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 Post subject: The Rehab Rort
PostPosted: Mon Jun 19, 2017 1:16 am 
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An interesting article about the rivers of gold to be found in inpatient addiction treatment centres. I wonder if the rehab industry would be in such a boom if operators were honest about their success rates. In my experience it doesn't matter ONE BIT how expensive the rehab is, how good their program is, what treatment methodology they run. Usually one person in 20 stays clean for 2+ years regardless of the quality of the program. The only thing that influences that figure is (a) how long the rehab goes for and (b) the substance of choice of the majority of residents.

Opioid addiction is the worst for relapse rates, and it is also the riskiest for mortality when a person leaves the care of the facility.

http://www.sbsun.com/social-affairs/20170618/addiction-treatment-the-new-gold-rush-its-almost-chic

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Addiction treatment: The new gold rush. ‘It’s almost chic’

On Tuesday, Sovereign Health properties were raided by dozens of FBI agents as part of a criminal probe into alleged financial and other irregularities, according to company and federal officials. Sovereign Health characterized the raids as “retaliation from a bunch of jack-booted thugs” for its lawsuits against state officials challenging how regulators do business, and said the company remains committed to providing the highest quality care.

Richards, of Maple Valley, Washington, came to Sovereign Health for help in July of 2014, according to court documents. She had private insurance — Regence Blue Shield — and signed forms agreeing to residential mental health treatment costing $3,410 per day. That care — plus 15 urine tests at $1,200 a pop — brought Richards’ bill to $123,000 for her first month of treatment.

Similar stays at well-appointed treatment centers can run from $30,000 to $65,000 per month. Richards stayed at Sovereign Health until November in varying levels of care, the cheapest of which was $1,980 per day, according to billing statements filed in a lawsuit Sovereign Health brought against her over reimbursement.

On Tuesday, Sovereign Health properties were raided by dozens of FBI agents as part of a criminal probe into alleged financial and other irregularities, according to company and federal officials. Sovereign Health characterized the raids as “retaliation from a bunch of jack-booted thugs” for its lawsuits against state officials challenging how regulators do business, and said the company remains committed to providing the highest quality care.

Two things are undisputed: Such care can be extremely expensive, and more people than ever need it.

Addiction treatment was a $21 billion business in 2003, and is expected to double to $42 billion by 2020 — a growth rate some three times faster than inflation, according to federal health and census data.

With a raging opioid epidemic — overdose deaths have quadrupled since 1999 — and mandated addiction treatment coverage under Obamacare, Wall Street knows there’s money to be made.

At the JP Morgan Healthcare Conference earlier this year — the largest in the nation — the frenzied courtship between treatment providers and would-be investors resembled speed-dating.

“It’s hot,” said Eric Coburn, managing director for healthcare mergers and acquisitions practice at Duff & Phelps, a financial analysis and investment banking firm with offices all over the world. “There’s a big need out there. It’s a growth sector for Medicaid and commercial private pay. You’d think, with all the talk about changing the Affordable Care Act, investors would be very, very nervous — but they’re not.”

Investors are attracted because the business is so fragmented and ripe for modernization; in the world of health care, size matters, Coburn said. Addiction treatment has been dominated for decades by small mom-and-pop enterprises, which leaves tremendous room for consolidation and efficiencies. Unifying small centers into larger networks spreads administration costs over larger revenue bases, while more sophisticated operations can allow for investment in technology and data-mining that may better manage health and financial outcomes. And the stigma attached to substance abuse treatment is finally receding.

“There’s wider recognition that addiction is an illness,” Coburn said. “People are less embarrassed about asking for help compared to years ago. You could argue it’s almost chic.”

Consolidating addiction treatment companies are reaping the benefits of “vertical integration” what happens when web sites, call centers, rehab facilities, drug-testing labs and sober- living homes are all gathered under one corporate roof, capturing all that spending for the same corporate family.

MARKET IN HYPER-DRIVE

But the huge financial opportunity presented by addiction treatment has a dark side.

A MarketAlert brief for investors, by The Braff Group, which provides financial analysis of the treatment industry, described financial risk in the recovery businesses this way:

“It’s not all kittens and rainbows. As we have seen countless times in other frenzied health care sectors, when the money flows in, so do the ne’er-do-wells, which can bring the sector the kind of attention it doesn’t want. Markets in hyper-drive are extremely fragile. And sometimes all it takes to bring a high-flying sector crashing to the ground are a few, high-profile cases of chicanery that paints the entire industry with a broad brush of suspicion (and in a sector sorely lacking definitive data to quantify the good work you do, the industry is particularly vulnerable).

“Do we think a collapse is imminent? Not at all. But are market forces coalescing to surface the precursors to a shake out? Sadly, yes.”

The Southern California News Group recently investigated the addiction industry and found it peppered with financial abuses that bleed untold millions from public and private pockets, can upend neighborhoods and often fails to set addicts on a path to sobriety. Lax government regulation and widely-divergent treatment approaches have meant poor care for many. The revolving door between detox centers, treatment facilities, sober living homes and back again generates huge money for operators who know how to game the system. And even obvious fixes can be hard to make.

In a health-care sector that has long been cut off from mainstream medicine, the landscape has turned volatile since the rush of investment over the last few years, many long-time providers said.

“I’m not pointing the finger at any particular company, but the fact is, it’s a lot worse than it ever has been,” said Mark Mishek, president and CEO at the Hazelden Betty Ford Foundation, one of the oldest, most established — and nonprofit — treatment chains in the nation.

