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Treatment at an ethics cross roads: could unethical practices in Treatment Centers derail the addiction field's progress?

Addiction treatment providers may be getting a free ride when it comes to what they promise and what they deliver, and the Internet is giving them some extra fuel in terms of getting what they depend on: patients. But who is policing what is being promised on the Internet, as well as by the call centers interwoven into the marketing strategies of treatment providers? Who comes between the desperate family member looking for help right now and the treatment provider, to guarantee that the treatment is evidence-based, worth the money, and likely to produce a good outcome?

The answer: Right now, if the program is not a public program, nobody, at least not from a federal standpoint, and not in the two states--Florida and California--that we will take a closer look at in this article.

Public programs--those paid for by taxpayer dollars such as the Substance Abuse Prevention and Treatment Block Grant, Medicaid, or Medicare--are more closely scrutinized than private programs. And treatment providers know it.

"In the public sector you have to be pretty accountable for those dollars," says Mark Fontaine, executive director of the Florida Alcohol and Drug Abuse Association (FADAA), which represents treatment facilities in the state. "You get sanctioned if it's not appropriate." But for private programs, paid by insurance companies or increasingly by "self-pay" patients who go into debt to afford the treatment, there is no such accountability--not in Florida, not in California, and not in the federal government.

The "treatment locator" of Substance Abuse and Mental Health Services Administration (SAMHSA) lists any program that is state-licensed. There are no ratings--SAMHSA depends on the states to do the monitoring.

The single state authorities (SSAs) in the states are responsible for monitoring treatment programs that receive federal block grant funding. Licensing authorities in states are responsible for making sure that programs adhere to licensing statutes.

The bottom line: Programs must not break laws. But as the top lawyer-physician in SAMHSA, H. Westley Clark, MD, JD, director of the Center for Substance Abuse Treatment (CSAT), says, "Just because something is legal doesn't mean it's ethical.

Questionable practices

Here are the most common practices we heard about that are taking place in the addiction treatment industry, and that are considered unethical by leaders in the treatment industry and by government officials. Many of these practices, especially those involving kickbacks, are also illegal if performed by providers that are paid by taxpayer dollars:

* Using call centers to share patient prospect information with and between treatment providers.

* Paying bounties for referrals.

* Giving large gifts to interventionists with whom a program works.

* Claiming to take a patient's insurance, when in fact the anticipated reimbursement is very low.

* Paying kickbacks to labs that are overcharging insurance companies for drug tests performed on a facility's patients.

* Promising a cure.

* Using nutrient supplements that are proprietary and billing the patient.

* Using brain scans and other unproven treatments and billing the patient.

* Internet marketing scams.

"Why are most of these practices occurring on the private side?" rhetorically asks Michael Cunningham, acting director of the California Department of Alcohol and Drug Programs (ADP), the SSA for the state. "I would surmise it's because that's where the dollars are.

That leaves licensing, but licensing has its limits. In California, ADP's Licensing and Certification Division conducts an initial site visit to review health and safety issues and program policies. Compliance reviews are conducted once within each two-year licensure period. If a complaint is received, ADP initiates an investigation. But ADP's licensing division doesn't give any advice to consumers. It is simply the licensing authority, with its mandate to follow.

Clearly there are many ethical and high-quality providers in the addiction treatment field. But at a time when addiction treatment is continually blasted by negative press and patients are saddled with stigma, it is equally clear that unethical providers--however legal their operations may be--can hurt the whole field.

As David Lisonbee, president and CEO of Twin Town Treatment Centers in Los Alamitos, Calif, observes, "We all get painted by the same brush."

And there is another phenomenon at work here. Everyone is now going to be under more scrutiny under the Affordable Care Act (ACA), where many patients will be covered by Medicaid. And if they're not covered by Medicaid, they will be covered by an insurance company. Unless the addiction treatment Field becomes entirely self-pay, with programs operating under the radar of public and private payers, it not only will be locked out of the biggest expansion of healthcare in decades, but it will turn back the clock on its place as a valid medical treatment for a medical disease.

