The ADSS Cost Study: Costs of Substance Abuse

Treatment in the Specialty Sector

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Office of Applied Studies
ii

Acknowledgments

This report was developed for the Substance Abuse and Mental Health Services Administration

(SAMHSA), Office of Applied Studies (OAS), by the Schneider Institute for Health Policy, Brandeis

University, P.O. Box 549110, Waltham, MA 02454-9110, under Contract No. 283-99-9018. Significant

contributors at Brandeis include Donald S. Shepard (Director of the Cost Study), Aaron BeastonBlaakman (Cost Study Manager), Grant Ritter (Statistician), Constance Horgan (Principal Investigator of

the Alcohol and Drug Services Study [ADSS]), Della Faulkner, and Aggrey Kihombo. The significant

contributor at Capital Consulting Corporation was Robert B. Bennett. Reviewers at OAS include Albert

Woodward (lead SAMHSA reviewer on the ADSS cost study), Anita Gadzuk (ADSS Project Officer),

and Sarah Duffy. At RTI, Research Triangle Park, NC, under Contract No. 283-99-9018, Michael A.

Penne and David C. Heller validated the data appearing in the tables in Chapter 4, and Moshe Feder

prepared the variance estimation appearing in Appendix D. Also at RTI, the document was reviewed by

Carol Council and Mary Ellen Marsden; it was prepared for print and web publication by Richard S.

Straw, Pamela Couch-Prevatt, Teresa F. Gurley, and David Belton. Final report production was provided

by Beatrice Rouse, Coleen Sanderson, and Jane Feldmann at SAMHSA.

Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied without

permission from the Substance Abuse and Mental Health Services Administration. However, this

publication may not be reproduced or distributed for a fee without specific, written authorization of the

Office of Communications, SAMHSA, U.S. Department of Health and Human Services. Citation of the

source is appreciated. Suggested citation:

Substance Abuse and Mental Health Services Administration. The ADSS Cost Study:

Costs of Substance Abuse Treatment in the Specialty Sector. Office of Applied Studies

(DHHS Publication No. SMA 03-3762, Analytic Series A-20). Rockville, MD, 2003.

Obtaining Additional Copies of Publications

Copies may be obtained, free of charge, from the National Clearinghouse for Alcohol and Drug

Information (NCADI), a service of SAMHSA. For copies of publications, please write or call:

National Clearinghouse for Alcohol and Drug Information (NCADI)

P.O. Box 2345

Rockville, MD 20847-2345

(301) 468-2600 1-800-729-6686 TDD 1-800-487-4889

Electronic Access to Publication

This publication can be accessed electronically through World Wide Web connections:

http://www.SAMHSA.gov

http://www.DrugAbuseStatistics.SAMHSA.gov

http://www.samhsa.gov/oas/adss.htm

Originating Office

SAMHSA, Office of Applied Studies

5600 Fishers Lane, Room 16-105

Rockville, MD 20857

July 2003
iii

Table of Contents

Section Page

List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

1. Introduction ...........................................................1

1.1 Purpose of the ADSS Cost Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Outline of the ADSS Cost Report .....................................2

1.3 Previous Methods ..................................................3

1.4 Need for an Efficient Strategy to Capture Cost Data . . . . . . . . . . . . . . . . . . . . . . . 3

2. Data Verification Methods of the ADSS Cost Study ...........................5

2.1 Study Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2.2 Data Review Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.2.1 Questionnaire Variables .......................................7

2.2.2 Source Identifiers ............................................7

2.3 Key Ratios and Analysis Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

2.3.1 Comparisons of Phases I and II .................................9

2.3.2 Comparisons Within Phase I and Phase II . . . . . . . . . . . . . . . . . . . . . . . . 10

2.3.3 Comparisons Within Phase II Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

2.4 Facility Callback Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

3. Data Quality Control Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4. Results of the ADSS Cost Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4.1 Key Unit Cost Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4.2 Personnel Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

4.3 National Cost-Adjusted Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

5. Discussion and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Appendices

A Data Review Worksheet—ADSS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

B Phases I and II Questionnaire Data Summary Table . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

C Internal and External Data Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

D Variance Estimation of Ratio Estimators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
iv

List of Tables

Page

Table 2.1 Distribution of Sample Facilities Responding to ADSS Phase II Cost Study .....5

Table 2.2 Distribution of Modalities in the 280 Sample Facilities ......................5

Table 2.3 Questionnaire Variables Entered from Phases I and II .......................8

Table 2.4 Four Main Clusters of Analysis Ratios Comparing Phase I and Phase II Data . . . 10

Table 2.5 Ratios Used to Examine Data Collected Within Phase I and Phase II . . . . . . . . . . 11

Table 2.6 Ratios Used to Examine Personnel and Counseling Data Specifically

Collected Within Phase II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Table 4.1 Estimated Cost Per Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Table 4.2 Estimated Cost Per Enrolled Client Day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Table 4.3 Estimated Cost Per Reported Outpatient Visit: 1997 (Based on

Administrator-Reported Mean Individual and Group Counseling

Sessions Per Client and Methadone Treatment Visits) . . . . . . . . . . . . . . . . . . . . . . 22

Table 4.4 Cost Per Counseling Hour: 1997 (Based on the Total Number of

Counseling Hours) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Table 4.5 Cost Per Group Counseling Hour Per Client: 1997 (Based on the Total

Number of Counseling Hours and Mean Number of Clients Per

Group) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Table 4.6 Mean Fringe Benefit Rate, by Type of Care and Ownership: 1997 . . . . . . . . . . . . 24

Table 4.7 Mean Hourly Personnel Rates, by Full-Time Staffing Category: 1997 . . . . . . . . . 24

Table 4.8 Mean Weekly Hours Worked for Part-Time and Contract Staff, by

Staffing Category: 1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Table 4.9 Mean Proportion of Personnel Costs to Total Facility Costs, by Type

of Care: 1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Table 4.10 National Cost-Adjusted Estimates of Substance Abuse Treatment in

the Specialty Sector Covered by ADSS: 1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
v

List of Figures

Page

Figure 3.1 Key Phase II Variables: Point Prevalence, Admissions, and Average

Length of Stay, by Final Data Source Distribution . . . . . . . . . . . . . . . . . . . . . . . . . 16

Figure 3.2 Percentage Distribution of Additional Key Phase II Variables:

Revenues, Costs, and Discharges, by Final Data Source Distribution . . . . . . . . . . 17

Figure 3.3 Percentage Distribution of the Final Data Sources of Key Phase II

Variables: Provider-Reported and Estimate-Based Proportions . . . . . . . . . . . . . . . 18

Figure 4.1 Percentage Distribution of Personnel Costs for Outpatient

Nonmethadone Treatment (n = 222), by Staffing Category: 1997 . . . . . . . . . . . . . 26

Figure 4.2 Percentage Distribution of Personnel Costs for Outpatient Methadone

Treatment (n = 44), by Staffing Category: 1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Figure 4.3 Percentage Distribution of Personnel Costs for Nonhospital

Residential Treatment (n = 48), by Staffing Category: 1997 . . . . . . . . . . . . . . . . . 27
vi
1

 The types of facilities that define the sector coincide with the sampling strata used in the study: hospital

inpatient, non-hospital residential, outpatient-predominantly methadone, outpatient-nonmethadone, and combined

types of care. For the outpatient, non-methadone type of care, the sample was further stratified to reflect whether or

not facility clients were almost exclusively alcohol abusers. A seventh stratum was included for facilities whose type

of care could not be determined based on existing information at the time of sampling. Types of facilities excluded

from the ADSS sampling frame were halfway houses without paid counselors, solo practitioners, correctional

facilities, Department of Defense and Indian Health Service facilities, and facilities that were prevention or intake

and referral only.

2

 The documentation and data files for ADSS can be found at the following website:

http://www.icpsr.umich.edu:8080/ABSTRACTS/03088.xml?format=SAMHDA-DISPLAY. Two documents are of

particular interest: Codebook, Part 2: Phase II, Administrator Interview (filename: cb3088p2.pdf.gz) and Phase II,

Administrator Interview Questionnaire (Part 2) (filename: qu3088p2.pdf.gz).

3

 However, 13 of the 280 facilities in Phase II had a hospital inpatient unit in combination with an eligible

residential or outpatient unit. The cost data were collected for these 13 hospital units, but they were not

representative of all hospital facilities nationwide. As a result, they were excluded from the cost analysis. 

1

1. Introduction

1.1 Purpose of the ADSS Cost Study

Understanding the cost of resources used in substance abuse treatment is of critical

concern to policymakers, payers, and providers of care. Federal and State policymakers are

interested in cost-effective allocation of limited funds and in developing efficient financing

structures to deliver substance abuse treatment services. State agencies, Medicaid, and managed

behavioral health organizations allocate resources among types of care. Substance abuse

treatment organizations are oriented toward producing services efficiently, setting appropriate

charge rates, and negotiating contracts with managed care organizations. Each of these decision

makers can use improved information about the costs of substance abuse treatment to better

serve patients receiving treatment.

The Alcohol and Drug Services Study (ADSS) was performed from 1996 to 1999. ADSS

is a national study conducted in three phases to collect representative data on the characteristics

of substance abuse treatment facilities, clients in treatment, post-treatment client status, and

financing of care in the specialty substance abuse treatment sector. This sector includes

freestanding substance abuse treatment centers, methadone maintenance clinics, and other

facilities that primarily serve persons with substance abuse problems.1 Phase I of ADSS

surveyed a nationally representative set of 2,395 treatment facilities by telephone. Phase II

conducted in-person interviews with administrators regarding revenues, costs, and staffing, and

it analyzed a client record abstraction at a subset of 280 facilities. Phase III conducted follow-up

interviews with a sample of clients for whom records were abstracted. ADSS data are an

important aid in understanding the organization of treatment, cost and availability of treatment

services, characteristics of the client population, and managed care contract arrangements.2

The purpose of the ADSS cost study was to provide a detailed data file and national

estimates for cost, revenue, counseling activities, and staffing collected from a nationally

representative sample of substance abuse treatment facilities. A new, more accurate cost

collection strategy was developed for this study and is described in the following steps.

First, cost, revenue, personnel, client volume, and counseling activity data were collected

from a sample of facilities as part of Phases I (2,395 facilities) and II (280 facilities) of ADSS.

Although hospital inpatient facilities were sampled and included in the larger ADSS Phase I

facility telephone survey, they were excluded from the Phase II site visit data collection in order

to sample more facilities that better represented the predominant types of care.3

 After data

collection was completed, an intensive facility callback process was undertaken to review cost,
4

 The Phase II questionnaire can be found at the following website:

http://www.icpsr.umich.edu:8080/ABSTRACTS/03088.xml?format=SAMHDA-DISPLAY: Phase II, Administrator

Interview Questionnaire (Part 2) (filename: qu3088p2.pdf.gz).

2

personnel, services, and client data submitted by these facilities.4

 This callback process began in

May 1998 and was completed in September 1999. Staff used an innovative spreadsheet data

audit instrument developed by Capital Consulting Corporation (CCC) to simultaneously analyze

and update the data file on each facility during the callback process. The instrument incorporates

a series of reliability checks to aid in obtaining the most accurate data possible (Zarkin et al.,

1995).

1.2 Outline of the ADSS Cost Report

This report provides a detailed description of the methods used in the ADSS cost study,

along with findings regarding key cost variables important to understanding the use of resources

in substance abuse treatment. This report contains the first findings from the rich ADSS cost data

base; much more analysis remains to be done. The first section of the report provides an

overview of methods used in prior studies to estimate substance abuse treatment costs and

describes the need for a more accurate and efficient way to collect treatment cost data in large

national studies.

The second section describes the methods used in the ADSS cost study to verify data

collected in the ADSS. These methods involve the application of a computerized data audit

instrument, a spreadsheet workbook used to enter and review selected questionnaire data from

Phases I and II of the ADSS.

The third section discusses data quality control analyses. Analyses of the distribution of

data sources for key questionnaire variables collected in ADSS are discussed. These analyses

indicate that a standard questionnaire administration is insufficient for collecting accurate

substance abuse treatment cost and revenue data.

The fourth section discusses the ADSS cost study findings. Three types of cost measures

are examined: unit cost estimates, personnel costs, and national estimates. Mean unit cost

measures such as "cost per admission," "cost per enrolled client day," "cost per visit," and "cost

per counseling hour" are presented for three types of care: nonhospital residential, outpatient

methadone, and outpatient nonmethadone treatment. Personnel cost analyses include cost per

counseling hour, mean fringe benefit rates, mean hourly personnel rates, the proportion of

personnel costs to total facility costs, and the proportion of personnel category costs to total

personnel costs and are presented for all three types of care. National cost-adjusted estimates for

the three types of care are developed by considering the estimated point prevalence client count

for each type of care and the estimated cost per enrolled client day.

Section 5 discusses results and the implications for estimating substance abuse treatment

costs.
5

 Indirect cost allocation is the process of assigning costs of support services and personnel to client care.

The task of collecting and analyzing cost data in substance abuse treatment is complicated by the lack of a

standardized reimbursement system for substance abuse treatment services. These services are generally publicly

funded, and thus a substance abuse treatment organization has no need to develop the cost of services beyond the

program level. Substance abuse treatment organizations often maintain and report expenditures at an aggregate level

of care such as residential or outpatient services.

