The Addiction and Treatment Epidemic

I have been following with great interest the hard-hitting investigative series on the addiction treatment industry in South Florida currently running in the Palm Beach Post. “Addiction Treatment: Inside the Gold Rush” takes a critical look at the booming recovery industry in South Florida.

As many are all too painfully aware, opioid addiction in this country is out of control. It’s a national epidemic and not a day goes by when the news of another overdose isn’t published in the paper or reported on the news. But, what might come as startling news to many is the lengths to which those in the recovery business are going to in order to capitalize on those suffering with the disease of addiction.

As the Post reminds its readers, recovery is big business in South Florida—over $1 billion dollars annually—and the fourth largest industry in Palm Beach County.  But what is really troubling, is that the paper has uncovered that “reports of kickbacks, patient brokering, inflated medical testing bills and insurance fraud are rampant” while at the same time, unlicensed sober homes and drug testing labs are popping up on every corner.

As someone who oversees the management of a reputable drug detox center, I am outraged at what I read and praise the Post for shining light on this criminal behavior.

After reading the newspaper’s series and in the wake of the death of another superstar—Prince—seemingly to drugs, I wondered again what those of us in the health care industry can do to help combat the problem of addiction.

Here in Florida, our Attorney General made huge strides in getting drugs off the street by cracking down on illegal pill mills. However, closing this drug pipeline resulted in addicts seeking drugs in emergency rooms, urgent care centers and physician offices or turning to heroin as it is easy to get and very cheap. What should have happened in tandem with the crack down on pill mills, was a push to improve access to effective treatment. There is very little support at both the state and national level for medically-supervised treatment and that needs to change.

We also have the problem of the ease at which doctors dole out pain medication. While I believe that the vast majority of physicians are prescribing these medications for the right reasons, the reality is that these drugs are highly addictive. We need to put systems in place to identify and help patients who might be heading on the path of addiction before it is too late. We also need to offer support and education to our doctors on the dangers of dispensing these drugs.  Finally, we have to realize that addiction is a long-term battle that needs to be fought on many fronts—from hospitals, to outpatient clinics to behavioral health programs and related treatment centers.

Where Do We Go From Here?

There is no denying that the Affordable Health Care Act is one of the most hotly debated issues in this year’s presidential election. It is also true that it has increased access to health care for millions of Americans. However, many questions remain when it comes to the health care law of the land. “Has it improved the quality of care that patients receive?” “Has it provided adequate coverage for a class of previously uninsured Americans or has it simply created a class of the under insured?” “Does the law do what it set out to do or will it have created a system so problematic that we won’t realize it until there is no turning back?”

Here’s the reality. We now have millions of underinsured Americans enrolled in health care plans through exchanges that don’t provide adequate coverage. The only coverage most of these Americans can afford is in the form of high-deductible bronze and silver plans that push upfront “first coverage” cost onto the consumer and only provide catastrophic coverage. Many times, this results in the inability for these patients to pay the collectable portion of their care and leaves the hospital or medical provider holding the bag. In fact, a recent study from Citi predicts that bad debt could reach $200 billion by 2019, making it more likely for providers to reject patients enrolled in these plans.

In addition, as many of these underinsured Americans are also newly insured, they have not received ongoing preventive care, often resulting in a higher number of claims when first insured. In fact, the largest health insurer in the United States, United Health Care recently announced that it plans to exit most exchanges by 2017, having previously stated losses of upwards of $475 million in 2015 and projecting $500 million in losses this year.

Finally, what has also started to happen is that commercial insurance companies are coming to hospitals asking for the hospital to take less reimbursement for the claims through the insurance exchanges in which they participate. The reality is that payments made by the commercial insurance companies have historically helped to subsidize the gap between government support and the uninsured.

Yet, amidst the financial losses has come an increase in quality of care provided. This is, in part, due to the increase in the consumer-driven marketplace and a shift from volume to value. Also, as part of new payment models from the Centers for Medicare and Medicaid Services, the government has put incentives in place that reward those who provide better outcomes for their patients, less complications. This has also changed the way we orient around the patient and the quality of care we provide. In fact, there has been a 17% reduction in hospital-acquired conditions since 2010, which seems to imply that the increased pressure on hospital safety has positively affected patient care. In addition, CMS’ Bundled Payment for Care Improvement Initiative links payments for multiples services a patient receives during an episode of care. Here, medical providers enter into payment arrangements that include financial and performance accountability for episodes of care. This payment model is most commonly put into practice in regards to an orthopedic procedure. By bundling payments for the services around, say a knee replacement, quality of patient care is likely to increase while there is likely to be a reduction in cost.

So the real question becomes: how do we provide health care and health coverage for as many people as possible that is affordable for the consumer without stratospheric losses to insurance carriers?

