 million. 48

Specialized Practitioners
It is likely that many of these professionals will also be incorporated into the expense of
institutions mentioned elsewhere in this analysis. They are included here for completeness.

Number of psychiatrist MD (302) physicians is per the Oklahoma Board of Medical Licensure
website for active, licensed MD physicians in Oklahoma; the DO Physicians (30) are from the
respective licensing agency; Psychologists (800) are from the National Center for Health
Workforce Analysis for 2000 (published 2004). The average compensation and retirement
benefits for each specialty is based upon the Medical Group Management 2003 (2002 data)
Physician Compensation and Production Survey.

Oklahoma Social Worker numbers (8,810) are from the National Center for Health Workforce
Analysis for 2000 (published 2004). The calculation includes 1,060 social workers employed in
mental health and substance abuse services. Oklahoma has an additional 1,010 social workers in
public health, and 6,740 employed in children and family services. Salaries are per University of
Oklahoma salary schedule. Allocations were made intuitively and proportionately.

The census of Licensed Professional Counselors (2,569-223 out of state); the number of Licensed
Behavioral Practitioners (312); and Licensed Marriage and Family Counselors (508) are from
Oklahoma Health Department, Division of Professional Counselor. The salaries/benefits
projected at $30,000 annually.

Prescription Drugs
Oklahomans purchased over $2 billion of retail prescription drugs in
2002. 49 It is estimated that public and private purchases of medications
for mental health purposes exceeded $200 million.

Our projected prescription drug expense is entirely attributable to mental illness. It was not
possible to identify or separate substance abuse related prescription drug expenses, nor any
expenses identifiably related to domestic violence/sexual assault.

There are several major providers of psychotropic and related medications. They are the
Oklahoma Health Care Authority (Medicaid), the State Insurance Board (State Employees Health
Plan), private insurers statewide, the Department of Mental Health and Substance Abuse
Services, the Oklahoma Department of Corrections and individual purchases. The one source that
has not been easily available is county and municipal jail purchases. The table below indicates the
actual or estimated expense of these medications.




Direct Costs: Health Care                               20                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                    FY 2003 Costs of Prescription Drugs

                                                                        Mental Health
                            PRESCRIPTION DRUGS                           $200,097,541
                            Health Care Authority                          90,363,463
                            State Employees Plan                           20,489,646
                            Private Insurance                              69,106,099
                            DMHSAS Donated Meds                            20,138,334



Prescription drugs have grown to become an essential component of health care. For millions of
Americans, prescription therapies are necessary to their health and ability to function in society.
While prescriptions are a relatively small share of overall health spending (11%), they are a key
driver of health spending trends, growing almost twice as fast all other health services in recent
years.

Public attention has focused on prescription drugs and on the pharmaceutical industry because of
the very rapid growth of drug costs, and because a significant portion of the population lacks
insurance to cover the costs of the drugs they need. Older Americans, who use a disproportionate
share of prescription drugs, are less likely to have coverage than younger people because
Medicare generally does not cover outpatient pharmaceutical costs. Higher drug costs are placing
a stress in public and private insurance programs, and are an important component of the recent
growth in state Medicaid spending. Methods of controlling prescription costs (such formularies,
requiring generic rather than brand name drugs, tiered copayments) are being used, and their
impact on costs and consumers studied.

Many of these prescription issues are being examined as policy-makers explore options for
expanding Medicare’s coverage to include outpatient drugs. 50




Direct Costs: Health Care                               21                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
Health Professions Education
There are 27 public colleges and universities that offer
programs to prepare the workforce to deal with the
consequences of mental illness, substance abuse and
domestic violence/sexual assault. The academic disciplines
included in this analysis were education, health professions,
psychology, social sciences and social work. 51


                                 Professional Education Costs in Oklahoma
                        mental illness, substance abuse and domestic violence/sexual assault

                       Health Professions Education                              $50,507,912


                       University of Oklahoma                                     14,679,316
                       Oklahoma State University                                   7,382,369
                       University of Central Oklahoma                              4,022,872
                       Northeastern State University                               3,835,369
                       East Central University                                     3,519,226
                       Southwestern Oklahoma State University                      2,121,915
                       Cameron University                                          1,913,566
                       Tulsa Community College                                     1,733,687
                       Langston University                                         1,609,488
                       Northwestern Oklahoma State University                      1,401,550
                       Oklahoma City Community College                             1,327,283
                       Southeastern Oklahoma State University                      1,173,509
                       Rogers State University                                       926,426
                       Eastern Oklahoma State College                                704,338
                       OSU OKC                                                       704,173
                       Rose State College                                            688,865
                       University of Science and Arts of Oklahoma                    414,982
                       Panhandle Oklahoma State University                           323,560
                       Seminole State College                                        303,437
                       Connors State College                                         282,277
                       Northeastern Oklahoma State College A&M                       261,761
                       Redlands Community College                                    255,540
                       Northern Oklahoma College                                     250,150
                       Western Oklahoma State College                                225,419
                       Carl Albert State College                                     199,940
                       Murray State College                                          191,054
                       OSU Okmulgee                                                   55,840




Direct Costs: Health Care                               22                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
Federally Sponsored Research
In addition to the educational expense, there is almost $2.5 million of federally sponsored
research that is occurring in Oklahoma. 52 All of the listed research is funded from the federal
department of Health and Human Services. It is unlikely that a substantial volume of related
health care related research is funded by other agencies.

