Andrea was in her 17th day of addiction treatment for opioids when she was called in to the administration office. She had been through so much at this point, 7 days of detox, early morning group meetings, AA meetings, an appointment with her therapist for an hour every day, extensive introspection and so much more that her head was spinning. Every day she gave it her all in an effort to get on the other side of this deadly disease. Now she finds herself sitting nervously in the lobby of the administration office wondering what she might have done to precipitate such an unusual meeting. It didn’t take long for Andrea to learn of her fate. The staff informed her that her insurance company had determined that treatment was no longer a ‘medical necessity’ for her and they would not pay for any further services. I wish Andrea’s situation was a one off but this tactic is used far more frequently than most people know.
It’s stories like Andrea’s (a composite character consisting of several people I’ve treated for opioid addiction) that make me think back to the lead-up of the 2008 presidential elections when there was a lot of talk about nefarious government ‘death panels’ evolving out of a single payer health care program and that the program would stand between the patient and their doctor. It was presented as being a group of bureaucrats who would decide which Americans were “worthy of medical care”. As you are aware, the single payer program never came to fruition. However, to a certain extent, the death panels did emerge, but in the form of insurance company case managers.
I shouldn’t be too critical of the case managers because their cold-hearted attitudes and callous actions are encouraged by their employers. It wasn’t always this way. Twenty-years ago, and before America’s opioid epidemic, insurance companies and the addiction treatment industry shared a symbiotic relationship where the patient’s well-being was the first and foremost concern. Sadly, those days are behind us.
Too often, when we think or speak about treatment centers and insurance companies, we forget that they are businesses, and as such, are working to deliver a profit at the end of each and every month. In fact, the CEO of any company has the fiduciary responsibility to deliver the largest profit possible at the end of each quarter. Most often, his or her income is based or strongly influenced by profit.
In an effort to comply with full disclosure, it is important that I note that I am a capitalist who always puts people first. I’ve either owned my own business or worked as a consultant my entire professional life.
In the late 90’s, when the opioid epidemic was ramping up, many new addiction treatment centers and clinics began opening across the country. Scientists and researchers were churning out more comprehensive information on addiction and its treatment than any time before.
As the industry grew, more and more bad actors jumped in trying to make a fast buck. They over-charged insurance companies for everything they could. Eventually, most of them were flushed out, but the damage was done – the counterproductive relationship between treatment and insurance began to germinate.
If this isn’t a death panel coming between a doctor and his patient than what is?!
It wasn’t long before insurance companies began hiring more case managers. They tended to be well educated in areas other than addiction treatment. In fact, the vast majority of these case workers never even stepped foot into a treatment center, much less hold even a rudimentary knowledge of how treatment works. They rely on a performance sheet questionnaire that they acquired the basics from SAMHSA, The Substance Abuse and Mental Health Services Administration, which is a branch of the U.S. Department of Health and Human Services. The case managers are in contact with patient’s therapists daily looking into the progress of their policy holder and scrutinizing every decision the doctor makes. When they’ve checked enough boxes on their sheet, the case manager informs the patients’ doctor that it’s their position that treatment is no longer a ‘medical necessity’ for their policy holder, and they refuse to pay for any more treatment. Needless to say, the doctors and centers contest the opinion of a case worker with little to no addiction treatment experience who sits in a cubical thousands of miles from the patient they’ve never even met. Unfortunately, the disputes are mediated by the insurance company’s staff, and rarely does the treatment centers doctor win.
To a practitioner such as myself, this is the most damaging course of action imaginable. Anyone in addiction treatment will tell you that drug abuse causes the patient to be foggy brained for at least the first two weeks of their treatment. Their limitations prevent them from picking up much of what is being taught. The real gain comes at the end of treatment. Denying someone who is desperate to get off of opioids at the most valuable portion of addiction treatment is inhumane and nearly always results in a relapse.
Insurance Companies are like gambling casinos on steroids.
As cold and callus as this may sound, the policy is in line with the core values of the insurance industry. They operate like a gambling casino on steroids. They make their money on what they don’t pay out. The insurance industry considers cutting someone like Andrea’s treatment back a savings that goes directly to their bottom line. Compassion and concern for the patient’s well being are totally void.
The insurance industry didn’t stop there. They instituted a claw-back policy requiring treatment centers to refund parts or all of the money paid to them for someone’s treatment months or even years before. This can amount to hundreds of thousands of dollars. The rationale behind the industry’s claw-back initiative varies by case, causing strong disputes from the treatment centers; however, the insurance companies have all the leverage. If the treatment centers ever hope to treat another person whose policy is held by these agencies, they must comply with their claw-back program. In most modern countries, I believe this is called extortion.
The insurance industry was not the only group concerned about to integrity of addiction treatment centers. Google, undoubtedly the most popular search engine with over 79% of the search market share and 85% of mobile traffic, shut down all addiction treatment advertising over a year ago. This was disruptive and financially devastating for addiction treatment centers. Nearly all treatment facilities depend on search engines for the majority of their new clients. In July 2018, the search engine giant required treatment facilities to be LegitScript certified before they could apply for Google certification. The new policy also makes it much harder and more expensive for third-party, non-service providers to advertise on Google. Bing and Facebook followed shortly after.
Although well intended, the broad scope and scrutiny of these new policies let many reputable treatment centers slip through the cracks. Directories of addiction treatment centers and other similar services commonly found in other industries are all but gone. Moreover, the qualifications of a treatment center are being judged by digital marketing specialists and not experts in addiction treatment. Once again, the treatment facilities have no leverage over the internet behemoths and must adhere to their policies or close their doors.
