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PostPosted: Wed Dec 02, 2015 8:43 pm 
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https://www.thefix.com/content/how-obamacare-killing-aa%E2%80%99s-membership

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Under Obamacare, insurance will only pay for evidence-based treatment. Consequently, rehabs are eliminating 12-step groups in favor of harm reduction and other statistically strong methods.

There is a section of the Affordable Care Act of 2008 called the Mental Health Parity and Addiction Equity Act. The Mental Health Parity Act of 2008 requires that insurance pay equally for mental and addiction treatment as general medical treatment. It ensures that if a person requires a 30-day inpatient program, insurance must pay for it.

On the surface, the Mental Health Parity and Addiction Equity Act looks extremely promising for those in the rehabilitation industry and perhaps a return to the glory days of the 1980s where 30-day inpatient drug rehabilitation was the norm. Alcoholics Anonymous very heavily depends on drug treatment centers as one of their main gateways for new membership and nearly 100% of drug rehabilitation programs treat patients with the Alcoholics Anonymous abstinence-based model. In fact, Steve Slate in his article, It’s All Twelve-Step – So Stop Talking About Science Already discusses that 98.6% of all rehabs in the United States are at least in part 12-step oriented with 78.8% directly using the 12-Step Facilitation Model.

Counting AA’s Membership: Historical Trends and Controversy

Alcoholics Anonymous uses a self-reporting system to count membership along with surveys to randomly assigned people to gather demographic information. Consistency within Alcoholics Anonymous reporting exists on the group level. Group establishment must go through a rigorous process of displaying staying power over time before being considered an official group of AA. Once a group is established, membership within a group is then reported as a group estimate of those who are regular attendees or “homegroup members.” This number is vastly overstated in most cases because many people who sign up for a homegroup fail to show up or drop out of AA without reporting. A lag of six months or more can exist before a group removes a member from its roster. This system, therefore, gives accurate reporting of groups in existence and not so accurate reporting of actual membership.



Many people have mistakenly claimed that in 1992 Alcoholics Anonymous saw its peak in membership and if we are to take these numbers at face value that is most certainly the case. Alcoholics Anonymous has a report of yearly membership and groups since its inception. However, these numbers do not add up with any mathematical consistency. From year to year, if we divide the number of members by the number of groups, on average, we see a value ranging from 18 to 22 members per group. This value significantly changes in the years 1990 to 1993. Values ranged in these years from 23 members to a whopping 28 members per group in 1992. It is simply unreasonable to believe that nearly 750,000 members showed up for those years and then suddenly dropped off the map without any new groups reporting in those years.

If we compare these values to a more consistent statistic of 19 members per group per year, however, we find those years where membership reporting was inflated. We also see some other interesting trends in the data. First, AA membership most likely did not peak in 1992, what actually occurred is the rate of membership began to diminish. According to the trend of actual group count, however, AA continued to see added membership up until 2008. It is possible based on the current trend that AA actually peaked in 2008. In fact, from 2000 to 2008, AA saw an average group count increase of 1,785 groups per year. However, from 2008 to 2011, the latest AA survey published shows an actual loss of 676 groups per year. For the past six years, AA has seen a smaller group count than they did in 2008. This is the first time in AA’s history that they have shown a consistent loss of actual group count which can then imply a significant loss in membership. As a relative value of comparing membership from year to year, it is clear that group count is much more consistent than actual membership reported.

Health Insurance and Historical Trends in AA

The rate of membership in Alcoholics Anonymous, and group count, has been shrinking over the past 20 years primarily due to health insurer’s resistance to paying for drug treatment admissions. Insurance has reverted to detox-only for inpatient, usually resulting in an average seven or more days for a form of outpatient treatment. After a few returns to detox, the health insurance industry refuses to pay for treatment altogether. The reduction of the rate at which Alcoholics Anonymous gained membership can be graphed as a direct correlation to the amount of inpatient dollars the health insurance industry was spending.

In 1992 there was a significant change in the healthcare industry where a majority of insurance companies began to place people in HMOs and began a serious crackdown on insurance payments. The first in line to go was addiction treatment, due to the high cost and low efficacy. The gradual decline in insurer’s refusal to pay for addiction treatment has been a constant trend all the way up to the Affordable Care Act of 2008. Relative to the American population, which saw an increase of 20% over the past 20 years, Alcoholics Anonymous’ numbers did not increase at the same rate. At an estimated 2.1 million members, which we know to be inflated, AA is now showing a relative decline in membership of 16% in comparison to the growing US population. That’s a serious drop in numbers over the last 20 years.

The Mental Health Parity Act of 2008 and the Final Rule

So the rehabilitation industry is in trouble. Big trouble. The recent Hazelden-Betty Ford merger should be a big clue as to how much trouble they are in. When Betty Ford had to merge with Hazelden just to survive under the new healthcare law and switch its treatment primarily to outpatient care, it shows how vulnerable the industry is. As the stats show, as the rehab industry goes so does AA.

