Morgan T.B., Crane D.R.
Journal of Marital and Family Therapy: 2010, 36(4), p. 486–498.
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For suitable patients, family-based therapies are among the most effective – but are they the most cost-effective? Not always finds this US-focused review, which argues that to compete in today's financially sensitive health care system, treatments must deliver the most clinical outcomes per unit of cost.
Summary Because it has been shown more effective than alternative approaches (individual treatment, family psychoeducation, and peer group therapy), family therapy is of interest not only to the focal patients, but also to their families and to the insurance companies which fund US health care. Including families in treatment is crucial because when a client's 'system' (family, siblings, spouse, partner, etc) is treated, it becomes healthier, affording the client a stronger support network to aid their recovery. There is no question that some family-based treatments are effective – but are they cost-effective? And how do costs influence the take-up of these treatments in a health care system? To compete in an increasingly financially sensitive health care system, successful treatments must deliver the most clinical outcome per unit of cost.
A search uncovered just eight studies which have documented the cost-effectiveness of explicitly family-based substance abuse treatment. They demonstrate that certain treatments not only work, but are also sometimes more cost-effective than the treatments against which they were compared.
The family-based treatments tested in these studies included brief relationship therapy, standard behavioural couple's therapy, Multisystemic Therapy, Multidimensional Family Therapy, Family Support Network, Adolescent Community Reinforcement Approach, interactional couples group therapy, and behavioural couple/marital therapy. Among these and the alternatives against which they were compared, in terms of the cost to achieve a given outcome, the most cost-effective were (family-based treatments are italicised):
• brief relationship therapy;
• a five-session version of motivational enhancement combined with cognitive behavioural therapy;
• behavioural couples therapy;
• a form of behavioural marital therapy; and
• a form of individual therapy.
These studies show that although family therapy is effective, work is needed to make it more cost-effective. Among the five relevant studies, in three family-based treatments were more cost-effective than individual treatments.
For a treatment that is already more effective than the alternatives, the prime way to improve cost-effectiveness is to cut costs without unduly affecting outcomes. The interests of health insurance companies, as well as competition for insurance claim money, mean treatments will compete with each other to produce the most desirable results at the lowest cost, leading developers to fine-tune available treatments. This phenomenon was illustrated by a study in which standard behavioural couples therapy was shortened to lower cost brief relationship therapy without compromising its efficacy in curbing drinking. This kind of fine-tuning promises to assuage the economic burden on society, health care insurers, families, and individuals.
A case has been made that the question research should address has moved from 'Does this treatment work?' to 'How much does this treatment cost to deliver, and is it really worth it?' This requires the collection of cost as well as outcome data. To compare the cost effectiveness of different approaches, outcomes and follow-up periods need to be comparable across studies. Costs would also ideally be calculated in a standard way. Outcomes should include impacts on the social and institutional systems in which the patients are involved. There is also a case for the client's needs and concern to determine which outcomes are measured. For example, what an adolescent substance user in trouble with the courts wants out of treatment is likely to be very different from the objectives of a married adult problem drinker with poor communication skills.
Conducting cost-effectiveness studies on family-based substance abuse treatment will not only demonstrate effectiveness but also that these approaches are competitive in terms of costs. Given the financial impact of substance abuse on society, individuals, and the health care system, and with health care companies dictating which treatments are on their preferred provider lists, it is imperative to produce cost-effective treatments. By doing so, substance abusers and their families will receive the most effective treatments, and health care insurers will receive an effective treatment at a competitive cost.
Last revised 24 June 2011