Cost Effectiveness of Treatment for People on Probation Farrokh Alemi, Ph.D. Faye Taxman, Ph.D. Jee Vang Meridith Thanner Victoria Doyon

Treatment Could Help Probation Over 4 million people on probation with little effect on recidivism Treatment and employment reduces recidivism  Does the benefits justify the cost? The Office of National Drug Control Policy (ONDCP)  High Intensity Drug Trafficking Areas (HIDTA)  Demonstration of a seamless probation program in the Baltimore-Washington, DC corridor

Perspective Government agencies costs Others  Clinician  Clients  Payers and insurers  Victims  Society

Population Examined Traditional ProbationSeamless Probation Variable Moderate-Risk (N = 75) High-Risk (N = 66) Moderate-Risk (N = 62) High-Risk (N = 69) Black, % Male, %77*** Married, % Age, years (sd)31.1 (9.8)*28.2 (9.4)31.3 (10.3)30.0 (7.8) Ever HIV Tested, % Negative, % Alcohol use in the past 30 days, % Drug use in the past 30 days, % Report committing criminal act in past year, %89*7889*77 Currently under parole, %230*5 Incarcerated during past year, %52***7863*77 Employed during the past 30 days, %74* Average legal income earned past 30 days, $792 (886)661 (909)1005 (1532)830 (1939) Table 1: No statistical significant difference between traditional and seamless groups at baseline ***p .01 ** p .05 * p .10 (significance tests run between seamless and traditional group)

Source of Data Self-report  We interviewed offenders at baseline and at 12 months Treatment & probation utilization Drug testing Re-arrest from FBI records Unit costs  Budget of the agencies  Literature review

Analytical Model

Probability of Participating in Treatment Traditional ProbationSeamless probation While under supervision Anytime during follow-up While under supervision Anytime during follow-up Number of cases Number of follow- up days per client Number of treatment days per client Daily probability of treatment per client * 10.4% * 7.5% * 17.9% * 14.6% * Table 2 Treatment Utilization * p<.01 for difference between corresponding seamless and traditional probation values

Probability of Reduced Drug use Traditional ProbationSeamless probation For all offenders in group While under supervision For all offenders in group While under supervision Number of cases Number of follow-up days per client Number of positive drug tests per client Daily probability of positive drug test per client + 0.3% * 0.4%0.3% * 0.4% Table 3 Relapse to Drug Use * p<.01 for difference between corresponding seamless and traditional probation values + A positive drug test is assumed to represent 7 days prior and 7 days post the test date unless another test is available contradicting this assumption

Daily Probability of Supervision Traditional ProbationSeamless probation For all clients in the group While in, or one month after, treatment For all clients in the group While in, or one month after, treatment Number of cases Number of follow-up days per client Number of supervision days per client Daily probability of supervision per client 70.1 * 97.0 * 68.5 * 85.7 * Table 4: Daily Probability of Being Under Supervision * p<.01 for difference between corresponding seamless and traditional probation values

Probability of Recidivism Traditional ProbationSeamless probation For all clients in the group While in, or one month after, probation For all clients in the group While in, or one month after, probation Number of cases Number of follow-up days per client Number of arrests per client Probability of arrest per client7% * 20% * 6% * 10% * Table 6: Daily Probability of Arrest * p<.05 for difference between corresponding seamless and traditional probation values

Probability of Conviction & Length of Prison Traditional ProbationSeamless probation For all clients in the group While in, or one month after, probation For all clients in the group While in, or one month after, probation Number of cases Number of follow-up days per client Number of days in prison per client Daily probability of incarceration per client * 0.7% * 5.4% * 0.8% * 6.3% * Table 7: Probability of a Day in Prison * p<.01 for difference between corresponding seamless and traditional probation values

Probability of Unemployment Traditional ProbationSeamless probation For all clients in the group While in, or one month after, probation For all clients in the group While in, or one month after, probation Number of cases Number of follow-up days per client Number of days employed per client Daily probability of employment per client 6.7% * 26.0% * 4.4% * 22.1% * Table 8: Probability of Employment * p<0.01 for difference between corresponding seamless and traditional probation values

