Supporting your desire to live free from self-destructive behavior as you embark on a life long journey of recovery.
Supporting your desire to live free from self-destructive behavior as you embark on a life long journey of recovery.
Mental Health Awareness Month has been observed since 1949; and yet, mental illness is still poorly understood and highly stigmatized in our country today.
Unfortunately, the vast majority of people continue to believe that psychiatric disorders are “made up,”” instead of viewing them as very real, potentially fatal, brain diseases. The truth is mental illness deeply impacts all aspects of a person’s life—their relationships, identity and behaviors.
Possibly the greatest hindrance to widespread understanding and acceptance of psychiatric disorders is that they cannot be seen physically (in many, but not all psychiatric illnesses). What’s more, unlike cancer or other medical diseases, mental illness cannot be identified via an x-ray or blood test. Therefore, a man hobbling on crutches with a broken leg is shown mercy; bystanders might assist by opening doors or carrying items. Conversely, a woman lying in bed with crippling depression is often extended no mercy whatsoever; instead, she is perceived of as lazy and is encouraged to snap out of it.
In fact, depression is very commonly misunderstood in today’s world, primarily by patients themselves who tend to blame themselves for having the illness or being lazy (these are distortions associated with the disease!), and also by the very people that are most supportive of those with other medical illnesses–doctors and family members.
Often a mother, father, wife or husband incorrectly uses themselves and their own life experiences as a unilateral barometer. They may recall times when they felt sorrow or despair in their own lives. In time, the sorrow passed or the despair lifted. In other words, they ultimately “got over it.” Therefore, the tendency is to apply this same standard to the loved one who seemingly can no longer function. The problem is, the standard is not applicable. The individual weighed down by clinical depression can no more resiliently bounce back than the other family member can fly. The bottom line is this: if they could, they would; but they can’t all on their own. Give the family member who can’t fly an airplane and a pilot and off they go. Give the family member with debilitating depression good care (therapy, medication, supportive community) and they can recover.
What an individual struggling with depression, anxiety, or any one of the other myriad psychiatric disorders truly requires is treatment; for many people this includes medication, which can help with the physical aspects of what the brain needs to recover from depression. Regrettably, due to the ongoing stigma associated with mental illness, people routinely fail to get the help they need. Sometimes they refuse to seek therapy due to the shame they feel about seeing a counselor or psychiatrist. Certain segments of the population are particularly vulnerable to this fear of stigma. Those in the military frequently go untreated due to the fear of jeopardizing their careers. Mothers, afraid their children might be taken away by a social service agency, are also often reluctant to seek care. Professionals many times avoid treatment because they have a career to tend to. Doctors and nurses do likewise because it’s their job to take care of others, not to receive care themselves.
Fortunately, due to initiatives such as Mental Health Awareness month, we have made strides in the area of eating disorders and substance use disorder. Today, the public has a greater understanding and appreciation for the complexity of these two illnesses. Now, if we can just promote greater comprehension surrounding other mental illnesses like depression and PTSD, perhaps the blame and stigma might be lifted and people could get the support they require and deserve.
On April 10, SCH was proud to send a representative to Congressman Peter Roskam’s office (US House of Representatives, Illinois’s 6th district) to discuss the value (financially, morally and otherwise) of providing people with mental health treatment. This topic is of particular importance in today’s political environment given the movement to overturn The Affordable Care Act and more specifically the discussion around eliminating what is referred to as “Essential Health Benefits” in some insurance policies. The discussion was initiated by Nancy Meier Brown, President of Meier Clinics Foundation, and we were joined by representatives from Timberline Knolls Residential Treatment Center, NAMI DuPage, Northwest Community Healthcare and Linden Oaks.
What we all know is that healthcare today in this country is a complete mess. With total spend at nearly 20% of our GDP and with a system that is fragmented, unorganized and full of waste, what we have today is unsustainable and we all deserve better. A system that is more fully integrated, more organized and measured based on its results is what we believe is the long term solution. What many don’t know, apparently, is that some don’t feel like mental health deserves the same treatment as other illnesses and diseases, as if disease of the brain somehow isn’t on the same level as disease, for example, of the heart. Though we all know someone who has been touched with one form of mental illness or another (from depression to substance use disorder), the fact of the matter is many still don’t feel these diseases deserve the same level of compassion and treatment that other diseases have received for decades. Maybe it is because of stigma or maybe it is because of the ignorant belief that mental illness is often a “poor choice” rather than an unavoidable disease. For those of us in the room with Congressman Roskam last week, frankly we simply do not understand why or how we are even discussing eliminating mental health benefits given what we know and see every day, and what the data and literature all support. Yet the conversation is happening, and that is why we were there last week. To plead a case that needs to be plead.
Hopefully in an attempt to support our case, we were asked at the meeting to present the Congressman with some facts as to why it makes sense to continue to fund mental illness treatment. Though to us this is intuitive and we don’t see cardiologists being asked to make the case for why heart disease treatment should be covered by benefits, the data he asks for exists, and we will of course oblige him with his request. That said, this is yet another wake up call for all of us that our world of caring about those who struggle with behavioral health issues is under utter attack at the moment. The parity law is great, but there is no parity, and things appear to be getting even worse.
Some of the data we will be presenting is as follows.
First of all, proper treatment works. For major depression, panic disorder and obsessive compulsive disorder rates (of improvement) are about 70%. This is comparable to rates of improvement for people who suffer from physical disorders, including diabetes and asthma at 70-80%, cardiovascular disease from 60-70% and heart disease at 41-52% (12).
