The business of addiction treatment and health care

Whether it’s you suffering with addiction or a loved one, it’s easy to forget that at least in this country, treating the sick is a cash-money-business. This is true for health-care as well as for addiction treatment, and as the polls right before the passage of the recent health-care reform suggest, enough Americans like it this way that it’s likely not going to change in my lifetime.

I attended a networking event for Los Angeles area investors (LAVA) that focused on health-care and technology, especially in the post Obama Care era. Though they didn’t specifically talk about addiction, I brought the topic up and spoke to a few of the panelists after. Based on everything I read until now and what I heard this morning, there’s big change a-comin’ in the addiction treatment industry. Here’s where I think we’re heading and why:

1. Obama Care will add millions of new health-insurance clients to the mix, most of whom are exactly part of the vulnerable populations (poor, disadvantaged, less-educated) that more commonly need addiction treatment.

2. The Mental Health Parity and Addiction Equity Act passed in Congress a few years ago and now in effect means that all health-insurance policies that offer mental health and addiction treatment coverage have to include it at levels equal to those of standard physical care. This means billions of dollars added to the pool of money for addiction treatment. As of right now, the details about coverage of therapy, outpatient substance abuse treatment, and residential programs is being worked out, but it’s likely that all three will  benefit.

3. Health insurance companies want standardization of services, and for their money, they’re going to get it. Just like there’s a standard way to treat diabetes, addiction treatment is going to become standard among the larger providers that are going to begin doing serious billing with insurance companies. So while CBT, MI, and medications will see a lot of reimbursement there, we’ll have to see about mindfulness therapy, yoga, and other less conventional approaches. My guess is that the bigger 12-step centered providers will be part of the mix whether they offer residential or outpatient substance abuse treatment.

4. More people will get addiction treatment, especially now that the government is refocusing its efforts on the initial assessment for substance abuse problems being performed in primary-care physician offices. forget about 10% of 24 million addicts getting attention for their problem, I think we’re going to see something more like 25%-30% of 60 million people with substance abuse problem of varying degrees (not just full blown addicts) making use of the system.

5. Addiction treatment will focus more on outpatient substance abuse treatment than inpatient services. Not only do we not have the capacity to put everyone in residential treatment, but as we cast a wider net, a smaller percentage of individuals will need intense residential work. Hopefully this will mean that residential facilities will actually start adhering to NIDA recommendations and extend their average lengths of stay towards the 90 day minimum recommended.

That’s a lot of change, but I think it’s about time for all of this to happen. Addiction treatment has spent too much time as a small industry that doesn’t have much power behind it. We’re going to start seeing better results soon because people are going to want to get a piece of this pie, and in the U.S., that’s almost always the biggest motivator for change.

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What makes the 12 steps (and other social support groups) a good part of addiction treatment aftercare?

I’m not a devout 12-step believer, though I think that AA and the offspring programs have some serious merit, especially when it comes to addiction treatment aftercare. In this discussion, I’m talking about all group-support based programs, including Smart Recovery and others. I’m personally a fan of non-religious groups, but that’s just me.

Chronic conditions require long term care

I’ve already talked about my view of addiction as a long-term, chronic condition. Regardless of the “disease” moniker, I think it’s undeniable that, at least for some people, addiction treatment needs to continue long past their initial “quitting” phase, regardless of whether they went through an inpatient or outpatient treatment (or quit alone at home).

Without getting hung-up on my misgivings about 12-step programs (I have a few), I’d like to talk about some of the factors that make me believe in the system as a continuous aftercare resource:

  1. It’s free – Most people, especially given current insurance limitations, can’t afford ongoing outpatient help be it through a psychologist or an addiction-treatment provider. While the latter two are can be superior in their knowledge about recent developments in addiction, they cost money.
  2. It normalizes behavior – One of the difficulties many addicts share is in talking to non-addicts about their problems. They feel ashamed, misunderstood, or judged. Being with like-minded individuals can eliminate some of those issues. Nevertheless, people often find understanding only regarding the specific issue a program deal with and therefore find they need to attend many different support groups to address all their issues.
  3. It provides ongoing support outside of meetings – The social connections people make in meetings can often help them outside the rooms. Your psychologist isn’t likely to do the same.
  4. It keeps the focus on relevant issues – When following the 12 step rigorously, one is always working on bettering his/her program. That sort of attention can help catch problems early on before they develop into real difficulties.
  5. It keeps people busy – Some addicts need to stay occupied to keep out of trouble, especially in the transition from their acute treatment back to everyday life. Attending social-support meetings can make the time go faster while providing a relatively safe social environment.

Even with all these advantages, I can’t help but object to some of the AA dogma, especially when it comes to religion and to the unwavering resistance to adapt their system as it was handed down in the late 30s. We’ve learned a lot since and I think 12-Step programs could benefit greatly by incorporating recent knowledge. In fact, reviews of studies regarding the effectiveness of AA find it no more useful than other interventions overall. This is why I believe that 12-Step programs are best used along with, and no instead of, additional treatment options.

Citation:

Cochrane Review – Alcoholics Anonymous and other 12-step programmes for alcohol dependence

How does Obama’s health care reform affect substance abuse treatment for Medicare patients?

Co-Authored by: Jamie Felzer

Medicare and addiction?  Do you typically think of these things as related? After the recent passage of Obama’s health care system reform, those utilizing Medicare and other government-sponsored systems will obviously be affected.

Government sponsored substance abuse treatment

A recent study on substance abuse treatment services for people with Medicare found that those who were younger than 65, and with a disability or mental disorder, had a much higher prevalence of substance abuse. About 100,000 people that fit into this category.

When it comes to debating health care reform, the elderly are the ones that are most often discussed as being affected by the changes in Medicare.  However, there is also a large population of people who are not elderly but also rely on the government-provided health care (like those on Medicaid for instance).

Most often substance abuse treatment co-occurs with mental health disorders, especially in the younger group receiving Medicare services.  76% of the younger claimants received substance abuse and mental health services while for those over age 65, only 54% received both treatments.  However, putting these percentages into the broader picture, only 1% of the elderly Medicare claimants have a primary diagnosis of substance abuse while for the younger group that same classification represents 5.7% of their age group.

How the law will affect substance abuse treatment

Part of Obama’s new health care reform increases the amount of research conducted regarding Medicare/Medicaid patients and their service utilization.  This research will focus on areas of providers, new treatment methods, as well as payment options to best suit all claimants. This could prove very beneficial, especially for those patients seeking treatment for co-morbid disorders.

With the recent passage in Congress of mental health parity laws that are set to begin in 2010, the healthcare system’s overhall should allow substance abuse treatment and mental health services to finally catch up with the rest of the health-care world. American will be far better off for it.

Citation:

Utilization of substance abuse treatment services under Medicare, 2001-2002. Journal of Substance Abuse Treatment. 36 (2009) 414-419

Holahan & Blumberg. An Analysis of the Obama Healthcare Plan. Urban Institute Health Policy Center.