From insurance fraud to deceptive marketing to patient brokering, the largely unregulated field of addiction treatment is rife with unscrupulous and unethical—even illegal—business practices. Mark Mishek, JD, president and CEO of the nonprofit Hazelden Betty Ford treatment centers, and Marvin D. Seppala, MD, chief medical officer, join host William C. Moyers to discuss the need for industry reforms, professional standards and consumer protections. Until such reforms are in place, consumers should proceed with caution and ask pointed questions when seeking care.
0:00:15 William Moyers
Hello and welcome to another edition of Let’s Talk, a series of podcasts produced by the Hazelden Betty Ford Foundation on the issues related to addiction, treatment and recovery. I’m your host William Moyers I’m the Vice President of Public Affairs and Community Relations for Hazelden Betty Ford. I’ve been with the organization since 1996. But on a personal note, I was a patient at Hazelden almost 30 years ago. And so I have a keen personal and professional perspective on the issues that bring us here today.
0:00:45 William Moyers
Joining me today are the President and CEO of Hazelden Betty Ford, Mark Mishek. Mark, welcome. Thanks for joining us.
0:00:53 Mark Mishek
Thanks for having me William.
0:00:53 William Moyers
You’re welcome. And our Chief Medical Officer Dr. Marvin Seppala. Marv, good to see you again.
0:01:00 Dr. Marv Seppala
Glad to be here.
0:01:00 William Moyers
And our topic today is reforms in our field. There was a time when well people just seemed to be pleased in delivering addiction treatment whatever that meant and whatever it looked like. But a lot has changed in our field over the years. And Mark I wanna start with you by talking about the fact that it’s been almost ten years now since you joined us as the President and CEO of Hazelden Betty Ford. And I wanted to get your perspective on what you see has changed the most in these past ten years.
0:01:29 Mark Mishek
Well William, the one thing that has really changed over the past ten years is the rise in the number of for-profit addiction treatment centers in the United States. It’s remarkable how many have come on board, have come online, really in the last five years.
0:01:45 William Moyers
Versus us as a not-for-profit.
0:01:47 Mark Mishek
Correct. Correct. In fact I think the number of nonprofits has probably stayed pretty steady. The number of public programs has stayed pretty steady. But the number of for-profit investor fueled enterprises has really, really expanded over the last few years.
0:02:04 William Moyers
Now there’s nothing wrong with being for-profit—
0:02:06 Mark Mishek
No, no, not at all.
0:02:08 William Moyers
But what has happened as a result of this explosion, if you will, in the number of treatment providers that have come to address this issue?
0:02:16 Mark Mishek
Well two big things have happened. Number one there’s been an incredible proliferation or rise in unethical, dishonest business practices in our field. Something I’ve never seen before in healthcare. ‘Cause I’ve worked in many aspects of healthcare and what we’re seeing in the addiction field is actually pretty remarkable. Second of all because there’s been such an influx of treatment providers it’s really laid bare the fact that there are not universal clinical and accreditation standards for the field. That’s become very apparent over the last few years.
0:02:51 William Moyers
And Marv from your perspective as a doctor and as somebody—and you’ve been very open about your own journey in long-term recovery—one of the issues that seems to have dogged us has been this lack of a consensus on what it means to deliver good treatment. Can you talk a little bit about that?
0:03:11 Dr. Marv Seppala
I sure can. There’s not regulatory requirements for treatment. For the education of the providers in treatment. And as a result, especially with all of the money coming into this field right now in a for-profit sort of exposure and understanding of treatment. We’re getting really mixed messages about what treatment consists of. And a lot of it’s very poorly done. In fact, some of the places are gonna describe their sheet count and the food way before they’re gonna even mention the type of treatment being provided and whether it’s evidence-based or not. So we’ve got terrible practices going on. We’ve got mixed practices going on. And little oversight of those practices.
0:03:56 William Moyers
And then there’s also the issue of evidence-based treatment. Why is evidence-based treatment so important, Mark, to the delivery of care?
0:04:05 Mark Mishek
Well it’s important in any field. It’s certainly important when you’re working with human beings and you’re working with those that are touched by the disease of addiction, of substance use disorder whether it’s opioids or alcohol. Does what you’re doing work? Is the patient getting well? Are they entering into lifelong recovery? Those are really, really critical questions for the patients and their families. Because the consequences of addiction are so devastating to a person and to the family. So, you gotta make sure that what you’re doing is actually making a difference.
0:04:37 William Moyers
So what is it that’s happening in this field, whether it’s in the for-profit side or the not-for-profit side, that has got you concerned?
0:04:44 Mark Mishek
Well there’s a couple of big ones. Number one: insurance fraud. The amount of insurance fraud that’s going on in our field is remarkable. It takes the form of such simple things as a treatment center describing on their website and to their patients and families who call them that their services are covered by insurance when in fact they’re not. When in fact the treatment center may not be in-network with the insurance companies that they list on their website. Other examples are treatment centers billing for drug testing at an exorbitant markup. I have personally talked to patients and families and I have seen bills where the bill for drug testing is more than the treatment bill itself. This can take the form of a treatment center getting kickbacks from a lab that it refers to. It can take the form of a treatment center actually owning the lab and marking up the drug test. It can take the form of a treatment center requiring that every test that they perform then validated by a second confirmatory test and so on and so on. When you add up the numbers, for just urine testing, it is remarkable how much money you can make if you really set your mind to it. And it in fact has been done. And many insurance companies are really pulling back of offering coverage or even operating in certain states where these abuses have occurred. So that’s one.
0:06:11 Mark Mishek
The second big one has to do with deceptive bargaining practices particularly on the web. Many of the new treatment centers that have come online have found that their core competency is not clinical care, but their core competency is how well they can do on the web. What they can do with search engine optimization. How well they can steer patients into certain websites. And they’re remarkably good at it. And we have seen over and over again these practices of dummy websites, of redirecting traffic when a person maybe misspells the name of Hazelden, they’ll get redirected to a completely different website cause they purchased our misspelled name. And on and on. And these practices are well-documented now. Many states are looking to prohibiting them. But they’re a real, real big problem.
0:07:04 Mark Mishek
The third area, big area, is what is generally referred to as patient brokering. And that again can take many forms. But the basic idea here is that a website or an individual or a group will collect the names of families or patients who are ready to go into treatment. They will then, on the web, put those patients out for bid for the treatment center that would like to buy the lead and the broker will then make money because the treatment center will pay them for the phone number or the lead. They’ll go so far as to qualify a family or a patient with their insurance company. Again with their dummy website. Knowing that they qualify for let’s say a Blue Cross plan. And then they will put that out for bid. And they’ll broker the patient to the right treatment center.
0:07:49 Mark Mishek
We’ve seen examples of patient brokers who will find an individual maybe trolling an AA meeting or a methadone clinic or another area where there’s vulnerable people. And will get them signed up for an insurance policy in a state, take the person then to Florida for example, have them go through treatment in Florida, bill the insurance company and as soon as the benefits run out, the broker of course is long gone, the patient gets kicked out of treatment. But the treatment center has received the payment through the insurance company. Again, these are very well-documented. People have actually been criminally prosecuted in the state of Florida for some of these things. So, they’re out there. They’re alive and well. And they’re a real, real problem in our field right now.
0:08:32 William Moyers
So some of these things have to do with unethical activities. Some of them are criminal or illegal. And then some of them are within our own field in terms of standards and in terms of educational standards for counselors. Dr. Seppala, what do you see as being the need within our field to make sure that the employees or the counselors that are delivering care are actually qualified to do so?
0:08:56 Dr. Marv Seppala
Absolutely. In any part of medicine, any branch of medicine, the people that provide the care are qualified to do so. There’s requirements for those qualifications both within that specialty, within the state, and maybe even nationally. And in our field, there’s not national standards for educational counselors. And the states haven’t come up with a reasonable way of doing this across the country. In fact, some states, you know we operate in California, and in an outpatient setting there’s no requirements for the type of counselors that would provide the services. So you could get anyone that has an ability to talk to people, to sit in that chair, without any type of degree that would qualify them to provide addiction services. Really undermining quality.
0:09:45 Mark Mishek
This is one of the areas that really irks me is that about two years ago, maybe three years ago, the federal government through the substance abuse and mental health administration issued a bulletin or a declaration that they were not going to promulgate national standards for addiction counselors. I think that was a huge mistake that they made. Because right now as Dr. Seppala said, we have a patchwork that is from A to Z around the country in terms of the requirements to be an addiction counselor. And it shouldn’t be that way. If you go into treatment for a substance use disorder in California, you should be entitled to the same level of training and education and professionalism as if you go into and need that type of service in New York. They should be the same. And they’re not at all. They are the moon and Mars. They’re really, really different. In terms of what’s required. And that leads to very, very poor quality of care. And cynicism. On the part of patients and families. About what they’re actually getting.
0:10:42 William Moyers
Mark, you—go ahead Dr. Seppala.
0:10:44 Dr. Marv Seppala
In our system, we require a Bachelor degree for our counselors and we’re actually moving toward Master’s requirements, almost all our counselors have Master’s now.
0:10:52 William Moyers
And some states are requiring that too, right? Where where you have to have a Master’s degree to be a counselor.
0:10:57 Mark Mishek
I’m not aware of any states that require a Master’s degree. I think the best you’re gonna find is a Baccalaureate degree right now.
0:11:03 William Moyers
Mark, you worked in healthcare before you came to Hazelden Betty Ford. You’re now the CEO of the largest not-for-profit addiction treatment provider in the country. What do you see as the failure within our field to rally around these concerns that you’ve articulated? What’s missing among us?
0:11:22 Mark Mishek
Well, what has been missing and I think is being corrected is really strong professional associations where we agree as a field to come together and promulgate and enforce quality standards for the field. The National Association of Addiction Treatment Providers is finally grabbing the bull by the horns on this and taking a really, really hard line on both membership and standards and what you need to be to be a member, to be a treatment provider, an addiction treatment provider in the country. And we need to have more than that. Because if we don’t do it, we’re gonna get regulated by some third party. And you know frankly at this point we probably deserve it based on what we’re seeing in the field right now.
0:12:00 William Moyers
Now ASAM, the American Society of Addiction Medicine, has also taken an active role. Dr. Seppala, I know you’ve been on their—within their membership ranks and their leadership ranks over the years. What is ASAM’s role in this?
0:12:11 Dr. Marv Seppala
You know ASAM has established fellowships across the country in addiction medicine. And have brought a lot more attention to that and requirements. That people have ASAM certification in order to practice addiction medicine. They can’t—they don’t have state regs. So people could still practice this with any kind of background. But their requirements to be a member and to practice are changed dramatically. And all of our docs have to be ASAM-certified or on the path toward it during--early in their hiring.
0:12:44 Mark Mishek
And that—that’s great for the individual providers. For the treatment centers now, um, the National Association of Addiction Treatment Providers is promulgating a standard that every member now has to be accredited. Either by the joint commission, which accredits a lot of healthcare organizations, or at CARF. The Commission on the Accreditation of Rehabilitation Facilities. Those are the two accrediting bodies. You need to have one or the other to be a member. And that’s the floor as far as I’m concerned. But unfortunately there are many, many treatment centers out there that have no accreditation of any kind whatsoever.
0:13:18 William Moyers
So what does a consumer, a family member, who might hear this and is struggling with addiction in their own family and wants to—needs to find help—what—what’s your counsel to the consumer, the family member, in terms of how they decide on what is the right place for their loved one?
0:13:35 Mark Mishek
Well we’ve talked about two of ‘em. Number one is the facility accredited? Are they accredited by either the joint commission or by CARF? That’s number one.
0:13:45 William Moyers
So the—they should ask ‘Are you accredited?’
0:13:47 Mark Mishek
Yeah. And look on the website. They’ll—the designation will be there for ‘em. Number two, what type of qualifications do their counselors actually have? Do they actually have a degree in counseling? Do they actually have a degree in addiction counseling? What about their mental health services? Do they have PhD level Psychologists on staff? Do they have a Psychiatrist on staff? Do they have medical doctors who can provide medication-assisted treatment if in fact they need that type of help if they have an opioid use disorder for example? So those are the types of things that they need to look for. Are they transparent about their business practices? Let’s go back to the business practices ‘cause that’s a window into a treatment center. If their business practices are not straight up, transparent, easy to understand, then I would walk away as fast as you can. Because this should not, at a time of incredible, you know stress and turmoil in a family when a loved one is getting ready to go into treatment, to have to deal with these types of things—it’s very, very difficult. ‘Cause you’re just worried about getting your loved one safe and into treatment. And if the center is not gonna be clear about what their pricing is, what they’re charging for, what health plans are they in-network with, then I would get away.
0:14:59 William Moyers
On that issue of network plans, when you came to Hazelden Betty Ford ten years ago parity for an insurance coverage had just been passed.
0:15:10 Mark Mishek
0:15:12 William Moyers
One of the reasons why so many issues now exist in our field is because insurance does, for the most part, cover addictions treatment in a fair and equitable way. You’ve seen that how it’s transformed our business. Could you talk a little bit about the role that insurance plays both in a delivery of—or access to care—and maybe in some of these reforms?
0:15:33 Mark Mishek
Sure. You know, any other part of health care, primary care with your—your family practitioner, specialty care you may get from a dermatologist or orthopedic surgeon and hospital care, people just assume it’s covered by insurance. And it is. It typically is. And then with the Affordable Care Act there are ways to get insurance if you’re not employed. If you’re 65 or older you have insurance through the Medicare program. If you’re a poor person you have insurance coverage through Medicaid. When it comes to addiction, it’s not that simple unfortunately. There’re a lot of holes in the coverage. Until parity was passed and until the Affordable Care Act was passed, there was not good insurance coverage for addiction. It’s much, much better now. It can still get better. Parity still has some holes in it. It still needs some enforcement that needs to happen with certain insurance carriers out there. But by and large now what we’re trying to do at Hazelden Betty Ford and many other providers is what we call mainstream addiction treatment. It’s a disease, let’s treat it as a disease. And part of that on the economic side is to make sure that patients and families have coverage under their insurance policies. And that they use the coverage. Where the battle comes, where the friction comes, is many of the treatment modalities for addiction are longer term. You have to stay in treatment for a longer period of time. That can rub with some of the insurance companies. So navigating that properly with the insurance partner is really important. And to have a good treatment center that has good partnerships, good partnerships, with their insurance plans that they’re in-network is really, really important for the health and welfare of their patients and the families.