The National Institute on Drug Abuse estimates that every dollar invested in addiction treatment programs yields a return of between $4 and 7$ in reduced drug related crime, criminal justice costs and theft. When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1! (13).
The US Department of Health and Human Services estimates that for every $100,000 invested in treatment for substance abuse (measured in California, New York and Washington), there are savings of $484,000 in health care costs and $700,000 of crime costs were shown to be avoided. (14) In a comparison of medical expenses of Medicaid clients who received treatment, the following savings were noted (measured in Washington): $170.00/month for patients receiving inpatient; $215/month for those in outpatient treatment, and $230/month for those receiving medication assisted therapy (specifically methadone). In California treated patients have been shown to reduce ER visits by 39%, hospital stays by 35% and total medical costs by 26% (14).
Just by integrating medical and behavioral services, The National Council for Behavioral Health estimates that between $26-$48 billion can potentially be saved!
Thanks to Nancy Meier Brown for including us in this discussion, and thanks to the Congressman for taking the time to meet with us. Clearly there is a lot of work to be done, and it will be done. We have no choice. Our patients and their families deserve every ounce of time we can devote to advocating on their behalf. Please join us in the fight.
The world places a high value on certain things–money, happiness, thinness (sadly), comfort and security, to name a few. However, in our fervent efforts to pursue such conditions in our lives, we often neglect an essential underpinning to any living experience worth having: values. When we live unconsciously, blind to our values our lives become unbalanced. The same is true for people who profess to value certain things, but their actions tell a very different story.
Lack of balance is rife throughout our society. The business man striving so hard to get to the top in order to make huge amounts of money–for noble reasons that are applauded by society–to pay the mortgage and keep his kids in private school. The woman, who could easily be married to this man, who must be “perfect”: thin, industrious, beautiful, with equally perfect children involved in every possible after school sport and activity.
The truth is, this lack of balance is sustainable for a while. But soon, our business man, having sacrificed time with his family, time in the gym or stress-relieving sports to spend more time in the office, begins to rely on alcohol earlier in the day, and even more at night, simply to relax. And our woman, unable to cope with her many self-imposed demands, starts taking Adderall to keep up with her hectic schedule.
Even this offers a modicum of sustainability. But in the end, when we lose balance and succumb to self- destructive and addictive behaviors designed to sustain us in our unbalanced, achievement at all cost-oriented lives, we can find ourselves in a place we don’t want to be.
Without a single doubt, I lived this way as a young woman. In the end, no achievement would ever be enough to sustainably anesthetize the pain that arises from living a life disconnected from real values. In college and medical school, when I was fully in the throws of an eating disorder and getting more deeply sucked into alcohol, my only priority was becoming a doctor. Various moments of clarity, fostered by loved ones and strangers alike, helped me to see that left unchecked, my eating disorder would kill me before I’d ever graduate from medical school. My priorities were off, and my life was unmanageable–despite the fact that I was still showing up, and meeting the demands, of school. From as far back as I can remember, it never occurred to me that my health and wellness needed to be my first priority.
In my recovery I have gained a whole new respect for the necessity of balance. This concept grew in importance as my life got more and more abundant–a career doing what I love, a dog (another living thing to love and take care of), marriage to a man that I love with step-children I also love, and most recently, the grandest gift I’ve experienced in recovery, motherhood.
My work has been, and always will be, tremendously important to me. I have personally worn the chains of addiction, which is why I choose to spend my professional life helping others to gain the freedom that I enjoy. Today, I am firmly and consciously rooted in my values, with my own recovery and health topping the list. My behaviors and choices reflect my values (most of the time!).
Beginning SunCloud is one example of this in my life. Not only is it consistent with me keeping a positive work/family balance, it has given me the latitude and opportunity to fulfill a long-held dream: to create a fully integrated treatment center that offers the comprehensive care required to help people truly heal, one that values health and wellness first and foremost for every single patient and family–a place with values that are aligned with mine.
The customer is always right…
By: David Newton, Director of Operations
“The customer is always right” is a slogan by which most successful businesses live and die. We learn early in our careers that we must listen to “the voice of the customer.” “No” is a word we don’t use when talking with customers, and a disappointed customer is one who will likely not be around for very long. Solving problems and providing solutions for customers is what lies at the essence of all successful business, and as we do so we want a happy customer whose interests are aligned with ours and who feels taken care of and listened to. Business people have entire departments (sales) dedicated to making sure that the customer is not only “always right” but also that they are never told “No” and that ultimately, they are happy. Success is optimized when there is alignment and a “Win-Win” dynamic in place. In this respect, medicine is not unlike any other business. We are solving problems by saving lives. We want positive outcomes for our patients and we do well if they do well. We too want happy patients, but not at the expense of quality of care, and this is where things differ.
As stewards of knowledge that our patients may not have and having taken the oath to place others interests above our own, we simply cannot make every patient happy all of the time. We want them happy, if for no other reason than a happy patient is one who is more likely to stay committed to long-term recovery. However, it’s not that simple.
In treating those who struggle with addiction and other behavioral health issues, we find ourselves at this crossroads nearly every day; patients who want medications that we know aren’t good for them and patients who need more care than what we might be able to provide are two issues which come up regularly. Another is optimal group size for treatment. Deciding what to recommend to a patient becomes even more challenging when there is not necessarily a correct and incorrect answer. For instance, what exactly is the optimal group size for treating complex co-occurring eating and substance use disorders? Is it 6, 8 or maybe 10? The answer, it depends…. Deciding whether a patient needs IOP, PHP or Residential is another one where there is not always a black or white answer. ASAM has specific criteria for determining the appropriate level of care, but anyone in this field knows there is always some subjectivity as to what is best for the patient and that can easily lean either way depending on who is doing the analysis. Is it always the right decision to deny prescribing a stimulant such as Adderall to an addict? The answer is generally yes, as this medication is addictive in and of itself and it further dissociates people from their insides- all bad for the addict. However, it could be helping with ones ADHD, in which case there could be an argument made to keep the person on it.