In essence, addiction could find itself in the same category, fairly or not, as other predators on the Internet looking for the desperate, who will pay anything to save a loved one.

It's about transparency

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.

"People are vulnerable when they present for treatment," says CSAT's Clark. 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."

Clark adds, "We need to have people raise the issue of ethical practice, about those programs that are legal, but marginal and unethical." 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.

"If the government doesn't tolerate a certain type of practice, such as kickbacks, why should the private sector?" Clark says.

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.

He adds, "Imagine the family finding this out for the first rime at discharge?" If this happened in the process of buying a car, he notes, it would be called "bait and switch."

Schwarzlose says it's very hard for ethical treatment providers to compete against insurance bait and switch. "When the family is told, 'We take your insurance; you can come to treatment,' and then after four days insurance won't cover it anymore, and the program says they need $15,000 for the next week, what is the family going to do?" says Schwarzlose. "Nobody governs this!"

Michael Walsh, president and CEO of the National Association of Addiction Treatment Providers (NAATP), the membership association representing private profit and not-for-profit treatment programs, agrees that insurance bait and switch is a huge problem that is seen in many programs large and small.

Ethical programs "eat the cost," says Walsh. "Once you make the decision and the commitment, you need to abide by it."

Walsh blames insurance companies as well, because they are far from transparent on what they will pay or how long they will pay, conducting utilization review while the patient is in treatment.

"The patient gets in and suddenly they say, 'You have to meet this criterion and that criterion,'" he says. And in Florida, the insurance company has up to two years to decide that the payment wasn't correct, and to recoup it.

Paying for referrals

Paying for referrals is the second-biggest ethical issue, Schwarzlose believes, with the primary offenders being for-profit programs. In Europe this is a common practice, and that is one reason why many for-profit programs in the United States do a significant overseas business, he says.

"I am asked when I am in Europe how much Betty Ford Center will pay for a referral, and when I say we don't pay for referrals I get a blank look back," Schwarzlose says.

The fees for referrals are unethical, even if nobody gets prosecuted for them, says Schwarzlose. "It's very sad that it goes on," he says. "You send your patients to other people for consultation, to help them, not because you're going to get something back."

Twin Town Treatment Centers' Lisonbee formerly ran psychiatric hospitals, and is well acquainted with Medicare's ban on paying for referrals. "In the private sector, its not illegal," he says. "But it is unethical."

Lisonbee thinks the ethical leadership of a program comes from the top, where paying for referrals--and accepting payments for referrals--should be prohibited. "If the CEO treats patients or people in need as if they're commodities, everyone does," he says. "You shouldn't objectify patients or pay for their heads. You should be paid for rendering services."

"Kickbacks happen all the time," says Carol McDaid, principal with Capitol Decisions and the foremost private treatment lobbyist in the country. While this practice is not illegal in the private sector, McDaid thinks treatment centers are going to be under more scrutiny under healthcare reform, as more take federal or state dollars through Medicaid.

"Treatment centers that are doing this will do so at their own peril in the future," she says.

NAATP role

"We're a membership organization, so we don't rate treatment centers, but we are talking about ethical issues," says NAATP president and CEO Walsh. "We want to have more standards than we had."

NAATP is going to start by looking at the policies of other membership associations focusing on not-for-profits. "We need a higher bar than being licensed," he says. "How can we encourage programs to police from within?" The field has changed since NAATP started 36 years ago, says Walsh. "People were trying to do the right thing; they didn't have to think about policing each other," he explains. "But it's a bigger industry now. There are more sharks in the water."

There is good treatment out there, but it's hard to make money doing it, says Walsh. "The good programs are not getting the reimbursement they should be getting." On the other hand, there are programs that are "just in it to make money," and those programs aren't as concerned about the patient experience, he says.