Probability of Mental Illness Traditional ProbationSeamless probation For all clients in the group While in, or one month after, probation For all clients in the group While in, or one month after, probation Number of cases Number of follow-up days per client Number of days in mental health hospital per client Daily probability of hospitalization for mental health per client 0.02% * 0.006% * 0.08% * 0.1% * Table 9: Probability of Mental Health Hospitalization * p<0.01 for difference between corresponding seamless and traditional probation values

Probability of Physical Hospitalization Traditional ProbationSeamless probation For all clients in the group While in, or one month after, probation For all clients in the group While in, or one month after, probation Number of cases Number of follow-up days per client Number of days in general hospital per client Daily probability of hospitalization for physical illness per client 0.03% * 0.008% * 0.1% * Table 9 (continued): Probability of Hospitalization for Physical Illness * p<.01 for difference between corresponding seamless and traditional probation values

Probability of Homelessness Traditional ProbationSeamless probation For all clients in the group While in, or one month after, probation For all clients in the group While in, or one month after, probation Number of cases Number of follow-up days per client Number of days in shelter per client Daily probability of homelessness per client 0.08% * 0.00% * 0.4% * 0.2% * Table 10: Probability of Homelessness * p<.01 for difference between corresponding seamless and traditional probation values

Cost of a Day of Probation Agency costs Investigative reporting++ Seamless supervision++ Traditional supervision++ Personnel services$1,191,362$163,182$79,320$948,859 Contractual services$11,984$1,641$798$9,544 Supplies & materials$9,436$1,293$628$7,516 Building rental$206,144$28,236$13,725$164,183 Equipment rentals*$122,083$16,722$8,128$97,233 Information services+$148,621$20,357$9,895$118,369 Economic cost of volunteers5,013$687$334$3,993 Total$1,694,643$232,117$112,828$1,349,697 Cost per work day$6,009$823$400$4,786 Number of client- days 15,7929,588206,424 Cost per day per client $15$12$7

Cost of Day of Treatment CategoryTotal CROP program Outpatient program Methadone program Personnel1,266,65164,425732,452469,774 Building lease value75,4355,37248,27521,788 Equipment lease value65,4202,45626,77336,191 Operations47,4251,25915,88830,278 Centralized management397,25915,814240,449140,996 Total costs1,852,18989,3251,063,836699,027 Enrollment days based on counselor’s estimated panel size 9,49089,79040,150 Enrollment days based on time between most recent discharge & admission dates 11,04344,86057,945 Cost per enrollment day $8.70$15.80$14.25 Table 12: Cost of a Day of Treatment This work is based on Alemi F, Sullivan T. An example of activity based costing of treatment programs using time between discharges (in review)

Cost of Arrest & Criminal Justice Number of cases in millions Expenditure in 2001 in millions Cost per case in 2001 Cost per case inflated to 2004 prices Police arrests13.7$72,406$ $ Adult judicial cases92.8$37,751$406.80$ Table 12: Cost of Arrest & Court Processing Includes local, State and Federal costs. Data are based on Bauer L, Owens SD. Justice expenditure and Employment in the United States 2001, Bureau of Justice Statistics Bulletin, May 2004.

Cost of Prison The Bureau of Justice Statistics:  Cost of a day in prison to be $62.01 in % inflation in prison costs in prior years Cost of a day in prison in 2004 to be $74.27

Cost of Day of Hospitalization Secretary of Health’s report to Congress inflated to 2004: $1, Maryland’s hospital cost reports: $1,868 per day of hospitalization in 2004

Cost of Day of Homelessness Fair Market rent set by U.S. Department of Housing & Urban Development as part of Section 8 Housing Assistance:  2004 for Washington DC- Maryland –Virginia- West Virginia metropolitan area: $30.43 per day for an efficiency apartment

Cost of Day of Employment AlexandriaMontgomery County SeamlessTraditionalSeamlessTraditional Average Income Per Day 1, (sd)$61.64 ($86.19) $66.32 ($96.18) $49.53 ($68.42) $46.63 ($65.96) Estimated per day tax on income based on single exemption $1.8$2.18$1.01$0.82 Any Full-Time Work, % Any Part-Time Work, % Table 13: Income Per Day at First Follow-up (12 month retrospective) 1 Months worked past year times average monthly income divided by 240 working days

So what? Expected costs  Does treatment pay for itself? What if we have better treatment? What if supervision is longer?