At SCH we have disappointed several patients because Dr. Kim would not prescribe a medication which she believed would be harmful to the patient. We have disappointed several because they wanted very badly to join our IOP but our clinical team felt it was best to say no either because our group size was already too big to provide optimal treatment, or because we felt a HLOC (higher level of care) was more appropriate for the patient. These decisions have in all cases lead to “unhappy” customers, yet any good clinician who puts their patient’s interests above those of themself would have made the same decision. Making such decisions to say “No” to patients is one that is never easy, as we all want to help everyone, nobody really wants to turn anyone away and we are all human- it is hard to say “No”. However, good clinical care in this field requires “No’s” all the time, and with good clinical care comes good long term business.
Medicine is unlike any other business. It requires us to say “No” all the time because that is what is in the best interest of our patients. Of course we want happy customers! More importantly, we want healthy customers who can recover from these deadly diseases. In time and with recovery, our hope is that these patients will look back and be grateful for the course on which we helped them stay. For the team at SCH and because of Dr. Kim’s unwavering commitment to always doing what is best for her patients, we know nothing else.
The American public willingly exists under many myths: the tooth fairy is real; love always lasts forever; one size fits all. Belief in such myths is basically harmless.
This one is not: the myth of mental health parity.
Far too many people labor under the notion that insurance coverage for mental health issues is equal to that for problems of a physical nature. After all, wasn’t that legislated by the federal government a while ago?
Here’s the answer: no.
Every single day, we on the outpatient side of things, fight insurance companies to provide just one more day of care for those struggling with severe depression, an eating disorder, or substance addiction with co-occurring bipolar disorder or post-traumatic stress disorder. What does this translate into in real terms? Approximately $400 at the outside. And yet, a recent patient of mine, who was also a physician, told me about a surgical procedure in which the doctor elected to use a new semi-synthetic mesh product to close a patient’s abdomen, without making a single phone call to an insurance representative. The cost: $10K.
Due to much coverage by the media lately, there is now widespread awareness of opiate addiction throughout our country. This increased awareness is extremely positive on many levels. Yet again, a severe disconnect remains in the minds and hearts of insurance companies.
A patient of mine nearly died from an opiate addiction. On his current insurance plan, the co-pay for narcotic pain medications such as vicodin, oxycodone and morphine is literally nothing; it is essentially free. However, a prescription for suboxone, a medication that actually treats opiate addiction, requires a co-pay of $80 a month. Mind you, this is only after I, as his physician, spent 15-20 minutes on the phone with the insurance company to get the authorization required to treat him with this potentially lifesaving adjunct to his treatment.
Several roadblocks already exist for those with the disease of addiction. The stigma associated with substance abuse is very real and frequently proves a huge deterrent to accessing treatment, especially for those in the military. Moreover, instead of viewing addiction as a genuine illness, too many people continue to perceive it as a moral failing. Denial, a core symptom of many mental illnesses, keeps untold numbers of individuals from treatment. Add to this, a health care system that sets up serious barriers to both the patient and the treatment professionals and you have a perfect storm in which people remain addicted until they die, often due to overdose.
All of us need to be conscious of this ongoing injustice and question it whenever we can. Additionally, we must be grateful for groups like the Kennedy Forum, NAPHS, REDC and the Parity Implementation Coalition for working specifically and diligently on this issue of lack of parity. Only through both awareness and action will we witness much-needed change.
Despite all of the politicians involved, this really is not a political issue. It will be resolved through legislation and a lot of politicking, but at the end of the day this issue affects every single one of us, directly or indirectly. We all care about people who struggle with these diseases. We all have family members and friends who struggle with these diseases. Mental illness does not discriminate based on one’s political beliefs, religion, gender, class, ethnicity, or the color of one’s skin. It affects every single one of us, it can be deadly, and we all care, regardless of our political beliefs.
We don’t really know how this will end. However, the reality of the proposed legislation is that if the roll-back begins on “essential health benefits”, we are all at risk. It is the ignorant and misinformed mindset that somehow coverage for mental health is not “essential” that we need to be most concerned about. Those who think they know this to be true are wrong and those who feel this way simply do not have the facts. Ensuring mental health coverage for everyone, or at the very least ensuring that mental health is treated on par with other illnesses, is the right thing to do and it adds value to society in just about every way imaginable.
It will likely take months, maybe years, for a true “repeal and replace” to come to fruition. One can hope that when it does happen, mental health remains a priority, or at least on par with other medical conditions. What has been proposed thus far is indeed extremely concerning, yet we must remember this is just an initial proposal. This is a negotiation. We must keep this in mind and we have plenty of time and opportunity to make our case.
At the core we need to remain focused on key issues, such as increased access to care, real parity, de-stigmatization of these diseases, and ultimately integrated, increased access to treatment for all human beings. This work is truly meaningful. Our patients need us to advocate for them. They deserve it. We can reach out to our congressmen and congresswomen, write about and speak about the issues at every opportunity, and support groups like The Kennedy Forum, who will undoubtedly be continuing to take a leading role in the fight against this misguided mindset and peacefully fight for justice at every corner.