The Betty Ford Center is no longer a member of NAATP, because of ethical issues involving some members' practices such as the ones detailed in this article. Walsh says he hopes that the program will rejoin, because he shares much of the same philosophy as Schwarzlose.

"It's crazy that we have treatment centers inviting interventionists and other referents on a cruise, and then giving everyone an iPad," says Schwarzlose. This is one of the reasons he no longer belongs to NAATP, where he was a board member for more than two decades.

"I think Michael Walsh is trying to do the best job that he can," says Schwarzlose. "But through all the parity fights, it wasn't NAATP, it was Carol McDaid and the Legal Action Center who were on the front lines."

Pay per click

In fact, programs that just want to make money are investing heavily in Internet marketing, says Walsh. "From what I've been told, it costs a fortune if you want to be up high in the searches," he says. "And if you're charging a lot for treatment, you can make that back."

Depending on what search term is used, Internet marketing can be very expensive. According to a story published in Wired magazine in 2011, "rehab" cost $33.59 per click, and "recovery" was even more expensive at $42.03 per click. "Treatment" was $37.18 per click. Number one was "insurance" ($54.91 per click), with other costly terms including "loans" ($44.28 per click), "mortgage" ($47.12 per click), and "attorney" ($47.07 per click).

The point is that the most desperate people searching for help on the Internet cost a lot of money to reach. And by spending that money--not necessarily by providing good service--treatment providers can come out on top on searches. It's the new marketing to the desperate. Whether you're a bank looking for someone to lend money to (especially someone with bad credit who has to look on the Internet) or a treatment provider looking for a patient who will pay out of pocket, pay Google. This is not the company many NAATP members want to be in, says Walsh.

Call centers

Call centers operating as referral centers are particularly likely to be guilty of ethical lapses, says Walsh. "We need to look at this as an industry--I have no idea what their standards are," he says.

If licensed professionals were manning the call centers, the standards would be higher, he says, just as if a treatment program physician is on the phone with another physician marketing a program.

McDaid is concerned, in terms of the private sector, with call centers operating as referral centers. "In my view, the state consumer board should pass a law that requires disclosure and transparency," she says.

McDaid is disappointed that SAMHSA hasn't taken a larger role in standards for addiction treatment. "Wouldn't you think that for however many years SAMHSA has been the biggest purchaser that they would have put out standards on what constitutes addiction treatment, and hold the places they reimburse for care to standards?" she says.

SAMHSA does have a "comments or questions" tab on its "treatment locator" for consumers, but a spokesman for the federal agency explains that it urges individuals with complaints about a facility to contact authorities at the state level.

A matter of trust

It boils down to trust, says Lisonbee. "Do people trust what we're doing?" If they don't, they won't go to treatment, because they won't be able to tell the difference between providers they can trust and those they can't.

Even after treatment, when patients are in early recovery, they are not safe from the burgeoning recovery industry. Schwarzlose related a recent experience in which a Betty Ford Center patient from Arizona was sent home for sober living.

"We found one that seemed reasonable, at $750 a week," he says. "But the patient was there for three days, and the staff came to him and said, 'We think you need sober coaching. We offer that for $10,000 a month.' No one is doing anything about it. I don't know who it is who should be doing something about it. As a person at the end of his career, it's sad for me to see this continuing to go on."

Ocean views, ethical clouds

In Florida and California, two states where new addiction treatment programs crop up on a regular basis in an intensely competitive environment, it is the best of times and the worst of dines for patients--depending on whether you have money. Patients frequently are recruited to treatment centers in these states from out of state, or even out of the country. And it's not only because of the climate and the opportunity to enjoy beautiful ocean views while paying for treatment in a "luxury rehab."

Business is booming also because of regulatory bodies that have minimal mandates for overseeing and monitoring private treatment programs. These are the programs where people who are not covered by Medicaid, with some insurance benefits but not enough to cover a monthly stay that could exceed $40,000, go hoping for recovery.

