Insurance Companies Play Doctor Part II

By: John Giordano DHL, MAC

businessmen walking across bridge, hand picking up one

This is the second installment of “Insurance Companies Play Doctor.” Among other things in the first segment, I outlined how many people like Avery – a bright young woman with a promising future whose life fell apart after becoming addicted to heroin in college – are trying their best to get off drugs but are being diverted away from treatment due to insurance payment complications and put on methadone or suboxone. This is a pattern that occurs with increasing frequency everyday. I also delved into the similarity between healthcare industry’s business model and that of casinos and bingo parlors in that both profit the most when they pay out the least. I also pointed out the insanity of literally placing our health in the hands of an industry whose mere existence depends on not providing you and I with the healthcare we paid for.

As fate would have it, I recently met a substance abuse case manager who works for one of the major health insurance companies. It was in a social setting that I found Angela (not her real name) to be very well educated, kind and warm. She earned her masters degree in health. We were having a wonderful conversation until the inevitable happened; the subject of addiction treatment and health insurance came up. Although we both remained cordial towards each other, the mood changed making the tension became palpable.

Angela started the conversation with a defense of her position. She explained to me how back in the day doctors got rich by over-proscribing addiction treatment and it is her job to make sure her company only pays out for what is “medically necessary” in accordance with The American Society of Addiction Medicine (ASAM). I could only think that what she was referring to was years ago when I first got involved with addiction treatment when 30 days meant intense level 1 residential treatment. This is the first stage where a person spends their entire time living at the facility while being treated for their disease by their doctors, therapists and trained staff.

What Angela quoted me were the core principles of assembly line treatment where addiction treatment protocols are no different then that for a broken bone; a one size fits all. Once a patient passes an ASAM benchmark they’re moved on the conveyer belt to the next station on the line never to return; just like setting a broken bone – put a cast on it and in six weeks take it off and everything will be just ducky. While ASAM may sound all neat and tidy to the layman, the reality is that addiction treatment is non-linear – it doesn’t follow a straight path. Anyone who has been involved in addiction and/or mental health treatment – even in the slightest way – knows it follows a curvy path. There are highs and lows, twists and turns; it looks more like a roller coaster then a straight assembly line conveyer belt.

As I tried to explain this to Angela I was quickly shut down. She was having nothing of it and went on to tell me that even today centers are over billing for unnecessary protocols, tests and expenses. My agreement with her position seemed to calm her a bit. The reality is treatment centers are like any other business and you will find some bad apples among the operators. Yet if you talk to a number of treatment centers as I do, many of the owners will tell you that the insurance companies have squeezed them so tightly that they can’t stay in business without using some form of creative billing. I’ve spoken with many practicing doctors and therapists who work everyday in the facilities treating their patients who are afraid to tell the insurance company someone is improving for fear that they’ll mandate a lower level of treatment before the patient is ready.

I decided to take control and shifted the discussion to outcomes. Angela informed me that out-patient treatment – the least expensive drive-through treatment available – was showing great results; and later admitted there is no imperial data to support that claim. She also reminded me that the treatment centers could challenge her decisions and have the case arbitrated by one of their physicians. Upon hearing their physicians roll, I asked Angela if she was familiar with the Physicians Health Program. She looked at me like I had two heads.

The Physicians Health Program came into presence in the early 70’s. At the time, many talented doctors were loosing their license to practice because they became addicted to the drugs they were prescribing, illicit drugs and also alcohol. The Physicians Health Program was created by doctors to act as an intermediary between addicted doctors and the medical board. They oversee the treatment of doctors in rehab. It’s a five year program that begins with intense level one, 90 day residential treatment, sometimes longer. The Physicians Health Program is the most effective addiction treatment protocol available boasting a success rate of over 75%!

Every doctor with a license to practice knows about the Physicians Health Program. Any competent doctor in addiction treatment knows that the longer a patient stays in intense level 1 residential treatment, the greater their chances are for a better outcome. This is where the hypocrisy becomes so thick you could cut it with a knife. The healthcare industry has proven that they can hire doctors – the ones Angela referred to as arbitrators – who are aware of effective treatment protocols, and for a few pieces of silver will look the other way and recommend treatment based on company profits but conflicts with the best interests of a vulnerable patient; sickening.

What really got to me about my conversation was how warm Angela was until we began talking about addiction. It was as if a switch went off in her head and she became very cold and callus. Angela was unabashed in her description of the adversarial relationship existing between her and treatment centers. She clearly presented her perception of treatment centers being petty thieves whose prime objective is to rob her company vault of all its treasures. Angela’s delivery left no doubt that she has dehumanized treatment workers – and to an extent addicts – in her own mind. Never did it seem to register with her that these are helpless people who paid their premiums and desperately need treatment. I never got the impression that she realized her decisions could be the difference between life and death. Not once did we speak of the consequences of the decisions she made daily. Her views were so skewed towards the insurance company she works for that I really don’t think she could emotionally handle the complete reality of it all. Most of the conversation was about money and very little about effective treatment.

Angela, and I’d suspect the vast majority of her coworkers are no more qualified to be addiction/mental health case managers than I am to be an aerospace engineer. A well paid billing manager yes, but certainly not a case manager which could imply they’re acting in some way with interests of the patient in mind. In fact, they are nothing more than a carefully fabricated image intended to give you the impression that the healthcare industry employs professionals in the field. But the veneer is paper thin. Just one scratch exposes Angela and her co-workers as being well educated in just about everything except addiction, mental health and their treatment. If I was forced to render a guess I’d say Angela has never even stepped foot in a treatment or detox center much less spent any time with a powerless person in the throes of trying to turn their lives around. I’d also go out on a limb and speculate that nearly all of her co-workers – if not all – are in the same boat.

After my conversation with Angela I couldn’t help but to harken back to the 2008 election cycle when some presidential candidates suggested that government run health care would create ‘death panels’ and put ‘the government between patient and doctor. As clearly shown within, their prediction partially came to fruition in the respect that death panels have indeed become part of the healthcare landscape. Where the candidates’ prophecy fell short in accuracy is the fact that the death panels are run by private sector insurance companies and not the U.S. Government. Healthcare company case managers like Angela are standing squarely between addicts and their doctors and therapists. The insurance companies’ are literally dictating treatment by way of the purse strings. The treatment facility either abides by the insurance companies’ demands or they don’t get paid – simple as that. What is best for the patient and best practices never enters into the conversation.

The curtain has been pulled back and enough fact has been exposed that no one is fooling anyone anymore. The hollowed out, cost-cutting addiction treatment protocols designed by the healthcare industry and implemented by treatment centers is woefully inept. This cost driven model was never designed to be effective, but rather to provide the illusion of treatment. There is a mountain of scientific research complete with real life case studies that prove addiction treatment can be very effective. The best example of this is the Physicians Heath Program’s 90 day intense level one residential treatment followed up with long term comprehensive aftercare.

As long as the patients remain faceless and the case managers and insurance company doctors can sit protected in their private cubical, addiction treatment will continue down this unsustainable path. The only action that could possibly change the course is a public outcry. For those of us fortunate enough to have gone through rehab 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 healthcare 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!

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: