The “War on Stigma” Misses the Point

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The “War on Stigma” Misses the Point

By Jordan Hansen 08/03/16

Once we declared a war on stigma, I knew we were screwed. Like poverty, racism, drugs, terror and obesity before it—fighting stigma ensures that we will likely make little progress.

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The “War on Stigma” Misses the Point
Re-aim the war.

Substance use disorders are among the most costly problems in all of health care, in large part because, in addition to the costs associated with their treatment, the price tag to the economy that results from the impact of drug use in the criminal justice, employment, welfare and other arenas, is gigantic. There is no better example of the concept of “Cost Offset” than money spent treating a substance use disorder, as every dollar invested leads to a larger amount of financial benefit. Unfortunately, since the entities that pay for substance use treatment are typically not in a position to benefit from the cost offset savings, they frequently apply a utilization review process that is driven by the motivation to achieve short-term savings, often utilizing criteria based on acute care models of care. Jordan Hansen sees the impact of these decisions in his work in substance use disorder treatment and reflects on its impact…Dr. Richard Juman

Once we declared a war on stigma, I knew we were screwed. Like poverty, racism, drugs, terror and obesity before it—fighting stigma ensures that we will likely make little progress. Instead of doing anything about the things actually killing drug addicts and alcoholics, we focus on something vague and unbeatable. It’s like fighting smoke. 

Forget stigma, let's focus on what’s actually decimating care for mentally ill and addicted persons—corporate greed. Some health care is lucrative. Hospitals usually have some great digs for these golden geese. The hospitals in my area show off their outpatient surgery recovery suites and I start thinking I should get cut open to go have a vacation. Then I visit the psych ward for an assessment in the same system and wonder how I got to 1967, where all my hope went, and how much trouble I’d get in if I broke everybody out of there to go fishing.

Treatment of the addicted and mentally ill will never be a money maker, nor should it have to be. I would love to see a beautiful new psych ward in the ads for my local hospital, but apparently this is not a demographic with disposable income—nor is this a group of people with a voice. This leads to efforts at reducing stigma. This would make a lot of sense if the thing blocking change in these massive healthcare systems was a misunderstanding of mental illness or addiction, or an active antipathy toward helping these people. I do not think this is the case. I just think it’s irrelevant. There is a reason that the people in charge of these organizations are in charge, and it’s not because they have a big heart. It’s because, non-profit or not, they have been able to find a way to make financial sense out of health care, which is no small feat.

Twenty miles from where I live, the CEO of UnitedHealth Group lives in a 7.8-million-dollar house. He has almost three quarters of a billion dollars in stock options and is consistently one of the highest-paid people in this industry. He might be a terrific human being, he might be a sociopath profiting from the pain of others—who knows for sure? His job is to make his company money. By all appearances, he seems to be able to do that. He is able to do this by having his company take in more money than he spends. Can you tell I’m a clinician? This is my understanding of business right here: Payments for treatments are referred to as “medical losses.” It doesn’t pay to pay. I just imagine some sort of Office Space scenario with a mid-level manager requesting that everybody come in on weekends and channel their inner Nancy Reagan—“Just say no.” This is the basic foundation of insurance, and it is imperative that this be kept in mind when dealing with these industries. 

You mention the pharmaceutical industry to just about anybody in America, and they lose their collective minds. We recoil at the thought of business concerns entering the interaction with our healthcare providers. Well, guess what? The power of clinicians to ensure that clinical concerns overshadow fiscal concerns—especially in the treatment of mental health and addiction—left a long time ago. Think about how much power an insurance company has relative to the pharmaceutical industry for a second. I haven’t heard of a pharmaceutical rep being able to call a provider and dictate the terms of care. A pharmaceutical rep cannot make a decision to refuse to cover existing treatments or deny the start of treatments, nor can they make continuing the payment for treatment contingent upon specific interventions, as inappropriate as they might be. This happens in treatment all day, every day. Every provider, unless they are a cash-based private practice, is at the mercy of the paying organization. 

Every clinician has stories of managed care companies interfering with their treatments. Most of us have experience working within a system which has embraced these practices to the point that they don’t even need an “accountable care organization;” they are able to establish administrational supremacy over clinical decisions in-house. There is nothing quite as disorienting as needing to explain a clinical decision to a low-level administrative employee who has no training outside of that around the financial considerations of their department. These gas-lighting moments come in many flavors.

Everybody has one or seven thousand outpatient detox stories. “Oh, you have a problem controlling your use of alcohol? Here are ten tablets of lorazepam. Be sure not to take too many of them, you might like it.” Or, “Here’s another bottle of hydromorphone. Be sure to taper this time. You can do that, right?” Some might argue that this is a problem with clinicians, and in some ways, I get that. The thing is that these almost unbelievably stupid practices are encouraged, and in many cases mandated, by the organizations or payors.

Then, there are the horrific stories of inappropriate discharges. Depending on where you work, these could account for a vast majority of your cases or just the odd story, but every clinician has them. People who were suicidal with intent and means somehow are recommended to discharge from a psych ward after 24 hours. I’m sure the call from the insurance utilization reviewer had nothing to do with that. People who just completed detoxification for the seventh time in the last two months need to “fail” a lower level of care prior to being authorized for the recommended level of care. Discharge plans for people with a rocking substance use disorder and severe co-occurring mental health issues are given a couple days of antipsychotics, a list of shelters and a reminder card for their appointment in three weeks—and a hearty slap on the back and a jovial “Good luck to you, sir!” 

Then, there is the garbage you have to deal with when you actually get people into treatment. Coverage is given in three-day chunks. There are the times the “clinician” from an insurance company is able to determine a course of treatment for my patient after looking at the chart for a few minutes. They have had no interaction with this person, yet they can dictate terms for treatment and withhold funding if their requests are not followed. I have been recommended to have family conferences with patients for whom it is clinically inappropriate more times than I can count. I have had to explain how agonist medications work and that they actually do work (despite what your cousin with two years of sobriety told you), why taking Wellbutrin during acute alcohol withdrawal is a bad idea, why people can’t just take ten days off of treatment before they start PHP, that Dilaudid is an opioid and that taking thirty of them in a day is generally not an indicator of stability; that active, severe PTSD might just be related to use; that an “on-unit sponsor” might not be able to help when the patient is still housing Librium—and a thousand other things that I’d rather not remember. All of this occurs while the caseload grows like some sort of mutant bacteria and the electronic health record becomes somehow more inefficient, if that was even deemed possible.

What it comes down to is that the clinical relationship between provider and patient becomes tainted by the attempts by institutions, primarily payors, to circumvent the decision-making of trained clinicians, usually in the guise of providing accountability. This leads to poorer outcomes, an utterly demoralizing experience for the client and clinician, and in the ironiest (that’s a word now) of ironies, more expensive care. This short-sighted approach to dealing with chronic diseases is making all of us sick and poor, and as long as financial concerns trump clinical expertise, we will continue to fight a losing battle.

Jordan Hansen MA, LADC, LPC is an experienced clinician, speaker and writer focused on integrating the science of cutting-edge treatment modalities with the wisdom found in peer-supported approaches to recovery. His approach is based on authenticity, interpersonal connection and a steadfast focus on person-centered, evidence-based interventions. His experience within residential, long-term and outpatient levels of care is informed by his background in journalism, vocational counseling and non-profit management. Areas of recent focus include assisting in the design and implementation of Medication-Assisted Therapy for opioid addiction, policy work with the MN state legislature, distribution of naloxone kits to local opioid addicts at risk for overdose, and artistic and literary efforts aimed at sharing his experience with long-term recovery from addiction and mental illness. 

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