First, in order to reduce the cost of health care in a substantial and meaningful way, there needs to be legislative reform. This includes changing the interstate commerce laws so business can purchase health insurance across state lines, and enacting tort reform at the federal level to protect our physicians and hospitals from frivolous lawsuits. This will enable doctors to leave behind defensive medicine — ordering tests or procedures to protect them from the potential patient plaintiff.

Second, we need to promote health and wellness programs as a way to reduce health care costs down the road. We need to offer opportunities to teach people to make better health-related decisions including diet and exercise. We also need to make people more accountable for their own health and wellness—rewarding the achievement of certain benchmarks tied to good health.

Third, we need to reevaluate the law requiring an employer to offer health insurance to any employee working more than 29 hours per week. Complying with this law can be incredibly expensive and is forcing employers to minimize part-time help and move to contract employees.  

Finally, we need to create specific health care programs through the federal government for the 30 to 40 million uninsured while allowing these programs to be run at the state level based on the need of each individual state.

Back to the simple truth: no change will happen in the last seven months of our president’s final term in office. Change will only happen after January 20th. Creating a law, that from the start was underfunded, and then trying to fund it through higher taxes, reducing provider payments to providers and eliminating certain subsidies from payers weakens the entire health care system. It actually makes you think this current administration was gunning for a single payer system.

In closing, the next President of the United States will need to take on this political hot potato and initiate some needed reform.

An ER on Every Corner

This weekend I was driving with my family across Florida - from Palm Beach to Tampa. As my family was preoccupied with their movies, music and books, I focused on what lay in front of me. As I drove through Orlando towards Tampa, I couldn’t help but notice the proliferation of health care facilities and medical service sites. From urgent care centers and free standing emergency rooms to imaging centers, rehab and physical therapy practices and surgery centers, there was no shortage of points for medical service.

It made me think: “Do we have too much in the way of health care services? Do we really need it? Does it help or hurt those we are trying to care for?”

The answer is yes. There are too many options for “drive-thru health care” and what we have is disjointed and not operating in the best interest of the patient or health care consumer. Take free standing emergency rooms as an example. These are facilities constructed like hospital-based emergency departments but without a hospital attached. They are not a new phenomenon because they have been around for the last 20 years. In fact, they were originally built by hospitals as a way to serve rural populations that could not support an entire hospital and pitched as a community outreach initiative. 

However, the reality is that Florida hospitals saw the construction of these emergency outposts as a way to drive the market share back to them and away from competing hospitals. What these facilities fail to tell the consumer upon entry is that they are going to pay “hospital prices” because these facilities are licensed under the hospital system and are not priced like the retail-oriented urgent care establishments.

While it is true that free standing ERs can take care of a sicker patient with more complex needs, the reality is that if the patient needs to be admitted to a hospital, she will most likely not be sent to the closest or most appropriate facility, but the one that is owned by the same medical system that owns the ER.

I recently read that a medical center based in Pasco County, Florida has opened a free standing emergency room in Palm Harbor, Florida (population 57,439). Palm Harbor currently has at least three outstanding hospitals — all of which are more than meeting the health care needs of the community. Why would you need additional emergency medicine in an area that does not need more service providers, when all it does is drive up the cost of health care? 

The reason is pure and simple: to drive market share back to the hospital operating the free standing emergency department.

Palm Harbor is a more lucrative community with a median income of $52,051 versus the statewide Florida average of $46,036. Why not place these ERs in areas where members of the community need additional access to care--communities like Holiday, a town north of Palm Beach with a population of roughly 30,000 people and a median household income of $36,213. I would imagine a community like Holiday could use access to a free standing emergency room wouldn't you?

Many will tell you to simply sit back and let the free market take control and the facility that is most needed and best serves the consumer will rise to the top. And while I am a true believer in a free market economy, the reality is that the health care industry does not operate in a free market system. Health care is a government regulated industry - the government tells us what they will pay us for our service and the commercial market often uses the government rate as a point of negotiation. This means that at the end of the day, we offer our services at a deep discount in order to have access to the insured patients whose health care is covered through commercial plans. 

And as I pulled into my destination, I thought: so what do we do to create a more affordable system that focuses on the health of the patient? An appropriate first step would be to create a regulatory environment that helps eliminate unnecessary duplication of services.

An example of a regulatory process that currently works in Florida is the Certificate of Needprogram that regulates beds for inpatient hospitals, balancing the number of hospital beds available with the demonstrated need.  If we did not have the Certificate of Need program here in Florida, we would have a proliferation of hospitals in a state where there are already more than enough beds--leading to a rise in cost and a potential decrease in quality. 

And so, in order to truly serve our community, providing affordable and accessible health care, we need more of these types of regulatory systems in place instead of ERs on every corner, don’t you think?