                                    Federally Sponsored Health Research


                                  Mental Health     Substance Abuse      Domestic Violence                 FY2003
Oklahoma                               $499,575            $1,987,186                     $0            $2,486,761
Mental Health                           499,575                      0                     0               499,575
Drug Abuse                                    0               944,988                      0               944,988
Alcohol Abuse                                 0             1,042,198                      0             1,042,198




Direct Costs: Health Care                               23                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                  Appendices




Direct Costs: Health Care                               24                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                       Appendix – Health Care Costs
               Program of Assertive Community Treatment (PACT)
Pennsylvania 53
Six mental health experts sat at a table in Warminster, Bucks County, Tuesday and planned the
futures of 15 seriously mentally ill men and women. The six are members of an innovative
outreach team called PACT - Program of Assertive Community Treatment. That morning, the
team had a lot on its plate.

They were discussing how best to handle a paranoid young man who hid in his closet to escape
police he believed were chasing him. They talked about a young mother who was released from a
long hospital stay; she had blamed the 9/11 attacks on herself.

They planned visits to a woman who frequently reverted to behaving like a little girl - then would
cut herself. Most pressing, though, was the case of a mentally ill homeless woman in her 40s who
had been hospitalized after going ballistic at the team's office. The woman was about to be
released in two days. And the team still hadn't found a place for her to live.

Imagine if you had a team of caring experts to look after you 24/7 and guide you past every bump
in life.

That is what PACT teams do for the severely mentally ill - especially those at risk of repeat
hospitalizations. Begun in Wisconsin, the PACT approach is widely hailed. It's what should have
happened decades ago when states began emptying mental hospitals.

Oklahoma PACT 54
The Program of Assertive Community Treatment (PACT) model has been in existence nationally
for nearly 30 years and is an effective, evidenced-based, outreach-oriented, service delivery
model using a 24-hour-a-day, seven-day-a-week approach to community-based mental health
services. PACT delivers comprehensive treatment, rehabilitation and supportive services to
consumers in their homes, at work and in community settings. The goal of PACT is to increase
the quality of life for mental health recipients by assisting them with their basic needs, increasing
medication compliance, securing competitive employment, and reducing debilitating symptoms
and the need for inpatient care.

Oklahoma Outcomes
Oklahoma’s PACT initiative continues to produce significant outcomes, particularly in the area of
reduced hospitalizations and jail days. A recent study compares the number of days in an
inpatient setting and jail days before admittance to PACT with number of such days while in
PACT.

For clients admitted to a PACT program in fiscal year 2003, the number of inpatient and jail
days experienced in the year before the PACT admission was compared to the number of days
experienced in the year following admission to PACT. For clients admitted to the PACT
program for less than 12 months, i.e., they were admitted in the last half of fiscal year 2003, a
one-year follow-up was not possible as of December 31, 2003. Therefore, inpatient and jail days
for the last six months of the follow-up were estimated based on the results of those clients
with a full one-year follow-up period.


Direct Costs: Health Care                               25                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
 Days
                                                                    The results of the study indicate a
  10,000
                                                                    78.4% reduction in inpatient utilization
   9,000                                                            and a 53.5% reduction in jail time. See
                79% fewer hospitalizations                          attachment for the detailed outcome
   8,000        reduces expense $2 million                          report.
   7,000        6,695
                                                             Funding
   6,000
                                                             Of the eight PACT teams currently
                               2003                          operating in the state, four are funded
   5,000                 Oklahoma PACT                       through a legislative appropriation of
                                                             $3.2 million and are operated by
   4,000                                                     contract providers in Tulsa and in
                                                             Oklahoma City. The other four teams
   3,000
                              54% fewer days in jail reduces were initiated at state-operated
   2,000                         expense by $40 thousand     community mental health centers
                   1,447
                                  1,009                      through a redirection of existing
   1,000                                 473                 resources. Collaboration with the
                                                             Oklahoma Health Care Authority has
       0                                                     resulted in the development of a
              Inpatient              Jail                    revenue source for PACT services
                                                             through Medicaid. Approval by the
federal government of this new Medicaid service is pending. A small portion of this year’s
appropriation was provided to the four state centers on a one-time only basis to initiate some
enhancement of the staffing of their teams, pending the anticipated Medicaid funding.

Costs
The chart showing the reduction of inpatient and jail days may lead one to believe that PACT
teams offer significant cost savings. It was the intent of this project to pursue that analysis.
However it appears too early to prove such a conclusion. Little is known of the start-up fixed
costs, marginal expense, optimal caseloads and other factors. Something is known of projected
reduction in services. Very little is known of associated and offsetting cost. Regardless, it is
obvious that the major cost savings accrued will be in reduced hospitalizations. This is because of
the dramatic success in reducing the rate and number of admissions – and its associated $400 per
day costs. The reduction of jail time is likely to accrue more non-cash benefits than the amount of
expense reduction.

Drug Courts
The Oklahoma Criminal Justice Resource Center analyzed data from 19 Adult Drug and DUI
Courts operating in 21 counties in Oklahoma. This included all active participants as of July 1,
2001, and all participants entering through June 30, 2003, which represents 1,666 participants.
Controlled Dangerous Substance (CDS) offenses accounted for 19.3% of all prison offenses in
2002, and 44.1% had no prior felony convictions, although it is possible that other extenuating
factors such as numerous prior arrests, misdemeanors, or a sentence that is about to be revoked or
accelerated may cause some offenders with no priors to be prison-bound (offenders who are
prison-bound typically have 2 or more prior felony convictions); and 86.3% of the drugs of
choice are alcohol, methamphetamine, cannabis, or cocaine.




Direct Costs: Health Care                               26                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
Compliance with Statute
Participants must plead guilty upon entry into drug court and receive a delayed imposition of
sentence. However, more than one-third of the participants received a deferred judgment or a
suspended sentence. It is unclear at this time whether these participants were given an
inappropriate judgment and sentence or if they were properly admitted to the drug court program
as a probation or parole disciplinary sanction.

