4/8/2014, Heroin addicts face barriers to treatment


Some users overcome their addictions in spite of the obstacles. But many, like Salvatore Marchese, struggle and fail. In the course of Marchese’s five-year battle with heroin, the young man from Blackwood, N.J., was repeatedly denied admission to treatment facilities, often because his insurance company wouldn’t cover the cost. After abusing marijuana and prescription painkillers as a teenager, Marchese had turned to heroin for a cheaper high.

Then one night in June 2010, a strung-out, 26-year-old Marchese went to the emergency room, frantically seeking help. The doctors shook their heads: Heroin withdrawal is not life-threatening, they said, and we can’t admit you. Doctors gave him an IV flush to clean out his system, and sent him home. Marchese and his sister stayed up all night calling inpatient treatment centers only to be told: We have no beds. We’ll put him on a waiting list. Call back in two weeks.

As Marchese grew sicker with diarrhea, body aches and shakes, his sister tried a new tack. She called one more place and told them her brother was using heroin and also drinking alcohol. That did the trick, because alcohol withdrawal can cause life-threatening seizures. He was admitted the next morning, and released 17 days later when his funding from the county ran out.

Less than three months later, Marchese was found dead of an overdose in his mother’s car, a needle and a bag of heroin on the center console…

Susan Pisano, a spokeswoman for America’s Health Insurance Plans, the national trade association that represents the health insurance industry, defended the industry’s practices. “Health insurers rely on evidence-based standards of care that look at: what is the right level of coverage, the right site of coverage, the right combination of treatments,” she said. 

C’mon, we all know that the insurance industry’s “standards” were arrived at by some computer software program, with the insurance company’s IT department engineering the algorithms.

A 30-day inpatient stay can cost as little as $5,000, but the average cost is about $30,000. The cost of heroin detoxification alone, which usually takes three to five days, is around $3,000, Rizzuto said. Most clinics require payment upfront if insurance can’t be used.

There are about 12,000 addiction treatment programs nationwide, according to McLellan’s organization. Of those, about 10 percent are residential facilities, about 80 percent are outpatient programs and about 10 percent are methadone clinics. There’s also a small number of state-run programs funded by Medicaid. Two-thirds of all treatment programs are nonprofit programs funded by government grants, McLellan said. When those block grants run out — they have been shrinking in recent years — programs are forced to put patients on a waiting list until they get more money…

Outpatients programs typically cost $1,000 per month and range from hospital-run programs that addicts attend five days a week to once-weekly group therapy sessions. Federal officials have been promoting outpatient care in the form of medication to help prevent relapse for opiate addicts. Most people pay the monthly $1,000 bill for these medications out of pocket, though some insurance companies cover them.

In New York, a bill going through the state Senate would amend the state’s insurance law to force providers to approve authorization and payment of substance abuse care. It would require that every policy that provides medical coverage has to include specific coverage for drug and alcohol abuse treatment services that are deemed necessary by a doctor. That means the only prerequisite for receiving any kind of drug abuse treatment would be a doctor’s referral, preventing insurance companies from denying treatment based on a complicated set of guidelines. A similar law was passed in Pennsylvania years ago and has helped addicts get better access to treatment, the bill’s advocates say.

Nora Milligan of Patchogue, N.Y., is among the supporters of the New York bill. A single mother and critical care nurse, she said she was forced to file for bankruptcy in 2011 after years of paying around $1,000 a month for her son’s heroin treatment. Her son eventually qualified for Medicaid — because of her financial woes — but then the Medicaid managed care company, Fidelis, refused to pay for inpatient treatment.

“He had all the high-risk stuff there. Homeless, dangerous living, addiction,” she said. “He had the physical aspects. And they denied him. I was floored.” Milligan took the company to court, which forced the provider to release its guidelines regarding “medical necessity.” Her son qualified for most of them, including risk of severe withdrawal and substantial risk of physical harm. The exceptions: He wasn’t homicidal or suicidal, and he had no “psychosis, mania or delusions.” 

“And meanwhile, people will die. That’s not melodramatic. That’s a fact.” 

I’m just not sure that the current treatments for addiction will ultimately save people, or prove to be more harmful than beneficial in the long run.

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