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.
Since opening our doors a little more than a year ago, we have tried every day to create a special treatment center that people want to come to for exceptionally high quality, individualized care at an affordable cost. Built in to our DNA is a ferocious desire to continuously focus on getting better at what we do in order to achieve our goal. We believe this is the only way we will survive in a highly competitive market, particularly given our desire to remain independent of anything or anyone who could get in the way of a laser like focus on quality of care. We have to want to be the best at what we do every single day, and willing to make changes when changes need to be made if it means our patients will benefit.
Outcome surveys and measurements help us accumulate and respond to the data we need in order to operate in this manner. Another arguably more effective and much simpler “tool” is just listening and paying very close attention to our patients when they provide thoughts and feedback. “Add a water cooler, we need a process group on Fridays before the weekend, the group size is too big, we need more “skills” groups”… This is information we must have in order to remain focused on continuous improvement. Fortunately we have a culture which encourages and supports all of us who have thoughts and ideas which can make us better as a recovery community. Pray this never changes.
Our patients are our customers. They are the ones whose interests must always come first and they are the ones who will either make or break the future of SCH. We know this, and we respect this. Our relationship with our patients is a professional relationship where very specific and predetermined protocol guides the nature of what is expected from both parties in the exchange. We provide the service, they hopefully get better and they pay us ideally for the value we are providing to them and their families.
When collecting patient satisfaction surveys last week one of our patients was insulted when referred to as a “customer”. To this person, the word, “customer” seemed to imply that it was just about the money… It is not all about the money but money is being exchanged and with that comes responsibilities inherent in such an exchange. The word, “patient”, on the other hand, implies “they” are sick and “we” are not… Yes our patients are here for help and our clinical care team is here to provide that help but we are all in this together and at the end of the day we are all just people who are doing our best with what we were given to survive in what can often be a challenging and beautiful world.
There is a lot written on the pluses and minuses of using the words, “patient” or “customer” when referring to people who receive healthcare services. Attached below is something from Yale’s Business School of Management on the topic which is interesting. Read it HERE
Whether we use the word person, patient or customer, the fact of the matter is we all need input from those we serve in order to be the best that we can be. It is critical not only to our success as a business but more importantly for patients and their families, which at the end of the day is our guiding principle. Asking questions is only part of it. Having the courage to change the things we can is what makes the difference.
As I was enjoying time with friends and family last night in Boston, I was asked the following question by a woman who is a Chief Healthcare Economist for The Office of Inspector General, US Department of Health and Human Services:
How do we get rid of the fraud and abuse in the substance use treatment industry, particularly with the atrocities happening in many sober homes and the over prescribing of medically unnecessary (and addictive) drugs which are being prescribed to some of societies’ most vulnerable citizens (addicts)?
The AIG recently participated in the largest health care fraud enforcement action in Department of Justice history. Hundreds of people were charged across multiple states involving over 1 billion dollars in fraudulent claim filings. In one noteworthy fraud scheme, a medical professional in Texas was charged with over-prescribing medically unnecessary narcotics to patients, some of whom died from drug overdoses. The doctor allegedly fraudulently billed Medicare and received more than $1.2 million in reimbursement. READ HERE for some quick facts on the action, and HERE for the official press release from the DOJ.
As I was thinking about how to answer this question to this woman who is probably 20x more intelligent than I am, what did come to mind is something along the lines of…. “It is no wonder insurance companies put us (as providers) through such rigorous and time consuming scrutiny in the form of questioning just about every decision we make and every action we take. All we are doing is trying to get what we often feel is the bare minimum amount of coverage for our patients and provide them with the best possible care, and yet they don’t ever seem to be on our side….”
For sure much of the intense scrutiny we get as providers in behavioral health is due to a lack of parity, stigma and shame and the misguided belief by some that addiction is a choice rather than a disease. However, much of it is also due to the fact that there are alot of really bad people out there capitalizing on our nation’s drug addiction epidemic by committing crimes and grossly taking advantage of very sick and vulnerable people. And insurance companies are dead smack in the middle of it.