If participants successfully complete drug court, their case is dismissed 59% of the time, while
26.1% receive a deferred judgment or suspended sentence.

The statewide average length of drug court is 16 months. This complies with statute, which
allows for a two-year treatment program and one year of supervision.

There is wide variance in the average length of the prison sentence given if a participant fails
drug court. The range is 10 months in Payne County to 189 months in Muskogee County, while
the statewide average is 77 months (6 years 5 months).

Intermediate Sanctions
A key component of Drug Court is that rule violations, including substance abuse, result in swift
and certain sanctions.

The top violation resulting in a sanction was positive drug tests at 23.7% (or 1,305 times). The
remaining top four violations involved missing group treatment sessions, self-help sessions (e.g.
alcoholics).

Outcomes
In determining whether or not drug courts are successful, outcomes must be assessed. The
retention rate (active and graduated participants) for drug courts at 83.1% is higher than the
national retention rate for drug courts, which is 70% according to the National Drug Court
Institute. With regard to outcomes among drug court graduates, comparisons were made between
graduates’ characteristics at entry and at graduation on a number of indicators. The findings are as
follows: there was a 75.1% decrease in unemployment; there was a 50.4% increase in income;
there was a 13.6% decrease in the percent of graduates without a high school diploma; there was
a 19.1% increase in the number of graduates who had children living with them; and there has
been an improvement in each of the seven components of the Addiction Severity Index (ASI). Of
successful standard probation offenders or released prison inmates indicates the following
findings: drug court graduates are 74% less likely to recidivate than successful standard probation
offenders; and drug court graduates are more than four times (or Cost A cost analysis model was
developed to compare the cost of sending 1,666 offenders (the number of offenders analyzed
during the reporting time period – July 2001 through June 2003) to drug court, instead of prison.
This model was also used to compare the cost of drug court to standard probation.

The results are as follows: if all 1,666 offenders would have otherwise served their
sentence in prison, the overall 4-year cost savings of drug court versus prison is $45,552,798;
and if all 1,666 offenders would have otherwise served standard probation sentences, the 4-year
costs of drug court were $4,334,599 more than the costs for standard probation.




Direct Costs: Health Care                               27                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                             Appendix – Health Care Costs
                             Primary Hospital Discharge Diagnoses
    Cost of inpatient services for patient discharges with applicable primary diagnoses, OK 2001

                   ICD       PRINCIPAL DIAGNOSIS                                 DISCHARGES     EXPENSE

                             DOMESTIC VIOLENCE
                   995.80    Abuse, Adult (995.80-995.85)                                 0              0
                   995.50    Abuse, Child (995.50-995.59)                                65        733,695
                   799.2     Nervousness                                                  4          3,271
                   783.6     Polyphagia (overeating)                                      2            701
                   780.5     Sleep Disorders                                            172        797,175
                             SUB-TOTAL DOMESTIC VIOLENCE                                243      1,534,842

                             SUBSTANCE ABUSE
                   303       Alcohol dependence syndrome                               2,179     4,511,434
                   291       Alcoholic psychoses                                         960     2,965,975
                   940-949   Burns                                                       189     2,658,048
                   191       Cancer, Brain                                               124     1,656,911
                   175       Cancer, Breast                                                1         4,390
                   153-54    Cancer, Colorectal                                          361     4,411,218
                   155       Cancer, Liver                                                37       356,914
                   758       Chromosomal Anomalies                                        10       370,038
                   571.2     Cirrhosis                                                   367     2,799,881
                   304       Drug dependence                                             987     1,960,815
                   292       Drug psychoses                                              830     2,374,051
                   779.5     Drug Reactions and Intoxication, Newborn                     0              0
                   779.4     Drug Withdrawl, Newborn                                      0              0
                   345       Epilepsy                                                   193        998,146
                   760.71    Fetal Alcohol Syndrome                                       2            534
                   535.3     Gastritis, Alcoholic                                       115        352,145
                   421       Heart Disease: Endocardititis                              175      4,845,732
                   070       Hepatitis A, B, C                                             0             0
                   401       Hypertension                                                205       551,735
                   305       Nondependent abuse of drugs                                 557     1,122,926
                   577.0     Pancreatitis, Acute                                       1,530    10,857,961
                   577.1     Pancreatitis, Chronic                                       225     1,944,822
                   532       Ulcer, Duodenal                                              52       494,990
                   531       Ulcer, Peptic, Stomach                                      188     1,336,465
                             SUB-TOTAL SUBSTANCE ABUSE                                 9,288    46,575,130

                             MENTAL ILLNESS
                   308       Acute reaction to stress                                     67       155,438
                   309       Adjustment reaction                                         989     3,194,509
                   296       Affective psychoses                                      13,663    45,479,810
                   311       Depressive disorder, NEC                                  2,238     6,366,727
                   312       Disturbance of conduct, NEC                               1,094     5,186,763
                   313       Disturbance of emotions/childhood, adolescents              476     2,164,107
                   314       Hyperkinetic syndrome of childhood                          210     1,083,398
                   V69.1     Inappropriate Diet/Eating Habits                              0             0
                   300       Neurotic disorders                                        1,001     3,062,389
                   V61       Other Family Circumstance                                     8        15,727
                   298       Other nonorganic psychoses                                1,291     4,177,989
                   294       Other organic psychotic conditions (chronic)              1,481     6,919,935
                   V62       Other Psychosocial Circumstances                              4         3,317
                   297       Paranoid states (Delusional disorders)                      115       343,784
                   301       Personality disorders                                        50       178,485
                   306       Physiological malfunction, mental factors                    82       240,983
                   316       Psychic factors associated w/DCE                              4         9,108
                   299       Psychoses with origin specific to childhood                  86       364,967
                   295       Schizophrenic disorders                                   4,117    15,655,333
                   290       Senile and presenile organic psychotic conditions         1,555     8,440,593
                   302       Sexual deviations and disorders                              11        81,515
                   307       Special symptoms or syndromes, NEC                          130       378,123
                   315       Specific delays in development                                0             0
                   310       Specific nonpsychotic mental disorders, obd                 132       391,001
                   293       Transient organic psychotic conditions                      385     1,632,099
                             SUB-TOTAL MENTAL ILLNESS                                 29,189   105,526,100

