Medical management of chronic disease is a mess

Push_vs_Pull_MarketingSenator Ron Wyden, with a focus on seniors, examines the problems Americans face with medical management of chronic diseases.

The struggles that people with chronic illness face are manifold. One problem is coordinating care. It’s hard enough for somebody who’s perfectly healthy to assemble medical records for a new doctor; consider how difficult it must be for an elderly woman who recently suffered a heart attack. Think about her journeying to a doctor appointment across town in the middle of the day. Or filling a hard-to-find prescription and adding it to an already-daunting battery of pills.

America’s health care system tells millions of seniors they’re on their own when it comes to managing their chronic illnesses. The result is a full-time job and far too many chances for dangerous errors and missteps.

Today, Medicare inexplicably charges older Americans a copay just to coordinate care among all their doctors. Doesn’t it defy common sense for seniors to pay extra for care coordination that holds costs down? In my view, this charge should be junked, and care coordination should begin right after seniors receive their free physical provided by the Affordable Care Act. This is one of many commonsense changes to Medicare that could improve the lives and health of seniors with chronic diseases, many of whom have stories all too familiar to every American family.

As Seth Mnookin shared last week, coordination of care is a huge problem. And, as Sen. Wyden’s article suggests, there’s little reason to believe care coordination would be much better if addiction treatment were housed within a doctor’s office.

This is an urgent need in the lives of many people with addiction. There are efforts to improve this inside and outside of traditional medicine. We started a primary care project 5 years ago to get all residential clients connected to recovery-informed primary care and improve coordination of care. It hasn’t been perfect, but there’s a stark difference between today and 2010. If only we could extend that into the rest of their medical care—specialists and emergency medicine.

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A Systems Approach Is The Only Way To Address The Opioid Crisis

wp17a759ca_05_06Health Affairs has a great summary of a recent report on the opioid crisis.

It identifies “six key components to develop a system-wide community solution.”

  1. Recognize That Everyone In Your Community Has A Role To Play
  2. Work Together
  3. Work On Multiple Parts Of The System Simultaneously
  4. Be Unambiguous About The Risks Of Prescription Opioids
  5. Re-Train The Medical Community
  6. Recognize That Addiction Is A Chronic Disease, And Treat It Accordingly

Read the article for details.

The most striking thing is a table that identifies objectives, actions and actors. Nothing groundbreaking, but it does s really nice job of pulling together the multiple needs and systems in one place.

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Sentences to ponder

photo credit: sarcasmo

photo credit: sarcasmo

On the Stanford rape case [emphasis mine]:

When Brock Turner sexually assaulted the woman now famous for her seething court statement about the crime, at least two other men had also seen her lying unnaturally still behind a dumpster near a fraternity house on the Stanford University campus. But while much has been said in recent weeks about the lax sentence Turner received, little attention has been paid to the fact that what he did was way worse than a sexual attack on a drunk woman unable to consent. It was actually an assault on an overdose victim, one who was at risk of serious medical problems and even death if she didn’t get help fast.

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Another day, another recovery hustle

51T1SeT4LRL._SX345_BO1,204,203,200_HuffPo has a new article on ethically impaired treatment providers:

The opioid epidemic, which just added Prince to its list of victims, has shoved the addiction industry into the spotlight, and many here at the National Association of Addiction Treatment Providers conference worried aloud how the industry’s lax ethical standards would look in the new glare.

Nor is greater attention to ethics the providers’ only threat. Drug treatment is now big business, and a wave of consolidation is sweeping the industry, as private equity firms and publicly traded companies look to cash in on the surging rates of addiction. Federal regulators, meanwhile, are pushing to reform the very nature of the services offered by treatment centers.

How the addiction industry faces up to all these changes will help set the course of drug treatment for years to come.

It hits upon two themes from yesterday’s post. First, patient recruitment and expensive IOP:

Among the more abusive practices the NAATP is trying to root out is “patient brokering,” which several conference attendees told The Huffington Post should be more accurately thought of as “human trafficking.” Art VanDivier, chair of the NAATP’s Ethics Committee, said the going rate to steer a patient with Affordable Care Act coverage to a particular facility is now $7,000. That sounds like a lot of money, but the clinic can bill the insurer $15,000 to $30,000 for a month of treatment, charge for lucrative drug tests along the way, and then bill for eight or so weeks of intensive outpatient treatment.

It also discuss internet marketing concerns:

Another area of concern is the twist that online marketing has taken. Try it for yourself — hop over to Google and search for addiction treatment options in your area. Chances are good that most of the results you’ll get will have gamed their way onto the list, and none of them will actually be in your area. Third-party sites that present themselves as independent aggregators of information are often run by a single treatment center, and every phone number routes to it rather than to the various clinics the site purports to link to. “Closers” on the other end of the line are charged with persuading the family in crisis to send their loved one to that single center — even if they may be located far away. (Indeed, the distance can be sold as a positive, since removing the patient from negative influences can be beneficial.)