“The black-hat marketing techniques, an incredible amount of fraudulent billing, payment for patient referrals, self-referrals, fraudulent work in drug testing — it’s all there and it’s terrible,” Mishek said. “If you ever did that in the real world of health care, you’d go to jail. It’s fraud.”

Greg Horvath is a documentary filmmaker from Huntington Beach who says he once worked as a “sober companion” to trust fund kids, athletes and a few celebrities. What he learned as an industry insider infuriated him, and his stinging film, “The Bu$iness of Recovery,” has been screening at festivals nationwide.

“There are nonprofit treatment centers that cost $53,000 a month, while good senior care can cost $4,000 a month. What’s the other $49,000 paying for?” asked Horvath. “It’s not like you’re using an MRI or an X-ray machine. It’s a bed, food and usually minimally-educated therapists. I’m really confused. Where’s the money going? No one has been able to show me.”

Personalized treatment is expensive, providers say, and many for-profits are as angry about the rush of ne’er-do-wells into the industry as everyone else and want them weeded out, too.

They lay the blame for the current state of affairs on state regulators who haven’t figured out how to effectively manage the industry or attack the disease of addiction, and with insurance companies that haven’t put any effort into figuring out what works and what doesn’t, and then covering treatment that produces results.

“We are funding research studies, we have on-going prevention and education outreach, we have a very sophisticated operation,” said Michael Cartwright, CEO of American Addiction Centers, one of the larger for-profit providers. “What we do is what detox and residential treatment should look like.

“We care about this industry and this disease,” Cartwright said. “We’re really are out there doing some really good things. We want to solve the problem of addiction.”

WALL STREET ADDICTED

Substance abuse treatment has, historically, been severed from the larger health care system, experts said. It was seen as a behavioral issue, not a medical issue, and often wasn’t covered by health insurance.

In this veritable no-man’s-land, the field became dominated by small nonprofit providers — the aforementioned “mom-and-pop” operations — which largely ascribed to the 12-step, social-support model of Alcoholics Anonymous.

The overwhelming majority of the nation’s non-governmental treatment facilities — about 70 percent — were nonprofits in 2005, according to SAMHSA data. By 2015, nonprofits shrank to about 60 percent of providers. And in California, the trend is even more pronounced; nonprofits now run less than half the licensed treatment centers in the Golden State, about 48 percent, according to the state’s most recent licensing data.

The trend away from nonprofits fuels a push toward more medical approaches to treatment, as well as a menu of therapy options that go beyond the traditional 12-step support system, operators say.

It also fuels staggering growth in the revenues of publicly-traded, for-profit treatment providers.

Consider Acadia Healthcare. In 2012, the Tennessee-based chain of recovery centers reported net revenues of $413.8 million. By 2016, that had ballooned by a factor of almost seven — to $2.85 billion.

The company’s growth will continue as management takes advantage of “a national marketing strategy to attract new patients and referral sources, increasing our volume of out-of-state referrals, providing a broader range of services to new and existing patients and clients and selectively pursuing opportunities to expand our facility and bed count in the U.S. and U.K.,” the company said in Security and Exchange Commission filings.

“While the growing awareness of mental health and substance abuse conditions is expected to accelerate demand for services, recent healthcare reform in the U.S. is expected to increase access to industry services as more people obtain insurance coverage,” Acadia’s filing said.

Acadia CEO Joey A. Jacobs had total compensation of $9.36 million in 2016, up from $6.2 million in 2014, according to SEC filings.

AAC Holdings — Cartwright’s American Addiction Centers — has seen net revenues skyrocket nearly tenfold in just five years, from $28.3 million in 2011 to $279.8 million in 2016, according to SEC filings. It projects revenues of $300 million this year.

AAC is buying up smaller centers and gaining control of businesses handling everything from advertising and patient referrals to laboratory work. It owns listing and referral websites Rehabs.com and Recovery.org, as well as Recovery Brands, which “provides online marketing solutions to other treatment providers such as enhanced facility profiles, audience targeting, lead generation and tools for digital reputation management.”

CEO Michael Cartwright’s total compensation was $902,737 last year, down from $1.2 million the year before, according to proxy statements.

Universal Health Services has acute-care hospitals as well as addiction centers, but is a major for-profit player in the treatment field, according to SEC filings. Universal’s behavioral health business — which includes treatment for depression, anxiety, bipolar disorder as well as substance use and other conditions — had $3.3 billion in net revenue in 2011, according to SEC filings. Last year, that rose to $4.76 billion. Alan B. Miller, Universal’s CEO and chair of the board, had total income of $19.9 million in 2016, up from $18.4 million in 2014.

The for-profits issue warnings about the future: Growth has been fueled by hundreds of millions of dollars in new acquisitions made possible by big borrowing, and the substantial debt could cause problems if the economy stumbles. There’s a great deal of uncertainty around Obamacare’s survival. Insurance companies are pressuring addiction treatment providers come in-network, which costs insurers less and may decrease revenue growth for providers. There have been lawsuits and investigations which could impact the business — or not. The market itself has been volatile.

But 2016 was a year of significant growth, and there’s great optimism for the future, the for-profits said.

“The combination of organic and acquisition growth enabled us to increase our admissions by over 50%, while leveraging a significant decrease in our advertising and marketing costs,” said a statement by CEO Cartwright when AAC announced its financial results in February.