                             GRAND TOTAL - OKLAHOMA                                   38,720   153,636,073




Direct Costs: Health Care                               28                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                                Appendix – Health Care Costs
                             Secondary Hospital Discharge Diagnoses
  Cost of inpatient services for patient discharges with applicable secondary diagnoses, OK 2001


                   ICD       SECONDARY DIAGNOSIS                                 DISCHARGES       EXPENSE

                             DOMESTIC VIOLENCE
                   995.80    Abuse, Adult (995.80-995.85)                                  0              0
                   995.50    Abuse, Child (995.50-995.59)                                235      2,954,676
                   799.2     Nervousness                                                  52        212,428
                   783.6     Polyphagia (overeating)                                     207      3,720,043
                   780.5     Sleep Disorders                                           6,464     69,783,128
                             SUB-TOTAL DOMESTIC VIOLENCE                               6,958     76,670,275

                             SUBSTANCE ABUSE
                   303       Alcohol dependence syndrome                               7,507     60,126,455
                   291       Alcoholic psychoses                                       1,664     17,352,923
                   940-949   Burns                                                       392      8,011,889
                   191       Cancer, Brain                                                95      1,076,042
                   175       Cancer, Breast                                                2         16,763
                   153-54    Cancer, Colorectal                                          277      2,950,584
                   155       Cancer, Liver                                                37        297,566
                   758       Chromosomal Anomalies                                       664      9,984,598
                   571.2     Cirrhosis                                                   943     11,034,516
                   304       Drug dependence                                           4,603     22,692,429
                   292       Drug psychoses                                            1,873     20,747,824
                   779.5     Drug Reactions and Intoxication, Newborn                      6         48,146
                   779.4     Drug Withdrawl, Newborn                                      33        352,952
                   345       Epilepsy                                                    205      2,887,870
                   760.71    Fetal Alcohol Syndrome                                       19        151,878
                   535.3     Gastritis, Alcoholic                                        180      1,169,211
                   421       Heart Disease: Endocardititis                                98      3,248,756
                   070       Hepatitis A, B, C                                             0              0
                   401       Hypertension                                             16,962    147,911,893
                   305       Nondependent abuse of drugs                              56,362    486,764,460
                   577.0     Pancreatitis, Acute                                         739     14,895,029
                   577.1     Pancreatitis, Chronic                                       561      6,535,826
                   532       Ulcer, Duodenal                                              53        784,021
                   531       Ulcer, Peptic, Stomach                                      241      3,755,738
                             SUB-TOTAL SUBSTANCE ABUSE                                93,513    822,797,368

                             MENTAL ILLNESS
                   308       Acute reaction to stress                                    373      2,329,892
                   309       Adjustment reaction                                       3,377     25,262,906
                   296       Affective psychoses                                       7,698     53,078,011
                   311       Depressive disorder, NEC                                 22,075    178,959,907
                   312       Disturbance of conduct, NEC                               1,978     11,390,505
                   313       Disturbance of emotions/childhood, adolescents            1,599      8,865,679
                   314       Hyperkinetic syndrome of childhood                        1,360      8,565,781
                   V69.1     Inappropriate Diet/Eating Habits                              2          3,118
                   300       Neurotic disorders                                       19,356    128,027,939
                   V61       Other Family Circumstance                                 1,921      7,991,106
                   298       Other nonorganic psychoses                                3,287     29,022,894
                   294       Other organic psychotic conditions (chronic)             20,064    146,214,022
                   V62       Other Psychosocial Circumstances                            629      3,047,284
                   297       Paranoid states (Delusional disorders)                      585      4,910,571
                   301       Personality disorders                                     4,545     24,040,716
                   306       Physiological malfunction, mental factors                   174      1,163,714
                   316       Psychic factors associated w/DCE                             10         45,683
                   299       Psychoses with origin specific to childhood                 126        829,321
                   295       Schizophrenic disorders                                   3,413     28,379,062
                   290       Senile and presenile organic psychotic conditions         6,074     47,244,304
                   302       Sexual deviations and disorders                              96        539,212
                   307       Special symptoms or syndromes, NEC                        1,402      9,905,980
                   315       Specific delays in development                              427      3,226,538
                   310       Specific nonpsychotic mental disorders, obd               1,496      8,549,738
                   293       Transient organic psychotic conditions                    2,189     23,912,104
                             SUB-TOTAL MENTAL ILLNESS                                104,255    755,505,988

                             GRAND TOTAL - OKLAHOMA                                  204,726   1,654,973,631




Direct Costs: Health Care                               29                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
                                       Appendix – Health Care Costs
                                            Costs of Injuries
The Costs of Injuries
“In Oklahoma, the emotional, physical, and economic devastation of injuries continues to be
extraordinary. Injuries are the leading killer of Oklahoma's children and young adults from 1 year
of age through 44 years of age. Injuries account for more premature deaths before 65 years of age
than cancer, heart disease, stroke, and diabetes combined. Yet, Oklahomans continue to view
injuries as unavoidable chance happenings.

