Disparate Care Reinforces Low Expectations of Recovery

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Earlier this week, the Washington Post published an article on how affordable treatment for mental health and substance use is getting harder to find.  The article, published December 1st can be found here.  It does not paint a pretty picture of our care system and shows that the main law, intended to protect persons seeking help for a substance use condition and ensure proper care is largely being ignored by the insurance industry.

From the article in the Washington Post:

  • People seeking inpatient care for behavioral health issues were 5.2 times more likely to be relegated to an out-of-network provider than for medical or surgical care in 2017, up from 2.8 times in 2013.
  • For substance abuse treatment, the numbers were even worse: Treatment at an inpatient facility was 10 times more likely to be provided out-of-network — up from 4.7 times in 2013.
  • In 2017, a child was 10 times more likely to go out-of-network for a behavioral health office visit than for a primary care office visit.
  • Spending for all types of substance abuse treatment was just 0.9 percent of total health-care spending in 2017. Mental health treatment accounted for 2.4 percent of total spending.

The Mental Health Parity and Addiction Equity Act of 2018 (MHPAEA) was intended to expand access to treatment and keep families from experiencing higher costs associated with seeking help with a substance use condition. It appears that we are moving in the wrong direction as far as access to care through insurance. It is deeply troubling that access to care through insurance is decreasing and people are utilizing out of network care, which can open them up to patient brokering, also known as the “Florida Shuffle.” These unethical practices are moving beyond Florida and make it harder for ethical providers to operate.

I see this as more evidence that we have built our care system around acute care needs with short stays and barriers to accessing help, even as the science has shown us that acute care models are of minimum effectiveness.  An oft cited principle of effective treatment from the National Institute on Drug Abuse is that “generally, for residential or outpatient treatment, participation for less than 90 days is of limited effectiveness, and treatment lasting significantly longer is recommended for maintaining positive outcomes.”  So, in other words short term care, which is not effective is all that is offered most Americans.

Long term treatment is rarely accessible through commercial insurance, and long-term support that includes peer support services in the community is nearly non-existent. This is a system that sets people up to be cost shifted to public care, and by focusing care on an acute care model sets up a reinforcing system of poor outcomes, which lowers expectations that people get better. To borrow a phrase from another time and issue, this sets up the soft bigotry of low expectations for all persons with a substance use condition and only people of means can access longer term care with long term support. This is simply unacceptable.

Despite this trend, we know that those of us who make long term recovery tend to stay in recovery for the rest of our lives. We know that five years of sustained substance use recovery is the benchmark for 85% of people with a substance use condition to remain in recovery for life, why are we not designing our care systems around this reality?

We need to start steering our care system towards recovery. A recovery focused care system acknowledges and addresses the multitude of social, physical, emotional, housing, financial, and other co-occurring conditions/ issues. There is growing recognition that the benchmark for a substance use disorder recovery is an orientation towards a system focused on getting people to five years of continuous recovery. We must retool our service system to support this truth.

“We can no longer accept the unacceptable – and the care and support that the vast majority of Americans gets right now is simply unacceptable. It sets up a reinforcing system or short-term care that results in poor outcomes, which reinforces low expectations of recovery. People are dying and families are suffering. Every American should have access to at least 90 days of effective treatment followed by long term recovery support services, which is a step towards a long term recovery focused model. It is time we insist on all of our policies and care to be measured under a long term recovery orientation.”

What would this look like? It would be:

  1. A Substance Use Care Service System that supports long term recovery for five years for all Americans
  2. A Service System that meets the needs of our young people – early intervention and comprehensive care
  3. Build the 21st Century workforce to serve the next generation, properly trained and compensated
  4. A focus on Employment, Education, and Self-Sufficiency
  5. Recovery Housing Opportunities to support safe and ethically run housing for people who need it as part of their recovery process

We can no longer accept the unacceptable – and the care and support that the vast majority of Americans gets right now is simply unacceptable. It sets up a reinforcing system or short-term care that results in poor outcomes, which reinforces low expectations of recovery. People are dying and families are suffering. Every American should have access to at least 90 days of effective treatment followed by long term recovery support services, which is a step towards a long term recovery focused model. It is time we insist on all of our policies and care to be measured under a long term recovery orientation.