3

1.3 Previous Methods

The task of collecting and analyzing cost data in substance abuse treatment is

complicated by a lack of standard methods of indirect cost allocation5

 and poor record keeping

or management information systems. As a result, cost data vary in quality and reliability. To

better understand the economics and financing of substance abuse treatment services, several

cost analysis methods have been developed over the past decade to capture improved data on

direct and indirect substance abuse treatment costs and revenues. These include the Drug Abuse

Treatment Cost Analysis Program (DATCAP) (French, Dunlap, Zarkin, McGeary, & McLellan,

1997) and CCC’s Cost Allocation Methodology (CCC, 1993).

DATCAP is a comprehensive 34-page cost analysis survey instrument that can be applied

to all types of substance abuse treatment providers. This extensive survey can be customized for

individual treatment settings and is structured to capture improved data on a facility’s total

resource use. The survey requires an extensive inventory of information on revenue data, client

volume, personnel counts and rates, supply and material costs, contracted services, building and

facility costs, and detailed information regarding equipment use and costs. The model attempts

to estimate both accounting and economic costs and to generate average cost estimates. This

survey allows for a detailed audit at the treatment site level and is feasible for large samples of

substance abuse treatment providers. DATCAP is an economic approach to measuring costs.

CCC’s Cost Allocation Methodology, in contrast to DATCAP, is an accounting-based

model. Financial data are collected, analyzed, and presented in accordance with generally

accepted accounting principles (GAAP). Data are collected and analyzed on-site at facilities by

professional accountants. CCC has developed tools for collecting and calculating actual lengths

of stay, admissions, discharges, and treatment staff services and hours. Furthermore, the firm has

developed data validation procedures to test the accuracy of provider-supplied statistics. CCC’s

model produces for each facility average cost estimates including "cost per client," "cost per

admission," and "cost per day." The CCC model is highly detailed and requires approximately

12 hours of on-site data collection and validation, 24 hours of analysis time, and 4 hours of

quality assurance review, totaling 40 hours of work per site. This highly intensive method is not

feasible to apply to large-scale nationally representative data collection.

CCC’s experience with the Cost Allocation Methodology served as the basis in

developing the analysis/telephone callback techniques and data audit instrument implemented in

the ADSS cost study. From their experience in examining cost data in substance abuse treatment

facilities, CCC was able to indicate which benchmark variables would be most important to

include in the ADSS data audit instrument. These variables include the unit cost variables

indicated above plus information pertaining to personnel, counseling, and total facility costs.

CCC also provided consultation and training for staff involved in the ADSS cost study to

communicate clearly and effectively with substance abuse treatment facilities about the variables

of interest. 

1.4 Need for an Efficient Strategy to Capture Cost Data

To capture substance abuse treatment cost data from a nationally representative sample,

the ADSS cost study used the Cost Allocation Methodology to obtain accurate data. The

methodology depends upon a computerized data audit instrument. This instrument was used in
4

conjunction with an intensive facility callback process based on data collected in Phases I and II

of ADSS from a sample large enough to be stable and representative. The next section addresses

in detail the methods of the ADSS cost study.
5

2. Data Verification Methods of the ADSS Cost Study

2.1 Study Design

The ADSS cost study methods involved a multistage data collection and verification

process. Initial data were collected through the ADSS Phase I and Phase II surveys from 1996 to

1999. Phase I was a telephone interview with the facility directors of a national stratified

probability sample of approximately 2,395 substance abuse treatment facilities. The

questionnaire was mailed to the facility 2 weeks prior to the interview to allow the facility time

to collect the information. Follow-up telephone calls were done as needed. This phase of the

study was conducted between December 1996 and June 1997. Phase II included site visits to a

subsample of 280 of the Phase I facilities for a personal interview with the facility director and

client record abstraction for a sample of over 6,000 clients from these facilities. This phase of the

study was conducted between August 1997 and April 1999. For each facility, information was

obtained on program treatment type (hospital inpatient, nonhospital residential, outpatient

nonmethadone, and outpatient methadone), costs, clients served, and services provided. More

detailed information on the facility selection and data collection procedures is presented in the

citations in the second footnote. Facilities offering only hospital inpatient treatment, although

included in the ADSS Phase I survey, were excluded from Phase II and the cost study analysis

for the reason cited in the third footnote (see also footnote 1 in Table 2.2).

The 280 substance abuse treatment facilities included in Phase II offered one or more

types of care (i.e., were single or multiple modalities). Table 2.1 provides a distribution of types

of facilities in the ADSS cost study, and Table 2.2 provides the distribution of types of

modalities.

Table 2.1 Distribution of Sample Facilities Responding to ADSS Phase II Cost Study

Type of Facility Sample Size

Single Modality 238

Multiple Modality 42

Total 280

Table 2.2 Distribution of Modalities in the 280 Sample Facilities

Type of Care (Modality) Sample Size

Hospital Inpatient 13

Nonhospital Residential 48

Outpatient Nonmethadone 222

Outpatient Methadone 44

Total Modalities 327

Eligible Modalities1 314

1 The number of eligible modalities is equal to 327-13 (Inpatient units) = 314. Facilities with hospital inpatient

care only and hospital inpatient units in multiple modality facilities were excluded from the cost study.

To obtain more meaningful results, most analyses for the ADSS cost study were

conducted at the modality or type of care level. The ADSS cost study was governed by the

sampling universe from which facilities were selected. A sampled "facility" could be one of

several levels in the treatment system, including a type of care. The ADSS cost study measured

the costs of the sampled facility and, if it covered several types of care or modalities, then the

cost study callback procedure broke the costs and activities down by type of care. Moreover,
6

 A complete list of all specific questionnaire variables in the ADSS cost study is in Appendix B.

6

facilities vary in their reporting of financial data. Facilities are generally able to distinguish costs

between residential and outpatient services. If the questionnaires had attempted to obtain more

detailed financial data, many facilities would have been unable to furnish accurate data.

Facilities can readily aggregate data, but disaggregation requires considerably more effort than

many facilities were willing to do, thus potentially reducing participation rates in the study. Data

items for the facility were entered into a spreadsheet data audit instrument for analyses at the

modality level. For example, unit costs per admission were identified in each of three types of

care: outpatient nonmethadone, outpatient methadone, and nonhospital residential treatment.

Within the residential and outpatient nonmethadone samples, different subtypes of care

were represented. For example, residential treatment units may include both detoxification and

rehabilitation services. Moreover, outpatient nonmethadone treatment units may include a

mixture of intensive and regular outpatient treatment. However, data were not analyzed for these

more specific types of care.

 The cost analysis and data validation efforts began after the Phase II data collection. The

data review worksheet or audit instrument was designed to compare Phase I versus II data for

consistency, and validate both cost and statistical data. During an initial review of Phase I and

Phase II data, the cost study analysts sought to identify missing data and inconsistent data.

Subsequently, staff recontacted facility administrators through an intensive facility callback

process to make an additional attempt to collect missing data and to verify specific data items

that appeared inconsistent through the data audit analysis. The only callbacks involving Phase I

data included facilities with Phase II cost data. The Phase I data were used to check consistency

with Phase II data. Upon final review with facility officials, variables were recorded and

described in the spreadsheet file as the most accurate data available. The source of updated

information was noted. Upon complete review and updating of each facility record, data were

transferred to the final ADSS cost study data file for research analyses.

 Time between the two phases of ADSS data collection was 6 to 12 months. The cost

study relied primarily on Phase II data. Except for a few items, the Phase I cost data were not

validated nor extensively checked for internal consistency.

The analysts found that 96.0 percent of the sample of facilities required a callback for at

least one variable in question and, of this group, 99.7 percent of facilities assisted in further

clarifying these data inconsistencies.

2.2 Data Review Worksheet

The data review worksheet is a spreadsheet workbook designed to analyze specific cost,

revenue, staffing, client volume, and counseling data reported in Phases I and II of ADSS. A

copy of the data review worksheet is provided in Appendix A. The workbook includes five data

entry pages, where data pertinent to the cost study from the original ADSS questionnaires were

entered, and five analysis pages that include formulas linking to the data entry worksheets for

further review.6 Each questionnaire variable included on the data review worksheet has an

associated data source identifier that serves as an indicator of the final source of data entered into

the cost study file (e.g., data originally supplied by facility director, data revised by facility

director). This information helps identify which variables are reported most reliably by facility

directors in the original questionnaire. The analysis pages also include a series of ratios that

serve as key analysis variables in the study. These ratios enabled comparison of data from each
7

 CCC has collected cost data on over 400 different programs. With few exceptions (fewer than a dozen),

the majority are public-sector programs. The majority of these were selected by the Substance Abuse and Mental

Health Services Administration (SAMHSA), were publicly funded, and offered services to those clients targeted by

SAMHSA. If data values for a facility were not within the ranges for ratios developed for the data review worksheet,

study staff reconfirmed selected data variables via a phone follow-up.

7

facility to expected industry norms identified through CCC’s previous site visit research.7

 ADSS

cost analysts were trained by Robert Bennett of CCC to identify inconsistencies for discussion

with facility officials. Inconsistencies could immediately be identified as deviations from

expected ratios and reported to facility officials for further review. These procedures were

designed to improve the internal consistency of data reported by sampled substance abuse

treatment facilities.

 The specific data entry items, the primary key analysis ratios, and expected data ranges

varied by data variable from 25 to 80 percent. The ranges developed were used as data screening

tools and for the cross data variable validation process. Many of the initial questionnaires had

missing data variables. These screening ratios were developed to inquire about submitted data

that did not appear within normal limits. The study attempted to minimize the number of facility

callbacks. The subsequent sections present more detailed information on the ranges.

2.2.1 Questionnaire Variables

Data items chosen for the ADSS cost study include client volume, total costs, total

revenues, staffing, and information on individual and group counseling. These variables were

necessary to derive estimates of the unit costs of substance abuse treatment, including cost per

admission, cost per client day, cost per visit, and cost per counseling hour. Table 2.3 shows the

questionnaire variables from Phases I and II of ADSS entered into the data audit spreadsheet

workbook. Phase II involved a more detailed collection of client services and other data

pertaining specifically to individual and group counseling sessions received by clients and

personnel costs borne by the sampled substance abuse treatment facility. Three variables

collected as part of Phase I were added to the cost study data audit spreadsheet midway through

the cost study verification process and were therefore not verified with the facility: "Dollar

Amount or Percentage of Costs Attributed to Employee Personnel," "Dollar Amount or

Percentage of Costs Attributed to Other Personnel (including consultants and other personnel),"

and "Dollar Amount or Percentage of Costs Attributed to Non-Personnel." There is less

confidence in the reliability of these three measures because they were not subject to rigorous

reliability checks.

2.2.2 Source Identifiers

Each questionnaire variable entered into the data audit instrument has an associated data

source identifier. The source identifier indicates the final accepted source of data entered into the

substance abuse treatment facility’s cost study spreadsheet workbook.

The following three source identifiers were used when dealing with data received directly

from a facility during the study:

 PO – Provider Original (This includes data as reported in Phase I or II of ADSS

with no change upon analysis or verification.)

 PR – Provider Revised (This includes revised data via telephone callback

with a facility official.)

 PD – Provider Documentation (This includes data as submitted to cost

study analysts from a facility official, e.g., financial statement, etc.)
8

 See Appendix C for a detailed explanation of how internal and external estimates were applied.

8

Table 2.3 Questionnaire Variables Entered from Phases I and II

Variables Phase I Phase II 

1. Point Prevalence  

2. Total Admissions  

3. Total Discharges  

4. Administrator-Reported Average Length of

Stay

 

5. Residential Bed Capacity (if applicable)  

6. Total Costs  

7. Total Revenues  

8. Dollar Amount or Percentage of Costs

Attributed to Employee Personnel1



9. Dollar Amount or Percentage of Costs

Attributed to Other Personnel1



10. Dollar Amount or Percentage of Costs

Attributed to Non-Personnel1



11. Individual Counseling Sessions Per Client Per

Week



12. Group Counseling Sessions Per Client Per

Week



13. FTE and PTE Count, by Type of Personnel 

14. FTE and PTE Hourly Rates, by Type of

Personnel



15. FTE and PTE Hours Worked Per Week, by

Type of Personnel



16. Average Fringe Rate for All Personnel 

1

 Variable added during the verification and therefore not verified with the facility.

Note: FTE is full-time equivalent; PTE is part-time equivalent.

The following two source identifiers are based on two methods used during the ADSS

cost study to estimate data unreported or unidentifiable by facility administrators or staff:

 IE – Internal Estimate (Estimates are based on other data collected from

the facility.)

 EE – External Estimate (Estimates are based on industry norms created by

CCC in the Cost Accounting Methodology.)8
9

 A complete list of all key ratios and analysis variables used in the ADSS cost study is in Appendix B.

9

2.3 Key Ratios and Analysis Variables 

Key ratios and analysis variables were developed to compare data reported in both

Phases I and II as well as to examine data collected within each phase.9

 The data audit

instrument was developed to examine the questionnaire variables from these two perspectives to

obtain the most accurate data possible. To compare data from Phases I and II, difference ratios

were developed to represent the difference in values for a specific variable between Phase I and

Phase II. For example, if a facility reported the number of admissions as 450 in Phase I and 485

in Phase II, the difference ratio would equal 7.78 percent, signifying a difference in admissions

of about 8 percent. Consistent responses among the data collection values engendered

confidence in the data, while large differences served as flags, indicating the need for a facility

callback and further data verification. Comparisons within Phases I and II involve analysis ratios

of cost per admission and cost per enrolled client day using three different measures of annual

client volume, including point prevalence and length of stay, to estimate admissions and

discharges. Similarly, ratios pertaining to phase-specific analyses either were accepted into the

file record or prompted a facility callback. No value for a variable was entered into the

spreadsheet workbook until the entire analysis for a substance abuse treatment facility was

complete. An update or change of one value for a variable may have prompted reexamination of

one or several related variables in the data set.