Patient brokering, providing services and products that people not only don’t need but which are also potentially deadly for them and falsely billing for products and services that aren’t provided are serious crimes and serious ethical breaches. We should not be surprised that these same insurance companies who are victims to this kind of abuse are also the ones giving us what often feels like an unnecessary and unappreciated fight over providing the appropriate level of care for the appropriate amount of time based on our clinical recommendation as legitimate and trustworthy providers. Their eyes and ears have to be wide open. They don’t trust anyone. It makes sense, and it is extremely bad for those of us who are actually doing the right thing.
More importantly, the fraud and abuse is bad for patients. They are the ones who are hurt the most by this high level of distrust between payer and provider. They suffer because of the actions of a few really bad people. It is not right and it is not fair. They deserve more and better from the entire industry.
While I try my best to answer this question posed last night, I will say to the majority of us who are playing by the rules and in this for the right reason that the next time a UR rep from an insurance company makes us question why we come to work every day, try to have an ounce of compassion for them! Do continue to advocate and fight aggressively and passionately for your patients. Do not allow discrimination for what we know are treatable diseases to go unspoken. Call it for what it is and settle for nothing less than what your patients need. Fight the stigma and the shame. Prove to them that there is value in what we do! After all, there is value and recovery is possible. Many just don’t know it or believe it.
And understand that the sooner this fraud is eliminated, the sooner we can all work together to achieve our goals. The ideal scenario is payer and provider trust one another and can work together to achieve a similar goal that is in the best interest of the patient. Second to that is just being able to trust one another. Without some level of trust, we will never get anywhere. And we won’t have trust until this nonsense such as the Del Ray, Florida Sober House scene gets cleaned up once and for all!
Thank you Marta and Leemore for inspiring us to think about this issue, and thank you Kim and the whole team at SCH for working effortlessly as we try to make a difference in this world in the work we are doing.
I listened to an interview this morning titled, “Building Clinicians’ and Non-Clinicians’ Trust and Respect”, by Thomas H. Lee, MD, MSc & Laura L. Forese, MD, MPH. It’s about building teamwork and trust within a healthcare organization, particularly between clinicians and non –clinicians at New York- Presbyterian Hospital. The article discusses the absolute need for high performing teams to have trust and mutual respect amongst all members of the team. Listening to this was not only insightful and right on point, but it helped put things in perspective for me as an Operations Director in a healthcare system that is tasked (and challenged) with a very similar initiative.
Where operations is focused on “boring” things like monitoring and reducing cost and measuring outcomes and optimizing operations, the therapists and doctors I work with are pretty much squarely focused on providing the best possible care they can. Though they understand the need for someone like me in the organization, I believe the cold hard truth of the matter is that they wish people like me would just get out of their way and allow them to work with patients and do their job.
Being a relative new comer to healthcare, I never thought that building trust and respect between clinicians and non- clinicians could be such a challenge. I suppose I should have known this “business” was like no other as I was sitting in Michael Porters Value Based Healthcare Class at Harvard Business School with probably some of the most brilliant physicians and healthcare leaders in the world back in January of 2016. Professor Porter was explaining concepts such of risk sharing and activity based costing (a fancy term for knowing where you spend your money) in very, very basic terms. As I sat there I remember asking myself two things; first, why is he explaining such basic material to people who are 100x smarter than I am and second, why are so many in the room so confused and or so resistant to running their “business” this way (which happened to be the only way I know how to run a business)? It all made perfect sense to me and yet I felt like a fish out of water. I acknowledge that medicine is unlike any business. In fact for those of us who believe we should all be given equal access, it can’t be like every other business. Regardless, I also believe that a healthcare system without 1) aligned goals amongst payers, providers and patients, 2) some level of transparency, 3) open competition, 4) accountability and 5) some form of risk sharing is a system that is simply not sustainable. It took someone with Michael Porter’s stature to make this case, and today I understand why.
