Saturday, March 13, 2010


Heaven knows, I like to beat a dead horse as much as anyone, and because of a few things that happened this week, I am going to take a few more whacks at this one. Insurance. Specifically, health insurance.

When I am working with a family or other group of appropriately concerned individuals to develop an intervention, one of the questions that invariably arises, is who is going to pay for treatment? In the past, it wasn't much of a concern: the insurance company. After all, isn't that what we pay those premiums for? As an addiction counselor with many years experience, I certainly wasn't going to make an inappropriate referral. An experienced intake worker and solid treatment team would do the rest. The individual at the center of the intervention would receive the treatment they need at the appropriate level of care, for the right amount of time. The family would be included in the treatment plan; there would be a good, well thought-out aftercare plan to take the individual and the family through their first six months to a year of recovery.

Treatment like this is available, it exists, and surprisingly, it is not as expensive as many people think. But here's the thing: insurance won't pay for it. It sounds like a bad joke, but insurance companies have figured out that if you rake in the premiums, but don't pay out more than a fraction of the income, you make one heck of a lot of money. It's nothing new. I think Myer Lansky first defined the principle in the 20's, and the Casinos have run on it for decades.

In short: over a period of time, the house always wins and the mark always loses. Always, ever, forever, 100% of the time. Exactly the way your insurance company plays, with one exception. Casinos operate on the up and up. They will show you exactly the odds that they will pay. Insurance companies don't.

They lie.

And here is how they do it. They publish a list of what they pay for, very thorough, very comprehensive. In Pennsylvania, the say in their benefits that they pay for 30 days of inpatient substance abuse treatment. That's what they say. What they do not say is that they pay this according to their criteria of need. In other words, they will pay it, but first, that means they have to decide that it is needed, that it meets their criteria.

Now, let me give you a little primer in addiction and alcoholism. Addicts and alcoholics are often in denial, they tend to be dishonest and unreliable reporters, they may not remember what they have taken, in what quantity or when. They may be motivated once the car ride to the rehab starts, change their mind fifteen times before they get there, (and twenty after admission.). When threatened they can become manipulative, panicky, and sometimes just run away. The effects of many of the substances they ingest can mimic other mental illnesses, from depression, to bi-polar disorder, to schizophrenia. The only way that their immediate treatment needs can be assessed is by a thorough, eyes on, in person evaluation. 

So, one would think that an experienced assessor meets with the client, relates the outcome of the interview to an insurance company rep, satisfies the criteria for admission and that is that, treatment begins, right?

Wrong. It is just the beginning of an agonizing, time-consuming process that drags on and on and on. More information is needed. Then more. Someone hasn't consulted with the psychiatrist that the client saw ten years ago, and how can we admit without that?  Did he take diazipam or Dexedrine? Is he compliant with his blood pressure medication? 

I have seen families sit in the lobby of a rehab for over 12 hours going through this crap, only to finally be told that their patient is authorized for 3 days of inpatient care. Or worse, that they are referred to an Intensive Outpatient Program 10 miles away and have an intake appointment for next Wednesday. The client will go three days a week--shame about that DUI, someone will have to drive him, and, oh yes, the co-pay will be $50.00 per session. But you can use a credit card.

These are things I have seen, over and over again, to the point where I find it hard to believe that this is not intentional. Aside for denial, addicts and alcoholics have notoriously low frustration levels, and are extremely prone to just get up an walk out.

And if you think about it for a minute, that is a really nice windfall for the insurance company. Then they don't have to pay anything at all. As for the client--he was unmotivated. As for the family? Insufficient support.

It's a disgrace. So, for now, do what I get my families to do. Learn to be a negotiator, a persistent advocate and a squeaky wheel. In therapy, we learn to ask for what you want. In this setting, learn to demand it! If we tolerate a broken, dysfunctional system that allows us to pay top dollar for virtually nonexistent treatment, then we get what we deserve. Shame on us.

But if we truly believe that addiction is an illness, then let's demand the kind of treatment that we would expect from any duly licensed facility; and let's demand that the insurance company pay for it, without qualification.


  1. As someone experienced in the area of health insurance, there is one thing I would add.

    I would say a large component of why inusrance companies limit claims for drug and alcohol rehab is the unpredictable nature of it.

    Like the rapid rise of HIV infection in the 1980's, the insurance companies did not see the epidemic of substance abuse coming.

    I would say that it is likely that they don't know what to do so they are doing very little.

    Not to argue the validity of your points. I am simply saying that "dealing with the unknown" is a significant factor. And they are likely dealing with it by avoiding it.

    It is funny, I remember asking my family doctor when I admitted my problem with cocaine to him, if I was the first white-collar suburbanite he has dealt with with such a problem. To which he laughed indicating it was prevelant and growing in the middle class suburbs.

    There are more substances available at greater convenience than any time in recoded history. And we are now classifying it as a disease.

    Insurance companies would not have weighed this into the actularial tables even 20 years ago. And to begin to allow definitions that make it easy and consistent to claim would potentially open a floodgate that they may not be able to close.

    They are engaging in the oldest and most basic of human and coporate behaviours... self-preservation.

    They have probably determined that they can't outright deny many claims, so they are perhaps choosing to keep their claims processes vague, inconsistent, cumbersome, and very subjective.

    I see some good in all of this though. I had been offered treatment on a number of occasions and often medically directed. I had little to no success from any of these.

    I finally made progress when I was sufficiently beaten and stepped (limpped) willingly into the rooms of 12 step programs. Once my thinking started to change, I then returned to my doctor and sought some medical help as part of my recovery strategy.

    Frankly, I was wasting the medical system's time and money when I was participating in it as an unwilling-to-recover addict/alcoholic.

    And there were times when I pointed blame at the medical system for my not finding recovery. When in the end, it was not the medical system that made the bigest impact on me.

    Maybe the insurance companies are experiencing a lot of not-ready addicts and alcoholics like I was, and find us too much of wild cards so they don't commit their resources to them.

    We are a pretty unpredictable, non-linear bunch when we are in our active and unwilling stages.

    I can't imagine insurance companies having much of a clue what to do with us. So they avoid and bumble.

    My take anyway.