I've worked in the substance abuse treatment and research field for quite some time. At this point, there are a few indisputable truths about this disease. One such truth, based on extensive research, is that longer times in treatment produce better outcomes. The longer a person stays in treatment, the higher the likelihood of sustained recovery and the lower the rate of relapse.
The National Institute on Drug Abuse (NIDA) says that the appropriate duration of treatment for an individual depends on the type and degree of the patient's problems and needs. Research indicates that three months in treatment is the minimum "dosage" needed to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment. It truly is an individualized process.
But with the nation in the midst of an explosion of opioid problems that many are saying are at "epidemic" levels, health insurance companies are seeing a surge in substance abuse treatment claims. Claims are also increased, in part, because the ACA requires everyone to have coverage and allows parents to keep their adult children on their policy until the age of 26, and patients (and their parents) are trying to use their insurance for its intended purpose: to access care when they are sick.
As an experienced professional with over 30 years in this field, I wholeheartedly embrace and practice the application of evidence-based treatment and acknowledge that this can be delivered in various modalities and levels of care. Medication-assisted treatments (like methadone and buprenorphine products) and outpatient programs are important parts of the continuum of care. But they cannot be the ONLY insurance-covered options for individuals struggling with addiction.
An analysis of treatment for cocaine dependence noted, for example, that patients with more severe drug problems were more likely to benefit from long-term residential care than from less intensive levels of care. Similarly, an analysis of patients in a VA program suggested that those with more severe alcohol or drug problems had better response when treated in residential settings than in intensive outpatient programs (IOPs). The authors of one study that compared residential treatment to IOPs acknowledged that "current literature suggests that a wide range of service intensities can be effective for individuals with substance use disorders" and that there is "substantial variability."
So what might motivate an insurance carrier to favor one type of treatment over another? Effectiveness? Consumer satisfaction? Not quite.
Our nation is in the throes of an opiate epidemic that has affected millions and is disproportionately affecting our young adults. Nearly 30,000 people died from opioids in 2014, the highest on record. This, combined with the above-mentioned surge in covered insureds, means that droves of people are seeking treatment. And their lives come down to the almighty dollar.
Because opiate/heroin withdrawal is not directly deadly, most insurance companies decline to pay for inpatient detoxification or rehab. They either claim that the insured individual who is addicted to heroin or prescription painkillers does not meet the criteria for medical necessity -- that inpatient care would be an unnecessary treatment -- or they require that the user first try outpatient rehab and "fail" before he or she can be considered for inpatient.
This "fail first" practice used by insurance companies to pay for the minimum level of care until a patient relapses and requires more treatment is killing people, quite literally. People with opioid problems die while waiting for treatment every day. Imagine, for a moment, if I was told to attend some healthy lifestyle classes or go to a self-help meeting to correct my severe heart disease rather than immediately going in for the more intensive but medically necessary stint or bypass surgery? To deny all individuals the option of residential treatment because some will be able to manage in an outpatient setting is but one example of the ongoing stigma of addiction, and too big a gamble in my opinion. When is the last time a cancer patient was told to "fail first" with chemotherapy prior to getting lifesaving surgery? Just like the cancer patient, the substance abusing patient may die while waiting to "fail" in a level of care that's been unsuccessful multiple times.
This is not one-size-fits-all health care. If we want to put a dent in our current drug crisis, we're going to need a multi-faceted treatment system and insurance coverage we can count on. Let's not forget that when someone with a substance use disorder gets effective treatment and goes on to enjoy a life of recovery, everyone wins: the individual and their family members who have a better life, the insurer won't have to pay for repeated episodes of care, the employer who now has a valuable, reliable employee, law enforcement who no longer has a substance abuser draining legal resources, the community who has another tax-paying citizen, and so on. We all benefit when someone gets the right level of help they need. And we should expect and settle for nothing less.
Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.