OTHERS GROW, TOO

It’s not just for-profits that are seeing revenues mushroom.

Hazelden in Minnesota and the Betty Ford Center in California were the field’s dominant nonprofits for decades. But with an eye toward Obamacare — and its expectations for more economical out-patient treatment, as opposed to the more-expensive in-patient treatment both had specialized in — the two merged in 2014 to form the Hazelden Betty Ford Foundation.

The new nonprofit filed tax returns with the Internal Revenue Service in 2013, reporting revenue of $154 million. That leaped 45 percent in just two years, to $223.55 million in 2015. CEO Mishek had total compensation of $820,315, up from $673,446.

Hazelden Betty Ford now has 15 sites across the nation, offering both residential and outpatient services based on the 12-step, abstinence-based treatment model. It houses the nation’s largest addiction and recovery publishing house, a fully-accredited graduate school of addiction studies, addiction research center, prevention training program, education arm for medical professionals and children’s program.

“We’re really working hard to grow our out-patient services and filling out our continuum of services,” said Mishek. “The best estimates are that 85 to 90 percent of people who get help do it on out-patient basis. We want to reach them. We want to help more people.”

And it’s not just the giants. Smaller nonprofits have been growing as well.

Consider Yellowstone Women’s First House, a long-established nonprofit that runs four centers in Costa Mesa and is tangling in court with city government over rehab rules. Revenues more than doubled between 2010 and 2014, from $863,809 to $1.9 million, according to Yellowstone’s IRS filings.

Yellowstone CEO Anna Thames had compensation of $101,296 in 2014, up from $74,178. Yellowstone also leased several properties that belonged to Thames, paying rent of $218,965 in 2014; and the nonprofit also leased a building owned by her son, paying rent of $4,672 a month, according to tax filings.

WHAT DO YOU GET FOR $3,410 A DAY?

Public records make it reasonably easy to track the growth of publicly-traded and nonprofit players in the industry, but much of the action is happening out of the public eye, at privately-held companies like Sovereign Health.

Such companies don’t share much financial information, but details can emerge via lawsuits.

In a suit filed in 2015, Sovereign Health accused two former employees of using its “administrative and marketing assets” and then referring prospective clients to its competitor, Solid Landings.

“Sovereign is unsure as to the number of prospective clients that it has lost, but believes that the number is at least 10 clients, resulting in lost profits of $350,000,” the suit said. That suggests each patient comes with a $35,000-or-so profit on his head.

Sovereign Health is where in-patient treatment cost $3,410 a day, and where Tara Richards ran up that $416,050 bill, and where law enforcement officials mounted a raid on June 13.

What does $3,410 a day buy? Life-changing treatment, Sovereign Health said.

The company hires experts with Ph.D.s and M.D.s, has 24/7 house managers, licensed therapists and a senior management team that oversees all programs, spokesman Haroon Ahmad said by email.

It provides specialized behavioral health treatment services to people who have mental illness, substance abuse and “co-occurring disorders” in a small, personalized setting. Medication can cost thousands. There’s detox, when the body rids itself of drugs or alcohol; group and/or individual therapy sessions to recognize and address the underlying causes of their addiction; and the development of a personalized aftercare plan, he said. In-patient facilities tend to cost more than out-patient treatment programs because they provide meals, lodging and activities as well; and facilities with many amenities in places like San Clemente can cost more than others.

“We customize the program to each patient, which makes it more of an intimate rehab,” Ahmad said.

Tonmoy Sharma, Sovereign Health’s CEO, is convinced that Tuesday’s raid had nothing to do with the company’s billing or financial practices — “We are an open book,” he said — but is really retribution over Sovereign Health’s lawsuits against insurer HealthNet and state regulators.

Sovereign Health sued HealthNet last year for failing to pay $55 million for medical services rendered. HealthNet claims that Sovereign Health’s billings were fraudulent.

The overwhelming majority of officials at the raid were not from the FBI but from state regulatory agencies, Sharma said, and they grabbed legal papers and work product that they couldn’t otherwise get during the course of litigation.

“It stinks so badly,” Sharma said. “When there are raids, there are charges. There were no charges here. If you want financial information, why are you rifling through information in the legal office? Why do you lock lawyers in a room and rummage through privileged information and work product? We’re doing good clinical work here. If you disagree with our billing, then let us have a conversation. It can be handled in court as a civil matter. That is how civilized societies work. You don’t barge in and rough up our people. It does a huge amount of damage.”

Details of Richards’ bill are in court records because Richards received $374,885 from her insurance company to pay Sovereign Health, but never forwarded the money, Sovereign Health’s suit states. Richards subsequently filed for bankruptcy and did not return calls for say if she did or didn’t gain sobriety.

“Patients in recovery should not be receiving a check that should be sent to the treatment center because there’s a chance of the patient relapsing, quitting rehab, spending the money for personal use and more,” Ahmad said. “If the check is sent directly to the treatment center, the patient can continue to stay on the path to recovery.”

Insurers don’t want to do that. Allowing direct insurance payments to out-of-network providers — that is, to recovery centers that don’t contract directly with the insurance company and don’t necessarily agree in advance on reimbursement rates and standards of care — would remove one of the few tools insurers have to encourage providers to come in-network, insurance officials said. Being in-network, as opposed to out-of-network, lowers costs, tightens oversight and provides more consumer protection, they argue.

