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.
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