Don't pay for it!?
 

Having made my position on what I will refer to as the commercialization of human suffering clear on another thread, I would like to invite SR members to contribute their thoughts about that topic on this thread. I am particularly interested in thoughts about rehab, because I see it as the place where the profit margins for providers are likely (in some cases) to be greatest, and where the cost to the user/family is most likely to be a hardship.

Just a few of the questions I have:

• Is there any evidence that treatment at cost is better than treatment that is free in terms of outcomes?
  
• Are there any particular kinds of addiction that really need rehab at cost, and why?
  
• Should insurance cover alcohol/drug rehabilitation? What would happen if it didn't -- what was the historical case when it didn't?

courage, I can't really contribute anything to your thread, since I'm the wife of an A who is currently sober and who has used only AA, no paid resources of any kind. The only thing I have to compare it with is my A's father, who did numerous paid rehabs and died an active alcoholic, never achieving any significant sober time. There are too many variables to make it a valid comparison, though, I think.

I'm looking forward to hearing what people have to say on this topic. I have a number of years as a medical transcriptionist in my resume, and during that time I developed a fairly deep distrust of the "health care" system. I feel an awful lot of what is done is done out of a profit motive rather than what is reasonable and/or helpful. I have to imagine there is at least some of the same involved in paid services revolving around addictions.

Thanks for starting this thread.

Honeypig, you just did contribute a lot. We share our experiences. Thanks!

Well, nothing is free. ;) If you get free, or nearly free, medical treatment (outpatient or inpatient) through insurance, either you're paying the premium (directly) or you're paying the premium (through your employer, who pays you less to cover the cost, and you may still contribute directly).

So I'm not sure what you mean - is it nonprofit vs. for-profit providers? Or are you comparing medical treatment groups to "free" (still not really free) support groups like AA or Smart? That comparison is truly apples and oranges.

I went through an outpatient program (Kaiser in California, a large non-profit HMO), and it saved my life so I can't complain. They claimed about a 40% success rate for at least a year of sobriety, which is very high in the recovery world. It was intensive, most of the day, 5 days a week, for 2 months, so not everyone can do that or even needs to do that, but I sure needed to do that. I didn't do inpatient rehab, but certainly for some people that's a huge help.

IOP was an important part of my recovery so for me it was 1 for 1 so 100%

The problem though is if it's not commercialised then who pays for it?

Huge amounts of public money spent on addiction is not cheap and if it is left to charities then money raised is always going to be limited.

It's a tough dilemma, but market forces will always raise more and make services available to more people than if it is left to government finance or charities, the downside though is motives will always be profit margins.

Interesting. Why do you say AA/Smart support groups aren't really free? And if they have the same goal as other programs of recovery -- i.e., recovery -- why is a comparison apples and oranges?

Just asking. I do not have an agenda here. Really. I want to know what people think so as to inform my own thinking about best courses of treatment, especially should I ever be in the position of helping others through early recovery. When I ask a question, it's a real question, not an expression of skepticism or in any other way rhetorical.

Someone pays for the room, the coffee, the pamphlets, etc., whether or not you personally make donations. And if you buy books, they aren't free either. :)

I think it's apples and oranges for several reasons, thinking mostly of an IOP which is what I have experience with. One is that in an IOP you are working with professionals (psychologists, MFTs, MSWs, at least experienced counselors), not amateurs, in a program put together by professionals. Another is that in a good IOP you will learn a great deal about addiction, the whole process, from people who understand it and work in recovery world every day. Another is that, there is no way you can match an IOP or an inpatient program for intensity, which can be huge. Another is that you're in a group with a bunch of other people going through the same things at the same time, so you build a comraderie that no weekly group of people in all phases of recovery can come close to.

A big one is that in a good program, you aren't boxed in to one philosophy like you will be with AA or Smart - in my experience (two of them, the second one stuck), you're exposed to a number of options for longer-term support including probably AA and Smart and others, but not restricted to any one of them. AA does not work for the vast majority of people who come to it, neither does Smart, neither does SOS, etc., but collectively they help many different people. So, you get the groundwork in a medical program, and decide what works for you for longer-term aftercare support.