As federal, state and local officials continue to sniff around Southern California’s Rehab Riviera, those in the industry are bracing for more raids like the one at Sovereign Health. And the industry itself may be in the thick of the shake-out that The Braff Group predicted.

On June 1, Solid Landings filed for bankruptcy protection for itself and its affiliates, listing assets of $63,071 and liabilities of nearly $10.9 million.

Solid Landings is the company that agreed to close dozens of sober living homes and counseling centers in Costa Mesa — and the one that Sovereign Health said got patient referrals that rightfully belonged to Sovereign.

Larissa Mooney is a board-certified psychiatrist and director of the UCLA Addiction Medicine Clinic. She teaches the principles of evidence-based treatments to psychiatrists-in-training. She doesn’t claim much expertise at the business side of treatment, but offers a general rule-of-thumb to those seeking services.

“The cost of the program is not a guarantee of the quality of the program,” Mooney said. “I wouldn’t use cost as a proxy for quality.”


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 Post subject: Re: The Rehab Rort
PostPosted: Mon Jun 19, 2017 2:53 am 
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I had plenty of time tonight, so coming across an article like this was perfect. And what an interesting read it was. To this day, I'd love to know where all the thousands of dollars for my treatment went. My inpatient hospital stay was comfortable but extremely minimal. The mattress I had to sleep on hurt my already aching back every night. The lousy one or two pillows sunk down after your head laying on them for more than 5 minutes.

The food was absolutely horrible. All they served was thick, high fat food with some form of pork at every meal, which was tough for me being mostly vegetarian. They even had a dietician doing one of the groups and we would talk about how and what we should be eating to help our bodies fight. And then go to lunch where it would be rare meat of some kind and very little vegetables or fruit. There were no nuts, or beans or any other protein source besides these "mystery meats" that they would serve. I would feel so nauseous after every meal, oh it was horrible!!

In terms of medical staff and therapists, well I felt under treated and rushed most of the time. But I never wanted to say anything, I didn't want to "rock the boat". I 'needed' that buprenorphine so bad and just said "yes ma'am" and kept my head low. Don't get me wrong, for the most part, everybody there was pretty kind to us considering there was always difficult ones to take care of day after day. I tried to remember that and stay patient. But overall, my experience was traumatizing... it really was. I still have nightmares about it now and again and it's been over 2 months ago that I got out.

Then came intensive outpatient... 7 weeks of 3 times a week for 3 hours a day. And every day was an estimated $760 a day. For what you might ask? A very kind staff, but an extremely overworked staff. And there was always someone in group, usually 2 or more, of the kind that just sucked the energy and air out of the room. You know the type, where everyday their pain is a 12 out of 10 and their mood was a minus 2 on a 1-10 scale. During check in someone would always have to stop them or we wouldn't get around to others. I guess they wanted their money's worth out of their time there. I can understand that.

Hey, I'm sorry. I don't want to be one of those that is constantly negative. But this whole subject is an important one. There seems to be so many barriers to treatment, including cost. When you're going to a facility that is nearly $4000 a day, you shouldn't be charged an extra $5 for an extra toothbrush because the one they gave you broke on the first day. It just doesn't make sense. And yet this is only part of my experience. And from what I've heard, I'm one of the lucky ones!! Wow!!

Thanks TeeJay, that really was interesting!!

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 Post subject: Re: The Rehab Rort
PostPosted: Mon Jun 19, 2017 8:31 am 
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Absolutely do I understand this topic. My rehab had me wondering what the heck was the money going to! It was a revolving door too, as soon as one person would graduate the program, another would begin. So this place made plenty of money and it wasn't exactly spent making the patients feel comfortable.

I won't go into major details but it just could have been better. There definitely wasn't enough counselors or one on one, after detox was over the woman had to go to a completely different facility than we were used to and that was a house. I didn't like the idea of a house. It was nice I guess but I wasn't comfortable. I didn't have my own room and the exercise equipment was just piled together on the front porch. It wasn't what I expected. Now before the made the ladies go to their own home, I was fine. I don't know, I just felt like they cut corners every single place they could and imo it showed.

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 Post subject: Re: The Rehab Rort
PostPosted: Mon Jun 19, 2017 10:52 am 
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I once had a patient who went to a place out west that cost over $70,000 per month. I wondered how they charged so much, and so she brought in the itemized invoices (it took many letters and threats before they sent the breakdown of costs). Each day there was hour after hour of different 'therapies', each a couple hundred bucks per hour... group emotional therapy, group process therapy, individual spiritual therapy, art therapy, conditioning therapy, relaxation therapy, music therapy... and some with names that were so bizarre that I can't remember them. THAT"S how you get to $70 K per month!

Thanks for sharing the article!


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 Post subject: Re: The Rehab Rort
PostPosted: Mon Jun 19, 2017 1:17 pm 
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There must be many good rehabs out there but this sure gives them all a bad name. Maybe it's time to start a new business...Hmmm, maybe using ORT as the main recovery tool and focus only on opiate addiction. Just a thought.

That is a search I may look into just out of curiosity.

How do these people sleep at night knowing how much they are messing up the rates of insurance and showing very little in regards to success?

Thanks TJ for article.

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 Post subject: Re: The Rehab Rort
PostPosted: Mon Jun 19, 2017 4:26 pm 
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I left a couple of points out of my previous reply, and I think it's really important for me to include them here.

