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Payers open to 5 year treatment plan

November 2, 2015
by Julie Miller, Editor in Chief
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No one in the addiction treatment field is truly clamoring for yet another model or yet another awareness campaign. But what if a new provider group just happened to have the undivided attention of commercial payers? That would be a different story.

The Independent Coalition of Treatment Providers began hatching last year when a few industry players approached several large commercial insurers to figure out a way to deliver optimal care that the payers would reimburse. They discovered that the insurers want to know who the best providers are and how to get the best care value.

The coalition aims to solve those quality and cost concerns. Founding member Ken Seeley, a board certified interventionist, who has been featured on the A&E series “Intervention,” tells Behavioral Healthcare that the insurers—big ones, such as Aetna, Cigna and Humana—were eager to listen and work on a model that would be mutually promising for payers and providers.

“They understand the problem,” Seeley says. “They hear us loud and clear. And working together is where they see a solution.”

Coalition criteria

In order to join the Independent Coalition of Treatment Providers, members must be Joint Commission accredited. But what could raise the bar even higher, according to Seeley, is the coalition’s proposed measure that would delve further into financial operations and examine whether a treatment center was paying out or receiving money for referrals. Seeley calls such paid referrals “human trafficking.”

“There are a lot of unethical things happening out there, and insurance carriers don’t know what to do,” Seeley says. “They’re at a loss.”

He believes the Joint Commission would be the best way that an outside source could hold members accountable. As an alternative, the coalition is considering contracting an independent certified public accountant that could review a member’s financials and serve as a third-party verification.

“We’re all willing to be transparent,” Seeley says.

The 5 Year Plan

Insurers also believe they’re paying a lot of money for addiction treatment but realizing a low return because recidivism is so high, with only a 3 percent to 7 percent success rate the first time around, Seeley says. Likewise, they’re noticing the added cost of medical care related to addiction, such as costly ER visits.

In response, the coalition is promoting a model of care similar to that used in drug courts and treatment programs for airline pilots and physicians with addiction, which Seeley says have success rates of 60 percent to 90 percent. But there’s a catch. The coalition’s program is a five-year, chronic care model.

Before anyone can cringe and jump to the conclusion that there’s simply no way an insurer would ever pay for such a thing, Seeley says the coalition has already presented the model to the top insurers in the country and received a positive reaction. He says it’s a standard of care that is lacking in the field, but the payers are hungry for it and seem willing to test it.

The 5 Year Plan includes the full continuum of care and 12-Step support, plus a dedicated recovery advocate who follows the patient for five years. Seeley believes the role could be an accredited position in the future.

“From my perspective, the role of the interventionist in this model is akin to the role that a social worker or nurse navigator fulfills in a health home that provides integrated behavioral and physical healthcare services,” says Tracy Griffin Collander, LCSW, executive director, Behavioral Health Care Accreditation Program for Joint Commission.

Collander says the coalition’s model sounds promising because it’s based on programs for professionals with addiction, and such programs have produced better outcomes than the acute care approach to addiction treatment, which she says has a 50 percent success rate at best. Also, case manager support has shown to produce patient satisfaction as well, she says. 

Affordable care

The 5 Year Plan also leverages random drug testing that parallels the drug court model. Seeley estimates a state might only pay $6,000 per-patient, per-year for the service.

“Looking at those numbers and what’s happening in our industry, you can see that the protocol in the 5 Year Plan could be done and could be reasonably priced out,” he says. 

The endorsement of the commercial insurance industry will be a boon. What is pioneering about the coalition is that it’s not only payers and treatment providers who are onboard with the initiative, but there are also legal teams, the Joint Commission, ancillary providers and vendor organizations.

“We have the full spectrum that represents our space,” Bill McCormick, CEO of Medivance Billing Service, one of the founding members says. “That diversity creates a level of strength.”

McCormick, who says he’s the voice of the coalition, notes work is already underway to organize an intensive, collaborative retreat in the coming months so stakeholders can share information with a larger group of payers on what addiction treatment looks like today.

Before yearend, the group is also going to reach consumers with mainstream media advertisements nationwide that would list the coalition provider members and explain their model. Seeley believes it’s important to get out ahead of the routinely bad press that too often places the entire industry in a bad light.

 “There are good providers out there,” he says. “We are going to have a third party verify that what we are doing is right—which is Joint Commission—and we are going to work as a team to show you that you can get the results you need for your loved ones that suffer from addiction.”