In reality, injuries, like disease, occur in highly predictable patterns. Injury is a problem that can
be diminished considerably if adequate attention and support are directed to it. It is through
systematic examination of data that the true effects of this problem are realized”. 55

             Alcohol: More than a third of all injury deaths in Oklahoma will have alcohol as a
             contributing factor. Alcohol will be a contributing factor in residential fires (52%),
             homicides (41%), drownings (39%), traffic accidents (38%), firearms (35%) and
             suicides (33%). The abovementioned categories are deaths. What is the contribution
             of alcohol to the two most serious and debilitating injuries for survivors – that being
             Spinal Cord Injuries (SCI) and Traumatic Brain Injuries (TBI)? It is calculated that
             alcohol is a contributing factor to 32% of SCI and 31% of TBI. In effect, alcohol
alone will be responsible for one-third of all the spinal cord and traumatic brain injuries in
Oklahoma.

Spinal Cord and Traumatic Brain Injuries: The State Health Department captures information
concerning deaths as a result of injury. There is no central data bank for survivors of accidents.
The economic impacts of these deaths may be examined in our companion study of the lost
productivity caused by these deaths. There are two exceptions in Oklahoma. One is Spinal Cord
Injuries and the other is Traumatic Brain Injury.

These survivors are tracked precisely because the effects of the injury are so debilitating and so
costly. While the costs involved do not contribute significantly to the overall $3 billion found in
this study, the impacts are huge on families, insurers and victims alike. It is worth talking about.

                What is a Spinal Cord Injury? 56 “Spinal Cord Injury (SCI) is damage to the spinal
               cord that results in a loss of function such as mobility or feeling. Frequent causes of
               damage are trauma (car accident, gunshot, falls, etc.) or disease (polio, spina bifida,
               Friedreich's Ataxia, etc.). The spinal cord does not have to be severed in order for a
               loss of functioning to occur. In fact, in most people with SCI, the spinal cord is
               intact, but the damage to it results in loss of functioning. SCI is very different from
               back injuries such as ruptured disks, spinal stenosis or pinched nerves. A person can
"break their back or neck" yet not sustain a spinal cord injury if only the bones around the spinal
cord (the vertebrae) are damaged, but the spinal cord is not affected. In these situations, the
individual may not experience paralysis after the bones are stabilized”.

                   What is Traumatic Brain Injury? 57 “A traumatic brain injury (TBI) is an injury to
                   the brain caused by the head being hit by something or shaken violently. (The
                   exact definition of TBI, according to special education law, is given below.) This
                   injury can change how the person acts, moves, and thinks. A traumatic brain
                   injury can also change how a student learns and acts in school. The term TBI is

Direct Costs: Health Care                               30                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
used for head injuries that can cause changes in one or more areas, such as: thinking and
reasoning, understanding words, remembering things, paying attention, solving problems,
thinking abstractly, talking, behaving, walking and other physical activities, seeing and/or
hearing, and learning. The term TBI is not used for a person who is born with a brain injury. It
also is not used for brain injuries that happen during birth. The definition of TBI below comes
from the Individuals with Disabilities Education Act (IDEA). The IDEA is the federal law that
guides how schools provide special education and related services to children and youth with
disabilities.

Our nation’s special education law, the Individuals with Disabilities Education Act (IDEA)
defines traumatic brain injury as...

“...an acquired injury to the brain caused by an external physical force, resulting in total or
partial functional disability or psychosocial impairment, or both, that adversely affects a child’s
educational performance. The term applies to open or closed head injuries resulting in
impairments in one or more areas, such as cognition; language; memory; attention; reasoning;
abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psycho-
social behavior; physical functions; information processing; and speech. The term does not apply
to brain injuries that are congenital or degenerative, or to brain injuries induced by birth trauma.”
[34 Code of Federal Regulations §300.7(c)(12)]