Clinicians are trained to spend the majority of their waking hours focused on improving the quality of life for the individuals they are treating. They pour their own blood, sweat and tears in to their work and the work they do is arguably the most important work on the planet. They don’t want to burdened with one ounce more of paperwork than what they are absolutely required to do. They don’t want to spend time making sure that the equipment needed to provide the care is not only “the best” to get the job done but also affordable for the organization. They don’t want to waste precious treatment time encouraging patients to complete outcome surveys. They don’t want to spend extra time in an EHR system documenting data that is not necessarily relevant to quality of care but which is incredibly relevant to payers as they try to measure the value patients are receiving. They don’t want to spend precious resource time arguing with payers over medical necessity in order to squeeze out a few extra days of treatment for a patient in need. They hate this piece, and rightfully so. And many of them don’t believe they should share in any of the risk of whether or not their patients’ outcomes are successful.
Some of this will naturally be remedied as healthcare systems shift away from a fee for service model which rewards providers for volume to a value based model which rewards providers for the value they deliver. Some of it is necessary in order to make this much needed transition. And some will likely always be a part of providing care in a world that demands more and more out of all of us every single day.
In order to be on the right side of making care more affordable, more efficient and more accessible to all, an organization must instill a culture which recognizes the value of all constituents within an organization, both clinical and non- clinical. This is mission critical. With this clinicians can focus on doing what they love and what they do best and the rest of us can support them in providing the best possible care and value for patients and their families.
Tom Lee, the brilliant physician and true social revolutionary, does a great job with this interview. It touches on a lot of really great thought provoking insights and challenges. The first time I met Tom he told me and my colleagues that healthcare is in dire need of more people who truly understand and know how to optimize “operations”. I was with a friend who is a black belt in Lean Six Sigma and Tom was impressed (hard to impress Tom so we were thrilled!). The reality is a high performing team requires that all members are trusted, respected and valued for the work they bring. An organizations’ culture must nurture and promote this philosophy from the top down. There is no other way to succeed in today’s world of healthcare. Those who embrace this reality will survive while those who do not will eventually fade away.
The team at SCH is looking to align with like-minded treatment centers, mental health professionals and business leaders as we form an alliance designed to enable close collaboration around patient care and quality improvement initiatives in the behavioral health space- specifically the addictions and mood disorders space in which SCH operates. The name of the alliance is VMH, for Value in Mental Health. We are seeking to create an atmosphere in which we as healthcare professionals are able to openly discuss outcomes data with each other in order to drive an increase in quality of care, a decrease in total cost and data which clearly shows the value that we in the mental health field provide to patients, their families and their payers. Please contact David Newton at SCH to learn more.
If ever there was a time for mental health providers to work together to demonstrate, document and prove the value that our care provides, now is that time. The fact remains unfortunately that a relatively large percentage of people in our country simply do not want to pay for mental health services. Human behavior teaches us that people generally don’t want to pay for something if they don’t see the value in it. This is absolutely the case in mental health. Those of us who have done the research, who have lived with these diseases and/or who have treated these diseases know first-hand just how valuable and powerful proper and effective treatment can be. Lives can be saved, dollars can be saved and families can be saved. However, so many people don’t know this or they don’t believe it and as a result they simply don’t want to pay for it.
