I’ve been giving a keynote speech over the last eighteen months called “The Medical Industrial Complex and the Opioid Epidemic” (the term is mine, though modeled after President Eisenhower’s warning about the Military Industrial Complex in his farewell address). The Medical Industrial Complex is made up of the following:
- Medical Professionals, particularly doctors and their professional organizations (American Medical Association is one example)
- Insurance Industry
- Big Pharma
- The Federal Government (Congress and Executive Branch agencies like the FDA). State Governments also have a role, though it is much smaller.
- The Treatment Industry
I’ll be releasing a series of articles over the next few months about these six groups and how they have each contributed to the problem (if you’ve paid attention recently, you’ll know that the Washington Post/60 Minutes released an expose on the Big Pharma-Government relationship and the New Yorker hammered Purdue Pharma last week).
Even if Big Pharma is reined in, doctors get more training and prescribe opioids less, insurance companies pay for the appropriate treatment and President Trump urges Congress to spend billions of dollars on a variety of programs, it will do little to improve the outcomes for people in addiction treatment programs.
Treatment programs are often understaffed and focus on paperwork over services. The senior counselors at programs rarely actually see clients; instead, they are monitoring clinical notes. They do this in order to meet standards set up by insurance companies and some state regulators (not all states are regulated). The idea behind this is noble, as documentation of individual, group and medical services let third parties know if and how treatment was provided. In theory. In practice, the notes are almost always better than the actual services provided. Supervisors are often not properly meeting with, training or observing their staff, and they evaluate them based on their notes (I’ll write a lot more about this in the future).
Treatment programs take in money the following ways:
- private pay from clients or their families
- medicaid or medicare
- county or state grants to provide free or discounted services
- private insurance
While most treatment providers would prefer #1 above all others, those kind of clients make up a tiny percentage of the population. Clients with private insurance are essential for for-profit treatment programs, and are highly desirous for non-profit programs to offset the costs of medicare/medicaid recipients and other indigent people. A number of insurance programs will not pay for services rendered by a treatment program (detox, inpatient or outpatient) unless they are certified by either CARF or the Joint Commission (JCAHO). Because they are often the gate keepers to insurance money, treatment programs scheme hard on getting CARF or Joint Commission accreditation.
CARF is an international program. It is not a government agency. JCAHO is an American non-profit (be cautious about when making snap judgments about programs just on their tax status). I want to spin you back to the housing crisis of 2008 and its aftermath. We learned about how high-interest mortgages were given to people without the means to pay for them, and that those crap mortgages were chopped up and sold as investments with AAA ratings (the highest rating, and often the only ones that state pension and certain retirement funds can buy). These mortgages were highly volatile, but only a handful of people knew that because the rating agencies (S&P, Moody’s, and the Fitch Group) rated B and C investments as AAA. When people couldn’t pay their mortgages, those investment products’ value plummeted. Several banks failed, the insurance companies teetered on the brink and our economy pulled the rest of the world into the Great Recession (for more on this, read “All the Devils are Here” or “The Big Short”). The rating agencies failed to do their job and protect the public.
One might argue that CARF and the Joint Commission have failed to properly rate treatment programs. There are terrible programs all over the country that brag about their CARF and/or Joint Commission accreditation, and proudly display it on their websites. These are not government agencies, but private companies. Their first goal is money, not consumer protection. Here is how the process seems to work:
- The treatment program contacts CARF and/or the Joint Commission.
- The treatment program pays a fee for the inspection and accreditation (this is a classic conflict of interest folks).
- CARF or JCAHO come out for a multi-day inspection. They usually let the program know in advance when they are coming.
- The treatment program spends the weeks leading up to the inspection getting their notes in order, cleaning the floors, making sure that files are locked, checking fire extinguishers, and getting paperwork signed that says that emergency drills and policy reviews have been conducted.
- CARF or JCAHO visit the agency. They may talk to a couple of clients. They meet with administration. They examine the physical aspects of the program and look at the notes. They might talk to clinicians or look into other aspects of the agency.
- Shortly thereafter, the program is either accredited or not accredited. Both CARF and the Joint Commission are a bit reluctant to provide data about pass/fail percentage rates for the programs they inspect. I suspect that the accreditation rates are quite high.
- Every couple of years, the program gets reinspected. They often get a notice of when the inspectors are coming. They write a check to pay for the re-accreditation.
Neither CARF nor Joint Commission certification means that staff are not abusive or neglectful. It doesn’t measure the effectiveness of group or individual sessions, or the ability of the supervisor to monitor and train the staff. CARF or JCAHO certification does not guarantee that there is a decent discharge plan, or that the discharge summary accurately reflects what happened throughout the course of treatment. A program does not need to show if (or how) it evaluates itself or what outcomes are actually achieved.
Some people consider CARF and JCAHO to be scams. They don’t ensure good treatment. They do not protect the public. This is regulation in a terrible form. We need better state and national regulation of treatment programs. This means clearer guidelines, more monitoring and observation, short and long term evaluation and third party outcome studies, and real punishment (huge fines, suspension, forced closing) for those that fail to comply.
When looking for a treatment program, here are some basic questions to ask:
- How long has the clinical and executive director been there?
- What percentage of counselors have at least a masters level license?
- How often do clients get to meet with counselors one-on-one? How long do those sessions last?
- How often do clinical staff get supervision? Is it individual and/or group supervision?
- Does the supervisor observe individual and group sessions by staff?
- How often do techs, housing staff and night workers get supervision? Are they observed?
- How does the program measure success?
- Does the program evaluate itself? Does it have a third party evaluate it?
- Who does the aftercare plans? How do you ensure that the places/professionals you refer to are good?
- Who does the diagnosing? How long do they meet with someone before giving them a substance misuse disorder and/or mental health diagnosis?
Programs can get CARF and JCAHO certification without having good answers to most or all of these questions. It’s the housing disaster all over again, but in the treatment industry.
Note: I would be happy to discuss my concerns with representatives from either CARF or the Joint Commission and assist them, free of charge, in improving their process for the benefit of the public.