The client, a man in his 20s, was addicted to heroin and wanted help. Now this story may be of this man but this happens every day to addicts everywhere. More often than not, the addict doesn’t get the help they need. Not because they don’t want it, but because their insurance doesn’t want to pay for it.
Medical professionals who evaluated him recommended an inpatient program — 10 days of around-the-clock care in a safe setting that offered medication, hot meals, counseling and coping skills to help him stay sober upon his release.
Then Richard Caruso, who oversees the treatment programs at Unity Health Systems’ Chemical Dependency, called the man’s insurance company for approval. And it all goes downhill from here.
Caruso recalled that the man had coverage, but the insurer declined to pay unless he had first failed to stay clean in a less expensive outpatient program, a nine-month regimen of voluntary therapy and medication.
“That’s a typical response from an insurance company,” said Caruso. “There are a lot of people who need inpatient services but because of denials from insurance companies are in outpatient.”
As heroin makes a comeback across the nation, addicts and their loved ones who are searching for help are contending with a shortage of services and constraints placed on care by insurance companies, health care and addiction specialists say.
Demand for treatment is quickly outstripping supply, leaving addicts whose internal clocks revolve around their next fix to wait weeks in some cases for care ranging from scheduling counseling sessions to getting medicine to combat withdrawal. The obstacles are perhaps felt more acutely by the heroin addicts of today, whom specialists characterize as younger, more affluent and more naive than users of the past, who were generally of lesser means and more hard-bitten to bureaucracy.
For example, specialists say before insurance companies agree to cover inpatient services they want evidence that an addict has tried one or more outpatient programs, has little or no outside support network, and has a health condition that makes treatment a medical necessity.
“A lot of these heroin users now have families, and the insurers aren’t looking at them the same way as someone who’s homeless or living in a drug house,” said Robert Lebman, president of Huther Doyle, an addiction treatment center in Rochester, N.Y.
James Redmond, a spokesman for Excellus BlueCross BlueShield, a major insurer in the Rochester area, said the company examines a host of clinical evidence to determine whether inpatient services are necessary.
“These are very fact-sensitive determinations and, in some circumstances, the applicable evidence-based clinical criteria require outpatient treatment attempts before coverage is approved for inpatient services,” said Redmond.
Lisa Thompson of Chili, N.Y., confronted the treatment barrier two years ago, when her son, then 26 and a longtime opiate abuser, threatened suicide and was admitted to the psychiatric ward at a hospital.
She recalled spending the night with him there and being told the next morning that he would be released.
“I said, ‘What do I do when he goes through withdrawal?’ ” Thompson recalled. “They said, ‘This isn’t the facility for him,’ and they gave him some phone numbers.”
While heroin withdrawal is an individual experience, it is almost universally described by addicts as excruciatingly painful.
But the symptoms of withdrawal, which author Edward St. Aubyn so harrowingly likened to “a litter of drowning kittens in the sack of (one’s) stomach,” do not qualify as a medical necessity for immediate treatment because they are almost never fatal.
“You don’t die from heroin withdrawal, you just wish you did,” Lebman said.
There are medications that make withdrawal more tolerable, but the most popular among them, buprenorphine, sold mostly in a compound called Suboxone, is increasingly difficult to come by legally in the Rochester area.
Unlike methadone, which has been used for decades to treat heroin addiction, Suboxone is available to addicts by prescription only from federally certified doctors whose patient loads are restricted to 100 by law. The restrictions have resulted in a shortage of doctors and fueled a thriving underground market whose dangers are not limited to economics. Like heroin, Suboxone is an opioid that can become addictive.
Nationally, there are about 24,000 doctors authorized to prescribe Suboxone legally, Renckitt Benckiser spokesman Tim Baxter said in an e-mail. He acknowledged the difficulty some have getting treatment, and said the company, which manufactures Suboxone, recommends doctor-created referral networks.
Specialists acknowledge there are limits to what rehab can do for an addict without the so-called wrap-around support from friends and relatives. They also concede that addicts’ and their relatives’ perceptions of what is needed to get clean are not always necessary or realistic.
“Insurance companies don’t see opiate addiction as life-threatening,” said Bill De Joy, the clinical director at Conifer Park Inc., a drug rehab center in Rochester. “They feel like people can get sober in an outpatient setting, and they can. What they don’t take into account are issues that people still have to deal with in their neighborhoods, in their homes, and the daily stresses that they learned to use opiates to cope with.”
A generation ago, the typical inpatient program lasted a month and the average detox program, in which an addict purges his system of drugs, ran seven to 10 days. Now, as a result of insurance companies scaling back their coverage and increasing their deductibles, inpatient services generally run 10 days and detoxes three to five days, according to specialists.
“Most insurances will only pay for up to 10 days,” said Caruso, of Unity Chemical Dependency. “You can apply for an extension, but you’d better expect a denial.”
For most addicts and their loved ones, the treatment options and the commitment needed to stay with them are overwhelming. The result is often a seemingly never-ending cycle of remissions and relapses that wreaks havoc on families.
After her son was discharged from the psychiatric ward, Thompson recalled an inpatient program telling her that even if her son qualified for services, which was unlikely, it could be a couple of weeks before a bed opened up. Another treatment program wanted $3,000 up front — money she didn’t have.
“As a mother, you’re always there protecting your child,” said Thompson, a beautician. “Helplessness is the most horrible feeling when you know your child could die.”
She eventually turned to Syracuse Teen Challenge, a Christian-based drug and alcohol residential rehabilitation program for adolescents and adults. The program, which survives mostly on donations, charges $750 for a 14-month stay.
Thompson’s son, Joshua VanDusen, now 28, graduated from the program in July 2013 and no longer uses heroin. He attends Valley Forge Christian College in Pennsylvania, where he is studying to be a pastor.
“I’m just so proud of him,” Thompson said.
So if you or someone you love has run into this problem while trying to get drug treatment, this is what we do! Please don’t hesitate to call us. We can give you a free assessment and get you help. We will fight with your insurance and make it happen regardless of the circumstances. If you just want to tell us how your insurance isn’t working please do that too. We are trying to help and better the system. Give us a call now. Get help. Do something!