Are There Ethical Substance Abuse Treatment Facilities?

Almost every week I am faced with reading an article in the newspaper conveying a horror story of unethical and hazardous business practice in substance abuse treatment. South Florida in particular has become a beacon for illegal, unprofessional, or otherwise illegitimate treatment of those with drug or alcohol difficulties. Unscrupulous “marketers” call our center to try to sell us on their methods of “acquiring patients” at least weekly.  As the epidemic of substance dependence has grown in this country, so too have the opportunists wishing to open up rehabs or “lead generation” companies to cash in on the exploitation of others.

Why has this happened? Unfortunately, unlike other regulated professions one does not need to be a licensed clinician in order to open a treatment facility. While there are certainly well intentioned businessmen who practice carefully by hiring licensed mental health and addiction professionals to guide them in developing a practice, this also leaves room for those who do not seek the proper consultation to start programs.

Decisions about marketing and clinical services are often made by those who have never had an ethics class and do not know or understand what it means to manipulate and misguide a patient.   Instead the focus becomes the best and most creative methods to market a program and increase revenue streams rather than through clinical and evidenced based practice to meet the individualized needs of the patient.   Couple this with large clusters of recovering individuals looking to cash in through brokering patients to treatment centers at a very high rate. Sometimes fees to brokers can be as high as $6,000 to $8,000 for placing somebody with a high paying insurance policy in a treatment center.

Examples of manipulative and unethical marketing practices include creating numerous landing pages that do not identify the name of the treatment center and or represent that services are being provided in states they are not licensed or located. The goal here is to get the individual to call them based on what is presented and then use whatever sales tactics are necessary in order to induce the potential patient into coming to their center in another state.

Another tactic is radio, television, or billboard ads that do not directly name the treatment center and are instead fronts for call centers looking to sell patient leads into treatment for substantial amounts per admission. Be very wary of an ad that says something like “call the addiction hotline”.  Yet another example of manipulative marketing occurs when individuals attend 12-step meetings such as AA and NA as if they too are seeking anonymous self-help support. The individual then in a veiled display of trying to help gets paid a fee per admission they place into a treatment center.  In most of these scenarios the first question is often “what type of insurance do you have”.  Those with good insurance may be offered free one way plane tickets, cigarettes, food, money, shelter and other incentives.  In all of the above examples treatment placements are not done based upon the best fit to help the patient, but rather who is willing to pay their fees.

Another major area of unethical practice has occurred because sober homes have recognized that if the same owners open Intensive Outpatient Programs (IOP) they can then maximize revenue through billing insurance carriers excessive fees for treatment and frequent urine drug testing. Often they are unqualified to provide treatment and steer unknowing patients into this type of care rather than true programs that can really help the individual get better and provide care at the medically necessary and appropriate level. Some of these programs can be ethical and legitimate if the services provided appropriately meet the individual’s need and are run by licensed professionals. However, very often the facility induces the patient to attend their programs and provide urine specimens by waiving or decreasing rent. This of course is not only unethical, but illegal and considered a kickback.

When programs are not run by professionals who develop clinical services in accordance with what has been advertized it can significantly harm the individual. Prognosis tends to get worse with every failed treatment experience. Additionally, when insurance no longer approves care in these deceitful facilities the individual is often discharged and put on the streets.

Having received poor treatment, they are far more likely to relapse. If the individual does not realize that his or her tolerance to their substance of choice has diminished they may pick up at the same level they left off and easily overdose. This is a very significant problem in the Delray Beach, Florida area where there are massive clusters of poorly run unethical programs that are essentially increasing, or directly related to, a surge in opioid overdoses. The problem has becomes so significant that local police officers and other emergency responders are now among the first in the nation to carry Naloxone (otherwise referred to as Narcan) the life saving opioid overdose reversal medication. Another problem with having attended an unethical and illegitimate treatment center is when the individual makes a concerted effort to try again to get better; he or she may find that their insurance carrier has already paid out claims for so long that they are far more resistant to provide approval for necessary treatment through a good facility.

Licensed mental health and addiction providers have received the proper education to treat patients. They have taken multiple ethics courses throughout training and passed state laws and rules examinations evidencing their understanding of the law and responsibilities to their patients. All licensed therapists and doctors must also adhere to the ethics codes of their profession.

