My Learnings About the Addiction Treatment Industry
Alexandra Piersiak, Marketing & Member Engagement Eleanor Health
Today marks my 90th day at Eleanor Health.
Until 90 days ago, I had spent my entire career in orthopedic medical device marketing. I could tell you everything you wanted to know about differing alignment techniques in total knee replacement or the benefits of various surgical approaches for total hip replacement, but substance use disorder (SUD) treatment…this was new for me.
To commemorate my first 90 days at Eleanor, I wanted to share some of my learnings about the addiction treatment industry.
Learning #1 — There are no universal clinical or accreditation standards for providers of addiction treatment.
This lack of regulation has led to excessive patient billing and even insurance fraud, particularly as it relates to the overuse of urine drug screens (UDS). Some patients are even encouraged to relapse so that facilities can re-admit them and generate additional insurance claims. In many states, laws prohibiting commissions and kickbacks in exchange for patient referrals are not strong, and licensure requirements vary from state to state, leading to deceptive marketing practices and patient brokering. In states like Florida and California, for example, some types of sober-living homes and programs don’t have to be licensed, creating a very low barrier to entry to the market.
In addition to under-regulation & low barriers to entry, market demand for addiction treatment is expanding drastically as a result of the opioid crisis and expanded insurance coverage mandated by the Affordable Care Act. This environment has attracted a rapid influx of new, for-profit treatment facilities that offer exclusive, resort-like accommodations that guarantee success in their advertisements, yet offer little in the way of evidence-based treatment or demonstrated clinical outcomes.
In the absence of regulation, it is nearly impossible for patients and their loved ones to distinguish between reputable, evidence-based providers and shady treatment centers that are commoditizing patients.
Learning #2 — Only one in ten Americans with SUD receive treatment, and of those that do, very few receive care that is grounded in science & evidence.
Scientific evidence has shown that SUD is a chronic illness affecting the brain that can be effectively treated with long-term care. Addiction is not a moral failing, a character flaw, and most importantly, it is not a choice. It is a chronic disease just like diabetes or asthma. SUD is highly stigmatized and associated with social disapproval, discouraging people from engaging in treatment and oftentimes inhibiting the delivery of evidence-based treatment, including medication-assisted treatment (MAT). MAT is the use of medications to treat addiction. These medications, including suboxone, vivitrol, and buprenorphine, help reduce cravings, prevent overdose, and in some cases, block the effects of alcohol & opioids.
Research shows that customized, comprehensive treatment programs that include MAT, counseling, psychiatry, and connection to community resources can successfully treat SUD. In fact, MAT is clinically proven to reduce the risk of overdose death by 50%.
Many agencies, including the American Academy of Addiction Psychiatry and the Substance Abuse & Mental Health Services Administration (SAMHSA), recommend MAT as a first line of treatment. So, why aren’t more providers & treatment facilities using it? While most doctors can prescribe opioids to treat pain without restriction, physicians must become specially certified to prescribe addiction medications. Due to the restrictions on who can prescribe MAT, facilities aren’t able to offer this as an option to all patients for which it may be clinically indicated. Moreover, cultural barriers exist that further inhibit the use of MAT, including clinician resistance due to personal beliefs.
Unfortunately, once someone with SUD finds a provider that can and is willing to prescribe MAT medications, they are still not guaranteed to receive them as many insurance plans and commercial programs don’t cover all medications, and many differ on whether prior authorization is required.
Learning #3 — Many addiction treatment facilities fire patients when their illness relapses.
Yes, you read that correctly. At many addiction treatment programs, the firing of patients goes by a different name, including “administrative discharge,” “discharge for cause,” “disciplinary discharge,” or “discharge upon staff request.” The criteria for these “discharges” vary across treatment programs, but generally include something about using alcohol or unprescribed substances. So, if a person’s illness relapses while in treatment, they are at risk for being “discharged,” or a nicer way of saying “kicked out.”
Addiction is a chronic illness, and relapse is a symptom of that illness. In fact, the National Institute on Drug Abuse estimates that roughly 40–60% of people who’ve gone through treatment for substance misuse will experience relapse. Moreover, relapse rates for addiction are similar to those of other chronic diseases including diabetes & hypertension.
Relapsing means someone needs more help, not less. Relapse means that treatment plans need to be adjusted, not completely eliminated. Would we deny a cancer patient treatment because their disease relapsed? Would we deny a diabetes patient access to insulin if they are eating too many sugary foods?
Learning #4 — Addiction treatment is largely billed on a fee-for-service model, with very few insurers and providers moving towards value-based care.
Many other healthcare verticals have shifted towards value-based payment models, which tie provider reimbursement to clinical outcomes, incentivizing providers to deliver higher quality, coordinated care at a lower cost. While these models have the potential to significantly improve the quality of addiction care, the industry predominantly operates in a fee-for-service (FFS) model.
In a FFS model, providers are reimbursed for each service they provide, such as the administration of a UDS or an individual therapy session, which places emphasis on the volume of services instead of the value of care.
Not only do these FFS models encourage volume of services, they create additional barriers to treatment for people with SUD. Addiction presents differently in every patient, and in a FFS environment, providers don’t have the flexibility to meet the varying needs of those patients and create personalized care plans. Additionally, like any chronic illness, SUD requires long-term management, creating financial barriers for many patients.
It is also important to note that there is no national standard of care in addiction, and outcomes data by provider or by facility is not publicly available. Outside of Eleanor Health, I’ve yet to find a treatment program or facility that regularly publishes its clinical outcomes.
Learning #5 — Eleanor Health’s mission is to help people affected by addiction live amazing lives, and Eleanor has the capacity to change the landscape of addiction treatment.
If you are interested in learning more about substance use disorder and the treatment industry, here are some resources that I’ve found useful in my education journey.
