According to the 2018 National Drug Threat Assessment (NDTA), the leading cause of injury death in the United States is drug overdose. Not only has drug overdose as a cause of death been on the rise for several years, but also it has outnumbered deaths by firearms, motor vehicle crashes, suicide, and homicide since 2011 (see Exhibit 1). In 2016, approximately 174 people died per day due to drug overdose, which included Controlled Prescription Drug (CPD), cocaine, psychostimulants with abuse potential, and heroin (see Exhibit 2) overdoses. Opioid abuse represented around 66% of those deaths, equivalent to 116 deaths per day.
As substance abuse has increased, the need to prevent drug overdose deaths has increased as well. Thus, the United States has experienced an increase in facilities focused on drug and alcohol rehabilitation services. Two laws had a particularly important influence on the number of treatment facilities: the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act. The Parity Act required insurance groups who already offered coverage for mental illness or substance abuse disorders to do so in a way that was comparable to other medical care, removing unequal financial requirements and limits on treatments such as provider visits for patients battling substance abuse. The Affordable Care Act expanded coverage and made insurance more affordable, meaning more people were able to take advantage of substance abuse benefits. While these laws made insurance dollars more abundant, they also reduced an out-of-pocket revenue stream that more long-standing rehabilitation centers once counted on, making it harder for institutions with stellar reputations to continue to operate.
Many entrepreneurs, often former addicts, have opened rehabilitation facilities either with the intention of helping addicts recover, making a profit, or both. In 2017, the revenue of the Drug and Alcohol Rehabilitation Clinics industry was $5.8 billion and, according to IBISWorld, it is expected to continue to grow to $8.2 billion by 2023. Additionally, the number of facilities is expected to reach 4,270 by 2022.[v] While many of these facilities serve as a way out out of addiction, many employ unethical practices that abuse addicts and even threaten patients’ lives. Because of this, a future in which this industry is more heavily regulated is inevitable, either through self-regulation or government intervention. To avoid the latter, operate in an ethical way, and not threaten patients’ lives, a set of guiding principles is being proposed.
Seven specific unethical practices exist in the addiction treatment industry and are described in more detail below.
Patient Brokering
When a person struggling with addiction or a concerned friend or family member chooses to seek out a treatment facility, they often call seemingly credible numbers seen on the internet or on television to connect them with appropriate services.[viii] Patient brokering is the process by which middlemen exploit patients by selling “leads” for patients calling these numbers to treatment facilities. These middlemen run call centers or hotlines and are paid a per-call finders fee, either a fixed amount or a bidded amount, by treatment facilities for connecting patients with their facility.
Patient brokering works in one of two ways. The first is that the call center serves largely as a phone operator, directing the number of calls paid for by a treatment facility directly to the facility’s line when the hotline number is dialed. This type of brokering can also happen as patients switch between recovery centers or sober houses. The second is that a call center employee poses as a caregiver, despite having no medical knowledge, who would ask a few questions and proceed to recommend treatment at a specific facility which had bid the highest for the lead.
Patients and caregivers are nearly always unaware of this practice. When they call the number of a broker, they may be desperate for help and are likely to believe whatever they are told. Buying and selling leads limits the number of treatment facilities patients vet before entering treatment, keeping them from receiving the highest quality care for them at a carefully selected facility. Often, this leads patients to pursue treatment in a different and far away state, adding costs and complexity and removing the possibility of support from their loved ones and local community.
Listing Theft
Once it became a lucrative business, unethical methods to increase the number of patient inquiries started being employed by call center operators as well as treatment centers. In an effort to receive more patient calls, individuals from call centers and treatment centers would edit Google business listings for other treatment centers by changing the address and phone number to their own. This results in patients reaching treatment facilities other than those they intended to reach, thwarting diligent patients’ attempts to research treatment facilities.
Patient Enticement
Patients are often incentivized to enter, stay in, or switch addiction treatment facilities through money, gifts, rent, flights, food, or other amenities. For example, addicts recommended treatment in other geographies are often provided with a one-way plane ticket to the facility courtesy of that facility. They may also be offered cheaper rates ($9k per month for treatment and $400 for rent at a sober living home) than the rates at more longstanding treatment facilities ($30k).
Offering patients these amenities is tantamount to bribing them to choose a specific facility. Additionally, offering “premium” services such as massages is often a way to get patients to select more expensive packages than they can reasonably afford or need.
Misrepresentation of Services
When treatment facilities distribute inaccurate information in marketing and sales channels such as websites, flyers, and initial phone calls with patients, this is a misrepresentation of services. Inaccurate information can include forging staff’s education, professional background, or accreditation, omission of important affiliations with other entities such as sober houses and call centers, and lying about the insurance they accept or the services they provide. Some entities have even been known to lie about their locations.
Patient Privacy Violations
Treatment facilities violate HIPAA and other patient privacy protection laws by disclosing patients’ health information, such as treatment plans and diagnoses. They do so often in the context of sales or marketing. Any sharing of such patient information with individuals outside of a patient’s care team without a legitimate medical reason for doing so is a HIPAA violation.
Insurance Overbilling
Many addiction treatment facilities are opened by recovered addicts who open their clinics initially under the mission of helping other addicts and providing them with better addiction recovery services.[ix] However, as greed kicks in, many begin billing insurance companies for unnecessary treatment or services. This manifests most often as excessive urine drug testing, with some patients’ bills exceeding $200,000[x] for testing alone, but can also include things like $5,000 for “Equine Treatment” and treatments of indefinite length. Many insurance companies have begun suing treatment facilities who make a habit of racking up high treatment bills, indicating this practice is decreasingly lucrative and not medically necessary.