By the time I arrived to the inpatient hospital, I had already been to the emergency room earlier that morning. I had spent another night shaking and jerking violently, went from extreme hot to cold, and thought about all of the times I caught myself in that same condition. I haven't talked about this part of my experience with anyone, including my counselor, because of what it might mean to my treatment in the future. But it was the closest I've come to suicide and it scared the hell out of me.

So I was at or near my own personal "rock bottom". I had never experienced so much agonizing physical pain and emotional torment. I was a wreck through and though. So this is what this understaffed facility had to contend with. I could barely control my bowels and was sweating profusely... and yet they provided me with a shower and clean clothes to wear.

Shortly after I was admitted, I had a lovely little panic attack, the kind where you really believe you're having a heart attack 'this time'. One of the night nurses took me into an empty room and held my sweaty shaking hands, she looked kindly into my eyes and helped me slow down my breathing. And I'm sure I probably didn't have the most fresh breath at that moment. She didn't care.

There was another person that worked in the kitchen that went out of her way everyday to set aside a plate of the best fruit and vegetables of the day. She knew I was having a problem with the food, and although she couldn't do anything about my options, she did what she could to take care of my needs the best she could. She didn't have to do that. I was the ONLY one to get a peanut butter and jelly sandwich every day. She also touched me on the shoulder in a very loving way and told me I looked nice when I know I didn't.

And the therapists that ran the groups were so completely overwhelmed, and yet they treated every individual with respect and dignity, even the few "bad apples" that tested everyone's patience. I can't imagine what an emotionally taxing job that would be to go somewhere everyday where people were suffering physically and some with serious cases of mental illness. There were some that truly wanted to help people, and not because of a paycheck. It wouldn't be right for me to not mention these saints.

Overall, my experience was traumatizing... and it saved my life thank God!! It's easy for me to only focus on the negative, but there are doctors and nurses, therapists and social workers, and even line cooks that want to make a difference in the lives of people that society routinely marginalizes. Please, we can't forget them. I just needed to set the record straight, thank you.

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 Post subject: Re: The Rehab Rort
PostPosted: Tue Jun 20, 2017 12:33 am 
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Open Mind,
Great to see you keeping things in perspective. So easy to se black/ white issues when the truth is always so much more complex.

I never went to inpatient rehab, so I don't have personal experience but I have read about and looked at price tags for these places. Even looking right now for my cousin who has an alcohol addiction. The industry seems out of control right now, Hopefully it can find its way back to the spirit of helping addicts recover rather than taking advantage of them.

*Note- I Really generalized regarding how rehabs treat addicts- I'm sure some rehabs that put the needs of the client first.

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 Post subject: Re: The Rehab Rort
PostPosted: Tue Jun 20, 2017 1:37 am 
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I found this article pretty much on point. Everything I am learning and have learned in my master's program supports these recommendations. I know it's a long hill to climb, but I would personally be satisfied if we could just accomplish #1 and #2. Here's the link: http://theinfluence.org/the-rehab-indus ... heres-how/

Amy

Quote:
No one argues that the American addiction treatment system is anywhere near optimal—even its cheerleaders recognize that there’s miles to go before all people with addiction have access to respectful, ethical, effective and evidence-based care. Worse, the past year has seen myriad media exposes and financial, sexual and maltreatment scandals.

Of course, done right, addiction treatment can transform lives, with a hugely positive impact on society. It is often the difference between life and death, or between a productive recovery and a life of despair. Yet all too often that opportunity is being blown.

So what is the best way forward? And what are the biggest steps the industry itself can take to improve?

“What we simply need is a nice bulldozer, so that we could level the entire industry and start from scratch,” says Dr. Mark Willenbring, former director of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism and the founder of Alltyr, a center in St. Paul, Minnesota offering evidence-based alternatives to the mainstream model. “Another approach is that you could use dynamite,” he deadpans.

But he’s serious about the need for radical change. “There’s no such thing as an evidence-based rehab,” he says. “That’s because no matter what you do, the whole concept of rehab is flawed and unsupported by evidence.”

Unsurprisingly, Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers (NAATP), an organization that has represented rehabs like Hazelden and the Betty Ford Center (now merged) since 1978, doesn’t see the need for such an extreme makeover.

However, even he says that the industry is at a “crossroads,” and “we have bad actors out there.” He adds, “If our procedures for self-policing and transparency aren’t improved, the industry is going to be seriously harmed.”

I have covered addiction as a journalist for nearly three decades, and also have my own history of heroin and cocaine addiction, and of receiving treatment. With the input of longtime leaders in and critics of the field, here are my views on what needs to change.

1. Remove 12-step-related content from treatment—or at least, stop charging for it

In no other mainstream medical or psychological specialty are patients told that the best treatment for their disease is surrender to a higher power, confession and prayer—and, often, that if they don’t accept this method, the only alternative is “jails, institutions or death.”

And in no other area of medicine do insurers pay for hours of group “therapy,” films and lectures that consist overwhelmingly of indoctrination into the teachings of a self-help group, available for free in church basements. As I see it, this is not only a violation of the Eighth Tradition of Alcoholics Anonymous—which says that members should not be paid for their “usual 12th-step work” of helping other alcoholics and addicts get the program—but also a tremendous waste of scarce resources.

