Avery was your typical suburban kid; bright and athletic with a bubbly personality and an infectious smile that just seemed to draw people to her. She grew-up in a comfortable home with a big oak tree in her back yard. Her parents were model citizens. Avery had to study hard to stay on the honor role but it paid off. In her senior year of high school, she was accepted at a prominent university in her state.
College didn’t come easy for Avery; she had to forgo many of the social aspects of school to have time for study. In her sophomore year a friend offered her an illicit drug to help get through an all- night cram session for a big test the next the morning. It was on this very night that Avery’s life changed for ever. She began using more and more to help keep up her GPA. Eventually she used for recreation. Her drug abuse, like so many before her, grew to become more that she could handle. Avery – who once had such a promising future – dropped out of college.
She wanted desperately to get off drugs but couldn’t do it on her own, she was hooked. Avery entered a rehab facility with a fierce determination to overcome her disease; but the treatment she received didn’t work. Drained and emotionally distraught by her entire addiction experience, Avery saw no options other than methadone. Now, everyday after she wipes the sleep from her eyes, Avery stands in line at a clinic in the seedy part of town waiting for her daily dose of methadone. Then she heads off to her minimum wage job in the gardening department of a big home improvement center; not exactly the career path Avery envisioned for herself a short time ago.
Avery is just one of what I suspect are millions of people who are abusing drugs or are in an alternative program like methadone who want to get clean but are trapped in the shadows due to insurance companies questionable policies.
The insurance industry can track their roots back to 1750 B.C. when Babylonian traders would pay financiers a premium up-front in exchange for their guarantee to cancel the loan should their shipment be stolen or lost at sea. The industry has experienced a lot of twists and turns since its beginnings. However, like any bingo parlor or casino, insurance companies’ profits are based on how little they payout.
“Managed Care” came to prominence in the 1970s through the influence of then U.S. President, Richard Nixon. It was sold to the American public as having cost containment benefits at a time of rising healthcare costs but never lived up to its billing. In the early stages of discussion during a White House meeting on February 17, 1971, Nixon expressed his support for the essential philosophy of the HMO. John Ehrlichman, counsel and Assistant to the President for Domestic Affairs, explained to the President: “All the incentives are toward less medical care, because the less care they give them, the more money they make.” I suspect decisions made at this and subsequent related meetings over forty-years ago are what sealed Avery’s fate.
Addiction treatment is a complicated process that looks more like a curvy path through a forest than a straight line. Research has proven that the best outcomes occur when the patient has had a minimum of 90 days of treatment. There are many judgment calls throughout the process that need to be made by the doctors, therapists and other treatment professionals who are elbow to elbow with the patient through their rehab stay. Patients’ conditions require different levels or tiers of modalities based on how long they’ve been using and how they respond to treatment – everyone responds differently and at their own pace.
There are four ‘tiers’ of addiction treatment after detox, with the first one being the most important. The first tier – residential – is what people envision when they think of rehab. It’s an intense thirty-day program where a patient lives on site and is in constant contact with doctors, therapists, counselors and other treatment specialists. This first tier is vitally important to the successful outcome of the patient. Lower levels of treatment are for patients who have completed tier one. Under normal circumstances doctors and therapists who are in close contact treating the patient measure their progress and recommend the next tier of treatment at the appropriate time.
Today, “Normal Circumstances” no longer applies. In fact, it has been replaced by “The New Normal” where science and facts hold little sway when considering the bottom line of an insurance company as predicted in the immortal words of John Ehrlichman, “the less care they give them, the more money they make.”
In October of 2008 the Mental Health Parity and Addiction Equity Act (MHPAEA) was enacted into law. In short, this bill forced health insurers as well as group health plans to cover mental health and substance abuse disorders much like they cover physical health issues. The legislation was applauded by treatment professionals across the country. Everyone in the field viewed this as a major step forward in addiction treatment. What could not have been anticipated at the time was how the insurance companies were going to manipulate the new law.
