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Enterhealth Speaks Out

Who Wins When Addiction is Designed to be Cheaper, not Better?

By January 25, 2018August 2nd, 2022No Comments

As we enter 2018, Enterhealth continues to see the decline of the addiction treatment industry in the United States even as the number of individuals suffering from the disease of addiction continues to grow. Nearly half of all Americans have a family member or close friend who’s been addicted to drugs. As good choices for treatment become more and more limited, the most vulnerable people – the individuals and families who are seeking help – will be the biggest losers. Not only are evidence-based treatment programs that deal with dual-disorder diseases limited, but reimbursement from insurance carriers is often denied. “In 2014, many insurance policies stated that they cover 30 days of inpatient treatment, but no one got all 30 days covered,” said A. Thomas McLellan, Founder of the Treatment Research Institute (TRI). “The average length of stay covered under insurance was between 11-14 days of that 30 days often identified in policies.”

To reduce the overall cost of healthcare as a percentage of U.S. GDP and cover more individuals with mental health issues (addiction falls into this category), the government and insurance carriers have redefined what appropriate addiction treatment is and what will be reimbursable. These steps – taken under the auspices of covering more and paying less – are placing many individuals and families in harm’s way. More than half (63%) of insurance coverage denials hinge upon the definition of “medically necessary” treatment, and many treatment providers are seeing lengths of coverage in programs shrinking – leaving people with the decision to stay in treatment and face high out-of-pocket costs or leave when their insurance coverage ends and with their needs for help unmet. The emerging treatment protocol of authorizing detox/stabilization and then only authorizing outpatient partial hospitalization and/or intensive outpatient programming may be more affordable, but it doesn’t work. Even those who provide addiction treatment services acknowledge it doesn’t work and is dangerous, but it is what insurance companies will reimburse. Congressman Patrick Kennedy recently spoke out about inadequate treatment saying, “At this point, the largest outstanding issue is treatment limits. Patients seeking addiction treatment including MAT (Medication-Assisted Treatment) are often subjected to dangerous fail-first protocols, an extremely limited provider network, frequent and often onerous prior authorization requirements, and claim denials without a truly transparent process.” Unfortunately, in life you get what you pay for, and in this case you will get treatment designed to be cheaper, not better. Why has this happened?

Our federal government has faced the growing challenge of ever-increasing healthcare costs for many years and has been trying to slow the growth or reduce it in conjunction with the insurance carriers. The signing into law by President Bush of The Mental Health Parity Act was meant to ensure mental health would be reimbursed on par with physical health issues. The Patient Protection and Affordable Care Act (also known as Obamacare) forced everyone to have insurance through the individual mandate, thereby dramatically increasing the number of individuals and number of claims to be reimbursed. How does this work with the overall goal of reducing healthcare costs? It doesn’t unless you redefine what appropriate treatment should be and who is eligible to receive such treatment. They really rang the Dumb Ass Bell on this exercise! The plan was supposed to improve treatment while also treating more individuals for the same or reduced cost. How do you think that is working?

Care is not improving for those suffering from the devastating disease of addiction. The insurance companies and the government are increasing the cost of policies and deductibles for those needing care and at the same time are continuing to deny care. It has become a tragedy not only for those needing care but also for many treatment providers. The treatment providers – whether residential or outpatient – that chose to go in-network to become a managed care provider and take insurance payments as their primary method of reimbursement have lost control of their ability to deliver quality care. 

The addiction treatment industry is unraveling at warp speed and will leave behind a graveyard of treatment providers who lost control of their products and services simply to fall neatly in line with managed care guidelines. When you lose control of your price, your programming and your service offerings, you lose the ability to provide good outcomes for patients. You‘re also closer to joining that graveyard filling up with addiction treatment providers in 2018! The United States is heading toward a two-tiered healthcare system much like in the U.K. and in Canada, with one tier for those who can pay for care and another tier for those on managed care. It isn’t fair, but it is where we are headed because there are a few treatment providers who will not compromise their standards of care to get in on the volume-care model. In the world of addiction, this is huge because good outcomes are already difficult to achieve and are surely not attainable with a cookie-cutter approach, whereas managed care providers seem happy to embrace a one-size-fits-all model which puts patients in a cheaper, ineffective 12-Step only or detox to PHP to IOP program. “Addiction recovery rates for popular 12-Step groups may be as low as 5-10%,” according to Dr. Lance Dodes, the author of “The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry.”

This shakeout will be difficult for those providers who are not strong financially, as they will need to continue to search for cheaper programming alternatives, reduce staff and minimize overall operating costs to adjust to the continued pressure of reduced reimbursements from insurance payors. This entire scenario will negatively impact the ability to provide any good outcomes for patients. It won’t work! The addiction treatment providers and the industry as a whole have brought much of this on themselves by not being able to deliver better outcomes, settling for treatment programs that don’t work and employing staff that sometimes appear to be charlatans or hustlers.

The cleanup will be painful for many in 2018. Enterhealth will continue to stand strong – as we have for nearly a decade – and remain a beacon of hope for those suffering from the disease of addiction. Enterhealth will hold steadfast to its founding principle that there is a better way to recover from this devastating illness. To achieve that goal it is incumbent upon our organization to hire the best and the brightest in the field and deliver treatment tailored specifically to each individual and family affected. To that end, Enterhealth will continue incorporating the latest scientific findings and credible research to apply to the patient situations we face daily. The road to recovery requires hard work, and each person deserves to go through the journey with their dignity intact. Enterhealth knows that the environment of care is equally as important as how the care and treatment is delivered. That is why each patient has the sanctuary of their own private room and bath, with healthy meals prepared each day by our renowned culinary staff and the ability to spend the time necessary for real healing within a serene and peaceful environment. Being able to create such an environment of care and deliver these services unencumbered by outside entities allows us to provide treatment of the highest quality to our patients and families and is the only real path to success and sobriety. As we look forward to 2018 and beyond, Enterhealth will hold tightly to our commitment to our community, our patients and their families.

David M. Kniffen                                                                

President and Chief Executive Officer