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Residential’s uncertain future

June 25, 2012
by Alison Knopf
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Caron Treatment Center, Penn.

Whatever the outcome of the U.S. Supreme Court decision on the Affordable Care Act (ACA), residential treatment for addiction will continue to face payer barriers, according to top treatment officials nationally. There remain various scenarios under which residential treatment will continue, but the perspective of some of the country’s most prominent treatment officials is that patients may be forced to bear the costs of “room and board,” with third-party payers covering detoxification and providers continuing to fight for reimbursement for the treatment portion of residential care.

While this is far from a happy prospect for programs whose very essence is residential, these organizations are coming up with creative ways to survive and even thrive in the new environment, so that they can continue to serve patients. This does not mean that they are not planning a fight, however. Some talk of litigation to enforce the federal parity law, which unlike the ACA is not up for the Supreme Court’s review. Leaders interviewed by Addiction Professional still cherish a residential treatment model that originated in the 1960s and led to their success as niche specialty providers.

“In the traditional programs that have been around for a while, we certainly rue the passing of a fixed length of stay, because it’s so easy to provide treatment at a very reasonable cost,” says Ken Gregoire, president and CEO of Valley Hope Association and vice chairman of the National Association of Addiction Treatment Providers (NAATP). “There’s a great value in it, a great benefit to patients.”

Mark G. Mishek, president and CEO of Minnesota-based Hazelden, agrees, but also notes that a “10 days and you’re out” philosophy from payers goes back as far as the 1980s. As a threat to residential treatment, this is nothing new, Mishek says. What is new is the expectation that this trend would be reversed by the parity mandate—and it wasn’t.

Mark G. Mishek

Mark G. Mishek

“I said this from the beginning: It’s going to take some fairly major litigation to get this set,” says Mishek.

The residential model arose from the need to “immerse people in a safe place,” says John Schwarzlose, CEO of the Betty Ford Center in Rancho Mirage, Calif. “You do that with clinical staff, and you do that with love,” he says.


Medical detox unit at Hazelden's Center City, Minn. campus (L). Patient room on the medical detox unit at Hazelden's Center City, Minn. campus (R)

Schwarzlose recalls a mother who was at the facility’s family program and told him that her son, a heroin addict in treatment for the fifth time, had expressed to her what was different about the Betty Ford Center. “‘Mom, they love us here,’” Schwarzlose says the mother heard from her child. “You can’t get that in outpatient treatment.”

The 28-day model developed because that is the minimum amount of time that someone needs away from their typical environment, says Schwarzlose. Treatment providers prefer someone to be in a sober-living setting, said Schwarzlose. “If they go home every night, what will that environment be?” That is the benefit of at least having sober homes, either on or off campus.

If nothing changes in the way healthcare reform appears to be heading, Schwarzlose envisions a future addiction treatment landscape in which payers readily pay for detox, battle over the treatment part of residential, and refuse to pay for “room and board.”

Valley Hope’s Gregoire agrees. “I think there will continue to be a place for residential treatment, but patients are going to pick up the tab for it if that’s what they want,” he says. “Most programs are having to live with that reality.”

The only programs that will survive on residential with a fixed length of stay are those serving only the rich, Gregoire says. Other programs have to find “creative ways to help our patients,” he insists.


Clinical benefits

There are many clinical justifications for residential treatment. Providers can take bigger risks, and with those risks come a bigger payoff clinically, says Gregoire. “There are people around the patients all the time, so you can do some creative interventions,” he says.

For example, if a patient is going through a painful issue in therapy, the person can talk about it and then go out into the building where the environment is safe, continuing to process it with other people. “You can’t do that if they’re going home that night; you have to help them feel better before they leave,” says Gregoire.

And there are simple things that are learned in residential that prove pivotal to recovery, says Doug Tieman, president and CEO of Caron Treatment Centers, based in eastern Pennsylvania. “You learn to show up on time. You can concentrate on your treatment without worrying about your marriage or your finances. If you’re in an outpatient setting you never stop thinking about those things,” says Tieman.




I believe one of the most important factors that I haven't heard discussed is the role treatment providers play in the over-utilization of residential services. This certainly has not improved (at least from my limited vantage point)since the use of ASAM Patient Placement Criteria has become somewhat the accepted standard in the field. To place a person that lacks motivation for change in a residential level of care usually only postpones the inevitable (relapse/use). We can complain all we want about managed care (and we certainly do a lot of that), but until we look at ourselves we will probably not be very successful. The courts surely play a role in the use of residential levels of care, but we as professionals in the field must be willing to stand up for what is clinically correct.
Don Lupien, PhD

Insurance providers are abusing individuals who are desperate for the needed care to help them become sober. I have yet to read one account that a drug addict who started on the road to recovery did so in an out-patient setting. It does not work.

How can you judge that a person "lacks motivation for change"? What medical tool allows you to do that?

Inpatient treatment for addicts and alcoholics should be made mandatory by government laws and regulation. How many deaths--accidental, suicidal, homicidal--will it take for this country to recognize its obligations to society?

A disease is a disease is a disease.

I would like to be present when John Schwarzlose explains to his outpatient staff why he believes that they don't "love their patients". This comment and some of the others typify the attitudes of many inpatient providers of addiction treatment. While they may want to think that they are the sole source of recovery for those addicted to substances, the simple truth, is that many people find recovery in outpatient programs and AA alone.
I was around 33 years ago, as well, and the reason that 28 days was chosen was because medical researchers had determined that it took 28 days for the body to totally eliminate alcohol. Today, we know that addiction is far more complicated than one substance or one variable.
As a former "affiliate" of the Betty Ford Center, I hope that John will rethink his statements. I assure you that my staff do love their patients and I bet his do too.

I don't understand why they want to give up on programs that are obviously working, I would understand if they wanted to improve them but not this. The people attending these centers are really in desperate need of help and by raising the costs you only drive them away. How many will be able to cope with the costs considering most of them are already broke thanks to their addiction? We should fight to minimize effects of alcohol by any means, and it seems to me that the new politics will only make the matters worse.