We also believe this is the perfect opportunity for all of us to work together to show the true value of prevention, early detection, and treatment for those who suffer from these diseases. Although is not about money at all for those who genuinely care about the individuals needing their help, if new legislation listens to one thing rational, it is cost. Most of us know that the treatment we provide and the time and money spent on prevention ultimately saves our patients (and society) money. This shows itself in direct costs, such as reduced medical co-morbidity costs, and indirect costs, such as reduced workplace absenteeism and increased productivity. It also makes people healthier, happier, and more productive members of society. We improve medical outcomes that matter to our patients and we do so in a way that saves money for all of us! In other words, we provide value to our patients, their payers, their employers, their families and ultimately to society and government. As we show the world the data that supports these facts (much of which is already well publicized), we will be in a stronger position to protect those who need our help the most at this critical time.
At SunCloud, we understand very well just how difficult it is to quantify the value we as treatment providers are creating for our patients and their families. Unfortunately, most don’t care and few want to listen. Today can mark the beginning of a new day for all of us. By working together to prove to the world just how important it is to support people with mental illness, we can protect the interests of our patients and ensure the best possible outcome for them at this precarious time in history. By focusing on our patients and what matters to them, and by working together to continue to do what we know is right and worthwhile, we will not lose this battle. We can’t lose this battle. Prevention and treatment does in fact create value and we have come too far to settle when this much is at stake.
Solving the addiction crisis in America is arguably one of the most challenging crises we have ever faced, particularly in recent decades. It is not the only one, but it is serious and wide spread. Like many other complex problems, we face as humans, we will likely never eradicate the world of addiction. There are cultural, biological, social, and genetic components to it which are all intertwined and which we are just now beginning to really understand.
Yet as the problem has reached the “epidemic” proportion, it seems that there is far more focus on treating the disease and not nearly enough on prevention. One area of prevention in particular, which we do not talk a lot about, starts at home with healthy, present parents.
Treating the disease of addition, no matter how it manifests itself, is incredibly important. Saving lives is ultimately the only thing that matters and effective, evidence-based treatment is capable of achieving amazing and proven results. Integrated treatment centers, programs such as “A Way Out” and “Text a Tip” in Illinois, helpful medications, and drugs like Naloxone are all incredibly useful. Without effective treatment, we would undoubtedly be far worse off than we are today. Further, evidence-based prevention programs such as “Botvin Life Skills” in schools, talks with our wiser elders, and reminders throughout our lives to avoid certain self- destructive behaviors are all incredibly helpful.
The one piece we seem to be missing is the fact that many of these issues, which come up later in life, start early on with our children as their brains are developing, particularly as they deal with loss and trauma. The data and literature show a direct link between early childhood trauma and addiction. Though I am not a therapist, I have zero clinical training, and have done no research myself on the effect that early childhood trauma can have on children as they grow older, I am a believer. Many minds far more brilliant than mine have published many compelling studies on the direct correlation, and I shall leave it to them to defend their thesis in the event anyone out there does not believe it. D.W. Winnicott (the late British child psychiatrist) defined trauma in early childhood as, “two things that can go wrong in childhood: things that happen that shouldn’t happen — that’s trauma — and things that should happen that don’t happen.” Early childhood loss is the essence of what trauma really is and when we recognize and admit that to ourselves, we realize there is so much more we can be doing (or not doing) as we raise our young children.
For me, I never thought of my children’s early experiences as being anything close to “traumatic”. There were no murders, no suicides, and no rapes. We did deal with one natural disaster, but we were able to escape before it hit and fortunately nobody was injured. My kids went to a good school when they were young, my family was always around, my kids played all sorts of extracurricular sports, had friends, we took vacations, etc.
Looking back, however, we had all sorts of trauma in our household as my two older kids were young. Some of it was avoidable and undoubtedly causing problems today, which is what keeps me awake at night on occasion and motivates me to share like I am doing today. For instance, I was, and still am in many ways, addicted to work. When I was home, much of the time I was not emotionally present for my kids. I was on my phone, checking emails, or just generally distracted living mostly a fear based life. I was in a horrible marriage. When we were together as a family I was anything but present and the tension in the home was palpable I am an anxious person and have been for a long time – worried about work, worried about making money to feed my family, worried about just about everything. Most people can’t see it, but my kids know it and it affected them – it still does. My ex-wife and I had a cantankerous divorce. We both played very aggressively, fighting for just about everything, and the kids got mixed up in it in ways that were both avoidable and unnecessary. Their mother struggled with substance use and, for several years, she was essentially gone. This was a huge loss to my kids and one that, to this day, they have not quite gotten ahold of. Looking back there was lots and lots of trauma for my two older kids and today one of them is showing concerning signs which the data very clearly could have predicted.
My advice to future parents, parents of young children, and the all of us who are concerned about this epidemic of addiction:
Be aware of the fact that early childhood trauma can increase one’s chances of becoming addicted to some form of self-destructive behavior as they get older.
Trauma is not only defined by life’s horrible events such as rape, murder, war or natural disasters. It is much more broad that that and includes things such as unavailable, distracted, or stressed parents and events such as divorce. In our society where many of us are stressed to the core, we have got to know that this takes us away from our kids and as they see this as a loss, therein lies a form of trauma.
What we can avoid and do better with as parents, we should. It starts with being aware of the long term consequences of our behavior. Yes, this is much easier said than done, particularly in today’s high stress, fast paced dog eat dog world. However, the importance of creating a nurturing, safe, and stable environment where we are present and available while our kids grow and their brains develop cannot be understated.