Florida's Department of Children and Families (DCF), which is responsible for licensing and regulation of addiction treatment programs in the state, investigates when there is a complaint. The DCF press secretary, who responded to Addiction Professionals questions in consultation with the director of Substance Abuse Policy and Planning, Kathy Goltry, says that regulations regarding patient brokering fall under insurance regulations.

"These are not under our agency," says Erin Gillespie, the press secretary (she recently left the state agency). She suggested that AP discuss the issue of ethics with the Florida Alcohol and Drug Abuse Association (FADAA), the trade association representing treatment providers.

FADAA executive director Fontaine is accustomed to such calls--from patients. "We get calls from parents who ask, 'What do you know about this program? My daughter is there, I looked it up on the Internet, and something doesn't sound quite right," Fontaine says. "Or they just want to know more about the program, and ask us for information."

If the program is a FADAA member, Fontaine can share what he knows. Sometimes Fontaine contacts DCF for information on a program, but the state agency "only knows about the programs they fund," he says.

Ethical issues seen in many private programs, such as deceptive statements regarding insurance coverage, are a "huge concern" for anyone who wants to "build an environment where addiction treatment and recovery are part of the culture of the state," says Fontaine. "We've been very articulate about the value of treatment, and the need to support treatment. But every time there's a bad incident it reflects on the whole industry."

Even FADAA doesn't know the size of the treatment industry in Florida. "We don't know how much is spent on treatment, and we don't know how big the industry is," says Fontaine. "Nobody does."

Kickbacks and cures

In California, a big part of the problem lies in there not being a level of science or medicine applied to licensing, says Twin Town Treatment Centers' Lisonbee. The state Department of Alcohol and Drug Programs (ADP) has a hands-off approach to a treatment industry that itself is unscientific, Lisonbee says.

"It's always been a social model," Lisonbee says of treatment programs. "The problem lies with the impotence in the state of California ADP."

For example, Lisonbee says, there are providers in Malibu that promise a cure for addiction. "They're outright misleading patients."

There also are providers that pay bounties for patients--in the thousands of dollars--and the state says it is unable to prevent it because Medicaid money is not involved. Federal anti-kickback laws, which can land providers in prison, apply only to Medicaid and Medicare.

Some drug testing companies also "share" their profits with referring treatment programs, which is illegal when someone else is paying, such as Medicaid. Last year, Calloway Laboratories paid $20 million to settle fraud charges brought by the Massachusetts Attorney General in which MassHealth (the state Medicaid program) paid for drug tests that included the kickback costs. According to Attorney General Martha Coakley, Calloway induced sober home operators to order drug screens. The sober home operators were charged as well.

The NAATP's Walsh says treatment providers in Florida--where drug testing kickbacks also have been an issue--don't know what is legal and what isn't. As long as Medicaid and Medicare aren't involved (or for that matter, any insurance company), and the patient is paying for the treatment and the drug test out of pocket, does fraud exist?

"I think this is a huge issue," says Walsh. "There is a line, and the best advice is, don't go near that line." In cases where a treatment provider is approached by a drug testing lab and offered a payment for ordering tests, Walsh's advice has been to say no. "Err on the side of caution," he says.

But if Medicaid were not involved, who would prevent the added charges for kickbacks from being passed on to patients?

The federal government points to the states--attorneys general, if it gets to that point, but substance abuse treatment licensing agencies as well. "The states are supposed to do the policing of the programs," says CSAT's Clark. "The reason we have programs on the locator is that they have been approved by the state."

States not the police

But the licensing authorities are not police, according to the states themselves. "We don't do policing, we do licensing," says Cunningham, ADP's acting director. "We do respond to complaints, but the primary authority we have is the licensing and the monitoring on the residential programs and the ongoing monitoring of primarily the public programs."

And Cunningham stops short of calling the list of ethical issues cited in this article "violations." He says, "It's like any business. Where there is competition, you want to engage in marketing, and you want to be what the client or the family is looking for."