2.3.1 Comparisons of Phases I and II

Four main clusters of analysis ratios pertain to the comparison of data reported in Phases

I and II of ADSS. These ratios are located in Appendix A in this report and are summarized in

Table 2.4. Expected values and ranges were applied to each modality of treatment. The values

used allowed for changes in facility structure and workload during the average 1-year interval

between Phase I and Phase II of ADSS.

The first cluster of comparison ratios used for analyzing the differences between Phases I

and II of ADSS pertains to differences in client volume as measured by the difference in point

prevalence client counts (difference "a" in Table 2.4), the difference in reported annual

admissions (difference "b"), and the difference in the average daily client count (difference "c").

Difference "c" is based on a formula using admissions and the administrator-reported average

length of stay. All three client count values are summarized in the ratio "average client count

difference," which is the mean difference in reported client volume. In the analysis, each specific

comparison count difference or ratio was expected to be within 20 percent of the average client

count difference. Values outside this range were marked for telephone verification with the

facility.

The second cluster of comparison ratios pertains to differences in financial data as

measured by the differences in total costs and the differences in total revenue. These two

measures are summarized in a summary ratio titled "average financial difference," which denotes

the mean difference in Phase I and Phase II reported costs and revenues. Given the linear

relationship between program finances and client volume, the average financial difference was

expected to be within 15 percent of the difference in client volume, summarized by the average

client difference. Values outside this range were marked for subsequent investigation with the

facility staff.

The third comparison ratio used for analysis of the differences between Phases I and II of

ADSS was "difference in the administrator-reported average length of stay." As more substance

abuse treatment programs shifted into the managed care market, there was a possibility for 
10

Table 2.4 Four Main Clusters of Analysis Ratios Comparing Phase I and Phase II Data

Type of Data

Specific Phase I and II

Ratios Summary Ratios

Differences Requiring

Verification

1. Client Volume a = Difference in point

prevalence client counts

b = Difference in 12-month

admissions

c = Difference in average

daily client count1

Average client

count difference =

(a+b+c)/3

Individual differences a,

b, and c were expected to

be within 20% of the

average client count

difference. Differences of

20% or greater were

verified.

2. Financial Data a = Difference in total costs

b = Difference in total

revenue

Average financial

difference =

(a+b)/2

The average financial

difference was expected to

be within 15% of the

average client count

difference. Differences of

15% or greater were

verified.

3. AdministratorReported Average

Length of Stay2

(ALOS)

Difference in ALOS None Differences in ALOS of

25% or greater were

verified.

4. Personnel Costs Difference in personnel

costs as a percentage of

total costs

None Differences of more than

5 percentage points.

1 Average daily client count = Annual admissions/(365/Average length of stay). 2 The administrator-reported estimate of average length of stay (ALOS) used within the cost study analysis is not

the final ALOS reported for ADSS. Client-specific length of stay based on a sample of client discharges in the

ADSS Phase II client abstract study provides the final ALOS estimates by type of treatment in other ADSS

reports. However, because those length-of-stay data cannot generate facility-specific averages needed in the

cost study, the facility-level estimate made by the facility administrator was used in the cost study calculations.

changes in the average length of stay for clients between the two data collection periods.

Differences of 25 percent or more were verified with the facility.

The fourth and final comparison ratio was analysis of personnel costs as a percentage of

total treatment costs for a sampled substance abuse treatment facility. This ratio estimated the

difference in the percentage of personnel costs as reported in Phase I versus Phase II. Up to a 5

percent difference was expected due to regular staff turnover. 

2.3.2 Comparisons Within Phase I and Phase II

Additional ratios were incorporated into the data audit instrument to examine data

collected within each phase. These ratios reflect the importance of understanding the relationship

between client volume, financial data, staffing information, and counseling activity within a

sample substance abuse treatment facility. The ratios internal to both data collection phases are

summarized in Table 2.5. These ratios include two derived average daily client counts; three 

measures of occupancy based on the number of beds in nonhospital residential facilities; three

measures of cost based on admissions, discharges, or point prevalence; and three measures of

cost per enrolled client day.
11

Table 2.5 Ratios Used to Examine Data Collected Within Phase I and Phase II

Type of Data Specific Ratios Summary Ratios

Differences Requiring

Verification

1. Point Prevalence

Count Versus

Average Daily Client

Count (ADCC)

ADCC-admissions (A)1

ADCC-discharges (D)2

Difference between the

ADCC-A and the point

prevalence count

Difference between the

ADCC-D and the point

prevalence count

Differences of 20% or

greater were verified.

2. Occupancy Rates

(Nonhospital

Residential Facilities

Only)

ADCC-admissions/bed

capacity

ADCC-discharges/bed

capacity

Point prevalence

Count/bed capacity

None

Occupancy rates below

70% or above 100%

were verified.

3. Cost Per Admission

Cost Per Discharge

Cost Per Estimated

Admission

Total costs/total

admissions

Total costs/total

discharges

Total costs/estimated

admissions based on

point prevalence3

None

Differences of 20% or

greater among the three

rates were verified.

4. Cost Per Enrolled

Client Day

Cost per enrolled client

day from

admissions/ALOS

Cost per day from

discharges/ALOS

Cost per day from point

prevalence/ALOS

None

Differences of 20% or

greater among the three

rates were verified.

1 ADCC-admissions (average daily client count using admissions) = Total 12-month admissions/(365/Average

length of stay). 2 ADCC-discharges = Total 12-month discharges/(365/Average length of stay). 3 Estimated admissions based on point prevalence = Point prevalence × (365/Average length of stay).

The development of derived point prevalence or census counts, based on reported

admissions and discharges, enabled analysts to understand the interaction between four primary

utilization variables: admissions, discharges, point prevalence, and the average length of stay.

Within a stable service delivery environment, the two derived point prevalence measures were

expected to be reasonably close to the reported point prevalence. Allowing for some reporting

and record keeping variability, along with possible changes in service delivery, values of the two

"difference summary ratios" comparing the admissions and discharge derivatives to the actual

point prevalence were expected to be less than 20 percent.

These point prevalence measures also were used in examining occupancy rates of

residential facilities. Three occupancy measures (see Table 2.5) were established as part of the

data audit instrument to further assess the reliability of the four primary client volume measures.
10 Derived client throughput = Point prevalence × (365 days/Administrator-reported average length of stay).

12

Again, assuming a stable environment, these variables were expected to be reasonably close to

each other but should individually fall within a range of 70 to 100 percent occupancy.

Cost per admission and cost per enrolled client day were two additional types of ratios

used in examining data reported within each phase. Cost per admission was developed as a ratio

of total costs to three measures of client volume: admissions, discharges, or a derived client

throughput measure developed from point prevalence and the average length of stay.10 The cost

per enrolled client day was in turn developed by taking each measure of cost per admission and

dividing it by the average length of stay. These ratios assisted analysts to understand not only the

relationship between the primary client volume measures but also provided insight into the

relationship between client volume and total cost. These values were expected to be reasonably

close within a stable environment, and any differences over 20 percent were discussed with

facility staff.

2.3.3 Comparisons Within Phase II Only

More detailed data specifically regarding staffing and counseling activities were

collected in Phase II than Phase I, so additional ratios internal to Phase II analyses were created

in the data audit instrument. These ratios are presented in Table 2.6.

Table 2.6 Ratios Used to Examine Personnel and Counseling Data Specifically Collected

Within Phase II

Expected Range by Type of Care 1

Type of Data Specific Ratios Residential Outpatient Methadone

1. Personnel

Costs

Proportion of personnel

costs to total costs 55% - 75% 70% - 90% 55% - 75%

Proportion of counselor

costs to total personnel

costs 50% - 100% 60% - 100% 35% - 55%

Proportion of medical

staff costs to total

personnel costs 0% - 15% 0% - 10% 30% - 50%

Proportion of

administrative personnel

costs to total personnel

costs 20% - 40% 15% - 30% 20% - 30%

Proportion of direct care

costs to total personnel

costs 60% - 80% 70% - 85% 70% - 80%

2. Counseling

Services Data

Proportion of counseling

hours received by clients

to total counseling staff

hours

65% - 85%

 1These ranges were developed by CCC and Brandeis. Some range values are 100% in order to include all treatment

settings and staffing levels. For example, if a solo practitioner were to have been included, the 100% range value

would have been necessary.

Two ratio clusters focusing on personnel costs and counseling services data were

developed within the data audit instrument specific to Phase II. Five ratios were specific to

personnel services, and one primary ratio was specific to analyzing counseling services data.
13

Each ratio had an expected range by type of care, based on the experience of CCC’s previous

analyses of substance abuse treatment facility data.

The ratios pertaining to personnel services included the proportion of personnel costs to

total costs, the proportion of counselor costs to total personnel costs, the proportion of medical

staff costs to total personnel costs, the proportion of administrative personnel costs to total

personnel costs, and the proportion of direct care costs to total personnel costs. This analysis

provided a series of summary variables for assessing the distribution of personnel costs in a

substance abuse treatment facility. According to CCC’s cost accounting study, 55 to 75 percent

of residential and methadone facility costs were likely to be attributed to personnel (including

salaries and fringe benefits of full-time, part-time, and contract staff). For outpatient

nonmethadone programs, the range was 70 to 90 percent. Personnel costs identified outside this

range prompted analysts to inquire further with the facility about its overall distribution of costs.

Counselor costs were identified by obtaining the number of counselors within various

categories identified by education level (e.g., master’s, bachelor’s, and nondegreed counselors),

and by obtaining the average number of hours worked per week by counselors in each category

along with their average hourly rates. Average fringe benefit rates were calculated for each

facility as well. Counselor costs were expected to be the highest proportion of personnel costs,

greater than 50 percent of personnel costs for residential facilities and greater than 60 percent of

personnel costs for outpatient nonmethadone facilities. For methadone facilities, medical staff

costs were expected to be equal to or greater than the proportion of counselor costs to total

personnel costs. Administrative personnel were expected to represent 20 to 40 percent of

residential total personnel costs, 15 to 30 percent of outpatient nonmethadone total personnel

costs, and 20 to 30 percent of methadone total personnel costs. Direct service staff was expected

to represent 60 to 80 percent of residential facility personnel costs, 70 to 85 percent of outpatient

nonmethadone facility personnel costs, and 70 to 80 percent of methadone facility personnel

costs.

Lastly, counseling services were analyzed by assessing the proportion of counseling

hours received by clients to total counseling staff hours. On average, 65 to 85 percent of

counseling staff time was expected to be attributed to client counseling services. Otherwise, cost

study analysts would have inquired about the reported data represented in this ratio.

Analyzing Phase I and Phase II data from the two perspectives provided a solid

framework for assessing the reliability of data collected from facilities. Changes in one set of

variables often prompted further review of related data. A facility data audit analysis was

considered complete only when the analysts were satisfied with their review of these primary

analysis ratios.

2.4 Facility Callback Process 

As previously indicated in this report, 96 percent of sample treatment modalities required

a callback from the cost analysis team for at least one variable in question. As a result, it was

imperative to develop an efficient, comprehensive strategy for entering the original ADSS Phase

I and Phase II data into individual spreadsheet workbooks, conducting an initial review,

summarizing the data in question for facility administrators to examine, and then contacting the

facility over the telephone to discuss and finalize the data for entry into the main cost file.

Upon completion of the ADSS data collection, Phase I and Phase II questionnaires were

sent to cost analysts for the ADSS cost study. Trained support staff first entered data into the

data audit instrument and identified any missing data. One of the cost analysts then conducted an

initial review of the data audit file, identified data inconsistencies as represented in the analysis

ratios, and prepared a series of summary tables and brief paragraphs explaining the data in

question for facility review. A telephone call was made to the facility to briefly summarize the
14

data in question and to set up a mutually convenient time to discuss the data review. The

document was then faxed to the facility in preparation for a callback. Generally, the call was

scheduled within a week of the initial fax, providing adequate time for facility officials to look

over the data inconsistencies.

The analysis staff called the administrator at the agreed-upon time and worked directly

over the phone with the data audit file within view. Ideally, the administrator discussed with the

analyst the necessary updates to the file, allowing for further prompting by the analyst if

necessary. Often, the analyst would be referred to additional administrative and clinical staff to

clarify information. This entailed additional follow-up with facility officials.

Initially, the time spent entering data, analyzing and reviewing the data audit, and

following up with facilities averaged about 10 to 12 hours per facility. After developing a more

efficient approach, this time was reduced to approximately 4 to 5 hours per facility.
11 In checking data on discharges, study staff asked facilities to consider a client "discharged" if she or he

had received no services within the past 45 days. Estimated lengths of stay were based on other data variables

contained within the questionnaire: staffing, admissions, discharges, and point prevalence. Estimates are based on

these factors and CCC historical data for length of stay.

15

3. Data Quality Control Analysis

Given the complex data collection methods undertaken in the ADSS, it is important to

assess the consistency of responses by facilities to the Phase I and Phase II surveys. Because the

data audit instrument provided for analysis of variables in relationship to one another through

formulas or ratios, as a single variable was checked, other variables that "related" to the variable

in question also required further review. Given this multistage data collection process, all

questionnaire variables were categorized by a "source identifier" in the cost file: provider

original, provider revised, and provider documentation (see Section 2.2.2). Data quality control

analyses of the source variables provided insight into which questionnaire variables were

reported most reliably and which variables were updated most frequently during the callback

process. 

