A very disturbing, yet relevant article was in the New Jersey Star-Ledger* recently.
The jist of this article titled, “A Heartbreaking Struggle: Addicts vs. Insurance Plans” by Dan Goldberg* reports the nightmare addicts and their families or loved ones go through trying to get medical care for addictions. Many insurance companies, staffed by decision-makers that are either failed-practitioners or non-clinical staff, base their decisions on whether or not someone is “addicted enough” or “crazy enough” to receive help!
What these criminals do is look at what is called evidenced-based criteria. In other words, does the addict abuse enough drugs or alcohol, or are they suicidal enough to qualify for proper care. If not, oh well. This is insanity. And driven by the all mighty dollar! Some in-take clinicians may even suggest to the addict, Are you sure you don’t want to kill your father, mother, whoever? with the wink of an eye in order to “justify” admission for a real problem! However illegal, unethical and unprofessional such things are, those criteria seem to be the only ticket to get into treatment. Most addicts will not say they are psychopathic to receive help. Can you blame them?
Families of addicts know very well how difficult it is to even get their loved one to admit they have a problem!
Getting them in the door to rehab is a miracle! Once there, the insurance companies tell the intake-workers, “Sorry. There’s not enough need for them to be treated.” Can you even imagine this scenerio?
Why? Well, the insurance companies have to be “cost efficient” at the cost of what doctors, psychologists, social workers and other licensed professionals say their clients or patients need to “get better!” The nightmare for professionals is justifying the need for their cients to bean counters at the insurance companies who either say they should be cured by now, or they aren’t needy enough for coverage. The nightmare for the client or family is “NOW WHAT?!”
If you consider that health insurance is a for profit business, how can they save money? The CEO for any of these organizations is not sitting around thinking, “Hmmm…how can we improve help for those who are covered and in need?” No. They are thinking about making the shareholders happy. The only way to do that is either to reduce, eliminate or deny needed care.
As much as I would presume that doctors and all medical care providers are kept in similar handcuffs, I can only speak for Addiction and Mental Health providers.
We dread that phone call that requests a “clinical review to authorize continued care” if our client has been seen X amount of times. Yup. The bean counter has reached the quota and now harasses the clinician. The clinician the organized crime companies know are very busy seeing clients all day (when can they call?), are typically nice, caring and helpful individuals that enter this field and are much less likely to argue anything, and clients who are addicted or emotionally unstable and therefore much less likely as well, to argue benefits! Its a win-win for insurance companies!
I am not sure how insurance companies can get-away with this type of uncaring, organized criminal activity. I would imagine legal actions could and probably should be taken when cases of denied treatment exist. Addiction treatment and mental health treatment are not easily evidenced, if they can be at all! Addicts and the emotionally ill are people! PEOPLE change day-to-day! Its not as if you prescibe them insulin (as with diabetics) and call it a day! It’s not like a broken leg where you can reset the break, cast it up, and say “see you in 6 weeks!”
Sometimes, these types of illness require months and even years of counseling, support and maintenance. The therapists or counselors are not the criminals, yet the insurance companies would certainly treat us as if we were. We are trying to help the clients, families and their loved ones!
Society, especially members of insurance companies should be outraged, and complain, complain and complain some more. To their senators, insurance providers, and human resources departments. You are entitled to care if covered, and the provider you choose should be the authority regarding your care! Not some person who has no clue as to who you are, or what you need!
There should be no reason to lie about your needs!” Your assessment must be determined by trained, educated and licensed professionals! However, these days, that is not the case. How sad. How sick. How unethical can this become before healthcare returns to the practioner, not the stock-holders?
Star Ledger Article:
Read more posts by Leo Battenhausen, MSW, addiction counselor. Leo is a blogger for JenningsWire.