To some extent, “caveat emptor”—buyer beware—applies to services purchased by consumers. But when those consumers are people desperate to have a loved one recover from addiction, should additional protections be built into the system for them?
Family members and patients frequently have no way of knowing that a treatment program was really a call center they got to by Googling “rehab,” and that the call center gets paid for referring patients to the actual treatment center. They don’t know that a program that promises to “work with” health insurance knows full well the insurance will cover only a few days at the facility, and the rest will have to be paid out of pocket.
SAMHSA’s limited role
“People are vulnerable when they present for treatment,” says H. Westley Clark, MD, JD, director of the Center for Substance Abuse Treatment (CSAT) at the federal Substance Abuse and Mental Health Services Administration (SAMHSA). And people in public programs do have more protection, because those programs ban practices such as bounties—the taxpayer is paying for treatment.
Under the Affordable Care Act (ACA), however, the picture will change, Clark says. More patients will be covered by health insurance, and they will have to understand the specifics about their own benefits. “We are trying to position people to know more about their benefit package,” says Clark. “And the industry has to be more straightforward about what that package will cover.”
Clinically, the federal Department of Health and Human Services (HHS) is “leading the charge to focus on evidence-based practices,” says Clark. “If there are practices that need to be cleaned up, it’s going to take some time to do that.”
The state Medicaid program is responsible for making sure Medicaid enrollees are protected, says Suzanne Fields, SAMHSA’s senior advisor on health financing. “The Medicaid office can refer practice patterns to the state Attorney General,” she says.
When it comes to private insurance paying for treatment, however, that is a business transaction outside the purview of the HHS Office of the Inspector General (OIG), which investigates Medicaid and Medicare fraud, and state Attorneys General. “The insurance company is setting up a payment for a service it is buying,” Fields says. “If a provider documents that a service occurred, the insurance company will pay an agreed-upon fee.”
Adds CSAT’s Clark, “If under Medicaid, we found that people actively recruit patients and give them tests they don’t need or bill for tests they don’t get, they would be investigated. ” Likewise, Medicaid would not pay for nutritional supplements that are proprietary, often sold by private addiction treatment programs as part of the treatment regimen.
Private vs. public
“We need to have people raise the issue of ethical practice, about those programs that are legal, but marginal and unethical,” says Clark.
He is particularly concerned about people who pay out of pocket, because these patients are most likely to be exploited when vulnerable. He thinks that private insurance, just like public payers, can help protect the patient.
“This dichotomy of the public sector vs. the private sector is a bad dichotomy,” says Clark. “The quality of care should be uniform in both, so people can feel free to go into treatment.”
He adds, “If the government doesn’t tolerate a certain type of practice, such as kickbacks, why should the private sector?”
There are some commonly used “treatments”—equine therapy, yoga, proprietary nutritional supplements, SPECT brain scans, to name just a few—that would not be covered by insurance because they are viewed as “experimental” or not treatment at all. “Generally, there is no way that any insurance will pay for equine therapy,” says Mark Fontaine, executive director of the Florida Alcohol and Drug Abuse Association (FADAA). And public payers definitely don’t cover such ancillary services, he says.
Many patients get medications, hydration and rest during detoxification, says Clark. But during the post-detoxification phase, when the patient is “normalizing,” the inconsistency of treatment approaches becomes apparent. “You see some programs pushing nutritional supplements,” says Clark. The fact is that many patients do have a long-term vitamin depletion. But patients should know exactly what is in the supplements they are taking, and what the purpose is, he says.
The top problem: insurance bait and switch
The number-one ethics issue in the addiction treatment field is transparency, according to John Schwarzlose, CEO of the Betty Ford Center. “Families, loved ones, and prospective patients need and deserve the truth about treatment, length of stay, and cost,” he says. “They are in crisis when they reach out for help, and are often taken advantage of.”
The favorite line today in many corners of the treatment field, says Schwarzlose, is, “Yes, we take your insurance.” In most cases, this is partially true, he says. But if there are going to be treatment add-ons such as psychological testing, acupuncture, and so on, there needs to be full disclosure of what these will cost—and the fact that insurance won’t cover it, he says.
In a typical scenario, the patient signs up for 30 days of treatment, and is told that the program accepts the patient’s insurance. What the patient isn’t told is that the insurance probably will cover only the first 7 days, and cover only $225 a day, for example. “They need to be told that after 30 days they will owe about $18,000 in their own money,” says Schwarzlose.