Funding Addictions Treatment: Medicare’s Horror Show

PsychOdyssey OpEd, July 9, 2010

What is a true Medicare abuse? Insufficient coverage for addiction treatments. Medicare’s miserly approach wastes millions. What it spends today is not nearly enough to avoid wasting much more down the road. As a social policy, it is a horror show.

Consider a young individual with a psychiatric disability and an addiction to, say, alcohol or cannibis. That’s not uncommon. Fifty percent of those with schizophrenia also have co-occuring substance abuse issues. Perhaps a quarter of those with schizophrenia are classically dual-diagnosed. Getting the addiction under control becomes the paramount challenge, because progress with psychiatric recovery is not possible when an addiction rages. For these unfortunates, what is the best course?

First, detox: five to ten days of “Level 4” intensive inpatient hospitalization to break the addiction. Then, long term residential: 60 to 90 days. Once stabilized, an individual ideally moves to a “Level 3” residential treatment for that time. Isolated from his usual triggers, the individual can be bathed in intensive group and individual therapy. He can have drilled into his  psyche the reasons and routines for sobriety. He can develop a new mental muscle memory for sobriety.

Then, intermediate stage: 4-6 months. Following such intensive residential therapy, the next step is a four to six month “Level 2” intermediate step-down stage, presumably in a group home or supervised living facility. Here, the new habits of sobriety can be reinforcement in a supportive group environment which emphasizes individual accountability and temptation resistance. Finally, outpatient stage: up to nine months. Over the next several months, there would be a “Level 1” engagement in an outpatient day program, either by an all-day “partial hospitalization” program or a half-day “intensive outpatient” program.

This optimal approach takes time, and money, but has the best outcomes overall. Yet that approach is not one any insurance company today will finance. Herein lies a great contradiction—and cruelty—of the current American health care system. A dually diagnosed individual on Medicare now can receive only five to ten days of detox “Level 4” treatment. That’s it. Thereafter? No residential treatment. Medicare will only pay for Intensive Outpatient Treatment in certain facilities. As a health care option, that’s a pittance.

Of course the optimal approach is expensive. But an insufficiently treated case is ultimately more expensive. More prone to relapse… More likely to fail in recovery… More certain to become an expensive burden to the society.

This is an awful unintended consequence of “health care reform”. By vastly expanding the program, in many cases for wealthy elders who don’t need necessarily need it, and in vowing to pay for its increased expenses by cutting “waste, fraud and abuse”, reformers have hurt those with psychiatric disabilities who are dually diagnosed. because of insufficient financial support for their treatment from their only source of coverage, these challenged souls on Medicare will by this policy be cursed to unresolved addiction. It is truly a horror show.

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