0:17:09 William Moyers
Marv, go ahead.
0:17:11 Dr. Marv Seppala
And we’re contracted with the major insurers around the country. And in those negotiations, we have to describe how we’re gonna provide treatment. What are the evidence-based practices we use. Do we use medications and how do we use them. And like Mark said, what—when we’ve established these partnerships, once there’s been a give and take for a while and we get used to one another, we’ve really established really good partnerships that have allowed us to provide the kind of care we would want to provide for that individual. And pursue continued care and engagement over time in the outpatient setting, when that’s necessary for those folks. This is a chronic illness and insurers are recognizing that. But they are so happy to hear that we have Master’s degree counselors, that we have ASAM you know certified docs. That we have Psychologists, full mental health services that we provide the medications and know what we’re doing. And that we don’t have our own lab [chuckles] to do lab tests. And we actually can describe that we do, you know, urine drug screens about once a week in our setting. And we do a screening test, that’s it. And they’re remarkably inexpensive. Under ten dollars for a little cup that the person would urinate into. And if there has to be a confirmatory test, we’ll send it off. But for most—most of the time, we don’t have to do that. And the confirmatory test is where the expense arises. And yet, you know, like Mark was saying earlier, these places are charging $1500 to $2,000 dollars for that confirmatory test that’s really about a hundred and fifty, two hundred bucks at most labs. Very simple to do. And they would test every possible medicine imaginable. Instead of just what was appropriate for that individual patient. So, which we do. We just kinda wanna focus in on what’s necessary. Since we’re partners insurance, the last thing we wanna do is start to charge a lot of money for what’s goin’ on on a day-to-day basis. ‘Cause usually we’re on a per diem system with them.
0:19:14 William Moyers
So our insurance partners are not just partners in terms of access or coverage but also in terms of some of these reforms and these quality standards that have to be met.
0:19:21 Mark Mishek
Well—well they are because they’re the ones that are paying these high bills. They’re the ones that are getting the brunt of this. Back to your original question, when I started ten years ago here, we were probably, at best, 35-40 percent of the money we received was through our in-network relationships with insurance companies. Last month it was 91 percent. We’re up in the nineties. You know, and that’s where most health care organizers are. They have self-pay of five to ten percent; that’s what we have now. And I’m proud of that I think that’s where we need to be. Patients and families don’t need to put, you know, $30,000 dollars down on the table before they can walk in the door with a credit card or a home equity line. No, they can use their health insurance to get the help that they need. And that’s the way it should be for everybody in the field.
0:20:04 William Moyers
We need to wrap it up here in just a minute, but some—a lot of what we’re talking about sounds—sounds doable, but it sounds big. What’s the timeframe that we should expect? What’s the timeframe that consumers should expect before we begin to see the implementation and the rallying around some of these issues in a way that gets the reforms that are necessary?
0:20:28 Mark Mishek
Well, I would say a couple things. One is there’s nothing like a good indictment to get people to change their behavior. And that’s in fact what’s happened in Florida. With a lot of the sober home operators actually getting indicted. With some of the lab owners getting indicted. A lot of these practices have very quickly faded away. Now those bad operators are still out there. A lot of ‘em. But, they’re getting pushed out of the field. I would say the timeframe is—is now. We have to clean this up now. We can’t wait five years. We’ve got to clean it up now. We’ve gotta drive these practices out of the field now. What Google did in shutting down the purchase of keywords for the addiction field, is what will happen if we don’t get our act together here. Now, kudos to Google for doing that and now for coming back and—and being much more rule-based on what you can do with addiction words uh with Google. So it has to be now.
0:21:19 William Moyers
Has to be now. Mark Mishek, our President and CEO, thank you for very much for joining us. Dr. Marvin Seppala, our Chief Medical Officer. On behalf of all of us at Hazelden Betty Ford, we thank you for your leadership and your time out today to be part of our Let’s Talk Podcast. Thank you for joining us today on behalf of our Executive Producer Lisa Stangl and the great crew that helps to produce these podcasts on a weekly basis, we thank you and we hope that you will join us again for another one of the Hazelden Betty Ford Let’s Talk Podcasts.