Ventrell disagrees, saying that “psychosocial care is not severable from 12-step care” and that 12-step rehabs like Hazelden provide a good model for treatment. But Willenbring argues, “We used to treat breast cancer with prayer, too. We don’t that do anymore.” He favors keeping 12-step programs and treatment separate.

We’re far from that, however. Currently, at least 80% of American inpatient and outpatient drug-free rehab is dominated by the goal of getting patients to accept the ideology of 12-step programs and to attend as aftercare. To my mind, while 12-step programs do help some people, there is absolutely no reason that taxpayers or insurers should pay for the exact same social support and information that can be had for nothing at meetings.

Instead, treatment providers need to cull from their programs the elements that are redundant with 12-step groups—and instead offer evidence-based therapies like cognitive behavioral therapy and motivational enhancement therapy. Patients don’t have the option of getting these for free outside of formal treatment—and the role of treatment should be provide professional medical and psychological care, not self-help.

Removing 12-step ideology from treatment will also allow for easier integration of medication and whatever new approaches research shows over time to be helpful.

2. Ensure access to maintenance treatment for opioid addiction

In any other area of medicine, if patients were not informed about a treatment that cuts mortality by at least half—while being given one that has no effect on it—it would be considered malpractice. And if there were a federal law that limited access to such treatment and said that doctors could only treat a limited number of patients… Well, there probably wouldn’t be one.

But in the addictions field—largely because the dominant abstinence-only model historically hasn’t recognized medication-assisted treatment (MAT) as an acceptable form of recovery—this happens almost every time someone with an opioid addiction enters an abstinence-only 28-day rehab, a detox or an abstinence-based outpatient program. As National Institute of Drug Abuse director Nora Volkow put it in testimony to Congress last year, for opioids, “treatment programs with an abstinence focus generally do not facilitate patients’ long-term, stable recovery.”

Research shows that people who stay on methadone or buprenorphine long term have half the death rate of those who detox from these medications or participate in abstinence-only treatment. (There is no similar data for antagonist medications, including Vivitrol).

Given this, stigmatizing maintenance or telling patients that it is “not really recovery,” is basically killing people. As is the federal cap on the number of buprenorphine patients doctors may treat for addiction in their practice, which was imposed when the FDA approved the drug for addiction and limits most doctors to 100 patients. Since some patients may stay in treatment for decades, the slots fill up fast.

Jeff Deeney, a social worker at a Philadelphia treatment program, is currently faced with the problem of the cap. “We’re dead stuck,” he says. “We have a line four blocks long on our waiting list. We’re maxed out. We’re trying to hire another doctor just to walk in and write scripts.”

President Obama should take executive action and end this arbitrary regulation immediately.

Thankfully, even many dedicated 12-step supporters have come to recognize the need for medication use. NAATP’s Ventrell says that “program integration,” is a critical part of improving addiction care, particularly “depolarizing” the clash between 12-step views and support for MAT. He states bluntly that if counselors or program management see it as being just another form of active addiction, “They’re not providing good care.”

Willenbring puts it even more strongly. “I think there needs to be a lawsuit against a prominent rehab for wrongful death and deprivation of informed consent and negligence,” he says, referring to cases where patients have overdosed immediately upon leaving and were not told that maintenance would reduce their mortality risk.

3. Fight corruption and unethical practices

In the past year, the addiction treatment industry—never trouble-free in the best of times—has been wracked by scandal. A New York Times front-page exposé revealed sickening conditions, kickbacks and even forcing addicts to relapse to stay housed in supposed “3/4 houses” in the city. The Huffington Post (disclosure: I’m interviewed) published an in-depth investigation of how people with addiction in Kentucky are mistreated and denied access to MAT.

Buzzfeed investigated overdose deaths, kickbacks and overcharging for urine testing in Delray Beach, Florida “sober living” homes, which were also the subject of 2014 FBI and IRS investigations. The Los Angeles Times revealed that the owner of a network of LA rehabs was being investigated by the state and the FBI, for, among other things, sexual relationships with patients, poor care and fraud.

And that wasn’t all. Longtime industry leader and Beyoncé-favorite Phoenix House was also investigated by Reuters for a patient death, for running facilities led by abusive staff and filled with drug use, assault and sexual violence, and for financial mismanagement.

Clearly, change is needed. Even the industry group, NAATP, wants federal regulation to ban practices like “patient brokering,” in which rehabs and sober living homes pay kickbacks for referrals to each other, without regard for whether a facility or service is appropriate for that patient. While the practice is illegal in some states, it is not against the law on the federal level. As Ventrell says, “It should be.”

Another common ethics issue involves misuse of the internet, with some rogue programs actually hijacking web traffic from other sites and transferring phone calls to their own agents. “Some horrible abuses have gone on there,” Ventrell says, noting that the only thing his organization can currently do about it is expel members if they are found to engage in such practices.

4. End the reliance on criminal justice system referrals

The great harm reductionist Alan Marlatt (RIP) frequently used an analogy that compared the rehab industry to other customer-focused businesses. A car company, he noted, faced with declining sales and lack of consumer interest, would not complain that customers are “in denial” about the quality of their vehicles. Nor would it try to have the government arrest people who refused to buy their cars. Instead, they’d improve their offerings—or, at the very least, their marketing and consumer outreach.

But the treatment industry has for too long relied on referrals from the criminal justice system to stay solvent. Because at least one-third of treatment slots—and in many programs up to 80%—are occupied by people whose only other alternative is prison, the industry has had little incentive to make itself warm and welcoming. Instead, it has frequently counseled relatives to practice “tough love” and stage “interventions,” where if the addicted person doesn’t immediately go to rehab, he will lose friends, family and possibly employment.

