After an addict or an alcoholic decides to do something about his or her problem, the most important question they’ll need to answer is this: Is residential inpatient or outpatient addiction treatment a better choice?
Let’s face it: Making the decision to get help, while never easy, is just the beginning of the process. Like most medical conditions, the path to wellness is long and complicated, and it’s never a straight line. The fact that addiction and alcoholism are complicated by public stigma, health insurance complexities and a lack of access to specialized care are all pitfalls along that path, but there are drug and alcohol treatment centers out there that can help individuals who suffer navigate them.
Ultimately, however, the decision of whether to choose inpatient vs. outpatient addiction treatment depends on a number of different factors, and all of them must be evaluated by the prospective patients themselves. But while that decision may seem overwhelming, there are some general rules of thumb that can be taken into account that might make it easier to make.
Inpatient vs. Outpatient Addiction Treatment: Who Pays For It?
To make those decisions, it’s important to know exactly what each choice involves. It’s important to remember that financial considerations have to be taken into account, and many individuals without a lot of disposable income — and let’s be honest, a great many addicts and alcoholics fall into that category — have little choice but to accept whatever their health insurance plans, if they have one, will cover.
And as the personal financial website ValuePenguin points out , even with a robust health insurance plan, out-of-pocket costs can be expensive: “People who are admitted as inpatients to hospitals and facilities will typically have more serious conditions that require prolonged monitoring and care from medical staff overnight or for more days. As a result, the costs for inpatient care tend to be significantly higher; the patient and insurance policyholder are hypothetically using up more resources including beds at the facility and time and service provided by other medical professionals on staff, and these costs get passed along to both the insurance company and the policyholder.”
The good news is that private health care policyholders are entitled to parity, which means that “under a 2008 federal law, insurers have to consider drug and alcohol addiction the same as any other medical problem, as far as access to treatment goes,” according to a 2015 piece by NPR . It’s also important to note that, according to the online insurance news agency Insurance Quotes , “With the exception of Arizona, Georgia, Indiana, Iowa, Idaho, Oklahoma, and Wyoming, all states currently require commercial group health insurers to cover addiction treatment services as they would any other prescribed medical treatment.”
So what does that mean? The federal government mandates that health insurance plans must pay for addiction treatment, and so do the laws of 43 states. However, just because an individual has a health plan that’s required to provide benefit coverage for drug and alcohol treatment doesn’t mean that getting help is as simple as showing up to a rehab and flashing a health insurance card.
What Do Insurance Companies Require?
Perhaps the most nebulous requirement by insurance companies is that of “Medical Necessity.” While that definition varies by insurance company, the standard Medicare definition  is pretty applicable across the board: “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
Or, as the Baldwin Research Institute (BRI)  puts it, “Medical necessity can take many forms but it is a form of scrutiny by the insurer that delays treatment in some way.” However, when it comes to addiction treatment, the institute points out, “There are concerns that medical necessity is one tool that has been used to unnecessarily delay or deny treatment and services for substance use disorders. Medical necessity has legitimate purposes but advocates fear it has been and may continue to be used to delay or deny services for substance users to a greater degree than those seeking services for medical needs.”
Many insurance companies base their coverage decisions on criteria defined by the American Society of Addiction Medicine (ASAM) , which are “the result of a collaboration that began in the 1980s to define one national set of criteria for providing outcome-oriented and results-based care in the treatment of addiction. Today the criteria have become the most widely used and comprehensive set of guidelines for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions.” More than 10 managed care providers use the ASAM criteria in determining coverage of addiction treatment for roughly 45 million Americans — and that’s both a good and not-so-good thing, as the health insurance company Anthem’s own website  points out:
- Good, because “the ASAM Criteria pays attention to the whole patient, including all of his or her life areas, as well as all risks, needs, strengths, and goals.”
- Not-so-good, because “It is the goal of treatment providers to make sure the care you receive keeps you safe, and addresses all risks, but also that the care is as ‘least intensive,’ as possible, which helps you avoid unnecessary or wasteful treatment.”
And while “least intensive” may sound good on your pocketbook, it may not be so good for recovery, as the BRI points out , because it sets up a situation known as “fail first,” which “requires people to fail first at less intensive and often less expensive treatments and programs, such as outpatient programs or counseling, before more intensive programs, including residential programs, may be looked at for insurance coverage.”