The sad reality to this saga is that we know how to effectively treat addiction. We’ve known for over thirty years. The Physicians’ Health Program (PHP) model has the highest rate of recovery of any modality practiced today. It was set up to help physicians, dentists and other eligible health care professionals suffering from addiction, mental illness or behavioral concerns, that impact their ability to practice their chosen profession safely.
According to their website (https://www.physicianhealthprogram.com): “Overall, PHPs report five-year abstinence rates for substance use disorders of 79%, return to work rates of 96%, and little or no evidence of serious risk or harm to patients.”
A few things that PHP does differently from other treatment programs is it requires a minimum of 90 days residential or inpatient treatment that can go as long as 180 days. Additionally, they have a vigorous aftercare program that includes advocacy, regular meetings, frequent random drug testing and other assistance to help impaired medical professionals and their families.
A bona fide 79% success rate is hard to argue. Why isn’t every treatment center following in their success? The Physicians’ Health Program should be the model by which all others are judged. But the reality is, most people have never even heard about it. Is anyone in a decision making capacity paying attention? Instead, we subscribe to a program called the Minnesota Model that was developed by a couple of med students with zero addiction treatment training or experience, who decided 28 days of treatment should be enough. There was no science to back their choice; they literally picked 28 days out of thin air.
The only drawback to the PHP is cost. Thirty days of treatment can cost upwards of $30,000.00. Ninety days can be three times that amount. Then, add in all the extras from aftercare, and you could be looking at a number over a hundred thousand dollars.
The insurance companies are never going to pay that amount. In all fairness, they’d have to increase the prices of their policies substantially to meet the financial obligation of that magnitude. Besides, they have a more cost-effective option in Medicated-Assisted Treatment (MAT). This is a program that is sweeping the country as therapy for substance use disorders.
In essence, this program helps addicts get off of elicit and prescription opioids by providing them with other opioids such as methadone, buprenorphine, Suboxone and a few others. With all due respect to advocates of MAT drugs, an opioid is an opioid; regardless if it’s sold in a pharmacy or on the street – Google it. Furthermore, I have never met one single person who has been through the MAT program who is now in recovery and not using any narcotics whatsoever. Yet, I have met a bunch of addicts who have been on MAT drugs for many, many years that have no intention at all to stop. Unfortunately, these people suffer the same long-term negative effects from the MAT drugs as they would from any other opioid.
The biggest winner in the Medicated-Assisted Treatment program is a company called Indivior, a spinoff of the UK parent company Reckitt Benckiser whose two products are Suboxone and Subutex, a brand name for buprenorphine. Indivior had over a billion dollars in sales last year.
This is my theory and mine alone, it seems to me that the meteoritic growth of Suboxone and Subutex can partially be attributed to insurance industries recognition that it is far more profitable to direct their addicted policy holders to Medicated-Assisted Treatment that will only cost them a dollar or two per day, as opposed to a treatment facility that costs $30,000.00 a month.
By the way, Indivior just lost a year-long lawsuit that prevented another pharmaceutical company from producing a generic version of Suboxone. And there is also this from the Department of Justice on April 9, 2019: A federal grand jury sitting in Abingdon, Virginia, has indicted Indivior Inc. (formerly known as Reckitt Benckiser Pharmaceuticals Inc.) and Indivior PLC (Indivior) for engaging in an illicit nationwide scheme to increase prescriptions of Suboxone Film, an opioid drug used in the treatment of opioid addiction.
The addiction treatment field as it is today reminds me of a fumble in a professional football game. You have huge, powerful men piling one on top of the other hoping to beat everyone and gain possession of the little football. Friendships are neither started nor kindled; it’s every man for himself.
Everyone involved with addiction treatment wants their share of the $35 billion-dollar treatment industry and are willing to throw elbows and pile on to get it. It’s that naked ambition devoid of any humanitarianism that drives them to abandon their core values so they can claim their prize; and this is why the American drug epidemic will continue into perpetuity. The sole emphasis of addiction treatment in America is profit. It’s the loose football flopping around the field with 22 large men chasing it. While everyone is chasing the money, who is looking out for Andrea and people like her? Do any of the CEOs at companies, other than the facility where she is being treated, or the insurance company case managers, really care if she lives or dies?
Imagine for a moment what treatment would look like today if the primary incentive was not money but better outcomes. In that vision, imagine the patient’s well-being as the first and foremost concern. What if we untied the treatment facilities hands and gave them what they needed to be successful- like 90 days residential or inpatient treatment combined with a comprehensive aftercare program? Would we have a 79% success rate? Probably not, but I can assure you it would be a far cry better than it is today.
As an industry, we need to have the same accountability for ourselves that we ask of the people we treat. But to do that, we need to level the playing field. As difficult as this is for me to say, it is long past time to take addiction treatment policy in America out of the hands of mercenary capitalist and place it under the care and direction of the doctors and professionals who actually work hands-on in the field. Moreover, we need to develop effective therapies that are more cost friendly – that do not include MAT drugs – and without sacrificing the quality of treatment.
John Giordano is the founder of ‘Life Enhancement Aftercare & Chronic Relapse Recovery Center,’ an Addiction Treatment Consultant, President and Founder of the National Institute for Holistic Addiction Studies, Chaplain of the North Miami Police Department and is the Second Vice President of the Greater North Miami Beach Chamber of Commerce. He is on the editorial board of the highly respected scientific Journal of Reward Deficiency Syndrome (JRDS) and has contributed to over 69 papers published in peer-reviewed scientific and medical journals. For the latest development in cutting-edge addiction treatment, check out his websites: www.PreventAddictionRelapse.com