The distribution of source identifiers for six primary key Phase II questionnaire variables

(point prevalence, admissions, discharges, the administrator-reported average length of stay,

total costs, and total revenues) are presented below. They are presented in order of reporting

reliability based on the distribution of source identifiers. Each distribution represents responses

from all 314 treatment units included in the ADSS cost study.

Figure 3.1 shows the distribution of source identifiers for three key questionnaire

variables: point prevalence, admissions, and the administrator-reported average length of stay.

Among key client volume and financial data collected from facilities, these three variables

maintained the highest percentage of final data coming from providers’ originally reported

information in the Phase II administrator interview. Point prevalence was the most reliable

variable for facilities to report, with 82 percent of the final data coming from Phase II originally

reported data. In contrast, Phase II admissions had 62 percent of final data coming from the

original Phase II questionnaire, while the Phase II administrator-reported average length of stay

had 43 percent of final data coming from this original source.11

All three variables had between 10 and 25 percent of final data coming from providerrevised data obtained from the facility callback process. A very small percentage of final data for

all three variables (under 5 percent) was obtained through additional provider documentation.

Internal and external estimates were used infrequently for both point prevalence and admissions

variables, but the administrator-reported average length of stay had a high percentage (30

percent) of internal estimates. The use of internal estimates often was required to determine the

final administrator-reported average length of stay because facility officials lacked confidence in

reporting the average length of stay for clients. In this type of situation, the client volume data

were used to develop an estimate of the average length of stay.
16

Figure 3.1 Key Phase II Variables: Point Prevalence, Admissions, and Average Length of

Stay, by Final Data Source Distribution

Note: Percentages may not sum to 100 due to rounding.

 * External estimate for point prevalence is 0 percent.

** Administrator-reported average length of stay.

Source: Office of Applied Studies, SAMHSA, 1996-1999 Alcohol and Drug Services Study.

Figure 3.2 shows the distribution of source identifiers for three additional key

questionnaire variables: total revenues, total costs, and discharges. All three variables had a

lower proportion of final data items coming from the original Phase II questionnaire than the

variables represented in Figure 3.1. Moreover, these variables generally had higher amounts of

final data coming from administrator revisions made during the callback process. Discharge

counts were the most difficult for facilities to report, with only 28 percent of the final data

coming from Phase II originally reported data and 34 percent of the final data coming from

facility callbacks. Total facility costs and revenues had the greatest percentage of final data

coming from provider or facility documentation (15 and 13 percent, respectively). Most of this

documentation was financial reports and fact sheets submitted by facilities during the callback

process.
17

Figure 3.2 Percentage Distribution of Additional Key Phase II Variables: Revenues, Costs,

and Discharges, by Final Data Source Distribution

Note: Percentages may not sum to 100 due to rounding.

Source: Office of Applied Studies, SAMHSA, 1996-1999 Alcohol and Drug Services Study.

Figure 3.3 compares the use of provider-reported data and estimate-based data for

obtaining the final source of data among the six key questionnaire variables. More than 90

percent of final data sources for point prevalence counts and admissions were from providerreported data, with estimates used for 5 percent and 8 percent, respectively, of those estimates.

Final data sources for total cost, total revenue, the number of discharges, and the administratorreported average length of stay had higher estimate-based data, ranging from 27 percent of the

total cost data to 34 percent of administrator-reported average length of stay. This high

representation of internal estimates as the final source of data among several key questionnaire

variables reflects the difficulty for substance abuse treatment program administrators to report

these items accurately. This use of estimates for some variables also provides evidence of the

importance of using a carefully designed data audit instrument to accurately develop estimates of

variables based upon other, more reliable data provided by the facility.
18

Figure 3.3 Percentage Distribution of the Final Data Sources of Key Phase II Variables:

Provider-Reported and Estimate-Based Proportions

 * Administrator-reported average length of stay.

** Includes original provider-reported data, provider-revised data, and data from provider-supplied documentation.

Source: Office of Applied Studies, SAMHSA, 1996-1999 Alcohol and Drug Services Study.
12 The documentation on weights can be found in the Codebook, Part 2: Phase II, Administrator Interview

(filename: cb3088p2.pdf.gz) at the website cited in footnote 2.

13 Reported visits were based on the number of visits reported in aggregate by the facility administrator.

14 Documented visits were based on actual visits documented in individual client records in the Phase II

client record abstract study.

15 Counseling hours were based on administrators’ report of the average number of counseling sessions per

client per week.

19

4. Results of the ADSS Cost Study

Estimates of the cost of treatment resulting from the ADSS cost study fall into three

categories: key unit costs, personnel costs, and national cost estimates. These cost data are key

indicators useful for policymakers and participants in the delivery and financing of substance

abuse treatment. All analyses were conducted using weighted Phase II sample data to produce

national estimates.12

Section 4.1 provides national estimates of key unit cost variables, including cost per

admission and cost per enrolled client day for nonhospital residential, outpatient methadone, and

outpatient nonmethadone facilities. The mean cost per reported visit13 also was analyzed for

outpatient methadone and outpatient nonmethadone facilities, and the cost per documented

visit14 and cost per counseling hour15 are reported for outpatient nonmethadone facilities.

Section 4.2 contains personnel cost estimates. This section also includes personnel

analyses, important to understanding the distribution and cost of personnel services in substance

abuse treatment. Personnel analyses include descriptive measures of fringe benefit rates,

personnel cost proportions, and weighted analyses of hourly rates by staffing category across

nonhospital residential, outpatient methadone, and outpatient nonmethadone facilities.

Finally, national cost-adjusted estimates are provided for all three types of care in Section

4.3.

4.1 Key Unit Cost Estimates 

Five main unit cost variables were developed as a result of the ADSS cost study: mean

cost per admission, mean cost per client day, mean cost per reported visit, mean cost per

documented visit, and mean cost per counseling hour. These variables have been used

consistently as benchmarks in other substance abuse treatment studies (see references) and have

been found to provide useful information to policymakers, payers, and providers of care.

Total annual costs, the numerator in the mean cost calculations, include all costs or

expenditures for the substance abuse treatment modality during the most recent 12-month

reporting period. Facilities were instructed to report explicit costs (direct and indirect facility

outlays and operating noncapital expenditures) as well as implicit costs (asset depreciation and

the estimated market value of resources used free of charge, such as donated use of a building,

by the treatment facility). Most facilities were able to report these latter costs accurately.

As indicated in the review of ratios contained in the data audit instrument, the unit

variable "mean cost per admission" was measured using three primary client volume measures:

annual admissions, annual discharges, and a derived annual throughput measure based on the

point prevalence count. These three measures were studied for reliability, and in the final

analysis, the annual admissions measure was found to be the best representative of reported

client volume data in the study. The number of admissions was more accurately reported by
20

facilities than the number of discharges, while the throughput measure was derived using the

administrator-reported average length of stay, which required internal or external estimates for

more than 30 percent of the facilities.

For the variable "cost per enrolled client day," three similar ratios were developed for

analysis purposes. For final reporting of this unit cost variable, client days were calculated for

each sampled substance abuse treatment facility based on the point prevalence count and the

administrator-reported average length of stay. The point prevalence count was reported with high

accuracy (82 percent based on original data provided by the administrator), while the

administrator-reported average length of stay was the only estimate of days enrolled in treatment

by facility. Note that, for outpatient modalities, "enrolled client days" included the entire

estimated enrollment period, not just the days a client visited the facility. A separate variable, the

"mean cost per visit," reflected only the days during which an outpatient client visited the

facility.

"Mean cost per visit" was calculated in two ways. The "cost per reported visit" measure

represented the average client counseling sessions based on the administrator’s best estimate in

the Phase II administrator interview. The "cost per documented visit" measure resulted from the

mean number of visits calculated from documented client visits in client records sampled and

reviewed in the Phase II client record abstract study.

"Cost per counseling hour" was calculated using an estimated total number of counseling

hours provided by the facility during the year. This is the product of the administrator’s estimate

of the number of counseling sessions per client per week times 52 weeks per year times the point

prevalence client count. Assuming individual sessions were approximately 1 hour in length, the

cost per counseling hour equaled the cost of an individual session. The cost per group counseling

hour was derived as the cost per counseling hour divided by the estimated mean number of

clients in a group session.

To calculate nationally representative statistics, facility-level weights were applied to

both the numerator (total annual costs), and denominators (annual admissions, client days, visits,

or counseling hours) of each of these unit cost measures. Estimates were calculated using

SUrvey DAta ANalysis (SUDAAN) statistical software, Release 8.0 (RTI, 2001). Furthermore,

for each mean unit cost measure, a minimum value, maximum value, standard error (SE), and

coefficient of variation (CV) were calculated. A detailed description regarding the derivation of

the standard error for these unit cost variables is provided in Appendix D.

As indicated in Table 4.1, the mean cost per admission for residential care (n = 48

treatment modalities) was $3,132, with a standard error of the mean of $490 and coefficient of

variation of 16 percent. The mean cost per admission for outpatient methadone treatment (n = 44

treatment modalities) was $6,048, with a standard error of the mean of $1,013 and coefficient of

variation of 17 percent. The mean cost per admission for outpatient nonmethadone facilities (n = 222 treatment modalities) was $1,169, with a standard error of the mean of $81 and coefficient

of variation of 7 percent. As indicated, the mean cost per admission for outpatient methadone

facilities was found to be greater than that of residential facilities, while the cost per admission

for outpatient nonmethadone facilities was the lowest among the three types of care. A likely

explanation for differences in cost per admission among the three types of care is that clients in

outpatient methadone treatment have a much longer average length of stay (an estimated 520

days for outpatient methadone care compared with 144 days for outpatient nonmethadone care

and 45 days in nonhospital residential care, based on Phase II client record abstract data). Total

costs for all facilities are presented to show how the mean cost per admission was calculated.

(The final total costs, derived with a more accurate method based on combining enrollment days

from the larger sample of Phase I facilities with detailed Phase II mean costs, are presented in

Table 4.10 at the end of this chapter.)
21

Table 4.1 Estimated Cost Per Admission

Type of Care

Total Weighted

Costs from

Cost Study

Facilities

Total

Weighted

Admissions

from Cost

Study

Facilities

Mean Cost

Per

Admission Minimum Maximum

SE of

the

Mean

CV of

the

Mean, %

Nonhospital

Residential 

(n = 48) $2,232,147,300 712,643 $3,132 $308 $18,482 $490 16%

Outpatient

Methadone

(n = 44) $789,160,362 130,472 $6,048 $2,109 $32,630 $1,013 17%

Outpatient

Nonmethadone 

(n = 222) $2,515,070,858 2,151,694 $1,169 $188 $12,650 $81 7%

Total, All

Facilities $5,536,378,520 2,994,809 $1,849 - - - -

Table 4.2 provides a summary of findings regarding cost per enrolled client day. The

mean cost per enrolled client day for residential care (n = 48) totaled $62.10, with a standard

error of the mean of $6.80 and coefficient of variation of 11 percent. The mean cost per enrolled

client day for outpatient methadone treatment (n = 44) totaled $10.32, with a standard error of

$0.90 and coefficient of variation of 9 percent. The mean cost per enrolled client day for

outpatient nonmethadone facilities (n = 222) totaled $9.17, with a standard error of $0.75 and

coefficient of variation of 8 percent.

Table 4.2 Estimated Cost Per Enrolled Client Day

Type of Care

Mean Cost Per

Enrolled Client

Day1 Minimum Maximum

SE of the

Mean

CV of the

Mean, %

Nonhospital Residential

(n = 48) $62.10 $11.16 $348.85 $6.80 11%

Outpatient Methadone

(n = 44) $10.32 $5.57 $41.86 $0.90 9%

Outpatient

Nonmethadone (n = 222) $9.17 $1.18 $58.67 $0.75 8%

1

 Total costs divided by Phase II point prevalence count of clients divided by 365 days.

Variability in both "cost per admission" and "cost per enrolled client day" were attributed

to the various subtypes of care represented in both the residential and outpatient nonmethadone

facilities as well as to the application of facility-level weights. Within residential services,

facilities offered detoxification services (with medical management) and rehabilitation services

(focusing on treatment of substance abuse and building skills). Within outpatient services,

patterns of staffing spanned three types of treatment, with increasing service intensity and cost:

driving while impaired/driving under the influence services (with educational sessions, often in

large groups), regular outpatient services (approximately 1 hour per week of group or individual

counseling), and intensive outpatient services (several hours per week of counseling services).

Within methadone care, treatment facilities offered both methadone dosing and counseling.

However, as a regulated service, methadone tended to exhibit less variability than the other types
22

of care. The variations within each type of care reflect both differences among the types of

treatment and facilities’ approaches to offering treatment.

The variations in cost per enrollment day depended on both the intensity and mix of

services per enrollment day and the prices of inputs (e.g., hourly wages of counselors and

medical personnel). Analyses in the cost study found relatively little variation in hourly wages,

but substantial variations in intensities and mix of services, suggesting that the latter was the

primary reason for the large variations in cost.

The following identity helps relate cost per enrollment day to another important unit

cost—the cost per admission: 

Cost per admission = (Enrollment days per admission) × (Cost per enrollment day).

On a log scale, the product on the right-hand side of the equation is transformed to a sum.

If the factors are independent, then the variance of the result is the sum of the variances of the

components. Because the components were empirically almost independent, the measures that

had more possible sources of variation did in fact show greater variation. Cost per admission

varied for two reasons: The number of enrollment days per admission (also known as the length

of stay) varied among facilities, as did the cost per enrollment day.