Originally, the Mental Health Parity Act gave rehabilitation medical practitioners hope that access to their facilities would increase under the law. The problem is a part of the law called the Final Rule, which most of the industry missed when making their initial projections. The Final Rule states that all treatment must be evidence-based medicine. This means that the treatment applied must be proven to work and the level of treatment must be in accordance to what is deemed necessary by scientific studies. Unfortunately for 12-step methods of treatment, it means that insurance can and will flat out refuse to pay for inpatient 12-step facilitation simply because it is not proven to be effective.

In light of this new rule, it is no wonder that Hazelden quickly switched to adding naltrexone to its treatment model. What this means is that the 12-step model in treatment centers must now take a backseat to actual evidence-based medicine or insurance will refuse to pay for it. How bad is it? Cigna has refused 47% more inpatient treatment claims than general inpatient treatment claims citing a lack of evidence-based treatment. United Healthcare under the new law has also significantly increased their denials of addiction treatment. Both insurance companies ended up in class action lawsuits over the issue (Cigna settled). The law is still being tested in court and the debate will continue simply because inpatient treatment using the Minnesota Model or Alcoholics Anonymous is simply not proven to be effective. This, while seeming bleak to many Alcoholics Anonymous proponents, is encouraging to those who promote evidence-based medicine. The American Mental Health Counselors Association hailed the Final Rule as a serious step forward for addiction medicine.



Ironically, the anonymity of Alcoholics Anonymous may be its own demise. As the law requires proof of 12-step treatment effectiveness, AA has traditionally resisted any direct involvement in studies. The same follows for 12-step rehabs. Many do not publish their efficacy most likely because it isn't encouraging. As the law requires evidence-based treatment for drug and alcohol addiction, many rehabs will be forced to switch to an evidence-based model, at least in part, in order to survive. This could be a very harsh awakening to Alcoholics Anonymous which previously saw the majority of treatment centers as private facilities that promoted their philosophy and encouraged their membership. Consider the statistics of drug and alcohol treatment admissions from the Substance Abuse and Mental Health Administration in comparison to the group count of Alcoholics Anonymous. It is undeniable seeing the two datasets together that they are correlated (see chart above) and the drop in admissions is staggering since 2008. In fact, the number of drug treatment admissions has fallen below the level of admissions in 2000. This means 2012 marked the lowest rate in drug treatment admissions for the past 12 years.

The majority of drug treatment denials have been on the basis of “medical necessity.” John T. Seybert, Esq. and Edward Stump, Esq. of the American Bar Association define medical necessity in their article, Will the Mental Health Parity and Addiction Equity Act of 2008 Successfully Encourage Employers to Provide Benefits for Inpatient Mental Health Treatment? They also clarify why health insurance is now no longer paying for non-evidence based treatment:

“Most insurance companies, however, will not provide coverage for residential treatment for mental illness or addiction unless the services are deemed ‘medically necessary.’ In general, a plan defines ‘medically necessity’ as ‘accepted medical practice or community standards of care; not for the convenience of the patient or provider; not experimental or investigational; and appropriate and effective.’”

The essential problem is that inpatient care has not been proven to be more effective than outpatient care and 12-step based models have not proven any efficacy at all. The prestigious Cochran review did a comprehensive study in 2006 and found no conclusive evidence that 12-step facilitation gave any results more favorable than no treatment. This does not bode well for inpatient treatment facilities that depend on health insurance for survival.

As a result of this law, evidence-based medicine will become the forefront of addiction treatment in America. As admissions to treatment facilities are significantly dropping, drug treatment centers will be required to change their model to a more evidence-based approach in order to receive payment from insurance. As the number of admissions to 12-step facilities continues to drop, Alcoholics Anonymous’ membership will also continue to drop. The result of this single rule in the Mental Health Parity Act has been a profound change in the way insurance now supports addiction medicine. At the rate we are currently moving, this one line in the Obamacare law may very well be the death of the 12-step movement.


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PostPosted: Wed Dec 02, 2015 10:17 pm 
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Why is it bad that treatment centers will have to rely on evidence based practices? It's certainly true that group therapy will continue even if 12 steps aren't a part of it. Why shouldn't 12 step programs be held accountable to a standard of being effective?

I read an article recently about a model of harm reduction in the homeless population, many or most of whom have co-occuring substance abuse disorders. The drop in day center for these folks was a low-threshold facility, meaning that addicts didn't have to be or pretend to be abstinent to receive services. Services included finding housing, group substance abuse therapy sessions. Here's a description of the place:

"The Help Center (pseudonym) was a community-based, drop-in center which provided hygiene supplies, showers, laundry facilities, meals, needle exchange, safer drug use kits, intensive case management, individual and group counseling, and a link to primary care, mental health, and substance abuse treatment within and outside of its larger agency."

