By Deni Carise, PhD & Chief Scientific Officer at Recovery Centers of America via Behavioral Healthcare Executive
Excellent treatment programs do exist. I want to start by emphasizing that point because it’s true. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), there are approximately 13,585 treatment facilities offering services for substance use disorders in the United States. Inside these programs are thousands of addiction treatment professionals working to provide quality, ethical, effective services and contributing to successful recovery outcomes. This is true across treatment levels (residential, PHP, IOP, sober living, etc.), modalities (cognitive behavioral, motivational interviewing, 12 Step facilitation, medication-assisted treatments, etc.), and types of business (not-for-profit, for-profit, self-pay, Medicaid, insurance-based, etc.).
And very fortunately, the ability to access treatment has significantly improved thanks to the Mental Health Parity and Addiction Equity Act, which stated that substance use disorder (SUD) and mental health treatment must be covered in the same manner as treatment for other medical diseases. Following Parity, healthcare reform passed and made substance abuse and mental health treatment “essential benefits” mandating that they must be covered by most insurers. It also had a number of components that led to increased availability and coverage of treatment for SUD; it allowed parents to keep children on healthcare policies up to age 26, and it prohibited insurers from declining coverage due to a pre-existing condition or dropping coverage once you got sick.
Unfortunately, the current, massive opioid epidemic combined with this increased access to treatment has bred a slew of unethical business practices within the addiction treatment field. This has been very damaging to our field and to those struggling with substance use disorders and their families. It’s unimaginable that there are those who would take advantage of families in crisis, but it’s the sad reality.
One example of this abhorrent behavior is a kickback scheme known as patient or body brokering, which is referring a patient to a drug treatment facility in return for a generous compensation anywhere from $500 to $5,000. Most of the providers engaging in brokering use out-of-network benefits, meaning they don’t have a negotiated rate with the insurance companies and charge separately (and often exorbitantly) for every “service” delivered. This can include billing over $1,500 each for frequent, unnecessary drug screens, a service reimbursed by the federal government for Medicare patients at a maximum of about $80 each.
With the ability to charge upwards of $80,000 for a 25-40 day stay in treatment, paying a body broker $5,000, however unethical, deceitful and even illegal, may seem like a bargain to some treatment programs. Brokers will even offer to share these kickbacks with patients or entice them with drugs to leave an existing facility and enter another when they have relapsed. These brokers troll 12 Step meetings, local hangouts in places where there are numerous treatment facilities, and even stoop so low as to check into detox and treatment centers to recruit patients they can then sell to another program.
Many of us have heard these crazy, sad stories firsthand. So, what can we do?
I propose that it will take a three-pronged approach: legislation, public awareness and – obviously where you and I can effect the most change – at the treatment level.
A bipartisan measure that will prohibit kickbacks – part of the “Opioid Bill” approved by Congress – is scheduled to be signed Wednesday by the president. Under the new law, federal prosecutors will finally be able to go after patient brokers and the providers who pay them. Conviction for taking or providing kickbacks will carry criminal penalties of up to 10 years in prison and as much as $200,000 in fines.
Alan Johnson, chief assistant state attorney in Florida, worked on this bill and heads the Sober Homes Task Force that was responsible for his state’s legislation that included barring addiction treatment centers from paying a commission, bonus, rebate, kickback or bribe for new patients. Arrests are being made. The laws are working in Florida and should make a big difference nationally. This is a major step in the right direction.
I’d also like to see more support of legislation and associations that call for increased oversight of treatment centers at all levels. During its national conference this past May, NAATP announced its Quality Assurance Initiative (QAI) designed to confront abuses in the treatment field, establish operational competence, and restore public trust in addiction treatment. This is a great effort that is worth supporting, but our two recognized accrediting bodies, The Joint Commission and CARF, need more specific guidelines to ensure ethical standards, transparency and quality of addiction treatment providers nationwide. Becoming accredited by them should be a true mark of compliance and quality.
Other ideas: Amend the Anti-Kickback Statute to apply equally to both federally funded and private treatment, not just Medicare and Medicaid programs. Institute an outcomes-based insurance reimbursement model and/or alternative payment models such as ASAM and AMA’s proposed Patient-Centered Opioid Addiction Treatment (P-COAT) model. These measures help encourage quality outcomes and discourage the “treatment center shuffle” that currently has clients going from one program to the next. Let’s care for our patients across their lifespan, not just for a small segment of inpatient or outpatient care.
It pains me to think that uncovering fraud in our field might lead some to be skeptical of all treatment and discourage those struggling with substance use disorder from getting help. I want us to weed out the bad players, but publicizing our weaknesses without emphasizing how we address these issues misses the mark and negates all the good being done in this field. That’s why I strongly support PSAs that educate Americans but don’t further stigmatize addiction. These campaigns can also provide information on reputable treatment options, particularly those in the neighborhoods where these ads run, as neighborhood-based programs are extremely successful for long-term recovery when they incorporate the whole family. New York, for example, is running radio ads urging individuals to be aware of possible scams and seek help through state-certified treatment programs.
Treatment level changes
Now to the part that may evoke the most criticism but is the closest to our reach. Let’s take a look at how we market treatment with the goal of moving toward a better marketing structure.
Going forward, treatment center marketers (other names include outreach, business development, sales, treatment program advocates, etc.) should be paid a fair market salary and not receive the bulk of their earnings based on the volume or value of the clients they refer. They don’t pay this way in cancer medicine or heart disease, and the delivery of healthcare is not the same as selling automobiles or cell phones.
When your employees make their commission or bonus predicated specifically on the number and value of patients being referred to specific programs or levels of care, you may unwittingly incentivize referral to a location or a level of care that may not be appropriate. The employee may benefit from their commission, but your treatment center doesn’t if the client is the wrong fit and therefore unsuccessful in your program. The biggest loser is the patient who may be wasting their time, insurance benefits and money on possibly unnecessary care or care in a location that is not the best choice for them and their success in recovery.
Taking out undue incentive for admissions does not mean we can’t still hold our marketers to benchmarks for calls made, visits with referring professionals, and other activities that produce referrals and admissions. It just means we don’t use number and value of admissions as a unilateral measure of success and basis for payment.
If we truly want to be successful, we should also ensure that there is a universally agreed upon standard for training marketers. Your marketers are often the first point of contact for your facility and must know the ins and outs of what you do, information that will help them successfully market your program to referents. What are your treatment modalities? Do you have a psychiatrist on staff? How much individual therapy do clients receive each week? The onboarding process should be comprehensive and significant. And importantly, your marketers must be aware of unethical practices that can severely hurt your program’s reputation (and may be against the law) such as offering money, spa or beauty treatments, or other incentives for admission.
There is a fair compensation for these individuals who provide such a significant service. It may vary in different areas of the country based on cost of living, but it should be reasonable for the breadth of work performed. It should not be based on the number or value of their admissions. NAATP has done significant and valuable work in this area in its revamped Code of Ethics and a Guidebook that is due out later this year.
Patient brokering is an unethical and inappropriate practice in all its forms. It hurts our field, our programs and most importantly, our patients. Stopping patient brokering isn’t rocket science. It can be addressed through legislation, public awareness and appropriate treatment practices. It takes a group of caring people who want to help others get well by doing the right thing. And that is exactly why most of us came to work in this field.
Deni Carise, PhD, is chief scientific officer for Recovery Centers of America.