For me, the silver lining is that Kim and I are raising our 2 ½ year old son with this awareness. Though nothing is ever perfect, both of us do what we can to provide him with the loving and nurturing environment he and his brain need and deserve right now. Life will throw curve balls and we will inevitably have a child at some point who blames all of his troubles on his parents. Yet our hope is that we are currently living a life that is conducive to the state he needs us to be in, and we can try and live this way because we are aware. Living a trauma informed life is something we should all aspire to. Knowing what can constitute trauma to our child’s brain is crucial if this is something we want to try to avoid. There is currently so much focus on treating addiction once our kids get older and they find themselves addicted or in some form of self-destructive behavior pattern. Starting earlier, I believe, is critical. For those of us fortunate to be able to do so, we owe it to our kids to do nothing less.
Having spent nearly 25 years in a business completely unrelated to healthcare before studying under some brilliant minds at Kellogg Northwestern and Harvard Business School as I was earning my MBA, I feel I bring a fresh, albeit sometimes naïve, perspective to the business of healthcare. Wherever possible, I try to use this to our patient’s advantage. Our patients need and deserve as much advocacy as possible, to include from those who come from other industries and see best practices not being performed in healthcare. A few of the things in our area of behavioral healthcare that are exceptionally bothersome to me include:
Lack of transparency on prices and quality
Lack of meaningful and universally accepted outcome measurements that patients and payers need in order to know who does what and how well they do it
Lack of meaningful accountability on all ends
The fee for service model
The damage caused to patients by care that can sometimes be so incredibly fragmented, unintegrated, and poorly aligned.
Recently I had to deal with something that simply did not sit well, and what unfolded so negatively impacts our patients that it is worthy of discussion. Several weeks ago, we received a call from a person who wanted to learn more about SunCloud Health (SCH). It turns out the individual had seen Dr. Kim, Founder and Medical Director at SCH, when they were at Timberline Knolls (TK), then under Dr. Kim’s leadership, a few years ago. She had developed a great relationship with Dr. Kim while in treatment at Timberline Knolls and wanted to learn more about what Dr. Kim is now doing at SCH. At the end of the initial evaluation, it was determined that this person was an ideal fit for the services provided at SCH, not to mention the fact that the person had a previous therapeutic relationship with Dr. Kim which, at the time, resulted in a dramatic improvement in the individual’s life. Research in the mental health and addiction field supports the notion that an individual’s relationship with their therapist is a key and integral factor in treatment.
The woman mentioned above was ready to start treatment at SCH the next day. The only problem with beginning treatment was that we were not in-network with her insurance company…YET. In fact, as of the time of this situation, we had been in the process of negotiations for months with this insurance company and had been told that we were close to finalizing a deal to go in-network with them. Thus, they know who we are and that we have all of the quality credentialing they need to feel confident in the care we provide. In addition, they know of Dr. Kim through her experience as CEO and Medical Director at TK. That said, at this time we were not officially in-network and this patient needed to use their insurance to pay for services. As a result, we did the only thing we could do under these circumstances and applied for a single case agreement that would provide an exception to allow us to treat this particular patient at rates at or near those that would apply if we were in-network.
With this patient, we felt our case for the exception was pretty rock solid. As a part of our proposal, we also made an offer to the insurance company that, to the rest of the world, would seem “impossible to pass up”. Our case to the insurance company included the fact that the patient had had a good therapeutic experience with Dr. Kim in the past which resulted in positive outcomes, she was committed to working with Dr. Kim and the treatment team at SCH, and we at SCH felt that we could provide her with what she needs at this point in her life. Medical necessity was clear according to American Society of Addiction Medicine (ASAM) criteria AND we offered to provide service at WHATEVER PRICE the insurance company was willing to pay us. We made it clear we would literally do it for any amount of money. One would think all of this would have been enough.
Despite all of this, the decision was unfortunately as feared – DENIED. It was denied on the basis that, according to this insurance company, there are other treatment centers in our surrounding area who are in-network with this insurance company and can provide similar services. Therefore, the member should go to one of these other “comparable” facilities. They did not care that we were willing to provide treatment at whatever price they wanted, and they apparently did not care that the member had a good relationship with Dr. Kim and felt if anyone could help her, she and the team at SCH could. Thus, if this woman wanted to receive treatment at SCH, she would need to pay for it herself with her “out-of-network” benefits, which means no discount from the insurance company and self-pay. Although we proceeded with this woman, we were left dumbfounded as to why this case was denied.
First, it is not true that there are other outpatient treatment centers in our area providing similar or comparable care. What we do here with co-occurring disorders and how we do it is relatively unique. Most in our area treat one symptom or the other and they do so by tracking people based on their “primary” symptom. Rarely do they treat more than one symptom in one facility and, even more rarely, do they spend as much time getting to the underlying cause of the self-destructive behavior as they do on the symptoms. And even if I am dead wrong about this and there are dozens who do exactly what we do within 2 miles of our location with equal or better outcomes, how would anyone know? We don’t measure or compare standardized outcomes in this field! This drives us crazy here at SCH. We are advocating every day for the inherent value of outcomes and the shift from fee for service to value based reimbursement, but for today, it’s not happening. Thus, none of us really know what is true and what is not true with regard to who does what and how well they do it. To deny based on what is really nothing more than a guestimate is just plain ignorant and wrong.
Second, treating a person with depression or an eating disorder or some form of deep trauma is not the same as replacing a knee or fixing a broken wrist. Yes, we all need to feel comfortable with the doctor from whom we seek treatment for any ailment, but WAY more so in this field than in any other. There has to be a high level of trust and an unwavering sense of safety in the Doctor/Patient relationship when treating these illnesses. The data shows this is a critical piece of treatment which leads to improved outcomes and it should be weighed heavily when considering whether or not to support a patient in getting help from someone with whom they feel safe and have a good and healthy relationship. This was the case here and yet it did not make enough of a difference. In our opinion, this alone should have been basis to approve the single case agreement.
