Rehab Center Founder Criticizes Managed Care

The founder of the Gateway Rehabilitation Center in Pittsburgh, Pa., blamed managed care for the problems being faced by treatment centers, the Pittsburgh Post-Gazette reported Nov. 2.

Dr. Abraham Twerski, 70, a physician and rabbi, started the Gateway rehabilitation center in 1972; it now has more than 30 treatment facilities in the region. In addition, Twerski established similar centers in Israel. Forbes Magazine recently named Gateway one of the top 12 treatment centers in the country.

But in talking about how illicit drug and alcohol treatment has changed over the past 30 years, Twerski, who now serves as the center's medical director emeritus, blamed managed care for wreaking havoc on the field.

“People who could have better services and a better chance at recovery are being deprived of it,” he said. “I believe every individual should be assessed so that their needs are addressed properly, but that's not what has happened. Many managed-care companies and HMOs are refusing most inpatient care on the grounds that it's not necessary. They are making arbitrary judgments.”

To adapt to the times, Gateway established 30 satellite outpatient facilities and halfway houses in the region. “We were opening outpatient clinics before insurers even were willing to pay for them,” said Dr. Neil Capretto, Gateway's medical director. “But there is still a population that needs inpatient care, and that's the part that's suffering.”

Capretto added, “Today, we're seeing people closer to age 30, plus a higher number of women and minorities. These people often have multiple addictions and complex medical and psychological problems, but often all they get are a couple of sessions in an outpatient program.”

According to Capretto, two decades ago only 35 percent of Gateway's patients were publicly funded. Today, 80 percent of its patients are on some form of government insurance, but many of those who would have received some kind of private insurance coverage for substance abuse aren't receiving it at all today.

Ken Ramsey, Gateway's chief executive officer, blames public attitudes about addiction and treatment. “The stigma about addiction has crept back in after a period in the 1980s when it was almost fashionable to go into a clinic,” he said. “But when people repeatedly fail, the public gets fed up, ignoring the fact that a large percentage do succeed when they seek help.”

Gateway officials point to Magellan Health Services, the nation's largest managed-care company for mental, health, drug and alcohol treatment, as the biggest blockade to providing the necessary help.

“Blue Cross really took a step backward in contracting with Magellan,” Capretto said. “That decision has really pushed cost savings into unsafe areas. They won't admit to it, but anyone who's worked for any time period in the field knows about Magellan tactics in setting up obstacles to treatment so they can deny care.”

Dr. Sam Donaldson, vice president of clinical services for Magellan and a licensed psychologist in Pittsburgh, who once worked for Gateway, said Magellan follows patient placement criteria established by the American Society of Addiction Medicine (ASAM). He said Magellan focuses on individualized treatment planning that includes inpatient care as well as hospital stays.

“Traditionally, Pittsburgh substance-abuse treatment has lagged behind the rest of the country in accountability,” said Donaldson, “with an insistence that hospitalization is necessary without the research to back it up. Substance-abuse treatment has been ideologically driven, almost by belief rather than by hard science.”

Despite the challenges, “I don't get depressed from this because I'm an incorrigible optimist,” Twerski said. “When you've been in the field this long, you realize one of the things about being an alcoholic is being in denial; they don't realize how bad things are until some crisis occurs and they hit rock bottom.”

He added, “Right now, the insurance industry hasn't hit rock bottom. But when they realize that they've cut so far on one end that they're now paying at the other end with huge medical bills, then there will be a change, an end to that denial. I don't give up on alcoholics, and I'm not giving up on the health-care industry. They'll realize it some day.”

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