Change rolls toward addiction treatment centers in waves. Insurance, managed care, 28-day inpatient treatment, methadone treatment, outpatient treatment, intensive outpatient programs, day treatment, 12-Step models, medical necessity, the Matrix Model, harm reduction, medical criteria, Suboxone, and now parity and healthcare reform. These are all waves of some importance, and sometimes they have had destructive influences that have struck the addiction industry like a tsunami. Each has certainly created an impact on the landscape.
Forecasting change has seemingly become as helpful as a man standing on a beach carrying a sign emblazoned with “BEWARE, TSUNAMI IS COMING…sometime!” How big will the next wave be, and will its impact be destructive? The answer truly depends on the structure of one’s organization at the moment of impact. Like all change, it truly depends on preparation. What is developed or built depends on the ability to balance risk and safety. Sure you can build on high ground, but there is no view of the ocean three miles from the beach.
This is an opportune time for treatment centers to build the programs that will lead us for the next 30 years. Most of us, including the L.E. Phillips-Libertas Treatment Center, were built in optimistic times of great expansion in the mid-1970s. This was a time when the insurance industry began to pay for treatment, and recovery programs blossomed like dandelions.
L.E. Phillips was no different. Opening in 1977, the 46-bed hospital-based facility was built on land adjacent to the new St. Joseph’s Hospital in Chippewa Falls, Wis. A low-slung single-story building, it was built in a utilitarian style, reflective of the Hospital Sisters of St. Francis, who have operated hospitals in the area for more than 100 years. Having first worked with loggers, the sisters quickly had learned about addiction and were early adopters of providing medical care for alcoholics as early as the 1940s. Dedicated to service to the poor and disenfranchised, the hospital saw providing addiction services as well within its mission.
The 1970s and 1980s were the golden years. Detox and 28-day treatment ruled! The facility was an early adopter of transitional residential services and opened the Transitus House for women offsite in 1976. But with the onset of managed care in the late 1980s, our treatment facility began to see reductions in admissions and lengths of stay. Dealing with declining services, the staff adopted what became known as the “redheaded stepchild syndrome” orientation. Program offerings and morale steadily shrunk as the payer mix increasingly focused on county detox patients.
In late 2006, the hospital hired a national firm to conduct a search for a new director, and I began to serve in that role in February 2007. Having moved from Minnesota, I believed the full continuum of care was everywhere. I was shocked to learn that the average length of stay here had become a mere 4.9 days.
In my three years as director, I have learned that, like personal recovery, organizational change is incremental. Reinvigorating an organization requires a deep understanding of the specific market, a drive to create a world-class organization dedicated to every patient, and an eye for the next wave. To market treatment is to understand who’s paying for the services and how to provide the service specifically enough to get paid.
Also, one must realize that insurance companies and other payers want a continuum of step-down services, regardless of cost. For our hospital-based acute care facility, this means understanding that not all addiction treatment is either hospital-based or outpatient. In order to capture the market more fully, it is necessary to create many levels of treatment, including medically managed and monitored treatment and non-medically based (residential) treatment in the same facility. This mindset has required our organization to embrace concepts such as medication-assisted therapies beyond our 12-Step foundational roots. Acute care hospital orientation, our old paradigm, presents a set of challenges and opportunities. There is a freedom provided by being a department of a hospital rather than a stand-alone treatment program. These advantages range from the ability to handle more complex funding streams, such as Medicare and Medicaid, to being able to connect directly with the health care providers. Other opportunities include accessible capital and planning processes that minimize spikes (little tsunamis) that can deter treatment centers from their goals.
In 2007, L.E. Phillips-Libertas offered adult and adolescent inpatient and adult outpatient treatment. It also had a newly developed outpatient mental health and employee assistance program. Unfortunately, given the “medical necessity” qualifier, justifying inpatient hospitalization for adolescents is nearly impossible. In a closer examination, it was determined that we would need to close our adolescent inpatient operation. To mitigate the effects of this change, we opened a 17-week adolescent intensive outpatient Matrix-modeled program and created a cooperative agreement with a local youth shelter to handle the housing component.