Third, we literally offered to treat this person for essentially any amount the payer wanted to pay us. At first, this really got me that this went in one ear and out the other. After all, we are on the verge of entering in to an in-network agreement with this insurance company and never before have I had such a good product or service and offered it at “any price”. After all, we meet all of this insurance company’s quality criteria for such agreements. They know us, they know our Medical Director and CEO, and they know that she has an exceptional reputation in this field. If they didn’t know all of this, I would expect a denial. It wasn’t as if we were approaching this insurance company and asking for $1,000.00 per day for treatment when their contracted rates with their in-network providers is $250.00 per day! If this were the case, I would expect a denial. In any other business, the buyer would have accepted our offer 10 times out of 10, yet not here.
I was so bothered by this denial that I reached out to one of my former business professors who is now teaching business strategy in healthcare at Harvard Business School. Admittedly, she was able to help me at least think through it a bit. Her response, from an economic perspective, was that economists believe “selective contracting” is necessary for lower negotiated rates and therefore this was likely the basis of the denial. Part of the in-network process includes negotiating highly discounted rates for insurance companies and their members from a select group of providers in exchange for volume. She also noted that if the insurance company agreed to pay for this woman to be treated at a facility not currently in-network it could potentially upset some other provider in the network. Needless to say, neither reason seems anywhere close to enough basis to deny care in this case. Illinois does have an “any willing provider” statute, but it does not apply to this case unfortunately.
In thinking through the concept of selective contracting, I, of course, understand the concept of having networks with a select group of suppliers who provide similar products and driving cost down from them in exchange for volume. In my experience, I have found this negotiating technique to be most useful when demand is greater than supply, and in general, the technique can be useful with many businesses and maybe even some areas in healthcare- BUT NOT OUR’S! A patient’s interests should come before the interests of the network, especially if it is a case such as this one.
Further, we currently do not have the means by which to evaluate or compare “precise products” in this field. Thus, how can an insurance company select whom they will contract with and whom they will not contract with (and at what price) if they don’t even know who really does what and more importantly what they do and do not do well? Second, even if we ignore this and were to concede the value of selective contracting in our field, is this really a legitimate and moral basis for denying a patient the care that they want and need? I would argue someone’s life is far more valuable than upsetting the apple cart with the “network”, especially if it can be done at a lower cost and at least as well as others. Third, in the outpatient treatment of co-occurring disorders, demand is far greater than actual supply. Good providers are needed and patients are suffering as a result of care that often does not meet their needs! Many say they can treat what we treat at SCH, but the reality is few actually can. In fact, this is one of the reasons Dr. Kim started SCH. In her role at the residential level at TK, where they do treat co-occurring disorders, she and her medical team would often struggle to find patients an outpatient treatment center that was capable of continuing with the relatively sophisticated level of treatment that their patients would receive while in residential. The reason for the struggle is that not many exist. This would often lead to relapses and re-admissions and is one of the reasons why Dr. Kim is so interested in providing this quality of care at the outpatient level – she knows there is a high level of need! When demand for a product or service exceeds supply, selective contracting can be useful as a means to offset some of the supplier’s “power”. However, when a supplier is willing to provide a product or service at “any price”, negotiating is simply not necessary.
Our patients face so many obstacles and barriers in getting the right treatment at the right time for their specific needs. From stigma to not knowing where to go and why, patients often rely on their insurance companies to help them make the right decisions. In this case, the right decision was to grant this single case agreement exception that we filed on behalf of the patient. There was no economic, moral, or medical reason to deny it and lots of rational and compelling reasons to grant it. Our hope is that nobody has to experience what this patient went through with this case. Our patients deserve more and better care from all of us. Allowing a provider like us to treat this particular case was the right decision for this patient. All of us benefit when patients heal. Our interests should be aligned. One day they will be. I believe that.
I read an article over the weekend which focused on helping the consumer find the right provider for mental health services when they may need it. Given the myriad of treatment options out there today, the unethical behavior by a few, the immense amount of marketing dollars spent on appealing to a sometimes naïve and desperate consumer with pictures of swimming pools and mountains, I found the article to be refreshing and very insightful. It was clearly written by someone who has been around long enough to understand the pitfalls one can easily fall in to when faced with a mental health crisis and someone who clearly cares about patients and their families. The author lists the following criteria that one should ask a provider when seeking or considering treatment options. Many of these are good to know, a few (I think) are not overly helpful and many probably mean a lot more to professionals than to a consumer. The last one, however, is critical to all of us. It is written as, “How does the treatment provider measure success?” and it deserves recognition and further conversation.
· How is your program licensed? (Residential, IOP/ PHP or ?)
· What is the length of the program?
· What do you do for detox if needed?
· Where are your services provided?
· What is a typical day in your program?
· What is your relapse policy?
· What is your maximum patient capacity?
· How do you work with co-occurring issues?
· How many on your treatment team have Masters Level or above educations?
· Are there medical personnel on-site 24/7?
· What does insurance cover?
· What is your cash pay cost?
· If a client leaves treatment early, is there a refund for unused amount
· What age group/gender do you serve?
· How many one-on-one sessions does a client have with Master’s Level or above clinician per week?
· Is the client expected to prepare their own meals (sober living level) while in treatment?
· How often do you drug test?
· Are phones and computers allowed?
· Is there a family program? If so, please explain.
· Do you have an MFT on staff (Marriage and Family Therapist)
· Is there an aftercare program?
· How does the treatment provider measure “success”?