So they took this population that is marginalized by substance abuse and homelessness and with the services they provide, they also treat the people with dignity and respect. The clients together with the counselors determine reachable goals, that don't necessarily include abstinence. This is in contrast to the high threshold facilities that require complete abstinence in order for them to receive services. The study found very positive outcomes when the clients were provided with human dignity and counselors who truly advocated for them, whether they were using or not.

I bring this up because I do not like what I've read or heard about abstinence-only treatment. There is a whole segment of addicts who are given up on because they are not prepared to be abstinent. They are told by 12 step groups that they can't be in the club and ostensibly don't deserve treatment because they can't achieve abstinence. That is bullcrap as far as I'm concerned! Didn't the founders of AA write, "progress not perfection"? That's what the Help Center and places like it offer. Progress for these addicts.

It makes me annoyed that most 12 step programs think that MAT (Medication assisted Treatment) is not as good as what they achieve. But it makes me sick that abstinence-only, 12 step based treatment centers are ready to turn their backs on those addicts who cannot maintain abstinence. "Well it's too bad if that addict was kicked out of our program and OD'd and died, but they just weren't ready to be in treatment." Maybe the problem is that 12 step based treatment is far too rigid a treatment system to deal with the reality of addiction.

Amy

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PostPosted: Thu Dec 03, 2015 2:29 pm 
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Yes! I completely agree. I've been through and "graduated" an inpatient treatment facility that was solely based on NA & the 12 steps. I'm sure it works for some, but it didn't me and the majority I kept in touch with were bk using again within just a little while.

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PostPosted: Thu Dec 03, 2015 9:11 pm 
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It's about time! Although, I have to say, what in the hell is going on here? This is the second time in a week as well as my entire life, I've agreed with Obama. Finally, something I like about Obamacare. What's next, they admit global warming had been a farce all along?

I digress. Interesting how "AA has resisted studies". Well how convienant! My sense is AA May work for alcohol and some drugs but clearly with opiates it appears to often be as good as nothing at all. On one hand, as amy pointed out, some of the AA folks skoff and even condem MAT, yet AA may not work nearly as well. Talk about crazy!

Why should we continue ANY medical treatment not proven to work? And then refuse to stand up to study? Must be nice. How about I just make a claim that running 4 miles in your underware is a cure for opiate addiction? Give you proof, you say? Oh no, not going to do that. That's not what my treatment is about. Plus, we don't want to jeopardize a person by enrolling them in trials. But, trust me, it's the gold standard for treatment. Just trust me.

Just think of all the treatments over the years that have changed! Medicine is flush with treatments that were actually doing more harm than good. Will AA become one of them?

I said this on another thread last week, the tide is starting to change. I am getting more certain of that all the time. This report is yet another example.


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PostPosted: Sat Dec 05, 2015 8:45 pm 
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donh wrote:
How about I just make a claim that running 4 miles in your underware is a cure for opiate addiction?


That's the recovery I've been waiting for all these years!


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PostPosted: Sun Dec 06, 2015 1:58 pm 
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TeeJay wrote:
donh wrote:
How about I just make a claim that running 4 miles in your underware is a cure for opiate addiction?


That's the recovery I've been waiting for all these years!


Well, some of us look better in our underwear than others! TJ, I always picture you as the Australian guy from the show House, which I suppose is not really fair. :)

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PostPosted: Sun Dec 06, 2015 2:19 pm 
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Hey donh, I bet if you sat down with Obama and I sat down with George W. both of us would find plenty of things to like, plenty of common ground. I get so discouraged when I read comments from both sides of the political fence at the vitriol and word vomiting. If we all lived in the same town we would have to treat each other with some civility. Instead we are so anonymous that we can say all sorts of horrific things to each other without even thinking about it.

You know how sometimes a local news station or even a national organization will create an internet space where we can all pledge to not text and drive, or to wear our seatbelts, etc. I wish there were a national registry where we could pledge to engage in civil discourse, and there would be a forum where people disagreed without name calling, and actual research was required before making unsubstantiated claims.

Anyone who is an addict can not in good conscience call out Bill Clinton for making immoral decisions or George W. for making dumb decisions because we have all been immoral and dumb as addicts. In fact, everyone but Mother Teresa, Ghandi, and the Pope has been immoral and made dumb decisions. And I bet that the three of them would also admit to stupidity and immorality too. It's so much easier to vilify the other side when we strip them of their humanity in our minds. I refuse to do that starting now. I will move forward and pledge civility while also acknowledging my own imperfection and the fact that I will make mistakes.

We can all do better.

Amy

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