If just going to AA or Smart meetings is enough, that's great, but certainly that does not work for many people, who need intensive professional care at least early on. :)

My sister has just finished a 6 month rehab but in the uk the spaces are very limited she didnt pay for it but had to apply more than once

She is now moving into a aftercare sober home for 2 years i dont know how that works payment wise but it has changed her life still early days but looking really positive because of rehab

I'm gonna have to disagree with you Jeffery AK. Most rehabs, a great majority of rehabs, whether for profit or not - even the nonprofits cost a ton of money btw - are 12 step based. They introduce people to meetings and have a group from the outside hold meetings on a daily bases, either AA or NA. And they expect clients to find a home group/sponsor etc as soon as they leave. They are given meeting lists of the area as they are getting ready to leave. That is my experience in Pennsylvania at least. And Florida too. And from what I hear reported from others.
They do not offer alternative means for clients to continue in sobriety.
In fact, it seems to be frowned upon. Just my experience.

also, the non-profit (supposedly) I was at told me unless I could come up with around a grand a day my stay was over. The insurance deemed in unnecessary for me to continue in rehab. Amazingly, I was "coined out" as having completed the program. I've seen people "coined out" for having "completed" the program after a week or ten days. I don't care what anyone says, in the USA rehabs are almost entirely based on an individuals ability to pay for it. Very few free passes. Very few.

Salvation Army, I think, still does free rehab.

Abstract
We compared the effectiveness, safety, and costs of outpatient (n = 87) and inpatient (n = 77) detoxification from alcohol in a randomized, prospective trial involving 164 male veterans of low socioeconomic status. The outpatients were evaluated medically and psychiatrically and then were prescribed decreasing doses of oxazepam on the basis of daily clinic visits. The inpatient program combined comprehensive psychiatric and medical evaluation, detoxification with oxazepam, and the initiation of rehabilitation treatment.

The mean duration of treatment was significantly shorter for outpatients (6.5 days) than for inpatients (9.2 days). On the other hand, significantly more inpatients (95 percent) than outpatients (72 percent) completed detoxification. There were no serious medical complications in either group. Outcome evaluations completed at one and six months for 93 and 85 percent of the patients, respectively, showed substantial improvement in both groups at both follow-up periods. At one month there were fewer alcohol-related problems among inpatients and fewer medical problems among outpatients. However, no group differences were found at the six-month follow-up, nor were differences found in the subsequent use of other alcoholism-treatment services. Costs were substantially greater for inpatients ($3,319 to $3,665 per patient) than for outpatients ($175 to $388).

We conclude that outpatient medical detoxification is an effective, safe, and low-cost treatment for patients with mild-to-moderate symptoms of alcohol withdrawal.

Citation: Motoi Hayashida, M.D., Sc.D., Arthur I. Alterman, Ph.D., A. Thomas McLellan, Ph.D., Charles P. O'Brien, M.D., Ph.D., James J. Purtill, B.A., Joseph R. Volpicelli, M.D., Ph.D., Arnold H. Raphaelson, Ph.D., and Charles P. Hall, Ph.D. N Engl J Med 1989; 320:358-365February 9, 1989DOI: 10.1056/NEJM198902093200605

Advances in Alcohol & Substance Abuse
Volume 5, Issue 1-2, 1985
Is Inpatient Rehabilitation of the Alcoholic Cost Effective?
DOI:10.1300/J251v05n01_12
Helen M. Annis PhD, CPsycha
pages 175-190

Across all sectors of the health care system there is pressure to increase the cost-effectiveness of service delivery. In recent years, a number of official reports in the alcoholism field have called for the establishment of alternatives to traditional inpatient hospitalization for alcoholics. This paper briefly reviews five bodies of scientific evidence that bear on this recommendation. It is concluded that: (i) inhospital alcoholism programmes of a few weeks to a few months duration show no higher success rates than periods of brief hospitalization of a few days; (ii) the great majority of alcoholics seeking treatment for alcohol withdrawal can be safely detoxified without pharmacotherapy and in nonhospital-based units -- detoxification with pharmacotherapy on an ambulatory basis has also been shown to be a safe alternative at one-tenth the cost; (iii) "partial hospitalization" (day treatment) programmes have been found to have equal or superior results to inpatient hospitalization at one-half to one-third the cost; (iv) well-controlled trials have also demonstrated that outpatient programmes can produce comparable results to inpatient programmes -- one estimate places the cost saving at $3700 per patient compared with the typical course of inpatient treatment; and (v) a growing body of evidence suggests that if patients could be matched on clincally significant dimensions to a range of treatment alternatives, much higher overall improvement rates in the alcoholism treatment field would be observed. The question that should guide future investigation is "What treatments are more effective for what types of alcoholics?"

I think the number one factor in success in quitting drinking is that the person wants to quit more than they want to drink, reach that stage and no program at all is needed. The reality of course is that not everyone will ever reach that point or they may die or completely wreck their life before they ever get there.