As with any purchase, the right choice for a buyer is subjective. People make decisions based on what matters to them and what value they may place on something (referred to sometimes as a consumer’s “reservation price”). Some place price above all else whereas others include additional criteria such as quality, convenience, turnaround and durability in their decision making process. Some people buy from a brand or a particular company regardless of cost whereas others shop around and compare products as they make their decision. What is common is that most rational people who are spending their own money like to have some reliable and relevant information on the products or services they intend to purchase prior to making their decision. In most cases people tend to use that information to compare products and services across multiple sellers; for example- if I can buy an 8 ½ x 11 piece of white paper for 2 pennies from a seller 5 minutes away and I can buy the exact same piece of paper for 1 penny from another seller 5 minutes away (the other way), all other things equal I am going to buy from the 1 penny seller. If my intention is to print on that piece of paper I would want to know that the print-ability of the two papers is comparable.
In this simple example if I am unable to ascertain whether or not the two papers are of similar quality, it would be very difficult for me to make a rational decision on which paper to purchase. In fact, I probably wouldn’t buy either! It could be that the 1 penny paper is completely ragged and will not run through my printer. If my goal is to run the paper through my printer for a wedding invitation, this paper could cost nothing and I still wouldn’t want it. Looking at it another way and assuming now that the 2 penny paper is a much nicer shade of white than the 1 penny paper, if I can afford the 2 penny paper and a nice shade is something that matters to me, then I would likely buy the 2 penny paper.
Having this information is not only helpful as we make an assessment on who to buy from but it is also helpful for both sides (the buyer and the seller) as to what the agreed price is and in exchange for that price what the buyer should expect to receive in return (the bargain). For instance, if I agree to buy a sheet of paper from either seller which is supposed to measure 8 1/2 x 11 yet when it arrives at my office it measures 8 ½ x 5 ½, then I know I have not received what I bargained for. Maybe the seller made a mistake, maybe there was a problem in production or maybe I ordered the wrong size. Assuming I did not make the mistake, having had this information up front enables me to hold the seller accountable for what she agreed to sell me in the first place. In this instance I have the option of sending the wrong size back or possibly I bargain for a reduction in cost given the smaller size of the paper I received. If it was unclear what size I was going to receive when I agreed to make the purchase, I would have an impossible time holding the seller accountable for what to me is nothing short of an error.
The point is we need information in order to make decisions and yet in healthcare, particularly in mental health, this information does not readily exist for the consumer. This makes the decision on who to see, where to go and when to go nearly impossible. In mental health we currently rely on word of mouth, referrals and marketing materials. This works for some but not optimally for many. Fortunately, this is changing as the focus is turning to having reliable and relevant data from providers which measure outcomes (results) and value, just as we had in my simple example of the paper. That said, the reason we are living in the dark ages at the moment is not necessarily because providers are inherently not interested in providing data for consumers. Rather, it is because there is currently very little in terms of universally accepted outcome measurements that the field agrees are relevant, it is extremely difficult to measure these outcomes with our patient population and it is even more difficult to risk adjust- which is critical if we are to use outcomes to make decisions.
Some providers are tracking functional outcomes such as follow up visits made and medication adherence. Some are tracking re-admissions and relapses. Others are tracking using tools such as Beck Depression Index, PHQ-9 and the Addiction Severity Index. While all of these measurements provide valuable data for both patient and provider, unless we all agree on universally standardized outcome measurements for the diseases we are treating, we simply cannot compare one provider to the next. Esteemed groups such as ICHOM have recently established a standard set of measurements for depression that the world is being encouraged to use. However, to date there is nothing for substance use disorder nor eating disorders, and this is troubling.
To make matters more complicated, risk adjusting our patient population is extremely difficult to do and yet it is a critical piece of data one must have when evaluating outcomes. For instance, if you have two providers who treat eating disorders and one sees only patients who have been hospitalized at least three times whereas the other sees patients who have never been hospitalized and whose disease is generally caught early, looking at an outcome such as readmission rates in a comparison between these two providers will tell us nothing. Of course the provider who sees the higher risk patients is likely to have a significantly higher relapse rate that the provider who sees the lower risk patients. Does that mean the former is not as good of a provider? Absolutely not. Only once risk adjusted do outcomes in this field mean anything when comparing providers.
When one is measuring a patient reported outcome measurement such as level of happiness or self- content on a given day, in this field we all know our patient population’s answer can sometimes be subject to the effects of the very illness we are trying to treat. Relying on an important outcome such as this can therefore be potentially misleading. Yet this is the type of outcome that matters most to our patients and capturing the accurate answer when we want to know it can be incredibly powerful.
Comparing results across multiple providers is what is ultimately most important to a consumer as they attempt to make a rational decision for themselves and their healthcare, given their specific situation. In mental health we want to know what a provider is particularly good at, and what they may not be so good at. If our goal is to truly live free from the disease of addiction, then we probably do not want to work with an eating disorder provider who focuses mostly if not exclusively on achieving a certain weight for a patient. It would be similar to going to Burger King for a 5 dollar meal if what you really wanted was a 50 dollar steak from Morton’s. Yet we know not to go to Burger King for a really good steak because we have visibility in to what each provider really specializes in.
If our goal is to get back to work and live free from our active addiction, and we are able to compare three providers against one another and all three show relevant outcomes that are more or less comparable and yet one is 10% less expensive, then we want to know that. If a provider advertises that they are experts in treating co-occurring disorders, then we want to be able to see what happens 3 and 5 years out for their discharged patients…. How do we know if a provider is truly an expert in treating the more complex co-occurring cases? We would know if that provider and others who claim to do the same are tracking and measuring relevant outcomes that matter to the patient who suffers from a co-occurring illness. If someone says they specialize in co-occurring disorders and yet the data shows that the majority of their patients post treatment over a 5 year period re-admit to different specialists in eating disorders and anxiety, then maybe that provider really doesn’t specialize in treating co-occurring cases but rather what they really do well is treat people with less complex substance use disorder cases.
