The Silent Assault On Americans With Addictions- Part IV: Medical Necessity 2.0

By: John Giordano DHL, MAC

stethoscope on money

By all accounts, Salvatore Marchese was a lovable guy who was kind, sensitive, moral and embarrassed by his disease. He struggled with addiction through his high school years. Sal wanted desperately to get off of drugs and lead a normal life. He reached out asking for help; but help arrived in the form of insurance claim denials. Marchese was in and out of rehab facilities, but never for more than eleven days at a time. It was a constant struggle for Sal and his family to get insurance companies’ approval for the treatment he so direly needed. In the end, the insurance company won, saving thousands of dollars on life-saving treatment they determined to be not ‘medically necessary’ for Sal. Marchese is survived by his son, Salvatore W. II, who was eighteen- months old at the time of his father’s death.

Sadly, stories like Sal’s are becoming too frequent. In 2010, the year Sal died, 38,329 people perished from fatal drug overdoses in the United States, more than double the 16,849 fatal overdoses observed in 1999. Fatal overdoses from prescription opiate medications such as oxycodone, hydrocodone, and methadone have quadrupled in the same time frame. Americans, who represent less than 5% of the global population, consume over 80% of the world’s production of opiate pain killers – and 99 percent of the world’s hydrocodone – every year. There are ten times more people suffering with addiction than people who receive life-saving treatment – and that ratio continues to grow.

We came to a point long ago where there was no denying we have a full-blown, non-discriminating deadly addiction epidemic here in America. The question that still remains today is what are we, as a society, going to do about it? Politicians told us the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 and the Affordable Care Act (ACA) of 2010 would right the ship. It has been seven and five years respectively since each piece of legislation has been signed into law. In that time over 200,000 Americans have died preventable deaths. The intent of the legislation looks good on paper, but its impact on turning the corner on this deadly epidemic has been negligible. In fact, many believe the legislation has been a boon for the insurance industry and a bust for addicts trying so desperately to get off drugs. Neither bill appears to have the teeth to rein in the insurance industry’s ramped and indiscriminate wielding of ‘medical necessity’ that is causing ineffective treatment and avoidable deaths – all for the sake of bigger profits.

The insurance industries never-ending quest to grow their profits at the expense of their policyholders continues to erode addiction treatment best practices. Their policies are a sure recipe for more preventable deaths. I was talking to a friend of mine, Ira Levy, who was instrumental in the growth of Sunrise Detox. Facilities like Sunrise play an important role in not only detoxifying a patient, but also preparing them for the next level of care by providing therapy and a professional medical team for support and counsel. Ira mentioned to me that some insurance companies are toying with the idea of not paying for detoxifying opiate addicts. Their reasoning is this: the chances are an addict will not die if they don’t receive detox – therefore detox is not ‘medically necessary.’ Everyone should be concerned should the insurance industry decide to expand on this logic. This policy is tantamount to a person having his appendix removed without anesthesia.

Apparently, the insurance industry is floating another detox protocol – out-patient detox. Considering no detox at all, this option almost seems humane. However, at its core, the concept of out-patient detox is as absurd as asking an addict to arrange his own intervention. The simple reality is that if addicts could detox on their own, they would have done it a long time ago. Neither of these options are based in science or reality. The insurance industry’s dictation of patients’ care protocols is centered solely in their opinion of what is medically necessary and on the strong objection of nearly every doctor, therapist and professional specializing in addiction treatment. Best practices and what is clinically appropriate are simply not part of the equation.

I’ve also heard from reputable sources that addicts are being denied detox because they were incarcerated for a couple of days or more prior to treatment. This practice is becoming more and more common. Apparently the insurance industry, based on the supposition that drugs are not available in our correctional facilities, has determined detox is not medically necessary for opiate addicts who are assumed to have not used for a couple of days. If nothing else, this policy is certainly a fine example of your insurance company making medical decisions for you without consulting with your doctor.

Unfortunately in making their decision, the insurance industry does not take into account the much needed therapy and twenty-four hour medical support an addict receives at reputable detox centers. Nor are they willing to accept science that has proven beyond any reasonable doubt that the time necessary to detox an opiate addict is directly proportional to the years said individual used, the amount used in the 30 days prior to detox, whether the patient is a quick or slow metabolizer, their liver and physical condition. Obviously the detoxifying process is far more complicated than the insurance industry wants to acknowledge.