Several problems result. For one, since their biggest customer is often the criminal justice system, many programs shape themselves to its dictates. “The field has been so distorted by its dependence on the criminal justice system, which is really the client,” Willenbring says, contrasting it to other forms of medical care which have to work to attract patients. Since the criminal justice system is supposed to punish offenders, this leads to support for controlling, punitive and shaming practices in treatment, which are counterproductive.

This is problematic not only for people mandated to treatment, but for everyone else. Because research shows that empathy and rapport between clients and counselors is the best predictor of positive outcomes, a treatment center that is cold and punitive will be less effective on that basis alone.

Secondly, if a large proportion of the people in a treatment center have been forced to be there and only grudgingly participate, this can interfere with its ability to create a “safe space” for others. It’s hard to open up and be vulnerable while sharing deeply personal experiences of trauma when other patients are laughing or staring stonily at the clock.

One way around this is for programs not to accept coerced patients who haven’t been provided a menu of treatment options—a policy that would also improve drug court outcomes by better matching patients to treatment they prefer. This way, too, providers would have to compete for customers and the criminal justice system’s influence would be reduced. (Even better, of course, would be to decriminalize drugs, but that’s another column.)

5. End humiliation and confrontation

It’s been known for decades—as I showed in-depth in my 2006 book, Help At Any Cost: How The Troubled-Teen Industry Cons Parents and Hurts Kids—that confrontational and humiliating “attack therapies” are ineffective and often harmful.

Unfortunately, nearly all long-term residential treatment centers in America— i.e., “therapeutic community” programs that last three months or longer—were originally modeled on a destructive cult called Synanon. Most famous for placing a poisonous snake in the mailbox of an attorney who opposed it, Synanon was founded by an AA member who believed that the steps needed to be applied by force and that people with addiction needed to be broken down completely before they could recover.

Phoenix House, Daytop and Delancey Street were all directly modeled on Synanon—and any program that uses “marathon” therapy groups, “pull ups” (confrontations), makes patients wear degrading signs or outfits and has a hierarchy of positions through which patients rise towards graduation has its roots in Synanon, either directly or indirectly, through staff training. And unfortunately, these methods are also favored by some staff at 28-day rehab programs or intensive outpatient treatments.

While many have moved away from the most extreme tactics, a widespread belief that all people with addiction are lying “whenever their lips are moving” and a sense that negative experience is necessary to get people to realize that they need to change remains common. This is a barrier to successful treatment, because, as William White and William Miller show in this devastating 2007 paper, no study has ever found this approach to be better than kinder alternatives. More confrontation tends to lead to more drinking and drug use, not less.

If we want better treatment, the industry must treat clients with respect and dignity, and stop taking an attitude that the rest of medicine abandoned as harmful decades ago.

6. De-emphasize residential treatment

Research has long shown that in most cases, outpatient treatment is as effective as inpatient care for alcoholism and other addictions. Moreover, as noted earlier, when the substance involved is opioids, outpatient maintenance with methadone or buprenorphine cuts the death rate by at least half compared to residential or outpatient abstinence treatment.

Many people believe that since celebrities go to exclusive spa-like rehabs, this is the most effective type of addiction care. But the data doesn’t support this. “Staying overnight together confers no outcomes advantage,” Willenbring says, adding that research on learning shows that people do not transfer skills acquired in an isolated setting back to their daily lives where they are most needed.

“You cannot learn recovery skills in rehab,” he says. “The work doesn’t start till you get home.” Given that—and the expense of inpatient treatment—it makes sense to limit inpatient care to the shortest possible period necessary for medical stabilization. People also do better at recovering from all types of illness when they are surrounded by their loved ones and can sleep in their own beds.

Of course, for people who live with drug dealers and are in a social setting in which they have no friends or relatives who aren’t also drug buddies, a change of locale could well be beneficial. But that doesn’t mean that living in a treatment program that costs thousands of dollars a day for a month or longer is the best way to accomplish this.

7. Create truly independent accrediting bodies that are consumer-friendly—and national standards of care

Since I write regularly about abusive treatment programs—I’m talking places where beating, sleep-depriving, sexually humiliating and starving patients are seen as acceptable—I’ve had some experience with patients who have legitimate complaints. This is where program accreditors like the Joint Commission and CARF are supposed to come in. Being accredited by at least one of these organizations is supposed to be a sign that the program provides high quality treatment and treats patients with dignity and respect.

Unfortunately, one of the most abusive programs I ever wrote about—Straight Incorporated— was accredited by the Joint Commission at several of its sites. And as late as 2007, a copycat program was accredited by CARF.

At that time, it was extremely difficult for patients to navigate their websites even to figure out how to make a complaint—I’m happy to say that at least in terms of accessibility, that has changed and both groups now have easily located complaint forms. Still, even now, at least one program that was the subject of a major media expose involving serious patient safety and maltreatment problems last year remains accredited.

Further, in order to complain, consumers need to know which of these groups has accredited the program—and the accreditation process is still paid for and guided by the programs. Basically, this means that rehabs know in advance when they will be inspected for accreditation and that accreditors are financially dependent on the programs they are evaluating.