Once we have outcomes and results available to consumers, we can begin to rely on those results as we make decisions and we can hold our providers accountable for delivering those results to me. Let’s say in a perfect world (the future) I am a consumer and I present with a risk adjusted case of substance abuse category “A”. I am able to pull up data on three providers who specialize in treating what I have. The reported outcomes that matter to me are all essentially the same. However, two of the three quote a price of 20 and estimate the time I will be in treatment and away from work at 5 days. The third provider quotes a price of 30 but estimates the time I will be in treatment and away from work at 3 days. If I have the means and if getting back to work is very important to me, I may choose the third provider. Granted I am paying a little more but in exchange I am getting something that is of value to me. Let’s say, however, that for reasons that don’t have to do with me interfering with my treatment (KEY AND NOT SIMPLE), I choose the third provider and yet after all is said and done I am in treatment for 6 days. First of all, having had the information I had before making my decision on where to go I am in a much better position to hold my provider accountable for the extra 3 days I was in treatment. In other words, when they come to me and ask for another 30 because of the extra 3 days, I don’t fork over the money without a thorough analysis of what went “wrong” and who should be held accountable for the extra 3 days’ worth of treatment….. There is a measure of accountability that comes with having data prior to making a decision. Patients can hold their providers accountable for their side of the bargain. One may think this is horrible for providers, yet it is not at all. This type of risk sharing inherently incentivizes providers to be more efficient and effective with everything they do from diagnosis to treatment to follow up. And it goes both ways. In this example if I chose the 30-dollar provider and they treated me in 2 days, conceivably there is a savings of 10. If the provider gets to share in that savings, there is incentive, motivation and an inherent alignment of goals. Risk sharing can’t go just one way. That’s not fair to providers and it will never work.
If we are all measuring ourselves against one another using standardized outcomes, then we know what we are good at and we know what we may not be so good at. With this information, we can choose to focus on improving where we need to and can improve or possibly get out of the business of what we may not do so well and focus on what we do exceptionally well. This would be good for all providers and all patients. We can’t all be good at everything, yet what we are really good at is where we should be focusing our time and energy. This makes good business sense, and it is good for patients.
The outcomes that we are measuring must be standardized and relevant, and they must be results that matter to patients. Without this, a consumer can look at the best data in the world and have no basis with which to compare providers against one another in an effort to find what works for them. This is how markets work. It is normal, and this is where healthcare is headed. Getting there with mental health is anything but easy. However, as providers and payers work together to establish mutually agreeable standardized outcome measurements, we will get there. And when we do, our patients will be ecstatic as the quality of care will naturally increase and no longer will patients be forced to live in the dark ages as they make decisions at an incredibly vulnerable time in their lives.
Vulnerability and Truth in Recovery, by Shale Marks, LSW, CADC- Therapist at SCH
Several months ago I was looking at a journal entry written by a 17 year-old me and there were eight words that leapt from the page, which animated my spirit with a warmth and preciousness that made my heart swell. My 17-year-old self had written the words, “I think I’m finally starting to get it.” I look back at the boy I was then and hold him up to the light with compassion. I smile at the notion that he thought he was finally starting to get “it”. All these years later I realize that the greatest wisdom in the world is to know that I don’t know. This is the ungraspable truth that comes to many in recovery and what I as a clinician try to impart to our patients at SunCloud Health – that it’s okay to not know. It is okay to not be okay. In fact, the farther along we get in recovery, the more wonderful it feels to be able to say the three hardest words for us to say, “I don’t know.” As Brené Brown eloquently states – this is the power of vulnerability. It is from our weaknesses that we find our strength and sometimes what seems to be our final hour, often becomes our finest hour.
What was the “it” that I thought I was starting to get?
My first career was as an actor. I moved to New York City when I was 18 to pursue acting because performing ignited something in me that gave me access to a personality that I did not know that I owned. Often, people pursue a career in acting because it provides the space and opportunity to be somebody else for a few hours, to take an audience in and convince them that what is happening on the stage is actually occurring. But for me, it was just the opposite. When I was performing on stage or in front of the camera, it was when I felt most like myself. Acting gave me access to the present moment, a place I had rarely visited. Today I can access to power of the present moment anytime I like. This is the primary gift of grace in recovery.
My first Christmas in recovery was a dismal one. The day before Christmas, I was depressed because it was the day before Christmas. Christmas day, I was depressed because it was Christmas day and the day after Christmas I was depressed because it was the day after Christmas. I now realize two things about that Christmas. First, I am not a Christian. Second, it had nothing to do with the holiday and everything to do with an internal condition, which seemed utterly hopeless. It was what we in recovery often refer to as the hole in the belly that the wind blows through, a divine dissatisfaction, an unsatisfied God-hunger or an unquenchable thirst.
Not too long after that Christmas, I began to see that recovery can only begin when a person realizes that the problem is not external, though external conditions can certainly contribute to dis-ease. Recovery is now and has always been an inside job. And what of the “it” for which I yearned – the itch that couldn’t be scratched? It is always available in the here and now. The present moment isn’t just something sandwiched between the past and the future. Contained within the present moment are hope, possibility, an internal revolution waiting to be quickened and a stirring of love, which we all have within us. We simply have to open our eyes to see it and if you can’t find it on your own resources in this holiday season, there is help available. Light and love.
Shale Marks, LSW CADC
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