Direct Costs: Health Care                               31                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
End Notes
1
     The 2003 estimated Oklahoma population was 3,511,532 per the Census Bureau. The national health
     expenditures for 2002 (per the Kaiser Family Foundation) were an estimated $3,740.44 per capita,
     Therefore, the statewide estimated expenditures would exceed $13 billion ($13.28 billion).
2
     Patricia Anderson, Vice President, Oklahoma Hospital Association
3
     Binitha Kunnel, MS, Biostatistician, Center for Health Statistics, Oklahoma State Department of
     Health, Oklahoma State Dept. of Health, OKC - OK - 73117.
4
     Oklahoma Hospital Association internal study.
5
     The Lewin report estimates (1995) that mental health conditions and co-occurring substance abuse
     problems add one-half day to hospital discharges. The average 2001 length of stay in Oklahoma
     community hospitals was 4.97 days - use 5 days to be clear. By adding one-half day - one is increasing
     LOS by 10%. Binitha Kunnel, MS, Biostatistician, Oklahoma State Dept. of Health.
6
     Source: 2003 American Hospital Association Hospital Statistics (2001 data). 1,226,716 ER visits.
7
     National Hospital Ambulatory Medical Care Survey: 2001 Emergency Department Summary by Linda
     F. McCaig, M.P.H., and Catharine W. Burt, Ed.D., Division of Health Care Statistics. Table 9. Number
     and percent distribution of emergency department visits with corresponding standard errors, by
     primary diagnosis: United States, 2001. ICD-9 codes 290-319 - presented as 3.3% of all ER visits are
     "mental disorders". These cases INCLUDE substance abuse related visits.
8
     The Drug Abuse Warning Network (DAWN) is a national public health surveillance system that
     collects data on drug abuse-related visits to emergency departments (EDs) and drug abuse-related
     deaths reviewed by medical examiners and coroners. See http://dawninfo.samhsa.gov. According to
     DAWN in 2002, there were an estimated 670,307 ED visits related to drug abuse in the coterminous
     U.S - about 261 visits per 100,000 population.
9
     Source: 2003 American Hospital Association Hospital Statistics (2001 data); 3,343,188 other
     outpatient visits.
10
     National Hospital Ambulatory Medical Care Survey: 2001 Outpatient Department Summary by Esther
     Hing, M.P.H., and Kimberly Middleton, B.S.N., M.P.H., Division of Health Care Statistics. Table 11.
     Number and percent distribution of outpatient department visits with corresponding standard errors, by
     primary diagnosis: United States, 2001. ICD-9 codes 290-319 ("mental disorders") represented 8% of
     all hospital outpatient visits. These cases INCLUDE substance abuse related visits.
11
     Injury Prevention Service, Oklahoma State Department of Health.
12
     Family Caregiver Alliance (www.caregiver.org/caregiver). Lewin-ICF (1992) The Cost of Disorders of
     the Brain, Washington DC: The National Foundation for Brain Research. [Updated figures based on
     $44 billion in 1988 dollars as estimated by: W. Max, E.J. MacKenzie & D. P. Rice (1991), Head
     Injuries: Cost and Consequences. Journal of Head Trauma Rehabilitation, 6: 76-91].
13
     Family Caregiver Alliance (www.caregiver.org/caregiver). National Institute of Neurological
     Disorders and Stroke (1989, February) Interagency Head Injury Task Force Report. Bethesda, MD.
14
     Family Caregiver Alliance (www.caregiver.org/caregiver). Lewin-ICF (1992) The Cost of Disorders of
     the Brain, Washington DC: The National Foundation for Brain Research. [Updated figures based on
     $44 billion in 1988 dollars as estimated by: W. Max, E.J. MacKenzie & D. P. Rice (1991), Head
     Injuries: Cost and Consequences. Journal of Head Trauma Rehabilitation, 6: 76-91]

Direct Costs: Health Care                               32                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
15
     Family Caregiver Alliance (www.caregiver.org/caregiver). Brooks, A., Lindstrom, J., McCray, J. et al
     (1995) Cost of Medical Care for a Population-Based Sample of Persons Surviving Traumatic Brain
     Injury. Journal of Head Trauma Rehabilitation, 10(4): 1-13.
16
     Family Caregiver Alliance (www.caregiver.org/caregiver). Whitlock, J. A. & Hamilton, B. B. (1995)
     Functional Outcome After Rehabilitation for Severe Traumatic Brain Injury. Archives of Physical
     Medicine and Rehabilitation, 76: 1103-1112.
17
     Family Caregiver Alliance (www.caregiver.org/caregiver). Lewin-ICF (1992) The Cost of Disorders of
     the Brain, Washington DC: The National Foundation for Brain Research. [Updated figures based on
     $44 billion in 1988 dollars as estimated by: W. Max, E.J. MacKenzie & D. P. Rice (1991), Head
     Injuries: Cost and Consequences. Journal of Head Trauma Rehabilitation, 6: 76-91]
18
     Family Caregiver Alliance (www.caregiver.org/caregiver). Wehman, P., Kregel, J., West, M..& Cifu,
     D. (1994) Return to Work for Patients with Traumatic Brain Injury: Analysis of Costs. American
     Journal of Physical Medicine and Rehabilitation, 73(4): 280-282.
19
     The FY2003 mean charges per TBI case was $120,426 for inpatient hospital care and $43,993 for
     inpatient rehabilitation per Ken Wood, PhD, The Traumatic Brain Injury National Data Center, July 8,
     2004 (www.tbindc.org). These charges may be multiplied by a 44.9% Oklahoma hospital cost to
     charge ratio to yield expense. This yields a total hospital expense of $73,824 per case. There were
     2,874 cases in FY 2002 yielding a total hospital expense of $212,170. The Traumatic Brain Injury
     National Data Center (TBINDC) at Kessler Medical Rehabilitation Research and Education Center is
     the coordinating center for the research and dissemination efforts of the Traumatic Brain Injury Model
     Systems (TBIMS) program funded by the National Institute on Disability and Rehabilitation Research
     (NIDRR). The TBI Model Systems consist of 16 comprehensive systems of care distributed throughout
     the United States that conduct innovative research and provide “model” care to persons who
     experience traumatic brain injury. The TBIMS program seeks to improve the lives of persons who
     experience traumatic brain injury, their families and their communities by creating and disseminating
     new knowledge about the course, treatment and outcomes relating to their condition.
20
     The numbers for SCI and TBI are: SCI - from 1988-2002 (15 years) a total of 1,925 persons were
     hospitalized and survived an SCI, in 2002 alone, 134 persons survived SCI. TBI - from 1992-2002 (11
     years) a total of 26,502 persons were hospitalized with a TBI and survived, in 2002 alone, 2,874
     persons survived TBI. Source: Sheryl Brown, Injury Prevention Division, Oklahoma State Department
     of Health, July 8, 2004.
21
     Injury Prevention Service, Oklahoma State Department of Health.
22
     The Spinalcord Injury Information Network (UAB Spinal Cord Injury Model System). The UAB
     Model SCI System conducts research to improve upon and maintain a cost-effective comprehensive
     service delivery system from the moment of injury across the lifespan of persons who sustain spinal
     cord injury. Emphasis is on collaborative clinical research to solve the medical management and acute
     rehabilitation problems of individuals with SCI. The UAB Model SCI Care System is funded by grant
     #H133N000016 from the National Institute on Disability and Rehabilitation Research, Office of
     Special Education and Rehabilitative Services, U.S. Department of Education, Washington, D.C.
     Opinions expressed in the material listed are not necessarily those of the granting agency.
     www.spinalcord.uab.edu