To me, this is a real conflict of interest. Given the fact that state treatment regulation is often lax and there are no federal standards even for basic things like counselor education, accreditation may be the only serious oversight some programs get. We need to make accreditors independent (or at least, less dependent) and ensure that consumer complaints about unsafe or harmful practices are easy to make and are taken seriously.

We also need national standards for counselor education, for best practices in all types of treatment and for informed consent regarding options like medication. All counselors need to be educated about all aspects of addiction, not just their own recovery—and especially, about mental illness and what they are and are not equipped to treat without medical supervision. We should create scholarships to ensure that people in recovery can get the education they need to qualify and create staff positions that allow for various levels of education—but we should not have lower standards for addiction care than for other specialties.

8. Expand harm reduction

It’s completely outrageous that it took 27 years for the federal government to finally end its ban on funding needle exchange programs, which happened last December. Even when the ban was first passed in 1988, it was already clear from European data that the programs worked. It took an HIV outbreak in Indiana that infected 175 people last year to finally wake recalcitrant Republicans up.

But expanding needle exchange to where it is needed across the country is not enough. We also need to start providing safe injection facilities (like this one in Canada, which cut local overdose rates by 35%) make naloxone as accessible as possible (including to opioid-addicted people leaving abstinence programs and incarceration) and integrate harm reduction ideas into the treatment system so that people who are not ready for abstinence have options other than simply continuing without medical care.

Of course, none of these eight changes are easy to make, and there are substantial institutional and ideological barriers to many of them.

But even just one—done thoroughly—could have an enormous impact on the quality of addiction care in America. And if all of them were made, the system would be transformed—with or without a bulldozer.

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 Post subject: Re: The Rehab Rort
PostPosted: Tue Jun 20, 2017 10:02 am 
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Thanks Amy, I'm going to send this to the upper echelon at my group.
Mark Willenbring and I crossed paths briefly at the VA in the 90's. He is an excellent and compassionate clinician.
From near the end of the author's first point
Quote:
Instead, treatment providers need to cull from their programs the elements that are redundant with 12-step groups—and instead offer evidence-based therapies like cognitive behavioral therapy and motivational enhancement therapy. Patients don’t have the option of getting these for free outside of formal treatment—and the role of treatment should be provide professional medical and psychological care, not self-help


I would point out the SMART Recovery uses CBT and is free. The leader at the group I attend is also well versed in motivational interviewing.

PAX


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 Post subject: Re: The Rehab Rort
PostPosted: Tue Jun 20, 2017 10:09 am 
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I always had this image in my mind of what inpatient rehab was like (Sandra Bullock in 28 Days)..... and then I went. My several inpatient detox stays (different places than where I attended rehab, different city too) weren't what I was expecting either. I understand that things are usually different than movies or commercials portray them or ppl describe them, but I still expected individual therapy. That never happened.

Going through detox for 5 days was actually the only part I remember being able to eat and function. Whatever they were giving me was great because I wasn't sick at all. The second detox stopped, I never felt better again. I got in trouble for not eating, threatened that I'd be discharged if I didn't eat. I couldn't eat because my cravings and anxiety were off the charts. I had a panic attack and was told if I went to the emergency room, they'd definitely not give me anything especially since I was from the rehab facility. I never wanted to go to the ER anyway, I just wanted some type of relief from cravings that were literally making me crazy. I was struggling with cravings and that caused me to not eat, not sleep, not shower, not socialize with anybody and I sure couldn't focus on meetings. And it was meeting after meeting after meeting. I think they replaced individual treatment with meetings all over the city. Here we'd go in a van, running all over the city to meetings.... every day except Sunday.

Look I'm not trying to say that the ppl that worked there didn't do their job well because they did what they were told to do and I was treated decent. But no individual counseling? Really? To be treating addicts that's addicted to different things...... opiates, alcohol, cocain, meth and benzos.... some may need a little different attention and if there isn't enough counselors to do that, then hire more. Heck with the money it costs to go to inpatient treatment, I should have had a counselor following me around as my personal sober coach lol.

If I'd had the opportunity to attend a rehab that offered buprenorphine treatment, I would have thrived and I probably wouldn't have had an awful relapse months later. So I feel like all the money and time that came out of attending rehab was a total waste for me personally.

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 Post subject: Re: The Rehab Rort
PostPosted: Tue Jun 20, 2017 11:09 pm 
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jennjenn wrote:
Look I'm not trying to say that the ppl that worked there didn't do their job well because they did what they were told to do and I was treated decent. But no individual counseling? Really? To be treating addicts that's addicted to different things...... opiates, alcohol, cocain, meth and benzos.... some may need a little different attention and if there isn't enough counselors to do that, then hire more. Heck with the money it costs to go to inpatient treatment, I should have had a counselor following me around as my personal sober coach lol.


It comes down to $ for them I think. Also the 12-step paradigm is definitely "one size fits all" and doesn't require any 1-to-1 work aside from sponsorship.

This is why these 12-step based rehabs make so much money. A lot of them are simply a safe (though that's questionable) drug-free environment whose only program is taking people to meetings and introducing them to the steps, which as we know is completely FREE and costs the facilities nothing aside from petrol to transit minibuses full of recovering addicts to and from meetings.


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 Post subject: Re: The Rehab Rort
PostPosted: Wed Jun 21, 2017 10:10 am 
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Yes teejay that's exactly how mine was. U said it perfectly.

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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
  • Asst Clinical Professor, Medical College of Wisconsin

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