Inpatient vs. Outpatient Addiction Treatment: What Are They?
To put it in its simplest terms: Patients seeking inpatient treatment will stay as patients on the campus of the treatment center and be immersed in therapy throughout their stay, giving them a respite from the stress and chaos of their lives. For individuals who need to be removed from temptations, triggers and influences that make it difficult to stay clean and sober, it’s an idea scenario. Outpatient clients can stay in a sober living facility or at home and attend therapy groups for designated time frames several days a week; for those whose livelihoods depend on them continuing to work throughout the treatment process, this might be a better option.
When it comes to inpatient vs. outpatient addiction treatment, there are some commonalities that both types of programs share, as the University of Wisconsin-Madison’s School of Medicine and Public Health points out : “Both usually involve the 12-step program used by Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Treatment may include group therapy, one-on-one counseling, drug and alcohol education, medical care, and family therapy.”
And, as the National Institute on Drug Abuse states , most treatment programs “start with detoxification and medically managed withdrawal, often considered the first stage of treatment. Detoxification, the process by which the body clears itself of drugs, is designed to manage the acute and potentially dangerous physiological effects of stopping drug use.” But because “detoxification alone does not address the psychological, social, and behavioral problems associated with addiction and therefore does not typically produce lasting behavioral changes necessary for recovery,” additional treatment is often necessary.
So what does each program involve? According to the NIDA, inpatient treatment can be either short-term (the 28-day “Minnesota Model,” pioneered by Hazelden Betty Ford, is considered the gold standard, although changes to the industry have made 28 days rare these days) or long-term, which combines residential inpatient and intensive outpatient. Generally, however, inpatient treatment consists of “the ‘resocialization’ of the individual and use the program’s entire community — including other residents, staff, and the social context — as active components of treatment. Addiction is viewed in the context of an individual’s social and psychological deficits, and treatment focuses on developing personal accountability and responsibility as well as socially productive lives. Treatment is highly structured … with activities designed to help residents examine damaging beliefs, self-concepts, and destructive patterns of behavior and adopt new, more harmonious and constructive ways to interact with others.”
Reputable inpatient treatment provides, in addition to peer support, group therapy and one-on-one counseling, a number of evidence-based therapeutic modalities, including Cognitive Behavioral Therapy, Dialectical Behavior Therapy, Cognitive Processing Therapy, Trauma Therapy and more. And while some of those therapies are provided on a limited basis in intensive outpatient therapy, patients who are temporary residents in a round-the-clock community will, it stands to reason, have greater access to them.
So what is intensive outpatient treatment? According to the NIDA, “Outpatient treatment varies in the types and intensity of services offered. Such treatment costs less than residential or inpatient treatment and often is more suitable for people with jobs or extensive social supports. It should be noted, however, that low-intensity programs may offer little more than drug education. Other outpatient models, such as intensive day treatment, can be comparable to residential programs in services and effectiveness, depending on the individual patient’s characteristics and needs. In many outpatient programs, group counseling can be a major component.”
Ideally, a successful rehabilitation stay will include a combination of both, but that’s not always possible — logistically or financially. Again, it’s important to understand that many individuals may get approved for weeks, or even days, of inpatient treatment before insurance oversight reduces coverage to outpatient only. Some potential patients may not get any residential treatment covered at all. That’s probably confusing and may seem unfair, but the important thing to remember is that because of parity laws, some form of treatment must be offered. And much of its effectiveness is dependent on the willingness and the effort of the individual.
Inpatient vs. Outpatient Addiction Treatment: Which Is Best?
When considering inpatient vs. outpatient addiction treatment, potential patients should take an informal inventory of the same set of criteria used by ASAM. That organization’s Patient Placement Criteria, Second Edition, Revised, looks at :
- Acute intoxication and/or withdrawal potential: Is the patient’s drug and alcohol use going to necessitate a long-period of medical detox? The more these substances control an individual’s life, the more difficult they are to escape, and patients with a history of severe addiction and/or alcoholism may likely benefit from residential inpatient.
- Biomedical conditions and complications: Are there co-occurring physical disorders that may complicate treatment? Individuals who have become addicted to prescription narcotic because of chronic pain issues may find that one of a reputable treatment center’s inpatient resources includes non-narcotic pain management, which can help them achieve a quality of life that’s not dependent on opioids.