Table 4.3 presents the cost per reported outpatient visit for both outpatient methadone (n

= 44) and outpatient nonmethadone modalities (n = 221). The number of weekly visits to

outpatient methadone facilities was estimated at 5 per client on average, based on site visit data

collected previously by CCC. The annual number of visits per facility was calculated to equal: 

5 × 52 weeks per year × Point prevalence.

For each outpatient nonmethadone treatment facility, the number of visits was calculated to

equal: 

52 × (Mean administrator-reported individual counseling sessions per week × Point prevalence)

+ (Mean administrator-reported group counseling sessions per week ×

Point prevalence).

For outpatient methadone treatment (n = 44) the mean cost per reported visit was $14.50, with a

minimum of $7.82, a maximum of $58.81, and a standard error of the mean of $1.27, based on a

coefficient of variation of 9 percent. For outpatient nonmethadone treatment (n = 221), the mean

cost per visit was $21.80, with a minimum of $4.43, a maximum of $204.13, and a standard error

of the mean of $1.71 based on a coefficient of variation of 8 percent.

Table 4.3 Estimated Cost Per Reported Outpatient Visit: 1997 (Based on AdministratorReported Mean Individual and Group Counseling Sessions Per Client and

Methadone Treatment Visits)

Type of Care

Mean Cost Per

Reported

Outpatient Visit Minimum Maximum

SE of the

Mean

CV of the

Mean, %

Outpatient

Methadone (n = 44) $14.50 $7.82 $58.81 $1.27 9%

Outpatient NonMethadone (n = 221) $21.80 $4.43 $204.13 $1.71 8%
23

4.2 Personnel Costs

Tables 4.4 and 4.5 indicate the cost per counseling hour and the cost per group

counseling hour per client, respectively, for outpatient nonmethadone treatment. This unit cost

was derived only for outpatient nonmethadone treatment because nonhospital residential and

outpatient methadone facilities provided additional outputs that were not captured in the

analysis. As a result, it is likely that the derivation of cost per counseling hour for these two

modalities would overestimate the cost of counseling.

Table 4.4 Cost Per Counseling Hour: 1997 (Based on the Total Number of Counseling

Hours)

Type of Care

Mean Cost Per

Counseling Hour Minimum Maximum

SE of the

Mean

CV of the

Mean, %

Outpatient Nonmethadone 

(n = 215)1 $75.65 $20.24 $334.302 $3.53 5%

1

 Data to compute cost per counseling hour could not be obtained for seven facilities.

2

 Most likely a result of counseling costs much greater than counseling hours.

Table 4.5 Cost Per Group Counseling Hour Per Client: 1997 (Based on the Total Number

of Counseling Hours and Mean Number of Clients Per Group)

Type of

Care

Mean Cost Per

Counseling

Hour

Mean Client

Group

Attendance

Mean Cost Per

Group

Counseling

Hour Per Client

SE of the Mean

for Cost Per

Group

Counseling

Hour Per Client

CV of the

Mean, %

Outpatient

Nonmethadone

(n = 215 ) $75.65 9.57 $7.90 $0.59 7%

Table 4.4 shows the mean cost per counseling hour for outpatient nonmethadone

facilities (n = 215) as $75.65, with a minimum of $20.24 and a maximum of $334.30. The

standard error of the mean was $3.53, and the coefficient of variation was 5 percent. Table 4.5

again displays the mean cost per counseling hour as $75.65, but additionally provides the mean

client group attendance of 9.57. Subsequently, the mean cost per group counseling hour per

client was calculated to be $7.90, with a standard error of the mean of $0.59 and coefficient of

variation of 7 percent.

A series of personnel-level data analyses produced mean fringe benefit rates by type of

care and ownership, mean hourly personnel rates by staffing category, and mean proportion of

personnel costs to total facility costs by type of care and type of ownership. Additional analyses

were conducted of the mean proportion of personnel costs by aggregate staffing category and by

type of care.

Table 4.6 presents the mean fringe benefit rates, along with a standard error of the mean,

and the coefficient of variation by type of care and type of ownership. The mean fringe benefit

rate was 23 percent for nonhospital residential facilities, 20 percent for outpatient methadone,

and 18 percent for outpatient nonmethadone. The mean fringe benefit rate for public facilities

was 21 percent, 14 percent for private for-profit, and 21 percent for private nonprofit facilities.
24

Table 4.6 Mean Fringe Benefit Rate, by Type of Care and Ownership: 1997

Type of Care

Mean of Fringe 

Benefit Rate SE of the Mean

CV of the

Mean, %

Nonhospital Residential (n = 48) 23% 0.007 3.15%

Outpatient Methadone (n = 44) 20% 0.011 5.39%

Outpatient Nonmethadone (n = 222) 18% 0.006 3.21%

Ownership

Public (n = 54) 21% 0.013 6.12%

Private For-Profit (n = 59) 14% 0.015 10.93%

Private Nonprofit (n = 201) 21% 0.006 2.93%

Mean hourly rates for full-time staff across all three types of care are presented in Table

4.7. As expected, hourly rates for full-time physicians ($51.59) and doctoral-level counselors

($27.86) were the highest, while hourly rates for nondegreed staff ($10.83) and administrative

staff ($12.04) were the lowest relative to other staffing categories.

Table 4.7 Mean Hourly Personnel Rates, by Full-Time Staffing Category: 1997

Staffing Category Mean Hourly Rate SE of the Mean CV of the Mean, %

Physicians $51.59 $4.40 8.52%

Registered Nurses $18.71 $1.17 6.23%

Other Medical Staff $13.49 $0.88 6.50%

Doctoral-Level Counselors $27.86 $2.98 10.71%

Master’s-Level Counselors $16.95 $1.22 7.21%

Bachelor’s-Level Counselors $14.15 $1.21 8.51%

Nondegreed Counselors $10.83 $0.53 4.86%

Administrative/Other Staff $12.04 $0.42 3.84%

Mean hours worked per week for part-time and contract staff, by staffing category, are

presented in Table 4.8. Physicians were found to work the fewest part-time or contract hours per

week (7.65 hours), while nondegreed counselors were found to work the greatest amount of parttime or contract hours (18.12 hours).

Table 4.9 provides information on the mean proportion of personnel costs to total costs

by type of care and type of ownership. Outpatient nonmethadone facilities had on average 79

percent of total costs as personnel costs. Personnel cost proportions of total facility costs were 65

percent for outpatient methadone facilities and 63 percent for nonhospital residential facilities.

Personnel cost proportions were expected to be lower for the latter two types of care, given

additional administrative, medical, and housing costs associated with treatment provision.

The proportion of personnel costs by type of ownership was estimated to be 78 percent

for public facilities, 79 percent for private for-profit facilities, and 72 percent for private

nonprofit facilities.
25

Table 4.8 Mean Weekly Hours Worked for Part-Time and Contract Staff, by Staffing

Category: 1997

Staffing Category

Mean Weekly Hours

Worked SE of the Mean

CV of the Mean,

%

Physicians 7.65 0.92 12.03%

Registered Nurses 12.25 2.44 19.87%

Other Medical Staff 11.36 3.00 26.40%

Doctoral-Level Counselors 8.24 1.56 18.88%

Master’s-Level Counselors 12.80 1.13 8.82%

Bachelor’s-Level Counselors 15.24 0.85 5.60%

Nondegreed Counselors 18.12 1.41 7.77%

Administrative/Other Staff 15.86 1.18 7.46%

Table 4.9 Mean Proportion of Personnel Costs to Total Facility Costs, by Type of Care:

1997

Type of Care

Mean Proportion of

Personnel Costs to Total

Costs

SE of the

Mean

CV of the

Mean, %

Nonhospital Residential 63% 0.029 5%

Outpatient Methadone 65% 0.030 5%

Outpatient Nonmethadone 79% 0.017 2%

Ownership

Public (Government) 78% 0.029 4%

Private For-Profit 79% 0.048 6%

Private Nonprofit 72% 0.016 2%

Figures 4.1, 4.2, and 4.3 display the proportion of costs to total personnel costs by

staffing category, respectively, for outpatient nonmethadone treatment, outpatient methadone

treatment, and nonhospital residential care. Personnel costs by type of staff included only those

facilities that employed and reported those types of staff. For outpatient nonmethadone care, 71

percent of all personnel costs were counselor costs. This included salaries and fringe benefits for

master’s-level, bachelor’s-level, and nondegreed counselors. As expected, outpatient methadone

and nonhospital residential treatment had lower costs attributed to counseling because they

provide additional services beyond counseling. On average, counseling costs were found to be

37 percent for outpatient methadone treatment and 52 percent for nonhospital residential

treatment. Outpatient methadone care had the largest amount of personnel costs attributed to

medical staff (41 percent), while nonhospital residential treatment had the largest amount of

administrative personnel costs (39 percent).
26

Figure 4.1 Percentage Distribution of Personnel Costs for Outpatient Nonmethadone

Treatment (n = 222), by Staffing Category: 1997

Source: Office of Applied Studies, SAMHSA, 1996-1999 Alcohol and Drug Services Study.

Figure 4.2 Percentage Distribution of Personnel Costs for Outpatient Methadone

Treatment (n = 44), by Staffing Category: 1997

Source: Office of Applied Studies, SAMHSA, 1996-1999 Alcohol and Drug Services Study.
27

Figure 4.3 Percentage Distribution of Personnel Costs for Nonhospital Residential

Treatment (n = 48), by Staffing Category: 1997

Source: Office of Applied Studies, SAMHSA, 1996-1999 Alcohol and Drug Services Study.

4.3 National Cost-Adjusted Estimates

National cost-adjusted estimates for three types of care (i.e., nonhospital residential,

outpatient methadone, and outpatient nonmethadone services) in 1997 are indicated in Table 4.10.

These national estimates are derived for each type of care from the formula:

Phase I facility-weighted point prevalence client count × 365 × Cost per 

enrolled client day.

Table 4.10 National Cost-Adjusted Estimates of Substance Abuse Treatment in the

Specialty Sector Covered by ADSS: 1997

Type of Care

Estimated Point

Prevalence Client

Count1

Days in

12-Month

Period

Estimated Cost

Per Enrolled

Client Day

Estimated Total

Annual Costs

Nonhospital

Residential (n = 48) 99,895 365 $62.10 $2,264,270,018

Outpatient Methadone

(n = 44) 151,882 365 $10.32 $572,109,118

Outpatient

Nonmethadone (n =

222) 806,706 365 $9.17 $2,700,085,317

Total 1,058,483 N/A N/A $5,536,464,453

1

 These estimates are based on the ADSS Phase I facility survey of a sample equal to 2,395 facilities.
28

For nonhospital residential care in the specialty sector, the national cost estimate of

substance abuse treatment was $2.3 billion. For outpatient methadone care in the specialty sector,

the national cost estimate of substance abuse treatment was $0.6 billion. For outpatient

nonmethadone treatment in the specialty sector, the national cost estimate of substance abuse

treatment was $2.7 billion. The total cost of these three modalities in the specialty sector was

estimated to be $5.5 billion.
29

5. Discussion and Conclusions

The ADSS cost study is believed to be the first study of treatment costs with validated

cost data from a nationally representative sample of substance abuse treatment facilities. It builds

on previous studies that have each contained some but not all of the elements of this study. One

important group of previous studies (DATCAP) (French et al., 1997) was based on careful,

systematic procedures for collecting cost data based on principles of economics. The CCC (1993)

study and the Treatment Outcome Prospective Study (TOPS) (Hubbard et al., 1989) applied

systematic data collection based on accounting principles. In neither case, however, were the

methods applied to a representative random sample of facilities.

The ADSS cost study supports other studies that have found that nonmethadone outpatient

treatment is substantially less expensive than residential treatment. The cost study found that the

mean cost of a nonmethadone outpatient admission was only a third of the mean cost of a

nonhospital residential admission ($1,169 vs. $3,132). In terms of cost per enrolled client day, the

lower cost of nonmethadone outpatient care was even more dramatic—only one seventh of the

cost of a nonhospital residential day ($9.17 vs. $62.10). The ADSS cost study found that the cost

per enrolled client day in outpatient methadone care ($10.32) was only marginally higher than the

cost per enrolled client day in nonmethadone outpatient care ($9.17).

One of the most important conclusions from the ADSS cost study was the variability in

unit costs within a type of care. The variations in totals, such as cost or revenue per facility, were

not surprising. These magnitudes depended on the size of the facility. Other data in ADSS,

particularly the point prevalence client count, showed the extent of such variation. However,

within a type of care, the cost per admission would be expected to exhibit only moderate

variation, and cost per enrollment day would be expected to show little variation. In fact, both

variations proved to be relatively large.

The smallest element of cost was the cost per enrollment day. The coefficients of variation

of the means for nonhospital residential, outpatient methadone, and nonmethadone outpatient

were 11 percent, 9 percent, and 8 percent, respectively. Multiplying each of these coefficients by

the square roots of the respective sample sizes, approximate coefficients of variation of the cost

per day were obtained: 74 percent, 101 percent, and 372 percent, respectively. Although a more

precise estimate of the coefficient of variation would need to take the multistage sampling into

account, these approximations indicate the relative variations among the three types of care.