Unfortunately, the writer conflates 12 step facilitation (which is evidence-based) with these ethical failings, weirdness and zealotry.

UPDATE: It’s also unfortunate that they frame maintenance as the gold standard without any context. Of course, addicted physicians do not receive maintenance treatments, there’s a different gold standard for them.

UPDATE 2: It’s not enough to give the impression that people who believe residential and 12 step facilitation should be part of the continuum are weirdos and zealots. The author, while promoting his article, has now tweeted that “Industry leader says on the record he refuses to judge success ‘by who doesn’t die'”. It sounds like the guy was trying to make a point about quality of life, but it was a stupid comment nonetheless.

Who is this industry bigwig? Someone I never heard of and had to google. Turns out he’s the Director of Spiritual Care at Caron. “Industry leader.” smh


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Another hustle. “This is predatory.”

51T1SeT4LRL._SX345_BO1,204,203,200_Alcoholism and Drug Abuse Weekly (ADAW) posted an article that describes the system used by a Florida treatment program to fill beds with insured clients as an out-of-network provider. They want out-of-network admissions because they do not come with managed care restrictions. ADAW describes their approach as “not unusual for the field.”

The fact that virtually all Banyan patients have out-of-network insurance is by design — out-of-network insurance is the best kind from the provider’s point of view, as there are no cost limitations based on contracts. The main referral source is in Illinois, where Tim Ryan operates as Banyan’s Midwest regional outreach coordinator, a full-time salaried position. Ryan told us that he refers people with good insurance to Banyan, because that’s his job.

. . .

The vast majority of patients Ryan, who has no clinical credentials, refers to treatment have no insurance. He has a not-for-profit that, according to Banyan and Ryan, is independent of his work for Banyan, called the Man in Recovery Foundation. Through this, he attracts people who need treatment.

. . .

Ryberg [an industry consultant] grew up in the area of Chicago where Ryan is operating, and got sober there. He has heard about the Man in Recovery Foundation’s “outpatient groups,” which are used as recruiting mechanisms for patients. “In no way, shape or form does the job they do resemble a typical clinical outreach representative in the industry,” he said. “They’re not clinical, and they’re not sending clients to the appropriate level of care based on need. This is predatory.”


The Chicago Tribune ran a similar story months ago:

Ryan heads a Naperville-based nonprofit dedicated to aiding people with drug problems, but he also has a job marketing a $15,000-a-month rehab center in Florida. The line between those roles is blurry to some critics, who say it could create a conflict of interest.

. . .

The for-profit rehab, which opened in 2013, is one of hundreds of treatment centers in the state. Like many others, it follows the so-called “Florida Model,” in which patients receive therapy at a clinic but live in offsite apartments.

The arrangement allows patients to stay much longer than the typical 28 days of inpatient care, said John Lehman of the Florida Association of Recovery Residences. Low costs and substantial insurance reimbursements have turned such treatment centers into a lucrative business, he said, and many market their services far beyond the state’s borders.

That strikes a nerve with some Chicago-area rehabs — “I find it hard to believe that people need to leave this immediate area in order to get very effective and caring service,” said Pete McLenighan of Joliet’s Stepping Stones Treatment Center — but Banyan owner Joe Tuttle said leaving home can be good for someone seeking sobriety.

“We’re selling (the idea of) getting away from your environment,” he said. “If your friends are using, you’ll probably be using, too.”

Since joining Banyan 15 months ago, Ryan said, he has referred more than 100 people there, some of whom he met through his charitable work. Such an arrangement strikes some in the recovery community as problematic.

What’s the consequence of this?

“The sad thing is, someone sees a TV show [Ryan was recently on Steve Harvey] or a video [Ryan has several], and they make that call,” said VanDivier. “It’s an uninformed panic-stricken consumer out there, and that’s what these guys take advantage of.”

John Lehman, president of the Florida Association of Recovery Residences, told ADAW that lack of education among patients and family members is the systemic problem. “They go Google, and boom, they make a decision,” he said. “As an industry of ethical operators across the country, we should be building an infrastructure that supplants their SEO methods and gets them to a site that educates them on the levels of care, on the appropriate care for the individual, how you go about choosing a program,” he said.

That reference to SEO reminds me of this post and a conversation I had with a rep for program that had something like 6 boutique treatment sites and some ridiculous number of websites to market them.

What will the long term consequences be? It’s hard to know for sure, but I’m pretty certain that it will damage the reputation of all treatment providers (residential, in particular), damage the public perception of recovery, and give insurers reason to clamp down sufficiently indiscriminate manner that will make it more difficult for everyone to access higher levels of care.