We see this being played out in Washington DC with the new healthcare act coming down the pipeline, which will inevitably cut funding for mental health treatment one way or another. We also see this being played out in the way treatment is currently paid for by managed care with the sometimes ridiculous hurdles they often put providers through. At SunCloud Health, we have had two cases in the past three weeks where managed care denied our right to submit clinical’s on two separate patients (who absolutely needed what we were recommending) based on their claim that they did not receive the request to submit clinical’s in a timely manner (Yes, you read that right). Drilled down for those of us who are forced to spend and waste countless hours on contentious “peer reviews”, the facts are as follows: We were initially and in our opinion unjustly denied for the requested level of care at the pre-auth stage, we opted to advocate for the patient and elected to escalate to the next level, we left the voice mail advising as much, we have proof that we left the voice mail, they denied receiving the voice mail and as a result they closed the case and refused to even consider the case for the level of care we recommended. They never looked at the additional clinical information available for review, they did not speak to anyone on our clinical team and they refused to authorize the level of care for the patient. Clearly they do not see the value in the care being provided. If they did, this would not happen this way. It just wouldn’t.
When a payer can get away with not paying for legitimate care based not on a patient’s clinical’s but rather a technicality such as they supposedly did not receive a voice mail, when more than 50% of the highest leaders in this country are debating not whether or not to cut access and funding to mental health but rather how to cut it and when some people still believe many mental health illnesses are choices rather than diseases, we most definitely have a problem.
Living in a country and in an economic system where we pay for goods and services based on the perceived value that we place on those goods and services, the most effective way to successfully address this problem is to prove to the world that there is in fact value in what we do. We know it’s there. Our job is to convince those who don’t know it or who don’t believe it that it is there. This is done with honest and reliable data and a clear message. It requires collaboration and cooperation between like-minded quality providers who deserve to be paid for the work that they provide not just because they feel like it but because there is real tangible VALUE in the service they are providing.
To show value, we must be able to effectively and clearly show people the results (or outcomes) of the treatment we provide, and the cost to achieve those outcomes. And we must do so in a way that our patients, their families and their payers can easily understand and in a way where they can compare our services against one another so as to determine what each of us do well and what we may not do as well. It is only with this perspective that comes with being able to compare products and services that people will be able to confidently assign a value both to what we provide as an industry and as individual providers.
To actually do this, we need collaboration among ourselves as providers and we need the buy in from payers who hold all of the claims data to agree to do the analysis with the data that they have and the results that we will provide them. Together, we need to agree on a standardized set of outcome tools that we all use and we need to pool as much data as possible so as to make a convincing case. We need to be ready and willing to learn from the measurements we will be taking as we learn what we do and do not do so well, and to work to continuously improve where we can. We MUST be willing to shift our mindset and our business models from being rewarded for the volume of services that we provide to being rewarded for the value that we provide our patients and their families. We must be willing to share in some of the risk with our patients and their payers, which simply means we do better when our patients do better and we don’t do as well when they don’t do as well (due to something that was or is in our control). We should we interested in having patient representation on quality improvement teams, as patients know sometimes better than we do where we can improve. Where we can take our cooperation a step further and create mutually beneficial alliances which optimize and leverage our strengths, we should do so. And of course we need to continue to advocate for our patients and their families every chance we get.
An inspiring article was released this month from ICHOM, an international consortium based in Cambridge which measures, documents and publishes meaningful health outcomes, about a group of hospitals in the Netherlands that decided to form an alliance that would enable close collaboration around patient care and quality improvement initiatives. The group is called Santeon and what they have been able to accomplish by taking many of the steps mentioned above is simply remarkable. Though they are not in the mental health space, there are still many lessons to be learned and the path they took toward changing the paradigm is one that at the very least is worthy of looking at.
The business of healthcare has changed a lot in the past ten years. Providers are being held more and more accountable for our provision of care than at any time in recent history. The shift from paying for value over volume is one that has moved in to many area of healthcare, and it is one that mental health providers should embrace arguably more than any other specialty. Payment for our services is currently under attack from just about every angle and this is primarily because we have a very difficult time showing people just how valuable and powerful our services can be. By working together and changing the way we do business, we can address this attack head on. And the beauty is that while we do this we will not only save ourselves from the attack on everything that we do, but we will improve quality of care, we will reduce total cost and we will do our part in providing as much access as possible to patients and their families who are in dire need of our services.
Click here for the ICHOM article on Santeon.
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 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.
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.
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