I think it's really hard to compare support methods, paid vs free, AA vs AVRT or whatever because if the person can't relate to the method it's not going to be of much value to them. In patient is good because it puts you in a secure environment, but again you will only get out of that what you put into it, no free lunch or miracle cure there either. So in the end I don't think there exists any method that trumps personal motivation but many methods can motivate in many different ways.

I've already responded to the issue at hand here in a different forum (where Emily, one of the administrators, has provided some helpful responses to the posters):

http://www.soberrecovery.com/forums/...-format-5.html

Here is the most up-to-date information I could find in a brief look at respected resources that draw upon peer-reviewed research. Of note, the Kaiser Family Foundation is not connected to Kaiser Permanente.

From the Kaiser Family Foundation
Barriers Remain Despite Health Law?s Push To Expand Access To Substance Abuse Treatment | Kaiser Health News

Robert Wood Johnson Foundation -- cost-benefit analysis
Substance Abuse Treatment Benefits and Costs - Robert Wood Johnson Foundation

Substance Abuse Policy Research Center
SAPRP

And if you're yearning to dive deep into more public policy ... this 2012 report to Congress on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
2012 Report to Congress: Compliance With the Mental Health Parity and Addiction Equity Act of 2008

I'm not an epidemiologist or a statistician or a cost-benefit analyst so I'm reluctant to draw any conclusions. Does in-patient help? I think so, yes.

Also, as Wolfie points out by sharing his family example, this is all information related to the U.S. health care system. We have many members from other parts of the world here, too.

The rehab I went to was a shot gun approach with all kinds of "holistic" stuff but the main emphasis was 12 step. Two meetings a day brought in by local AA groups. These meetings were mandatory. They pressured you highly to get a sponsor and attend AA. They offered no information on alternative programs. 90 days were recommended in this program but magically at 34 days my insurance was cut off and I was cured. Complete with a graduation a magical coin and a plaque. Would have never made 90 anyway.
Do I think insurance should pay for this--NO. I certainly don't think my taxes should cover any non-medical faith healing.

Thanks, Venecia & all who are posting. I scanned Venecia's links and they mostly concerned the cost-benefits of treatment vs. no treatment. I have no doubt that treatment is better than no treatment LOL! There are some interesting things to dive into, which at least one of the (older) articles I posted referenced -- are there particular kinds of addicts/alcoholics who require more intensive (and therefore expensive to society) treatments? For instance, the sources you reference say some of the savings are due to decreased crime. Should relatively young, criminal addicts/alcoholics be guided to different treatment options than those who are old & sick, or those who are young & high-functioning?

I thought this sentence was interesting, from SAPRP and RWJ: Treating substance abuse problems as chronic medical conditions may improve cost-effectiveness of programs and provide greater benefits to patients. That means not intensive inpatient.

Note that as Jeffrey alluded to, when your insurance pays, you are paying:
More than this, though, all taxpayers and employees contribute to other people's recovery programs through taxes that fund federal programs like Medicare (or its analogous institution in other countries) and insurance premiums. What should Medicare (or its international alternatives) be covering? Greater medicalization of treatment, or commercial options?

As for the cost of peer-support-based programs: In my experience, participants pay room rates etc through voluntary donations. Why do you think rooms are usually in church basements? They're cheap! My home group's church is being shut down and we can't find another space we can afford, and we'll likely fold. All of my literature is borrowed from other alcoholics, and I will pass it on. The first edition of the Big Book is free online.

I'm not pushing AA. I'm not very program. But some alcoholics quit with very little outside support. And many who go to inpatient relapse. What's going on here? Why do we know so little about what works?

Google rehab success rates....
inside rehab by Anne fletcher is a well researched book about America's rehab industry.

LBrain, sorry you had a different experience, mine was a lifesaver. Just like community-based support groups (AA, smart, sos, lifering, etc.) are different, I'm sure IOPs are different too. The first IOP I went to was much more 12-step-based than the second, a large part of why it didn't work and I left. It's hard to escape 12-step influence, in part because it's been around a long time and many of the counselors who are former addicts (which is most, I think) are most familiar with it and may well be proponents themselves. Like everything else, if it ain't working, try something else. :)

I think it's quite simple, it's because people are different and there is no one magic solution that works for all, despite what some programs claim. More variety and more options is the way to help more addicts, not forcing them to fit into the Procrustrean Box.

Addiction treatment is big business. Inside Rehab by Anne M. Fletcher is a good book on the subject.

Oops. just saw that greens already posted this. Agree!