I don’t know anything about Tim Ryan or Banyan Treatment Center. But, I do know there are a lot of hustlers out there. Many of them are well-intentioned and want to do good and make a little money at the same time. Unfortunately, many of these people, for a variety of reasons (some financial, some personal) end up in ethically troubling places.


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Methadone retention

evidenceMAT advocates frequently accuse me of “cherry picking” articles that paint a distorted and negative view of MAT. The irony is that most of the articles I link to are pointed to as evidence of MAT’s effectiveness. I’m just looking deeper into what the article actually says.

BASIS just shared an analysis of a new article about methadone retention. I’m not going to comment, just highlight some of the content.

The article starts of with this introduction:

Did you know that methadone maintenance treatment (MMT), is one of the most effective treatments for opioid use disorders, especially when patients stay in treatment for at least 12 months?

What’s behind that link to “most effective treatments”? (Those are not intended to be scare quotes. Just trying to keep the source clear.)

The effectiveness of MMT is most apparent in its ability to reduce drug-related criminal behaviors. MMT had a moderate effect in reducing illicit opiate use and drug and property-related criminal behaviors, and a small to moderate effect in reducing HIV risk behaviors.

It’s important to note Looking beyond the abstract of that “most-effective treatments” meta-analysis, here’s a little more on the issue of methadone’s effects on criminal activity:

The inability of methadone maintenance intervention to produce a consistent and substantial effect on both drug-and non-drug related crimes, when considered together, suggests that treatment effects are restricted to those crimes that are associated with drug use, and that some opiate-dependent individuals may have a propensity to engage in certain criminal behaviors not directly related to drug use. Indeed, many studies report a negligible effect on non-drug-related crimes, while reporting a significant effect on drug-related crimes (e.g. Cushman, 1971; Jacobs et al., 1978; Bale et al., 1980), with one study noting an increase in non-drug-related crimes after admission to methadone maintenance treatment (Boudoris, 1976).

The “most-effective treatments” meta-analysis does have a line that speaks to the relevance of the retention article that BASIS is analyzing.

Findings from these analyses must be generalized with caution. The majority of studies included in the analyses examined the status of only those participants who remained in treat- ment throughout the entire period of assessment, and excluded those who left treatment during the intervention period. It is quite probable that those participants remaining in treatment throughout the assessment period represent a more  “successful” subset of participants.

Ok. Back to the BASIS analysis of the retention study. What were the retention findings?

Almost 50% of the patients were still in treatment 6 months after starting, and about 20% were still in treatment at 12 months.



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Recovery hustlers

51T1SeT4LRL._SX345_BO1,204,203,200_There’s more attention on addiction, treatment and recovery than there has ever been. It’s a good thing that brings some bad things. One of the bad things is the emergence of recovery hustlers. Some are exploiting it as an opportunity for profit and others are exploiting it as an opportunity for attention.

NPR just ran a story on big investors that are seeing big financial opportunities in addiction treatment, but is it good for patients?

Linda Rosenberg, president of the National Council on Behavioral Health, which represents non-profit addiction treatment programs, worries that private investors are too focused on the profitable inpatient beds and will neglect the services that help patients re-enter society.

“After rehab, you come back to your family and your family knows very little,” Rosenberg says. “You need a job, you need health insurance, you need medication-assisted treatment for addiction, you need counseling.”

She says there’s very little private investment in all that.

“I think that’s the biggest danger,” she says.

What’s the difference between a hustler and provider? Hustlers focus on profit over care.

I recently worked with a man who had been in one of these very expensive programs for months and said that, while in treatment, he expressed concern about his unemployment and insurance running out. They told his to not worry about that and to make recovery his priority. Once his insurance ran out, they discharged him. He was thousands of miles from home and relapsed on his way back. I contacted the program to see if they could offer him any help. They said they would not provide un-reimbursed services and suggested that he contact the alumni association for peer support. They said that they were trying to develop relationships with sober housing providers. I ended up putting him in touch with our intake staff to get on our scholarship wait list. He ended up going with Salvation Army because he could get in immediately. (Especially unfortunate, because he’s gay and not religious and his only option was a religious outreach.)

In that NPR story, the president of a small multi-site provider share his experience of exploring a sale to a larger provider/investor.

And that’s exactly what Tamasi found.

When he met with the first group of investors, he learned they only wanted to buy Gosnold’s money-making programs — inpatient detox and rehab, “A detox setting or a rehab program, they have a much wider stream of where revenue can come from,” Tamasi tells Shots. “They’re covered by insurance, people are willing to pay for it if they have the resources to pay for it.”

The investors didn’t want the prevention programs, the long-term care or the school-based programs. They didn’t want to invest in the recovery managers that help people get back on their feet once they get out of rehab.

But Tamasi thinks those things are important, so he didn’t sell.

“They’re almost like investments that a community-minded provider would make in order to do the things that they think the community could use,” he says


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