Although comparison with other studies would be of interest, the estimates from the

ADSS cost study are not directly comparable with those from similar studies because of

differences in methods, variables, and national representation. For example, the Substance Abuse

and Mental Health Services Administration (SAMHSA) spending estimates study also reported

aggregate national spending (Mark et al., 2000). However, that study covered more types of care

(such as treatment in inpatient hospitals, in the general medical sector, and retail prescription

drugs) than the ADSS cost study, which covered only outpatient and residential specialty

substance abuse treatment facilities. Thus, the amount reported in SAMHSA's spending estimates

study for 1997 ($11.9 billion) substantially exceeded the aggregate in the ADSS cost study ($5.5

billion). When one excludes services not counted in ADSS (hospital-based services, independent

practitioners, retail prescription drugs, and insurance administration), the remaining components

of the spending estimates study that approximated the ADSS cost study (termed "other") are

similar to the ADSS cost study. Their magnitude for 1997 ($5.3 billion) is similar to the amount

for the ADSS cost study ($5.5 billion). Other studies, such as those conducted by CCC or TOPS,

are not based on national probability samples and are therefore not directly comparable with those

derived in the ADSS cost study.
30
31

References

Capital Consulting Corporation. (1993). Uniform system of accounting and cost reporting for

substance abuse treatment providers (Contract No. SAMHSA 270-91-8327). Fairfax, VA:

Author.

French, M. T., Dunlap, L. J., Zarkin, G. A., McGeary, K. A., & McLellan, A. T. (1997). A

structured instrument for estimating the economic cost of drug abuse treatment: The Drug Abuse

Treatment Cost Analysis Program (DATCAP). Journal of Substance Abuse Treatment, 14, 445-455.

Hubbard, R. L., Marsden, M. E., Rachal, J. V., Harwood, H. J., Cavanaugh, E. R., & Ginzburg, H.

M. (1989). Drug abuse treatment: A national study of effectiveness. Chapel Hill, NC: University

of North Carolina Press.

Mark, T. L., Coffey, R. M., King, E., Harwood, H., McKusick, D., Genuardi, J., Dilonardo, J., &

Buck, J. A. (2000). Spending on mental health and substance abuse treatment, 1987-1997. Health

Affairs (Millwood), 19(4), 108-120.

RTI. (2001). SUDAAN user’s manual: Release 8.0. Research Triangle Park, NC: Author.

Zarkin, G. A., Galinis, D. N., French, M. T., Fountain, D. L., Ingram, P. W., & Guyett, J. A.

(1995). Financing strategies for drug abuse treatment programs. Journal of Substance Abuse

Treatment, 12, 385-399.
32
33

The ADSS Cost Study: Costs of Substance

Abuse Treatment in the Specialty Sector

Appendices
34
35

Appendix A

Data Review Worksheet—ADSS
36
37

Appendix A - Data Review

Worksheet - ADSS -

Instructions

This Data Review Worksheet is a series of linked spreadsheets. There are five that require entry. These

are labeled as: 

 Instructions

 Two1

 Two2

 Two3

 One

Hence, the name implies the source document from which the source input data is recorded.

The remaining six pages of spreadsheets are the actual cost report, which is locked, and

requires no input. These spreadsheets should be printed & reviewed after all data is inputted.

The Phase I survey instrument is titled: A. Facility Organization and Staffing (legal size)

The Phase II survey instrument is titled: Date of Interview and begins with page 2

In some cases, there are no identified input fields, such as facility ID number, and

survey date, facility type and setting. Use the F - 2 key to edit these fields. 

 1. Obtain the Facility ID from the - Facility Information Sheet

 2. Obtain Survey Date from - Phase II - top right corner - Date of Interview

 3. The Facility Type is from Phase II - Question 2

 4. The Setting is from Phase I - A5, please indicate in the space corresponding with facility type

Facility ID: 0000

Survey Date: _00__/_00_/_97__ Sources (SC) 

PO=Prov Original 

1. Facility Type: PR=Prov Revised 

 ( ) Hospital Inpatient IE=Internal Estimate 

 ( ) Non-Hosp Residential EE=External Estimate 

 ( ) Outpatient - Methadone

 ( ) Outpatient - Non Methadone

Setting (A5):

 

Preparer’s Initial (Below): 

 

Date of Preparation (below): 
38

ADSS - Data Review Worksheet - Input for Phase II

Variable

No.

Data Variable

Description Statistic Source Code

Instrument Source 

Reference:

1 Facility ID:0000

2 Client Count - Beginning 0 ( Q - 3 )

3 Admissions 0 ( Q6,Q13,Q20,Q27)

4 Discharges 0 ADSS Disch Sampling Wrksht A -4

5 Average Length of Stay 0 (Q7,Q15,Q21,Q28)

6 Point Prevalence 0 ( Q -3 )

7 Residential Bed Capacity 0 ( Q -5, Q -12 )

8 Total Expenditures $0 (Q55 )

9 Total Revenues $0 (Q52)

10 Individual Counseling 0 (Q9,17,23,33)

Sessions per Week

11 Group Counseling Sessions:

(Attendance)

Group Therapy Sessions 0 (Q11,Q19,Q23,Q35)

Group Educational Sessions 0 (Q11,Q19,Q23,Q35)

Self-help Group Meetings 0 (Q11,Q19,Q23,Q35)

Community or Governing 0 (Q11,Q19,Q23,Q35)

Other: 0 (Q11,Q19,Q23,Q35)

12 Group Sessions/Client 0 (Q9,17,23,33)

13 Group Session Length (Hours) 1 EE Assume 1 hour, or document 

the reason for other time length
39

ADSS - Data Review Worksheet - Input for Phase II

Facility ID: 0000

Variable Data Variable Description Statistic Source Instrument Source Reference:

 No. Code

14 Full Time Staff: FTE’s

a. Physicians 0 Q47, Column # 1

b. R N 0 Q47, Column # 1

c. Other Medical 0 Q47, Column # 1

d. Phd Counselors 0 Q47, Column # 1

e. Master Counselors 0 Q47, Column # 1

f. Bachelor Counselors 0 Q47, Column # 1

g. Non Degreed Counselors 0 Q47, Column # 1

h. Administrative Staff 0 Q47, Column # 1

Hrly Rate

a. Physicians $ - Q49, Please note if the dollar rate

b. R N $ - indicated is (YR) yearly, please 

c. Other Medical $ - divided by: 2080 for 40 hr work week,

d. Phd Counselors $ - 1950 for 37.5 hr work week, or 1820

e. Master Counselors $ - for 35 hour work week. The hours

f. Bachelor Counselors $ - per work week can be determined

g. Non Degreed Counselors $ - from Q47 - Column # 4

h. Administrative Staff $ - 

Hours/Wk

a. Physicians 0 Q47, Column # 4

b. R N 0 Q47, Column # 4

c. Other Medical 0 Q47, Column # 4

d. Phd Counselors 0 Q47, Column # 4

e. Master Counselors 0 Q47, Column # 4

f. Bachelor Counselors 0 Q47, Column # 4

g. Non Degreed Counselors 0 Q47, Column # 4

h. Administrative Staff 0 Q47, Column # 4
40

ADSS – Data Review Worksheet - Input for Phase II

Facility ID:0000

Variable Data Variable Description Statistic Source Instrument Source Reference:

 No. Code

15 Part-time & Contract Staff Number

a. Physicians Q47, Column # 2 & 3

b. R N Q47, Column # 2 & 3

c. Other Medical Q47, Column # 2 & 3

d. Phd Counselors Q47, Column # 2 & 3

e. Master Counselors Q47, Column # 2 & 3

f. Bachelor Counselors Q47, Column # 2 & 3

g. Non Degreed Counselors Q47, Column # 2 & 3

h. Administrative Staff Q47, Column # 2 & 3

Hrly Rate

a. Physicians $ - Q49, Please note if the dollar rate

b. R N $ - indicated is (YR) yearly, please 

c. Other Medical $ - divided by: 2080 for 40 hr work week,

d. Phd Counselors $ - 1950 for 37.5 hr work week, or 1820

e. Master Counselors $ - for 35 hour work week. The hours

f. Bachelor Counselors $ - per work week can be determined

g. Non Degreed Counselors $ - from Q47 - Column # 4

h. Administrative Staff $ - 

Hours/Wk

a. Physicians Q47, Column # 4

b. R N Q47, Column # 4

c. Other Medical Q47, Column # 4

d. Phd Counselors Q47, Column # 4

e. Master Counselors Q47, Column # 4

f. Bachelor Counselors Q47, Column # 4

g. Non Degreed Counselors Q47, Column # 4

h. Administrative Staff Q47, Column # 4

15 Fringe Benefit Rate 12.00% EE Q50
41

ADSS - Data Review Worksheet - Input for Phase I

Variable Data Variable Description Statistic Source Instrument Source Reference:

 No. Code

1 Facility ID:0000 

2 Client Count - Beginning 0 B –1

3 Admissions 0 C –2

4 Discharges 0 C –2

5 Average Length of Stay 0 C –3

6 Point Prevalence 0 B -1 (Col#2)

7 Residential Bed Capacity 0 Use Phase II - Q5,12

8 Total Expenditures $0 D – 14

9 Total Revenues $0 D – 7

Cost Breakdown

Expenses $0 D -15a

a. FTE 0% D -15a

Expenses $0 D -15b

b. Other Personnel 0% D -15b

Expenses $0 D -15c

c. Non-Personnel 0% D -15c

Total $0 D-15d

0% EE
42

Data Review Worksheet - 

ADSS Page -1 -

Facility ID:0000

1. Facility Type: Setting (A5): Sources (SC)

( ) Hospital Inpatient PO=Prov Original

( ) Non-Hosp Residential PR=Prov Revised

( ) Outpatient - Methadone IE=Internal Estimate

( ) Outpatient - Non Methadone EE=External Estimate

2. Statistical Data Section: Phase II SC Phase I SC Variance1

A. Client Count - Beginning 0 0 0 – Phase II-Phase I

Source: (Q - 3)

B. Admissions 0 0 0 – Phase II-Phase I

(Q6,Q13,Q20,Q27) (C-2)

C. Discharges 0 0 0 – Phase II-Phase I

0 (Annual Disch) (C-2)

(Discharge Worksheet)

D. Average Length of Stay (Days) 0 0 0 – Phase II-Phase I

(Q7,Q15,Q21,Q28) (C-3)

E. Average Client Count: (Calc)

 1. Admission Derivative2 0 0 Phase II-Phase I

 2. Discharge Derivative 0 0 Phase II-Phase I

 3. Point Prevalence - Reported 0 0.00 Phase II-Phase I

(Q-3) (B-1 (2))

F. Residential Bed Capacity: 0 0 0 –

(Q-5, 12) (Not requested)

G. Occupancy Rates: (Calc)

 1. Admission Based 0 0 Phase II-Phase I

 2. Discharged Based 0 0 Phase II-Phase I

 3. Point Prevalence Based 0 0 Phase II-Phase I

H. Client Var.: Admiss. vs. Pt. Prev. 0 0

I. Client Var.: Disch. vs. Pt. Prev. 0 0

1

 Variance is equal to difference of two measures of the same variable.

2

 Derivative is the variable adjusted for length of stay.
43

Data Review Worksheet - 

ADSS Page - 2 -

Facility ID:0000

3. Financial / Expenditures & Revenues

Phase II SC Phase I SC Variance1

 A. Total Expenditures $ - $ - 0 Phase II-Phase I

 (Q55) (D-14) 

 B. Total Revenues $ - $ - 0 Phase II-Phase I

(Q52) (D-7)

 C. Verification: 

 ( ) Traced to Financial Statements - Phase I, Phase II monthly amts annualized

 ( X) Compared with Previous Year

 ( ) No supporting information provided

 4. Unadjusted per Client Costs Phase II Phase I

 (All items calculated)

 A.1. Cost per Client Admissions - - Phase II-Phase I

 2. Per Day Costs - Admissions - -

 

 B.1. Cost per Client Discharge - - Phase II-Phase I

 2. Per Day Costs - Discharge - -

 C.1. Cost @ Point Prevalence - - Phase II-Phase I

- -

1

 Variance is equal to difference of two measures of the same variable.
44

Data Review Worksheet - ADSS

Page - 3 - 

Facility ID:0000

5. Salary Wage Analysis (Phase II): 

 (X ) As filed (Q47,Q49)

FTE’s SC Hrly Rate SC Hours/Wk SC Salaries

Full Time Staff (Q47-1) Q47(1) Q49 Q47(4)

 a. Physicians 0 0 $ - 0 0 0 $ - 

 b. R N 0 0 $ - 0 0 0 $ - 

 c. Other Medical 0 0 $ - 0 0 0 $ - 

 d. Phd Counselors 0 0 $ - 0 0 0 $ - 

 e. Master Counselors 0 0 $ - 0 0 0 $ - 

 f. Bachelor Counselors 0 0 $ - 0 0 0 $ - 

 g. Non Degree Counselors 0 0 $ - 0 0 0 $ - 

 h. Administrative Staff 0 0 $ - 0 0 0 $ - 

Number SC Hrly Rate SC Hours/Wk SC Salaries

Part time & Contract Staff (Q47-

1)

Q47

(2 & 3) Q49 Q47 (4)

 a. Physicians 0 0 $ - 0 0 0 $ - 

 b. R N 0 0 $ - 0 0 0 $ - 

 c. Other Medical 0 0 $ - 0 0 0 $ - 

 d. Phd Counselors 0 0 $ - 0 0 0 $ - 

 e. Master Counselors 0 0 $ - 0 0 0 $ - 

 f. Bachelor Counselors 0 0 $ - 0 0 0 $ - 

 g. Non Degree Counselors 0 0 $ - 0 0 0 $ - 

 h. Administrative Staff 0 0 $ - 0 0 0 $ - 

 Totals-Salaries Only 0 $ - 

 Fringe Benefits - (Q50)*** 12.0% EE $ - 

 Total Personal Services $ - 

 Current Expenditures: $ - 

6. Per Cent of Personal Services to Expenses: Salaries Ratio

 1. Ratio of Counselors / Total Personal Services $ - %

 2. Ratio of Medical /Total Personal Services $ - %

 3. Ratio of Admin/Total Personal Services $ - %

 4. Direct Care to Total Labor $ - %
45

Data Review Worksheet - ADSS Page - 4 -

Facility ID:0000

7. Counseling Services & Costs

 a. Counselor Personal Svcs ( d,e,f) $ - 

 b. Counselor Hrly Rate:

Professional Staff 0.00 0

All Counselors 0.00 0 ftes/yrly hrs

 (Based 1880 Net Hour basis-40 hr/wk) (ftes) (yrly hrs)

 (for 35 hour week use -1645 net hrs)

c. Individual Counseling Sessions/Wk 000 0

 (Sessions - Q9,17,23,33) (sessions) (admits) (alos-wks) (ind couns. hrs)

d. Group Counseling Sessions: Actual Attendance Adjusted Weighted

 (Sessions - Q9,17,23,33) Attends Weight Weight Attendance

 Group Therapy Sessions 0 70% 0% 0

 Group Educational Sessions 0 10% 0% 0

 Self-help Group Meetings 0 10% 0% 0

 Community or Governing 0 5% 0% 0

 Other: Family 0 5% 0% 0

 TOTAL 0 100% 0% 0

Counselor Requirement-Groups

(Based on Avg Client Count-Admits) (Avg Attend) (Couns Gps)

No. Weekly Sessions/Client 0

Counselor Group Counseling Hours - 1 50 -

(Sessions -Q9,17,25,34)*Couns Gps (sessions) (length in hrs) (wks/yr) (gp couns. hrs)

e.1. Total Counseling Hours: -

e.2. Percent of Available Hours (All Counselors) %

e.3. Percent of Professional Staff Hours (Phd, Masters, Bachelors) %

Total Costs Cost/Client

f. Counseling Svcs (Ind & Group) :

e.l.x.

