Top Menu

Commentary: Affordable Care Act Does Little to Increase Addiction Care Access

/By

The demand for addiction treatment is high. The supply of addiction specialists is comparatively low. Yet unlike traditional economic models where money is the obstacle, in our field, the obstacle is time.

There are two factors involved: the time required to provide reasonable quality of care, and the time required to produce a specialist who has the ability to provide that care. These limitations restrict the number of patients that can be seen per day by all available addiction specialists. While increasing pay for care would result in an increased interest in the field, development of appropriate training and the years of training necessary would result in only slow growth of available treatment.

Because addiction specialists are not currently sitting idly at their desks surfing the Internet, access to treatment is not limited by financial factors but rather by availability factors. There simply isn’t a great enough supply of specialists to meet the demand of patients.

In 20 years of practice, I have worked in an academic setting as a staff physician in an addiction specialty unit, as a medical director of a community mental health center (CMHC) and as a private practice physician specializing in addiction. In each setting, I have turned no patient away. At the private practice, as is the common practice here, we do not take insurance but always work out a fee arrangement that is compatible with a patient’s needs. The CMHC also utilized a sliding scale for patients, and in the academic center, patients who could not pay were seen by a fellow with oversight from faculty. Patients have roughly equal access to at least one part, if not all parts, of the system. But availability of service, not fiscal issues, always proved the greatest constraint. “We’re happy to see you, Miss Smith, but our next opening is in 2015.”

That’s not to say there is no fiscal issue: my CMHC lost money on physician-provided care for nearly 20 years. Expenses were more than my hourly wage, and included collection costs, billing, insurance reviews and audits, with the revenues limited to copays and insurance payments. Things got much worse a few years ago. Collections dropped, audit rates increased and ultimately the CMHC could no longer afford my services. Did I mention that the CMHC I worked for is in Massachusetts? The community no longer has an addiction specialist and was recently featured in the news due to increased problems associated with substance use.

But the fiscal issue does not represent an access constraint because we clinicians can easily practice outside the employed environment. Looking at my case above, I left the CMHC and took most of my existing patients with me into my private practice in an adjoining state. Because I do not take insurance yet charge a reasonable rate, my expenses are quite low and patients do not have a significant financial burden in comparison to the CMHC model. Thus payment again did not end up being a significant limitation to access.

Now let’s come to the headline of the hour: the recent Supreme Court ruling. In many ways, the ruling was a non-event in that it simply supports, largely, what had already passed in Congress. The Affordable Care Act does very little to increase access to addiction care because it does not solve the primary obstacle we’ve discussed. It promises to increase the number of those who have insurance coverage, but as I’ve pointed out, coverage has not represented a significant obstacle in long-term outpatient addiction treatment. And long-term outpatient treatment is the key to avoiding higher levels of care. Outpatient care is where addiction treatment truly takes place since the higher levels of care are limited to the acute manifestations of substance use (e.g. detox, rehabilitation, and medical/psychiatric sequelae) and not the chronic issues related to addictive illness.

The Act promises that substance use disorders will be covered at parity as part of the essential health benefit. But any expectation that this will lead to coverage of long-term outpatient treatment is misguided. Because the primary limiting factors – time – is not being addressed, we will see no significant improvements. Given my experience in Massachusetts, however, we may see a significant alteration in how services are provided, with greater numbers of independent clinicians moving away from an employed model and into private practice and fewer clinicians accepting insurance. Too, there may be higher charges because of the higher taxes in place now due to the very Act that is supposed to increase access. This is a good thing as costs are much lower in private practice due to the reduced administrative burden and overhead. The overall cost of health care will drop.

Remember pendulums swing both ways. Just as the past decade saw a decline in private practice, the Affordable Care Act, should it not be repealed, will likely prove an economic force in the other direction insofar as bio-psycho-social-spiritual treatment of addiction is concerned.

Stuart Gitlow MD MPH MBA is a member of the American Medical Association’s Council on Science & Public Health, and Acting President of the American Society of Addiction Medicine. This Op-Ed represents his personal opinion and does not imply any position or policy taken by either the AMA or ASAM.

3 Responses to this article

  1. Avatar of Kathy Ketcham
    Kathy Ketcham / July 28, 2012 at 1:27 pm

    Time is the key in addiction treatment and recovery. Thank you for this reminder, Dr. Gitlow. I would only add that when we speak about outpatient treatment and care, we also take care to emphasize the essential role of ongoing recovery support services. These can take place in an outpatient setting or in the community through recovery community organizations dedicated to providing peer recovery support. In our small rural community in Walla Walla, Washington, Trilogy Recovery Community helps guide youth into inpatient treatment, provides peer support groups for youth who are in outpatient treatment, and “plants the seeds” of recovery with youth incarcerated in the Juvenile Justice Center. Recovery is a life-long process and if compassionate support and access to resources are available at every step along the way, young people can and do find their way to health and happiness. Family education and support is a critically important part of this process for once family members learn how to take care of themselves and set firm and consistent boundaries, they make it awfully hard for the addiction to maintain its stranglehold on their loved ones. At every step along the way, we need to remember what Dr. Gitlow emphasizes: chronic issues in addictive illness require a long-term approach. TIME is of the essence.

  2. Luis Lozano / July 13, 2012 at 12:36 pm

    There are other alternatives than the medical model for helping addicts and alcoholics. The medical model that relies on drugs and professionals will only add to the cost of treatment un-necessarily and it will deplete resources that can be more effectively used by less costly methods.

  3. Stuart Gitlow / July 16, 2012 at 6:41 pm

    I often find I have to clarify the term “medical model,” as some infer it incorrectly as indicating there to be use of medications. The medical model simply indicates that a clinician takes into account all of the bio-psycho-social-spiritual realms that may or may not be applicable in any given case. For example, if an individual with depression is simply given an antidepressant without clinical examination first to determine if the depression is a normal response to a social stressor, or if the depression results from abnormal thyroid metabolism, the medical model has not been followed. I follow a medical model closely with treatment of those with addictive disease, but utilize pharmacotherapy only rarely.

Leave a Reply

Please read our comment policy and guidelines before you submit a comment. Your email address will not be published. Thank you for visiting Drugfree.org


7 − three =

Disclaimer:
Reproduction in whole or in part of this publication is strictly prohibited without prior consent. Photographic rights remain the property of Join Together and the Partnership for Drug-Free Kids. For reproduction inquiries, please e-mail jointogether@drugfree.org.