Direct Costs: Health Care                               33                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
23
     Tjaden P, Thoennes N. Prevalence, Incidence, and Consequences of Intimate Partner Violence Against
     Women: Findings from the National Violence Against Women Survey; 1999. Unpublished report for
     grant 93-IJ-CX-0012, funded by the U.S. Department of Justice, National Institute of Justice; and the
     Centers for Disease Control and Prevention. Published in Costs of Intimate Partner Violence Against
     Women in the United States, DHHS Centers for Disease Control and Prevention, March 2003.
24
     Tjaden P, Thoennes N. Prevalence, Incidence, and Consequences of Intimate Partner Violence Against
     Women: Findings from the National Violence Against Women Survey; 1999. Unpublished report for
     grant 93-IJ-CX-0012, funded by the U.S. Department of Justice, National Institute of Justice; and the
     Centers for Disease Control and Prevention. Published in Costs of Intimate Partner Violence Against
     Women in the United States, DHHS Centers for Disease Control and Prevention, March 2003.
25
     Draft, Oklahoma Department of Mental Health and Substance Abuse Services, Oklahoma State
     Treatment Needs Assessment Project, 1999 Household Survey, Domestic Violence Component, Becki
     Moore, Needs Assessment Project Manager.
26
     Table 13. Estimated Average Health Care Costs per Nonfatal Intimate Partner Rape, Physical Assault,
     and Stalking Victimization Against U.S. Adult Women, 1995, “Costs of Intimate Partner Violence
     Against Women in the United States", Department of Health and Human Services, Centers for Disease
     Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA. March 2003.
27
     FY2002 Oklahoma Crime Data per the FY2002 Uniform Crime Report, Oklahoma State Bureau of
     Investigation. Section 8 pages 8-2. OSBI data for FY 2002 indicates 540 sex crimes and 24,572
     assaults.
28
     Medical costs per type of service and type of injury are per "Costs of Intimate Partner Violence
     Against Women in the United States", Department of Health and Human Services, Centers for Disease
     Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA. March 2003
     (Table 13. Estimated Average Health Care Costs per Nonfatal Intimate Partner Rape, Physical Assault,
     and Stalking Victimization Against U.S. Adult Women, 1995).
29
     Inflation factor converting 1995 dollars to 2003 dollars is 1.1842.
30
     FY2002 Oklahoma Crime Data per the FY2002 Uniform Crime Report, Oklahoma State Bureau of
     Investigation. Section 8 pages 8-2. OSBI data for FY 2002 indicates 540 sex crimes and 24,572
     assaults.
31
     Note: The CDC report categorizes rape while the OSBI report lists sex crimes - their costs are assumed
     to be identical; the CDC report includes costs for stalking while the OSBI report does not list
     "stalking" as a reportable crime. Therefore, it was presumed the "stalking to assault ratio" nationally
     (11.31%) would apply to Oklahoma resulting in 2,777 cases of stalking. Calculation is 24,572*
     (503,485/4,450,807).
32
     National Advisory Council on Violence Against Women and the Violence Against Women Office.
     Toolkit to End Violence Against Women. Chapter 2: Improving the Health and Mental Health Care
     System’s Response to Violence Against Women. November 2000.
33
     National Advisory Council on Violence Against Women and the Violence Against Women Office.
     Toolkit to End Violence Against Women. Chapter 2: Improving the Health and Mental Health Care
     System’s Response to Violence Against Women. November 2000.
34
     ODMHSAS Data Book for FY2003. Public Domain Notice. The Data Book for Fiscal Year 2003 is in
     the public domain and may be reproduced or copied without permission from the Oklahoma
     Department of Mental Health and Substance Abuse Services. However, this publication may not be
     reproduced or distributed for a fee without the specific, written authorization of Oklahoma Department

Direct Costs: Health Care                               34                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
     of Mental Health and Substance Abuse Services. Citation of the source is appreciated. Electronic
     Access to Publication. This publication is available on the World Wide Web at:
     http://www.odmhsas.org/databooks.htm
35
     Oklahoma Department of Mental Health and Substance Abuse Services.
     www.odmhsas.org/agencyoverview.htm
36
     Personal communication with Annette Jacobi, JD, Chief, Child Abuse Prevention Service, Oklahoma
     State Department of Health, 7/1/04.

37
     Brown, S., Lowrance, A., Mallonee, S., Smith, M. 2003.Violence Against Women. An assessment of
     Oklahoma’s Response. OKC: Oklahoma State Department of Health.