Insurance Fraud
Treatment facilities sometimes scam insurance companies by abusing the definition of a qualifying life event which allows patients to change their insurance year-round without penalty if they move, rather than having to wait for an open enrollment period. These facilities enroll patients in premium insurance plans using false addresses which lead to higher reimbursement rates than the plans patients would be able to enroll in with their real addresses.
To address the unethical practices described above, we have come up with the following twelve guiding principles which fall into four categories: general, treatment-seeking, initiating treatment, and drug testing. These guiding principles were designed to ensure patients receive accurate information and quality care, meaning care provided in the right quantities, in the right place, and by the right people.
General:
- An audit committee will be established to ensure treatment facilities that are part of the coalition adhere to the below guidelines. All coalition members will be subject to random and periodic audits.
- To join the coalition, a facility must ensure all its care providers meet certain accreditation standards and maintain these as determined by the audit committee. This should reduce misrepresentation of services.
- In the long-term, facilities should target integration into the medical record systems used by hospitals and clinics.
- This would enable treatment facilities to access information regarding patients’ medical histories as well as record relevant information for use by healthcare providers in the future, all in a HIPAA-compliant manner. This would most seamlessly integrate patient care at separate facilities, mitigating drug-seeking behavior and excessive or inappropriate care.
Treatment-Seeking:
- An unbiased entity responsible for helping patients determine appropriate facilities from which they should receive treatment will be created. This will ensure patients receive care from the facility best suited to their clinical and financial needs.
- If a patient or caregiver calls a treatment center directly inquiring about initiating treatment, facilities will use a standard questionnaire. This questionnaire will include a question about what other facilities the patient or caregiver has researched as well as medical questions to be used when determining an appropriate treatment regimen. This will help ensure patients are well-informed on their options and that treatment facilities initiate only treatments that apply to a given new patient.
- The coalition will partner with Google to develop a verification process for the creation and editing of listing information for treatment facilities, as well as a way to flag to potential patients and caregivers that information may not be accurate while verification is in process. This will mitigate the effects of listing theft.
Initiating Treatment:
- Once onsite, standardized questionnaires will be used to assess the patient’s status and need for care in addition to the surveys used when the patient or caregiver initiated treatment discussions. These will be used to determine an appropriate and non-excessive treatment regimen tailored to the patient.
- Healthcare providers will be required to create a treatment plan for each patient that provides an estimated timeline and have periodical updates. This will limit the number of patients receiving excessively long treatments.
Drug Testing:
- Drug testing should be performed with a reasonable frequency (e.g. no more than once per week) as outlined by medical professionals on the audit committee.
- Separate facilities coordinating the care for a single patient should verify with one another whether drug testing has already been performed before initiating a test.
- Drug testing should be tailored to a patient’s addiction struggle. For example, patients struggling with addiction to steroids should not be tested for drugs they are unlikely to be on, such as heroin.
- Physicians found to be approving unnecessary testing should be recommended for review by the audit committee or the Joint Commission.
For the coalition to be successful, it must be able to convince treatment centers across the industry to join and abide by the guiding principles. The coalition can convince treatment centers to join with three strategies: create a certification network, appeal emotionally to the treatment centers, and show the consequences of what will happen if the industry continues its unethical practices.
The certification network would look similar to other industry coalitions in that treatment centers following the guiding principles of the coalition would get to showcase the certification. A current successful coalition that uses this strategy is Fair Trade. Fair Trade is a global movement made up of a diverse network of producers, companies, shoppers, advocates, and organizations putting people and planet first. A key reason why Fair Trade has been successful is that it marketed and trained the consumer to look for the Fair Trade certification on products they buy. This consumer-driven demand for Fair Trade products inspired companies to join the coalition. This had a compounding effect of spreading more awareness to consumers of what Fair Trade stood for, and created a self-perpetuating cycle of consumer awareness and supplier interest.
The treatment center coalition could use the same strategy of training consumers to look for the certification and teach them why the certification and the guiding principles are important for their treatment. The coalition could also market toward hospitals, doctors, and police centers, showing the positives of coalition treatment centers compared to non-coalition treatment centers to get them to refer addicts to treatment centers only within the coalition.
The coalition could begin by recruiting treatment centers that are acting ethically and simply want to help addicts recover from their addiction.[xii] The treatment centers can currently make more money if they act unethically. However, once consumers begin seeking out certified treatment centers, those abiding by the guiding principles will be in higher demand and thus more profitable than non-coalition centers. Another way the certification network could gain traction would be to work with insurance companies. For example, if the insurance companies know that the coalition treatment centers are abiding by the guiding principles, they could then make their policies cheaper or more convenient for patients who choose coalition-certified centers. This would again drive the consumers to seek out treatment centers within the coalition, driving up demand to act within the guiding principles while reducing the financial incentive to act unethically.
A second strategy to persuade treatment centers to join the coalition would be to appeal to them emotionally. A significant amount of outpatient treatment centers were started up by ex-addicts that were rehabilitated. The coalition could remind those individuals what it was like early on in their struggle with addiction and now that they are on the other side, they should see why patients need to be treated fairly and receive quality care that is affordable.
The last strategy would be to show treatment centers what could potentially happen to the industry if it continues the path it is on. The coalition could demonstrate to the centers what a government-regulated treatment center industry would look like and how that would affect their long-term success and profitability. The coalition could invite treatment centers to join the coalition to help shape the guiding principles with their industry knowledge rather than the government imposing rules that may or not may not be reasonable for the treatment industry.
