Chapter VIII
The Spending Gap
Despite the evidence that risky substance use
can be identified and reduced through screening
and early intervention, and that addiction can be
treated and managed effectively with
psychosocial and pharmaceutical interventions,*
financial investments in addressing risky
substance use and addiction are aimed
disproportionately at coping with the costly
health and social consequences of the disease
rather than at prevention and treatment. This
spending gap impairs health and imposes
extraordinary and unnecessary costs to
taxpayers. The continued inadequacy of
insurance coverage for these services further
flies in the face of a fiscally-sound approach to
disease prevention, treatment and management.The Rational Approach to Risky Substance Use and Addiction .....................................
The goals of medicine are the prevention of
disease, the diagnosis and treatment of illness or
injury and the relief of pain and suffering.^1 The
general standard for determining what health
care services should be provided to patients is
the “reasonable and necessary”^2 or the
“medically necessary” standard.^3 The definition
of what is considered necessary generally is
made by health care payers based on the strength
of the clinical evidence supporting the
effectiveness of interventions in improving
health outcomes.^4 In the Medicare and
Medicaid programs, medical necessity is defined
in various ways but generally as the prevention,
diagnosis or treatment of illness or injury that
endangers life, causes suffering or pain, causes
physical deformity or malfunction or results in
illness or infirmity.^5 Some states also require
that Medicaid services not be more costly than
reasonable available alternatives.^6* See Chapters IV and V.