Cunningham agrees that for many California programs, including the Malibu rehabs, treatment can be quite "lucrative," but there aren't necessarily any complaints.

Millicent Tidwell, acting deputy director of ADP's Licensing and Certification Division, explains that licenses expire after two years. "If we find any deficiencies or practices that are against our regulations, these are written into the reports," Tidwell says. If the violations are not serious, they an be rectified with a future site visit to ensure compliance, she says.

The state's ADP agency is going to sunset this July. Over the next two years, the Department of Social Services will take over licensing functions. Nobody is quite sure how that will work.

Just another business

"In the past there have been complaints lodged against private providers on rates charged, on clients feeling that they should get their money back, but those are issues which are outside of our jurisdiction," says Cunningham. "Those are referred to consumer affairs." At that point, the treatment program "is a business operation, which is governed by the same consumer protection laws as other businesses," he says.

Most if not all public programs in California are contracted through counties, which establish the conditions for the contract. Most counties do require that contractors be certified, says Cunningham. Because counties engage in ongoing oversight of contracted providers, what takes place in public programs can be very different from what takes place in private programs.

"Proprietary nutrition supplements, equine therapy, yoga--those are not taking place on the public side," says Cunningham.

"On the private side you can have a paid nutritionist, a spiritual healer, a setting overlooking the ocean," he says. There is certainly nothing wrong with that, he says. But public programs "use fairly standardized treatment protocols, and they tend to use the treatment of which both experiential data as well as the research we have thus far indicates that there is a solid evidentiary base behind it."

Cunningham doesn't think healthcare reform is going to solve problems around ethics, mainly because people will continue to self-pay. "Unfortunately, a number of these clients are parents and other family members who take money out of their own life savings in order to provide the opportunity for recovery," he says. "This is reflective of where our country is regarding substance use disorder treatment, the impact the disease has on families, and that people are willing to pay big bucks for it."

RELATED ARTICLE: Paying for luxuries

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 H. Westley Clark, MD, JD, director of the federal Center for Substance Abuse Treatment (CSAT). 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.

RELATED ARTICLE: Interventionist practices

Interventionists who are licensed are not supposed to take money from a family to get someone into treatment and also from the identified treatment center. It's also not acceptable to buy expensive gifts for interventionists that programs work with, says John Schwarzlose, CEO of the Betty Ford Center. "This is ethics 101," he says.

Schwarzlose says that iPads and laptops fall well outside the typical $20 limit that most ethical treatment programs impose on themselves for gifts.

RELATED ARTICLE: Time to unite on ethics?

At some point, the addiction treatment field has to "stand together" on ethics, says Betty Ford Center CEO Schwarzlose. He recalls speaking to a man who had lost his son to an overdose. In his grief, the father said, "I don't get it. There's the American Cancer Society, hut I look for drugs and alcohol and I can't find anything. There's no National Association for Addictive Disease. How can this be?" What really matters, says Schwarzlose, is outcomes. Patients may not care if someone got paid a kickback or took out a second mortgage or were lied to about costs as long as they recover. But treatment providers should care about both transparency and outcomes, he says. Twin Town Treatment Centers president and CEO David Lisonbee notes that even under American Society of Addiction Medicine (ASAM) patient placement criteria, which are very generous, few people in a higher-end residential treatment program would meet those criteria after one week of treatment. "But the patient is never informed that long residential treatment isn't necessary," he says. "It's part of informed consent to tell patients about the treatment we're rendering, to tell them that a certain kind of treatment only has anecdotal results, to be honest." The fact is that addiction treatment is held to a higher standard than medical treatment because of the qualitative nature of the diagnosis and treatment. "We don't have X-rays to measure need," says Lisonbee. "It's what we assess and document that determines the level of care we render'

Alison Knopf is a freelance writer based in New York. The full text of this report is available in three parts at www.addictionpro.com.
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Author:Knopf, Alison
Publication:Addiction Professional
Geographic Code:1U5FL
Date:Mar 1, 2013
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