- Are there emotional, behavioral or cognitive conditions that may complicate treatment? Patients who also suffer from severe depression or bipolar disorder may find that an inpatient program’s psychiatric services will be beneficial than attempting to sort those problems out on their own while completing intensive outpatient at the same time.
- Does the patient have a willingness to change? Let’s face it: Few people wake up raring to go to rehab like it’s a vacation destination. Some people wind up seeking addiction treatment because their reluctance to change is outweighed by the pain of staying the same. A self-assessment to determine a patient’s willingness to get clean and sober is imperative in order to give whatever choice the patient makes the best chance of success.
- Is the patient at higher risk of relapse or continued use? According to the NIDA , “The chronic nature of addiction means that for some people relapse, or a return to drug use after an attempt to stop, can be part of the process.” However, “relapse doesn’t mean treatment has failed. When a person recovering from an addiction relapses, it indicates that the person needs to speak with their doctor to resume treatment, modify it, or try another treatment.” In other words, some individuals may have a history of relapse or a return to drug and alcohol use, and choosing inpatient vs. outpatient addiction treatment may help remove them from sources of temptation and give them a longer base of sobriety upon which to build.
- What is a patient’s recovery/living environment like? For many addicts and alcoholics, the success of outpatient treatment is predicated on the home environment to which they return every night. If family members are supportive and nurturing and express understanding of the nature of addiction and alcoholism, then there’s a greater incentive to continue with treatment. However, if family members also drink and use, or just view recovery efforts with skepticism, then such a lack of support can lead to setbacks and even relapse. Taking the home environment into consideration is a major factor in deciding on inpatient vs. outpatient addiction treatment.
Of course, as literature from the U.S. Substance Abuse and Mental Health Services Administration points out , basing a needs assessment on a strict diagnosis of ASAM guidelines can be problematic: “ASAM placement guidelines are not always the best guide to placing a patient in the proper setting at the proper level. For example, what is the clinician to do with the patient who qualifies for outpatient treatment according to the ASAM guidelines but is homeless in sub-zero temperatures?” Fortunately, treatment program administrators do have some latitude in making arrangements, both financial and clinical, in those situations.
So What Do the Numbers Say?
One of the unenviable questions that treatment centers employees are often asked is, “What is your success rate?” Often, those numbers are varied and sometimes even arbitrary, depending on how “success” is defined. Patients in certain professional programs like Aviation, for example, have an extremely high success rate — due in part to the stringent requirements placed on them if they wish to return to work. And because determining a “success rate” is dependent on post-treatment monitoring, the numbers are always affected by individuals who change addresses and phone numbers or fall off the grid, so to speak.
In that regard, various studies over the years often produced mixed results when it comes to the efficacy of inpatient vs. outpatient addiction treatment:
- A 1993 article in the journal Psychiatric Quarterly  concluded that “patients with high psychiatric severity and/or a poor social support system are predicted to have a better outcome in inpatient treatment, while patients with low psychiatric severity and/or a good social support system may do well as outpatients without incurring the higher costs of inpatient treatment.” However, the article goes on to point out that “preliminary results from 183 inpatients and 120 outpatients indicated outpatients, regardless of level of psychiatric severity, were 4 times more likely to be early treatment failures.”
- A 2014 paper in the peer-reviewed journal Psychiatric Services  conducted “multiple randomized trials and naturalistic analyses compared IOPs with inpatient or residential care” and found that “these types of services had comparable outcomes. All studies reported substantial reductions in alcohol and drug use between baseline and follow-up.”
- In a 2006 study of inpatient vs. outpatient addiction treatment for individuals with a recent suicide attempt , those patients “were significantly more likely to have better substance‐related outcomes at 6‐month follow‐up if they were treated in inpatient compared with outpatient settings.”
- A 2015 paper in the Journal of Studies on Alcohol  found that inpatient vs. outpatient addiction treatment for alcoholics showed no statistical difference in terms of results, and while the results for cocaine users were marginally better, they weren’t “statistically significant.”
Clearly, the evidence is all over the place, but the point to keep in mind while deciding on inpatient vs. outpatient addiction treatment is this: Both can produce positive results. Which one is best depends on a number of factors, some of which are in the potential patient’s control and some not … but the most important takeaway is that when it comes to treatment for alcoholism and addiction, doing something is better than doing nothing.