38
     Olds D, Pettitt LM, Robinson J. Reducing risks for antisocial behavior with a program of prenatal and
     early childhood home visitation. J. Community Psychol. 1997;25:9-25.
39
     Olds D, Henderson CR Jr, Cole R, et. al. Long-term effects of home visitation on children’s criminal
     and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA 1998;
     280(14):1238-1244.
40
     Source: Oklahoma Health Care Authority, Nursing Facility Warrants Issued for Year Ending June 30,
     2003 provided by David Branson.
41
     National Nursing Home Survey (NNHS) www.cdc.gov/nchs/about/major/nnhsd/nnhsdesc.htm
42
     Use 16.4% as a multiplier. Jones A. The National Nursing Home Survey: 1999 summary. National
     Center for Health Statistics. Vital Health Stat 13(152). 2002. U.S. Department of HHS Centers for
     Disease Control and Prevention National Center for Health Statistics, Hyattsville, Maryland, June 2002
     DHHS Publication No. (PHS) 2002-1723. Table 27. Number and percent distribution of all-listed
     diagnoses for nursing home residents at admission and at time of survey: United States, 1999, indicates
     that 16.8% of residents had a primary diagnosis of a mental condition - then subtract the 0.4% that
     were classified as mental retardation - which yields 16.4%.
43
     ODMHSAS. www.odmhsas.org/agencyoverview.htm
44
     Melody Reifer, ODMHSAS, July 8, 2004.
45
     Loren Turner of the DMHSAS has provided total operating expenses; the FY2003 contract amounts
     are per the DMHSAS FY2003 Expense Report. Per John Hudgens, 75.6% of the beds are contracted
     by DMHSAS – therefore, at least 75.6% of the residents are considered to have mental health needs.
46
     Source: Allen Harder, Director, Inter-Tribal Health Board (405-951-6003). "The most recent amount I
     use is for 2000 and it totals $310,510,412 in funds to the Oklahoma City Area of IHS. The Oklahoma
     City Area includes four tribes in Kansas and one tribe in Texas so that total would need to be reduced
     by as much as $15-20 Million to determine funds to Oklahoma only. Again, as previously discussed.
     that does not include any tribal funds that were spent." Email to Michael Lapolla, July 14, 2004.
47
     IHS OKC Area Office, Marian Mitchell. Adviced FY2003 contracts for Mental Health and
     Alcohol/Substance Abuse to tribes and facilities in the state of Oklahoma. By fax June 1, 2004.
48
     National Ambulatory Medical Care Survey: 2001 Summary by Donald K. Cherry,M.S., Catharine
     W.Burt, Ed.D., and David A. Woodwell, Division of Health Care Statistics. There were an estimated
     880,487,000 office visits in the U.S. Oklahoma population represents 1.2% of the U.S. ICD-9 codes
     290-319 - presented as 5.1% of all physician office visits are "mental disorders". These cases

Direct Costs: Health Care                               35                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence
     INCLUDE substance abuse related visits. Table 12. Number and percent distribution of office visits
     with corresponding standard errors, by physician’s primary diagnosis: United States, 2001. Assume a
     cost of $123.10 per office visit (a physician cost of $45.60/visit; and a FY2003 non-physician cost of
     $77.50). Source is the Medical Group Management Association 2002 median cost and income data for
     General Internists. See page 142, Compensation and Production Survey yielding 3,637 office
     visits/year; page 34, Cost Survey showing median income of $165,861/year; and page 156 Cost Survey
     for $281,823 operating cost per year. This yields $447,684 annual expense divided by 3,637 visits for
     $128.10 per visit. Then ((880,487,000*0.0122)*($123.10)) = 1,322,332,986. This times 5.1% =
     67,438,982.

49
     Notes and Sources - Oklahoma - $2,025,906,000. These data come from Verispan Scott Levin's Source
     (TM) Prescription Audit, which collects over 140 million prescriptions on a monthly basis from nearly
     37,000 retail stores including chains, independents, mass merchandisers and food stores. The sample
     covers 71% of all retail dispensing activity nationwide and 1,300 regional zones to ensure the measures
     are not biased by regional differences in the prescription marketplace (i.e. managed care penetration,
     PBMs, state-level controls). Definitions: Prescriptions: All products dispensed in retail pharmacies,
     including new prescriptions and refills. These products do not include medicines purchased without a
     prescription (i.e., over the counter items). Sources: Verispan Scott-Levin, Source (TM) Prescription
     Audit: Special Data Request, 2003.
50
     www.kff.org/rxdrugs/index.cfm
51
     Source: Debbie Blanke, Oklahoma State Regents for Higher Education. Cost of Courses to Prepare
     Students to Work with the Mentally Ill or Substance Abusers at Oklahoma Colleges and Universities:
     Course Costs include the costs of selected courses in education, health professions, psychology, social
     sciences and social work. Note: The cost data includes both direct instructional costs plus indirect
     costs such as academic support, research, public service, student services, institutional support,
     physical plant and scholarships. Request was for the costs of educating and training new professionals
     such as Physicians, Psychologists, Counselors and Social Workers. There were 6,687 FTE students
     enrolled in these programs at Oklahoma Colleges and Universities in FY 2003. The total cost of these
     programs is estimated to be greater than $50 million. Apportioning 75% to mental illness and 25% to
     substance abuse yields expenses of $38 million and $13 million, respectively.
52
     Federal grants sponsored by the federal DHHS in FY2002. Source: harvester.census.gov.
53
     Philadelphia Inquirer, www.philly.com/mld/inquirer/news/editorial/5038221.htm?1c, January 27,
     2003.
54
     Report on the Implementation of Programs of Assertive Community Treatment (PACT) submitted to
     the Speaker of the House of Representatives and President Pro Tempore of the Senate pursuant to
     Senate Bill 1191 by the Oklahoma Department of Mental Health and Substance Abuse Services, April
     1, 2004.
55
     Sue Mallonee, R.N., M.P.H., Chief, Injury Prevention Service, Oklahoma State Department of Health.
56
     National Spinal Cord Injury Association, Bethesda, MD, www.spinalcord.org/html/factsheets/spin.php
57
     National Dissemination Center for Children with Disabilities.
     www.nichcy.org/pubs/factshe/fs18txt.htm#whatis




Direct Costs: Health Care                               36                                        February 17, 2005
Governor’s and Attorney General’s Blue Ribbon Task Force on Mental Health, Substance Abuse, and Domestic Violence

				
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