We soon found out. In recent years insurance companies have become emboldened. Their representatives have become increasingly involved in daily patient treatment to the point of entirely taking it over. Case managers, who sit comfortably in their remotely located cubicles, now hold enough power to randomly move a patient from a high tier of treatment to a lower level without medical justification by simply making one phone call. The insurance companies found a loop hole in the Mental Health Parity and Addiction Equity Act and are wielding it like a sledge hammer to lower their money outlay for treatment. They’re using their purse strings to control every aspect of a patient’s treatment. Just one of the consequences is an adversarial relationship pitting the facilities’ doctors and therapists against insurance company’s contract doctors. T
he stories I’ve been told are absolutely heartbreaking. One therapist told me she received a call from a case manager instructing her to release her patient who was in the middle of his treatment – that day. When she asked for justification, the case manager simply stated they were not going to pay for his treatment any more. Another professional told a story of how patients were being moved from ‘tier one’ to lower levels of treatment normally reserved for patients who have completed ‘tier one’ simply as a cost cutting measure. I was told by an addiction specialist of insurance case manager’s that on his first week on the job a high level executive from the home office was in town for meetings and walked through the claims department. The executive lifted a stack of claim files off the manager’s desk and rhetorically asked; “do you know what to do when you have too may claim files?” then threw the handful of files in the trash. In speaking with another knowledgeable professional in addiction treatment I asked; “from what I’ve seen and know, it appears to me that the insurance companies are now dictating all of the treatment protocols;” her response was ‘you are 100% correct!”
Nearly all of the decisions made by the case managers are over the objection of the treatment facilities doctors and therapists who are hands on treating the patient. Although the treatment center has the right to call a doctor to doctor meeting, their appeals have almost no effect because the insurance company’s doctor – who has never seen, much less met the patient – has final say over the treating doctor and/or therapist’s objections. In essence, the insurance company’s doctor is the judge, jury and sheriff in any dispute regarding the treatment of all patients – period.
The CBS TV Newsmagazine ‘60 Minutes’ did an exposé on Blue Cross Blue Shield Anthem (BCBSA) late last year titled “Denied.” I strongly recommend you take a look at it if you didn’t see the show – the link is below. In his report, Scott Pelley did a masterful job of uncovering the extent to which health insurance denies psychiatric care claims and how treatment protocols are being dictated by the insurance company. He found that most of their doctors are contractors paid by the case – earning up to $25,000/month – and managing up to 550 patients per month. Pelley looked at 11 BCBSA contract doctors’ denial rate and found it ranges from 82.76% to 100% over a six month period. This begs the question; how do these actions by the insurance companies help the patient/policy holder become whole again?
It just seems counterintuitive to me that we trust our health to an industry whose very existence depends on providing people like you and me with the least amount of care possible. What we have today is “Managing Profits” and not “Managed Care.” How we got here I know, but I’ll never understand how human beings could be so cold as to inflict so much pain and suffering on another just for money. Yet this is the society we live in today where what was once a humanitarian directive has been hijacked and reshaped into a new revenue stream for behemoth corporations at the expense of hard working Americans paying their insurance premiums and being denied their benefits. In the ‘New Normal’ all moral, ethical and societal standards are no longer a concern when the bottom line is being discussed.
Avery’s story is just one example of untold suffering happening to what I suspect to be millions of Americans across the country – all at the hands of the health insurance industry. What happens now to addicts like Avery who desperately want to get off drugs but are fading in the shadows of this nightmare? Well that depends on us. For those of us fortunate enough to have gone through rehab, we know we didn’t do it on our own. We relied on each other to produce a positive outcome. If we are to effect positive changes in the insurance industry, we need to band together one more time. All I ask is that you contact your congressman and senator and ask them what they are doing to prevent the insurance industry from dictating addiction treatment protocols. If you can’t do it for yourself, please do it for the person behind you who needs treatment but is being blocked by the many barriers put up by the insurance industry. This is our battle and this is our time to shine!
“The less care they give them, the more money they make.” – John Ehrlichman CBS TV Newsmagazine ‘60 Minutes’ exposé “Denied.”
John Giordano DHL, MAC is a counselor, President and Founder of the National Institute for Holistic Addiction Studies and Chaplain of the North Miami Police Department. For the latest development in cutting-edge treatment check out his website: http://www.holisticaddictioninfo.com