(ftes/yrly hrs) -

g. Counselors Activities: $ - -

I. Group Counseling Contact Hours: 

 (Session Length in Hours) ------> 1

 0 0 0 - 

 (sessions) (admits) (Alos - wks) (Gp Contact Hrs)
46

Data Review Worksheet - ADSS

Page - 5 -

Facility ID:0000

Analysis Ratios (Phase II versus I) :

1. Client Changes: Variance1

A. Beginning Client Count %

B. Admissions %

C. Average Client Count-Admits %

Average Client Variance %

2. Financial Analysis:

A. Expenditures %

B. Revenues %

Average Financial Variance %

3. Client Statistics Stat #1 Stat #2 Variance

A. Admissions vs Discharges 0 0

 Stat #1 

Stat #2-1

B. Adm vs Pt Prevalence Based 0

 Stat #1 

Stat #2-1

C. Disch vs Pt Prevalence Based 0

 Stat #1 

Stat #2-1

4. Staffing Analysis Phase II Phase I Ratio

A. Personal Services to Expenses (%): – % – % -

1

 Variance is equal to difference of two measures of the same variable.
47

Appendix B

Phases I and II Questionnaire Data Summary Table
48
49

Appendix B - Phases I and II Questionnaire Data Summary Table

(The following is a table of Phases I and II Variable Names and Their Descriptions) 

Variable Name Description / Reference

Variable Group 1. Facility-Specific Information and Ownership

Variable Group 2. Weights

F2FWA0 Phase II - Facility Final Weight. This weight, derived from the facility’s

probability of selection in the multistage sampling process of ADSS, indicates

the number of facilities in the country represented by the given facility in the

ADSS sample. The weight variable for a facility applies to each modality

offered by that facility. Specific weight details are provided in the subsequent

section.

CLWGT0 Phase II - Client Analysis Weight. Formula: F2FWA0 x Phase II Client

Admissions 

PPWGT0 Phase II - Prevalence Analysis Weight. Formula: F2FWA0 x Phase II Client

Point Prevalence

Variable Group 3. Client and Facility Activity Variables - Phase II

NQ3 Phase II – Point prevalence.

SQ3 Phase II – Point prevalence source identifier.

OADMIT Phase II – Unadjusted Admissions from P2ADMIN.'

NQA Phase II – Client admissions.

SQA Phase II – Client admissions source identifier.

BIG_N Phase II – Unadjusted Discharge Counts (6 Months) from P2ADMIN.'

BIG_N2 Phase II – Unadjusted Discharge Counts (BIG_N doubled to 12 months).

NQD Phase II – Client discharges (6 Months).

NQD2 Phase II – Client discharges (BIG_N doubled to 12 Months for annual

discharges).

SQD Phase II – Client discharges (6 months) source identifier.

NQL Phase II – Average length of stay – in days.

SQL Phase II – Average length of stay – in days source identifier.

NQB Phase II – Residential bed capacity – total beds.

SQB Phase II – Residential bed capacity – total beds source identifier.

NQ55 Phase II – Total costs.

SQ55 Phase II – Total costs source identifier.

NQ52 Phase II – Total revenues.

SQ52 Phase II – Total revenues source identifier.

NQI Phase II – Number of individual counseling sessions per client per week.

SQI Phase II – Number of individual counseling sessions per client per week source

identifier.

NQG1 Phase II – Group Therapy Sessions Mean Attendance.

SQG1 Phase II – Group Therapy Sessions Mean Attendance source identifier.

NQG2 Phase II – Group educational sessions mean attendance.

SQG2 Phase II – Group educational sessions mean attendance source identifier.

NQG3 Phase II – Self-help group meetings mean attendance.

SQG3 Phase II – Self-help group meetings mean attendance source identifier.

NQG4 Phase II – Community or governing sessions mean attendance.

SQG4 Phase II – Community or governing sessions mean attendance source identifier.

NQG5 Phase II – Other group sessions mean attendance.

SQG5 Phase II – Other group sessions mean attendance source identifier.

NQGS Phase II – Number of group counseling sessions per client per week.

SQGS Phase II – Number of group counseling sessions per client per week source

identifier.

NGrpHrs New variable asked in cost study – Length of group session, in hours. Default is

1 hour based on typical industry practice identified by Capital Consulting.

SGrpHrs New variable asked in cost study – Length of group session, in hours source

identifier.

(continued)
50

Appendix B - Phases I and II Questionnaire Data Summary Table (continued)

(The following is a table of Phases I and II Variable Names and Their Descriptions) 

Variable Name Description / Reference

Variable Group 4. Personnel Data - Phase II

NQ47a1– NQ47h1 Phase II – Number of FTEs for full-time staff.1

SQ47a1 – SQ47h1 Phase II – Number of FTEs for full-time staff source identifier.

NQ49a4 – NQ49h4 Phase II – Number of hours per week for full-time staff.

Q49a4 – SQ49h4 Phase II – Number of hours per week for full-time staff source identifier.

NQ47a23 – NQ47h23 Phase II – Number of part-time and contract staff, combined.2

SQ47a23 – SQ47h23 Phase II – Number of part-time and contract staff, combined, source identifier.

NQ49Pa – NQ49Ph Phase II – Hourly Wages for part-time staff.

SQ49Pa – SQ49Ph Phase II – Hourly Wages for part-time staff source identifier.

NQ47a4r – NQ47h4r Phase II – Number of hours per week for part-time staff.

SQ47a4r – SQ47h4r Phase II – Number of hours per week for part-time staff source identifier.

NQ50 Phase II – Fringe benefit rate.

SQ50 Phase II – Fringe benefit rate source identifier.

Variable Group 5. Client and Facility Activity Variables - Phase I

NB12 Phase I – Point prevalence, by modality.

SNB12 Phase I – Point prevalence, by modality source identifier.

NC21 Phase I – Admissions, by modality.

SNC21 Phase I – Admissions by modality source identifier.

NC22 Phase I – Discharges, by modality.

SNC22 Phase I – Discharges by modality source identifier.

NC3 Phase I – Average length of stay.

SC3 Phase I – Average length of stay source identifier.

ND14 Phase I – Total costs.

SD14 Phase I – Total costs source identifier.

ND7 Phase I – Total revenues.

SD7 Phase I – Total revenues source identifier.

The following Phase I questionnaire variables represent only raw or originally reported data from Phase I question

D15. Facility staff were not asked to discuss these data during the callback process.

ND15a, ND15ap, ND15a_d,

ND15a_p

Phase I – Raw costs for FTE.

SD15a, SD15ap Phase I – Raw costs source identifier.

ND15b, ND15bp, ND15b_d,

ND15b_p

Phase I – Raw costs for other personnel.

SD15b, SD15bp Phase I – Raw costs for other personnel source identifier.

ND15c, ND15cp, ND15c_d,

ND15c_p

Phase I – Raw costs for non-personnel.

SD15c, SD15cp Phase I – Raw costs for non-personnel source identifier.

ND15d, ND15dp, ND15d_d,

ND15d_p

Phase I – Raw total costs.

SD15d, SD15dp Phase I – Raw total costs source identifier.

(continued)
51

Appendix B (continued) -

Analysis Data and Key Variables Summary Table

Variable Name Description / Reference Formula

Variable Group 6. Phases I and II Comparison Analysis Variables

V1K14 Difference – Point prevalence NQ3/NB12-1

V1K17 Difference – Admissions NQA/NC21-1

V1K20 Difference – Discharges NQD/NC22-1

VIK23 Difference – Average length of stay NQL/NC3-1

NIC26, N1G263 Admission derivative = Admissions adjusted for

length of stay. Phase II and Phase I, respectively.

NQA/365/NQL, NC21/365/NC3

V1K26 Difference –Derived admission. N1C26/N1G26

N1C27, N1G27 Discharge derivative = Discharges adjusted for

length of stay. Phases II and I, respectively.

NQD/365/NQL, NC22/365/NC3

V1K27 Difference – Derived discharge. N1C27/N1G27

V1K28 Difference – Point prevalence. NQ3/NB12-1

N1C33, N1G33 Admission based occupancy = Admissions /

Residential bed capacity. Phases II and I,

respectively.

N1C26/NQB, N1G26/NQB

V1K33 Difference – Admission based occupancy. N1C33/N1G33-1

N1C34, N1G34 Discharge based occupancy = Discharges /

Residential bed capacity. Phases II and I,

respectively.

N1C27/NQB, NB12/NQB

V1K34 Difference – Discharge based occupancy. N1C34/N1G34-1

N1C35, N1G35 Point prevalence based occupancy = Point

prevalence / Residential bed capacity. Phases II

and I, respectively.

NQ3/NQB, NB12/NQB

V1K35 Difference – Point prevalence based occupancy. N1C35/N1G35-1

V1C37 Difference – Phase II – Admission vs. Point

prevalence.

N1C26/NQ3-1

V1G37 Difference – Phase I – Admission vs. Point

prevalence.

N1G26/NB12-1

V1C38 Difference – Phase II – Discharges vs. Point

prevalence.

N1C27/NQ3-1

V1G38 Difference – Phase I – Discharges vs. Point

prevalence.

N1G27/NB12-1

V2F9 Difference – Total costs. NQ55/ND14-1

V2F12 Difference – Total revenues. NQ52/ND7-1

Variable Group 7. Phases I and II Unit Cost Ratios

U2B22, U2D22 Cost per admission4

 (based on total costs). Phases

II and I, respectively.

NQ55/NQA, ND14/NC21

V2F22 Difference – Cost per admission. U2B22/U2D22-1

U2B23, U2D23 (K) Cost per enrolled patient data from admissions

(based on total costs and length of stay). Phases II

and I, respectively.

U2B22/NQL, U2D22/NC3

U2B25, U2D25 (K) Cost per discharge (based on total costs). Phases

II and I, respectively.

NQ55/NQD, ND14/NC22

V2F25 Difference – Cost per discharge. U2B25/U2D25-1

U2B26, U2D26 (K) Cost per enrolled patient day from discharges

(based on total costs and length of stay). Phases II

and I, respectively.

U2B25/NQL, U2D25/NC3

(continued)
52

Appendix B - Analysis Data and Key Variables Summary Table (continued)

Variable Name Description / Reference Formula

U2B28, U2D28 (K) Cost per episode from point prevalence and

average length of stay (based on total costs).

Phases II and I, respectively.

NQ55/(NQ3*(365/

NQL), ND14/(NB12*(365/

NC3)

V2F28 Difference – Cost per episode from point

prevalence and average length of stay.

U2B28/U2D28-1

U2B29, U2D29 (K) Cost per patient day from point prevalence and

average length of stay. Phases II and I,

respectively.

U2B28/NQL, U2D28/NC3

U2B30 (K) Cost per reported visit based on counseling

sessions and visits specific to methadone

treatment. For OP and Meth only.

OP: (NQ55) / (52*[(NQ3) x (NQI)

+ (NQ3) x (NQGS)]),

Meth: (NQ55) / [(NQ3) x 5 x 52]

U2B31 (K) Cost per documented visit based on average

number of visits per client abstracted in ADSS

client abstract file.

(NQ55/(ABVisit*NQA)

Variable Group 8. Phases I and II Analysis Variables

N3N12 – N3N195 Annualized salaries for each FT staff category.

Phase II.

NQ47x1*NQ49x1*

NQ47x4*52

N3N23 – N3N30 Annualized salaries for each PT/CT (combined)

staff category. Phase II.

NQ47x23*NQ49Px*

NQ47x4r*52

N3B32 Total number of employees (including FT and

PT/CT). Phase II.

