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John Oliver on Rehab. Nailed it!

The Rehab Industry Needs Rehab

This past week John Oliver took an in-depth look at the rehab industry. As a former Medical Director for a residential program, I appreciated his critical analysis of the industry. Like all businesses, there are both good and bad players. But when your business model thrives on your customers failing and needing your services again, we need to look critically at their motivation. I can summarize the motivation of the rehab industry; bill insurance as much as possible, for as long as possible. There you go, I said it. This is what I saw when I was a medical director and this is why I’m not doing it anymore. There is fraud, insurance abuse and lack of oversight in this industry.

My absolute favorite part of this segment is when they interviewed the folks at the super expensive $70,000/ month rehab. The owners make the straight-faced claim that they ” cure addiction” in 30 days. Really? Is that how they sucker you out of 70K? Unfortunately, desperate patients and their families believe them. I have met many families over the years who refinanced their house or cashed out retirement in order to pay for treatment; only to have it fail…again.  They weren’t cured and they are a lot poorer for it.

Why do we tolerate this in the drug and alcohol field? People wouldn’t stand for this with any other disease process. Would a cancer treatment center say they’ll treat and cure your cancer in 30 days? Then when they ultimately fail, you can pay to have them try again? Really? We’ll cure your diabetes in 28 days!. It’s just stupid and goes against everything we know about addiction being a chronic disease.

There are people who desperately need a supervised medical and structured program in early recovery. These patients simply don’t have the life skills or environment where early sobriety is possible.  They do need a residential program. However, this represents a small percentage of patients needing a recovery program. Most patients have a job. Most patients have a place to live. Most patients have some family support and some amount of resources. (transportation, food, housing, some money). It seems to me, almost everyone who has insurance looking for recovery gets recommend for a residential admission.  ASAM, The American Society of Addiction Medicine, has industry standard evaluation tools that help us objectively determine the level of care a patient needs when a patient decides it’s time to get sober. What I’ve seen is that if you have insurance… you need a residential program. As Trump would say; ” Sad!”  It’s like asking a barber if you need a haircut.

Outpatient programs cost less money and have better outcomes compared to residential programs.  Outpatient recovery programs can teach patients the tools they need to achieve real, authentic and lasting recovery on life’s terms, not in a secluded, insulated, and controlled setting. This is why the insurance industry isn’t paying what they used to for residential treatment. Insurance companies in the heyday would cover 30, even 60 days. Now they typically cover a week, maybe two at the residential level then step the patients down to PHP (partial hospitalization) or IOP ( Intensive outpatient program) care; both “outpatient” programs. I’ve heard one employee say that if a patient can get up, shower and eat they get stepped down.

John Oliver didn’t even focus on the fact that many counselors at recovery programs may have been sober for only weeks or months. Many of these staff have no formal education. Some rehabs offer their own ” certification” for their newly graduated residents to lead recovery groups. Now you can see how the money flows. Programs can pay an unlicensed recovery “coach” $15/hr to lead a large group of patients each paying thousands of dollars a day. Do the math.

For comparison, all of my therapists are licensed clinicians with a masters degree or higher. We don’t have interns or ” drug counselors”. I only send urine out for confirmatory drug testing when medically necessary. The pharmacists in our community trust my prescribing and physicians in our community trust our medical practice.

We are essentially the last card standing in our county. A busy outpatient practice in my community was just shut down for concerning prescribing habits and an outpatient program was closed down because the owners got indicted for fraud. They were billing insurance for urine samples that weren’t necessary, getting kickbacks from the lab, and falsified documents. I’m  now the only physician in the community focusing on addiction treatment.

As an industry, we need to be truthful with our patients, families, and communities. We need to provide the appropriate level of service and care to those suffering from addiction and do an honest ” inventory” of ourselves. Making absurd claims about curing addiction, advertising high percentage statistics of treatment successes, or putting patients at a higher level of care then medically necessary does more harm than good.

Like with any medical disease and it’s treatment, start with the simple and basic things first. Treatment can escalate and intensify as medically necessary. And as with any serious medical disease, it all starts with a thorough and accurate assessment of the underlying problem.

Ken Starr MD


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