For example, as a licensed psychologist I must adhere to the APA code of ethics. Within this code are certain responsibilities such as avoidance of false or deceptive statements in advertisement, not utilizing patients to solicit others into treatment, having competency to practice, and the prohibition of engaging in multiple relationships with a patient or former patient. A multiple relationship occurs when a psychologist is in a professional role with a person and another type of role simultaneously.

A psychologist must take steps to avoid this. Hiring an ex-patient is a clear example of violating this ethics code. It could easily lead to exploitation of the individual due to inherent power differentials. Utilizing ex-patients to work in admissions or marketing is an egregious example of violating both multiple relationship and marketing practices.

Having said the above, in answer to the question posed in the topic of this article there are plenty of extremely ethical substance abuse treatment centers that operate in a professional and evidence based manner.  I know of numerous quality centers that are clinically driven and focused on the recovery and well being of the patient regardless of profitability. These skilled treatment centers guide their decisions by the needs of the patient and not the extent of their insurance coverage. They may be at a disadvantage in that they will not engage in the type of practice that their so called competitors freely do. The trick is how to find an effective and principled treatment program when you are in need of good clinical services to help you have the best possible chance to recover. If you know how to avoid getting marketed by the wrong center you will likely have greater success finding the right one to meet your needs. Below are some suggested questions to ask in avoiding getting steered in the wrong direction for yourself or your loved one.

How can I find the best program and know what to avoid?

1.     Is the name of the treatment facility mentioned in the advertisement? If not it is likely that the marketing is being done by a lead generation company, call center, or some other marketing service which is really unaffiliated with treatment and plans to refer the patient to whatever center is paying them for admissions regardless of appropriateness of fit.

2.     Ask where they are located and confirm it matches what has been advertized. The address where they are licensed to provide services should always be clearly provided on the website for the treatment facility.

3.     Ask if they are not only licensed, but accredited by the Joint Commission or CARF. These are legitimate accreditation bodies that assure standards of care are being met.

4.     Ask who the owners are and what their backgrounds, education, and individual licenses are. While it may be helpful to receive treatment from those who can have great empathy because they are also in recovery from a substance use problem, it should never be the only credential. Too many times I hear stories of somebody going to treatment themselves, taking stock of the center and deciding it is a good way to make money. He or she gathers financial resources and opens a treatment program after having minimal clean time. Giving back to others may be an aspect of the program, but one should be qualified to do so and have substantial recovery time and the appropriate formal education to meet the patients need and not his/her own.

5.     Ask who the actual treatment providers are? Who are the clinicians that are providing the therapy, psychiatric services, and other aspects of treatment? They should possess the proper training and licensure to do so. Consider who you would go to if you needed treatment for a medical problem such as diabetes, a broken arm, or surgery. Would it be a patient who has previously received treatment with no formal education? If the treatment center does not list the clinical staff on their website this should be a huge flag of concern.

6.     Is the treatment center going over insurance responsibilities such as deductibles or co-pays? This is a standard aspect of most care. If you go for an MRI are you not asked to pay a deductible or co-pay? When things are too good to be true and all fees are being waived you should begin to get the feeling that the practice is focused on maximizing revenue through insurance and getting you in the door at all costs.

7.     Is the treatment facility offering you any incentives such as free cigarettes or money? Again these are illegal inducements that have nothing to do with the quality of care and getting you better.

8.     Is the individual on the phone with you stating that they are an alumni of the treatment program and a “success story”. If this is true it is highly unethical to hire an ex-patient let alone have them in a role to market or perform admissions for the program. This violates multiple ethics codes due to some of the reasons indicated above and speaks to the practices of the treatment center.

9.     Are the pictures promoted in marketing materials of the actual treatment center? Need I say more…

10.  Is the treatment facility telling you a specific percentage of successful outcomes? If so I would ask how they conduct their follow up assessments and if all patients treated are represented in the sample. In most cases it is not possible to get accurate long term outcome data due to difficulty in following up with those who may have relapsed. Many centers will only include those who they were able to get on the phone in their outcome data. Some centers will not even offer a number, but just postulate how high their success rates are with nothing to back it up.

11.  If you are utilizing healthcare insurance, ask what the program does if the insurance carrier stops approving treatment during the period the program explains as a mandatory minimum prior to admission (for example a 30 day program). An ethical center will not rapidly discharge patients who are unstable simply due to inability to pay when insurance coverage ceases.