NQ47x1+NQ47x23

N3N32 Total costs of salaries (annualized). Phase II. Sum (N2N12-N3N30)

N3N33 Total costs of fringe benefits = Total salaries *

fringe benefit rate (NQ50). Phase II.

N3N32/NQ50

N3N34 Total costs of personnel = N3N32 + N3N33.

Phase II

N3N32+N3N33

P3N38 (K) Proportion – Personnel costs to total costs. Phase

II.

N3N34/NQ55

N3J40 Sum of counseling personnel costs (FT and

PT/CT). Phase II.

(1+NQ50)*(N3N15+N3N16+N3N

17+N3N18+N3N26+N3N27+N3N

28+N3N29)

P3N40 (K) Proportion – Counseling personnel costs to total

personnel costs. Phase II.

N3J40/N3N34

N3J42 Sum of medical personnel costs (FT and PT/CT).

Phase II.

(1+NQ50)*(N3N12+N3N13+N3N

14+N3N23+N3N24+N3N25)

P3N42 (K) Proportion – Medical personnel costs to total

personnel costs. Phase II.

N3J42/N3N34

N3J44 Sum of administrative personnel costs (FT and

PT/CT). Phase II.

(1+NQ50)*(N3N19+N3N30)

P3N44 (K) Proportion – Administrative personnel costs to

total personnel costs. Phase II.

(N3J44/N3N34)

N3J46 Sum of direct care personnel costs (FT and

PT/CT). Phase II.

N3J40+N3J42

P3N46 (K) Proportion – Direct Care personnel costs to total

personnel costs. Phase II.

N3J46/N3n34

(continued)
53

Appendix B - Analysis Data and Key Variables Summary Table (continued)

Variable Name Description / Reference Formula

N4N7 Counseling salaries. Phase II. (N3N15+N3N16+N3N17+N3N18+N3N26+

N3N27+N3N28+N3N29)

N4B8 Total number of FTE hours for

professional staff = sum (FTEs) *

hrs/week. Phase II.

(Sum (NQ47d-f1) +

((NQ47d23*NQ47d4r)/40)+((NQ47e23*NQ

47e4r)/40)+((NQ47f23*NQ47f4r)/40)

N4F86 Total number of annualized FTE hours for

professional staff. Phase II.

N4B8*1880

N4B9 Total number of FTE hours for counselors.

Phase II.

(Sum (NQ47d-g1) +

((NQ47d23*NQ47d4r)/40)+((NQ47e23*NQ

47e4r)/40)+((NQ47f23*NQ47f4r)/40)+((NQ

47g23*NQ47g4r)/40)

N4F9 Total number of annualized FTE hours for

counselors. Phase II.

N4B9*1880

N4J9 Counseling personnel costs (salaries +

fringe) per annualized FTE hour (N4F9).

Phase II.

(NQ50+1)*(N4N7/N4F9)

N4J12 Average length of stay calculated in

weeks. Phase II.

NQL/7

N4N12 Individual counseling hours per week NQI*NQA*N4J12

N4N17 – N4N22 Weighted group attendance per week, for

each type of group, and total. Phase II.

NQG1*.70, NQG2*.10, NQG3*.10,

NQG4*.05, NQG5*.05,SumNQGx*1.)

N4F24 Average group attendance. Phase II. N4N22/ADJWT

N4J24 Number of groups per counselor (based on

admissions and average group attendance).

Phase II.

N1C26/NF424

N4B27 Number of group sessions. Phase II. NQGS*N4J24

N4N277 Annualized group counseling hours. Phase

II.

N4B27*NGRPHRS*50

N4N30 Total annualized counseling hours

(individual + group). Phase II.

N4N12+N4N27

N4N31 Annualized counseling hours as a

proportion of total annualized hours for

counselors. Phase II.

N4N30/N4F9

N4N32 Annualized counseling hours as a

proportion of total annualized hours for

professional staff. Phase II.

N4N30/N4F8

N4J36 Total cost for annualized counseling hours.

Phase II.

N4N30/N4J9

N4N36 Unit cost – per admission cost for

annualized counseling hours. Phase II.

N4J36/NQA

N4N38 Unit cost – per admission cost for

annualized FTE counselor hours. Phase II.

N4N7/NQA

(continued)
54

Appendix B - Analysis Data and Key Variables Summary Table (continued)

Variable Name Description / Reference Formula

N4N42 Total group contact hours (based on group length,

number of sessions, admissions, and length of

stay). Phase II.

NGRPHRS*NQGS*NQA*N4J12

V5B16 Difference – Average of admission, discharge,

and point prevalence differences.

(V1K14+V1K17+V1K26)/3

V5B24 Difference – Average of costs and revenues

differences.

(V2F9+V2F12)/2

V5F28 Difference – Phase II Admissions vs. Phase II

Discharges.

NQA/NQD-1

V5F30 Difference – Phase II Admissions vs. Phase II

Point prevalence.

NQA/(NQ3*365/NQL)

V5F32 Difference – Phase II Discharges vs. Phase II

Point prevalence.

NQD/(NQ3*365/NQL)

N5D36 (K) Phase I ratio of personnel costs to total costs. Maximum of

((ND15a+ND15b)/Nd15d+.0001) or

(Nd15ap+ND15bp)

V5F36 Difference – Personnel costs to total costs. P3N38/N5D36-1

Variable Group 9. Client Abstract Data Imported from "P2ABSTM" - ADSS Client Abstract File

ABVISIT Mean of Abstracted documented client visits –

OP Only – Phase II – from ‘P2ABSTM.'

Sum Q66/Client N

TRT_DUR Mean Treatment Duration for Abstracted Clients

– Phase II – from ‘P2ABSTM.'

Sum TRT_DUR (from

P2ABSTM)/Client N

ABALOS (k) Average Length of Stay Calculated from ADSS

Client Abstract File – Phase II – from

‘P2ABSTM.'

Sum ALOS/Client N

ABALOSSD Standard Deviation of ABALOS.

N Number of Client Abstracts Per Modality – Phase

II.

SE Standard Error of ABALOS. SD/SQRT(N-1)

Variable Group 10. Replicate Weights

Facility Replicate Weights from Westat

Client Replicate Weights

Prevalence Replicate Weights

Variable Group 11. Variance Estimation Strata and Units

VST_PSU Phase II Variance Estimation Strata

VUN_PSU Phase II Variance Estimation Unit

Footnotes

1

 FTE is used here and in the SAS file to refer to the number of full-time staff on payroll.

2

 The SAS file lists PTE as part-time and contract staff.

3

 365 days per year is used to derive number of treatment cycles, 365/NQL or NC3.

4

 Episodes are essentially equivalent to admissions.

5

 52 weeks per year used to calculate annual salaries.

6

 Estimated 1,880 hours per year worked per employee.

7

 Groups assumed to be held 50 weeks per year.
55

Appendix C

Internal and External Data Estimates
56
57

Appendix C – Internal and External Data Estimates

Internal Data Estimates

Internal estimation of a variable was based on the variable’s relationship to other variables reported by the

facility. Internal estimation was used for a variety of variable types including admissions, discharges, point

prevalence, facility costs and revenues, and staffing data and hourly rates. A series of examples are

provided below to demonstrate how "internal estimates" were developed.

Example 1 – Admissions and Discharges

Generally, if a facility administrator was confident in reporting either the annual admission or the annual

discharge count of clients, but not both variables, the reported measure was used to estimate the

corresponding unreported client count measure. Given a reliably reported point prevalence and average

length of stay, this provides the best estimate of client throughput, assuming a stable, steady state of

service delivery.

Example 2 – Facility Costs and Revenues

If a facility administrator was confident in reporting either the facility’s total annual costs or the total

annual revenues, but not both variables, the reported measure was used to estimate the corresponding

unreported measure of resource use. This occurred most frequently when a facility’s reporting sampled unit

or ‘modality' was administratively part of a larger umbrella organization. Often, facility officials were able

to report program costs, but were unable to report revenue data, which was maintained at a higher level

within the organization. In this type of situation, the unobtainable revenue data were estimated based on

reported cost figures. 

Example 3 – Staffing and Hourly Rates

If a multi-modality facility’s outpatient methadone program is able to report an hourly rate of pay for its

Master’s Degree Counselors, but the regular outpatient program is unable to report the same variable, the

identical hourly rate would similarly be applied to the outpatient program. This internal estimate assumes

an equivalent average rate of pay for a Master’s Degree Counselor throughout the entire substance abuse

treatment facility.

Example 4 – Average Length of Stay

A residential facility director confidently reports its point prevalence (55), along with the number of

admissions (1813) and discharges (1878) over the past 12-month period. The facility director also indicates

that he or she is very unclear about the average length of stay for clients and is uncomfortable giving any

data regarding this variable. As a result, the cost analyst staff would provide an internal estimate of the

average length of stay, NQL, based on the above reported variables, namely, point prevalence, total

admissions, and total discharges. In order to obtain this estimate, average client count calculations were

used as analysis variables in the facility’s data analysis. 

These variables include:

N1C26 (Phase II Admission Derivative) = NQA/(365/NQL)

N1C27 (Phase II Discharge Derivative) = NQD/(365/NQL)

NQ3 (Point Prevalence)

N1C26 and N1C27 are formulas of derived average client counts for the facility.

Subsequently, the information given by the director is entered into the above formulas.

N1C26 = 1813/(365/x1) = 55

N1C27 = 1878/(365/x2) = 55

NQ3 = 55
58

Solving, x1 (based on admission) = 11.1 days and x2 (based on discharges) = 10.7 days. As a result, x or

NQL = approximately 11 days.

This result would be entered into the facility’s data set as the internal estimate. It is apparent that this

analysis is heavily dependent upon the accuracy of the reported admissions, discharges, and point

prevalence.

In other facilities, the director could provide only a range, rather than a specific value, for some items.

Then a sensitivity analysis was conducted using the above formulas to identify a reasonable estimate of the

average length of stay, NQL.
59

Appendix D

Variance Estimation of Ratio Estimators
60
61

Appendix D - Variance Estimation of Ratio Estimators

One of the major goals of the ADSS cost study is the estimation of cost and revenues rates (e.g.,

the cost per client admission, the cost per client day, or the cost per client visit). These parameters of

interest involve ratios of population totals and means. In general, these ratios can be estimated by means of

either combined or separate ratio estimators. See Cochran (1977) and Lohr (1999) for a discussion.

The combined ratio estimator was the preferred method of estimation in the form , ˆ ˆ Rˆ = Y X

where and , respectively, are estimates of the population means and (N is ˆ

Y ˆX Y = Y / N X = X N/

the population size; Y and X are the corresponding population totals). One advantage, pointed out by Lohr

(p. 225), is smaller bias when there is a small number of primary sampling units (PSUs) in the strata.

Because ratio estimators are non-linear, estimation of their variances is more involved than that of

totals and means. In this report, variances of ratio estimators were estimated by the delete-1 Jackknife

method:

( ) , ( ) ( )

2

,

1 1

1 ˆ ˆ ˆ var h L n

h

JK h i

h i h

n

R R

n

β = =

− = − ∑ ∑

where h = 1,..., L are the strata, i = 1,...,nh are the PSUs in stratum h, and is the ( ) ,,, ( ) ( )

ˆ ˆ ˆ

R YX hi hi hi =

estimated ratio based on the sample with PSU i in stratum h deleted, and the weights recalibrated.

Note: In this appendix, true variances are denoted by Var and their estimates by lowercase var.

Variance of a Ratio of a Ratio and a Mean

One parameter of interest (e.g., cost per counseling hour per client) was of the form

U = = ( / )/ ( ) Y X Z Y XZ . It was estimated by . Note that where ˆ ˆˆ ˆU = Y YZ /( ) U = ⋅ N U1

. 1 U = Y XZ /( )

Its variance was estimated by first performing Taylor linearization and then estimating the

variance by applying delete-1 jackknife to the residuals. In more detail, the following steps were followed.

a. Taylor linearization:

If , then u = y x /( )z

. 0 0 00

2 2

00 0 0 00 00 0 0

1 1 y y yy u y x z yxz

xz xz xz xz x z

  ∆ ≈ ∆− ∆− ∆= ∆− ∆− ∆    

So,

( )1 2 2 ( ) 1 Var Var U G ˆ ˆ

X Z ≈

(1)

where

i i i ii i i

Y Y YY

g y x zy x z

X Z XZ =− − =− −

and where is the estimate of the population total . Gˆ i i Σ g
62

b. Applying the jackknife:

To estimate the variances in (1), because the gi

s involve the unknown values Y and X, we

approximate them by

(2)

ˆ ˆ ˆ ˆ

ˆˆ ˆˆ i i i ii i i

Y Y YY h y x zy x z

X Z X Z

=− − =− −

and use

( ) ( ), 1 2 2

1 ˆ ˆ var var ˆ ˆ U H

X Z =

where is the estimate of the population total of the variable h. Hˆ

Because U = N  U1, Var (U) = N 2Var(U1). So

. (3) 1 11 1 ˆ S.E.( ) S.E.( ) S.E.( ). S.E.( ) ˆ ˆˆ ˆ ˆ ˆˆ ˆˆ ( )( )

U NH H H

NX NZ XZ XZ N = ==

Therefore, the procedure used was as follows:

1. Create a new variable h for each unit, using (2).

2. Calculate the standard error S.E. . ˆ ( ) H

3. Use formula (3).

References

Cochran, W. G. (1977). Sampling techniques (3rd ed.). New York: John Wiley & Sons.

Lohr, S. L. (1999). Sampling: Design and analysis. Pacific Grove, CA: Duxbury Press.