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Bigger Than Minnesota's Shutdown

July 20, 2011
by Gary Enos, Editor
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Now that Minnesota’s political leaders finally have ended a government shutdown in which there were no winners, one addiction treatment organization leader would like to see some attention paid to a new state requirement that he foresees being burdensome to the treatment system.

The term that has been on addiction treatment centers’ minds this month is not “shutdown,” but “program enrollment,” according to David T. Smith, PhD, treatment director for the New Beginnings at Waverly organization. As Smith writes to me this week, “As of July 1, 2011, Minnesota treatment providers have been required to ‘re-enroll’ their programs, signing ‘attestations’ as to the services they provide. The byproduct has been increased bureaucratic and regulatory oversight, and further rate reductions.”

Smith, who wrote the November/December 2010 Addiction Professional cover story on planning for an electronic health record system, says state officials initiated the program enrollment process in an attempt to standardize payment rates to providers across counties. But in general, he sees the process as generating these results: “Providers get less money, and despite clear and powerful requests to reduce regulatory oversight, increased regulation and new regulators will measure compliance with new enrollment criteria.”

Smith says publicly supported treatment providers in Minnesota have seen six years of net reductions in state funding, with many now dealing with up to a 30% drop in operating revenue.

Another change that Smith says merits attention involves the emerging role of mental health professionals in signing off on treatment plans that once were the sole purview of chemical dependency counselors. He writes, “Basically we are training people as licensed chemical dependency counselors and when they get into a work environment we’re telling them that they are partially responsible for individual patient care and that someone has to sign off on their treatment plans in programs providing co-occurring disorders treatment.”

If you’re a treatment professional in Minnesota, how do you assess the current situation for providers there? If you’re from somewhere else, does this scenario resemble what’s going on in your state?

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Comments

We are faced with the increasing medicalization of our field, first in relying on ASAM to tell us what it is we should do and why, second in overmedicating our clients, and third in drifting increasingly closer to a point where CD will be considered the anomaly and MI/CD the norm. There was a time when Minnesota was hailed as the seat of knowledge as far as Addiction was concerned. Now we aren't. We have been manipulated and cajoled to the point where we have dramatically changed what it was that made us successful to begin with. And what's worse, we didn't even notice.

The medical profession had control of addiction treatment for decades. They screwed it up. Now they want to define addiction as a brain disease and, by extension, take it on again. Truthfully, addiction is a disease that manifests itself biologically, psychologically, socially, behaviorally and spiritually. If it is primarily a brain disease, it begs several questions was there a problem with brain chemistry that existed before the individual ingested a drug? if so, the path to addiction would be similar for most, if not all, and be much more predictable than we have seen so far. Is it a problem that manifests itself in brain chemistry after the introduction of a drug? If so, and we say addiction is a brain disease, that's the same as saying alcoholism is a liver disease. The average physician contributes to addiction more than he/she contributes to its eradication. Most M.D.s have less than 4 hours of classwork related to addiction.

Regarding the Integrated dual diagnosis treatment that has been legislated in Minnesota we have long known that people were routinely misdiagnosed in both the Mental Health system and the Substance Abuse Treatment system. And providing for concurrent treatment for those people who qualified to be diagnosed as both MI and CD was, and is, most effective. But MI/CD is far from a homogenous diagnosis, even if the duality is recognized. There are those who fit the definition who may be using drugs and alcohol to medicate their mental illness, and with proper medication may not fit a diagnosis of addiction whatsoever. Then there are those who are, for all practical purposes, CD/MI, whose addiction essentially brought on their mental illness. Furthermore, whether they walked first through the Mental Health door, or the Chemical Dependency door, just by itself may dictate what type of treatment they are most likely to respond to.

I can guarantee you that, development of a tool to assess both CD and MI will be done primarily by bureaucrats who have little or no firsthand experience with either, very similar to the author of the bill which brought about the mandate. And I can further guarantee that many more addicts will carry the MI label after it's implemented, and many programs, seeing dollar signs, will adjust their regimen accordingly.

The early pioneers of addiction treatment were adamant that addiction not be classified as a mental disorder, because they realized the complicated nature of the disease, and the futility of trying to fit a round peg in a square hole..

They also recognized something else. Something that we haven't been able to improve on in over 8 decades. And that's the reality that lots of approaches can get someone sober whether a roadmap like the 12 Steps, the faith-based approach, chemically assisted recovery, psychotherapy or the whole person approach of the therapeutic community. But for most, it takes a community to keep them sober, and defining/developing/integrating that supportive community, often unique for each individual, is the cornerstone of long term recovery.

Like most of the major changes in our industry over the past 4 decades that I have been involved, this too is more about money than sound clinical practice either about making it, or saving it. And it's about control.

If the new rate is an average, then half the treatment centers in the state should be getting a rate increase. I work at one of the cheapest treatment centers in the state and our rates are being reduced too. It seems like a strait cut in treatment funding. This is a bad financial move. Many studies (including one done recently by the White House) show that for every dollar spent on treatment, the tax payers save 3. So why is the state once again wasting tax payer money? In my opinion the state is not only wasting money by not investing in treatment for our citizens, but is also wasting money by paying bureaucrats to watch over treatment centers and counselors. I do believe there is a need to have some state involvement in the rules of operation and for sure there is a need to follow up on complaints, but to have so many people watching over something is only creating more paperwork, which requires more people to do the same job. Not only that, but plus then you have to have someone to watch over those people who are watching over the state workers who are watching over the probation agents who are watching over the administrators who are watching over the counselors. Coroners who testify in murder trials have less supervision and restrictions. Why require a person to have a four year degree, get licensed and certified and then watch over them as if they have no idea what they are doing? Next they will require a chemical dependency counselor to have mal practice insurance? Is that what we are going to if they have to start making mental health evaluations instead of dual diagnosis referrals?
Just my simple opinion.

The argument we are getting in Minnesota in favor of rate reform (reduction) is that on a National mandate the state has to have one price for all medicare/medicaid services. The state contacted providers asking us to basically send them our financial books. Many providers opted out of this, because let's face it, their trust in government is not at its highest. The State DHS said they "averaged" the numbers with some allowances and came up with figures that greatly decreased the majority of providers. Average, meaning what, mode, median, or mean. I think it was mean or at least cruel. After surviving several years of freezes, we are now facing a massive cut. I read the mandate from the state legislature and it required Minnesota DHS to have involvement from the providers in this matter. They had involvement, but I personally watched providers bullied during these sessions, told residential providers (you will not have to change your fee's for a person if he stops requiring medical services and to the insurance providers, we only pay on a fee for service basis. I am very disappointed in our Department of Human Services with this matter. I am curious as to what other states our facing or have faced.

Gary Enos

Editor

Gary Enos

@apeditor

www.addictionpro.com

Gary A. Enos has been the editor of Addiction Professional since its inception. He...