Anyone who is remotely associated with addiction treatment knows that one of opiate addict’s biggest deterrents to treatment is the pain associated with detox. Detoxifying the body of drugs can be so painful that many addicts view suicide as a realistic option – they’d rather die than go through the painful process. If you build a barrier between people wanting to get off drugs and detox, you are guaranteeing fewer individuals will seek treatment. Is it possible this new policy could be a diabolical plot to keep people from seeking effective treatment? Is the insurance industry herding addicts into the chute that leads to the lesser expensive Methadone/Suboxone clinic pens, or is this new policy just a coincidence? I’ll have more on this topic later.

The duplicity, regretfully, doesn’t end there. The insurance industry has invested quite a bit of time and money in developing a sequence of skewed questions for case managers to ask doctors. The directed questions are carefully framed in such a way that a response can only lead to one answer – the one the insurance company wants. These meticulously constructed questions were not born out of science or medicine; nor are the doctor’s forced responses a true measure of a patient’s progress in treatment. These questions – developed with interlacing self-serving bias – were never intended for that purpose; but rather to further blur the fine line between ‘clinically appropriate’ and ‘medical necessity’.

Once again this conscious and deliberate effort by the insurance industry to increase profits and pad their bottom line severely undermines their policyholder’s health and could lead to their death.

Doctors and therapists fear talking to case managers – and their trepidations are not unwarranted. Their job requires they talk with case managers regularly. Over time, the addiction experts have become aware of the case managers’ trick questions and learned through their experiences that they are looking for any little thing they can possibly find that might lead to a lower level of treatment – or no treatment at all – resulting in cost savings for the insurance company. Something as innocuous as a patient saying he or she is feeling a little better – which can change from day to day – is enough to influence case managers’ opinion and change the course of treatment. Doctors and therapists will at times down play a patient’s progress knowing full well the case manager will use the information in demanding the patient be relegated to a lower treatment level before they’re ready or ending treatment all together. It’s a constant, never ending tug of war between what is best for the patient and the insurance company’s cash outlays.

My good friend and colleague Dr. Ken Blum, co-discoverer of the reward gene – a.k.a. the addiction gene – is very disheartened by the lack in progress in addiction treatment over the last 25 years when he first announced his discovery of the addiction gene. He holds the insurance industry partially the blame. According to Dr. Blum; “It certainly takes more than thirty-days for an addict’s brain chemistry to normalize and potentially ninety days or more. Moreover, a person with a genetic predisposition to addiction has inherently lower dopamine function. Dopamine is the brain chemical associated with addiction function. Lower dopamine function is the key issue – one of the single most important treatment issues – that is not being discussed much less addressed in the vast majority of treatment programs available today. In addition, the oppressive policies instituted by the insurance industry have stymied the implementation of new evidenced-based and scientifically-proven treatment that can help every addict, especially people with chronic addiction issues. Imagine where we could be today if all the brain power and energies exerted over the last twenty-five years trying to determine what is medically necessary were instead focused on developing new and innovative addiction treatment protocols.” I’ll have more on this in my next segment.

Addiction is a chronic, incurable, life-threatening illness that can be managed. The ranks of people suffering with addiction grow every day. Yet the insurance industry continues to either deny or cut short life-saving treatment to people – ravaged by their disease and hanging on to life by a thread – based on their own set of complicated self-serving guidelines. Their matrix is more opinion than science; more managing profits as apposed to managed healthcare. Their motives are aligned with the board of directors while flying in the face of the medical board. The insurance industry has given no indication they intend to follow the spirit of the Affordable Care Act and the Mental Health Parity Act; in fact just the opposite. They are standing like an impenetrable road block between you and your doctor. There are some who say the insurance industry’s position and power to have the final say in what is medically necessary for you constitutes a death panel.

The only action that could possibly change the course is a public outcry. 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 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 life-saving 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!

“There are in fact two things, science and opinion; the former begets knowledge, the later ignorance.” ~ Hippocrates

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: