BATTLING ADDICTION AND YOUR HMO, TOO

It was an epilogue for the life of a 17-year-old who died of a heroin
overdose, written by a managed care company.

Sean Haubrich's mother received a letter from her health insurance company
dated March 25, the day her son died, saying he was denied coverage for a
five-day-a-week, eight-hour-per-day outpatient program. Haubrich had
attended the program, run by Daytop Village, a substance abuse treatment
center in Mendham Township, before he ran away and overdosed.

The treatment was approved one day later by Merit Behavioral Care, which
handles mental health benefits for Prudential HealthCare, a Prudential
spokesman said. The March 25 letter was sent only because insurance company
doctors were unavailable to review the request on the day it was made, said
Kevin Heine, Prudential spokesman. And the letter allowed Haubrich to
attend a less intensive program for nine to 12 hours a week, two to three
days a week.

But before it sent the letter, the insurance company knew Haubrich had
failed a drug test during a previous treatment, and that should have been
enough to approve the more intensive treatment, said the Rev. Joseph
Hennen, Daytop's executive director, who spoke with the permission of
Haubrich's family.

Often futile bid to save money

Sean's story is not an isolated incident, medical experts say. They contend
the managed care system often prevents heroin addicts from getting
appropriate levels of treatment.

Insurance companies, including HMOs, said patients receive the treatment
they need and managed care prevents doctors from giving patients
unnecessary and costly treatment.

Most people addicted to heroin require around-the-clock supervision in
facilities where the drug is unavailable, medical experts said. But
insurance companies commonly deny inpatient treatment until patients fail
in less intensive -- and less costly -- outpatient programs.

"That is typical of what insurance companies will do. If they grant you
anything, they'll grant you far below what is needed," Hennen said.

Doctors lose control over treatment

Four months before he died, Haubrich attended Daytop's five-day-a-week
program for the first time. His insurance paid only for the less intensive
program, Hennen said, so Daytop accepted less money.

Before the rise of managed care in the early 1990s, drug addiction was
treated as any other illness, said Gregg Benson, program administrator at
St. Clare's Hospital/Boonton Township chemical dependency services.

"You would go to any doctor you wanted to go to and have essentially an 80
percent reimbursement," he said. "The determination of the length of
treatment was in the hands of the practitioner."

Now, Benson said, the decision lies largely with the managed care company.
Dr. Joyce Bailey, Daytop's medical director, said patients can appeal those
decisions, but that's often time consuming and frustrating.

Bailey said she spends much of her time haggling with insurance company
doctors over treatment. In denying requests, insurance companies often send
letters saying patients don't meet certain criteria.

"And when you ask them what their criteria are, they don't tell you," she
said.

Benson said when they do approve treatment, insurance companies often allow
fewer days than a patient's doctor considers necessary. Many substance
abusers require 21 to 28 days of inpatient care, he said, but health plans
often approve only 14.

Addicts often have suffered some kind of trauma, such as abuse, which feeds
their addiction, Benson said. "You don't overcome that in a couple of
weeks," he said. "It takes a tremendous amount of time and energy."

Without insurance coverage, families would be responsible for all costs. At
Daytop, that comes to $225 per day for the five-day-a-week,
eight-hour-per-day outpatient treatment, although Daytop officials said
they don't turn anyone away for lack of ability to pay.

Insurance company officials said the new system encourages doctors to find
more effective and less costly ways to treat addiction.

"We don't have any interest in seeing a person fail," said Elizabeth Rody,
medical director of the Parsippany-based Green Spring of New Jersey.

Green Spring handles mental health benefits for HMOs and insurance
companies such as Blue Cross and Blue Shield and Aetna U.S. Healthcare. The
company works with health plans covering 35,000 Morris County residents.

"If I were to discover that nobody recovered from heroin addiction without
inpatient treatment, I guess everyone would get inpatient treatment," Rody
said.

Rody said her company approves inpatient care when necessary, but said
cases are decided on an individual basis and there are no general standards
set.

A spokeswoman for Green Spring said that among those covered by the company
nationwide, 41 percent of those who requested treatment for addiction last
year were approved for inpatient care. The remaining 59 percent were
approved for various levels of outpatient care.

The new system discourages doctors from giving patients treatment they
don't need, said Paul Langevin, president of the New Jersey Association of
Health Plans, which represents the state's 10 largest managed care
companies. Instead of automatically putting patients in residential
treatment centers for 28 days, doctors are asked to evaluate patients' needs.

The result, he said, benefits the both the patient and the health plans.

"It's less disruptive to the patient, and it's also less expensive,"
Langevin said.

Daytop's Hennen asserts that overcoming heroin addiction requires a
combination of both inpatient and outpatient treatments.

He cited a University of Maryland study released earlier this year that
showed among those who receive both types of treatment, 18 percent tested
positive for drugs during a follow-up visit. Of those who only received
inpatient treatment, 53 percent tested positive. (The study did not provide
results for those who received only outpatient treatment.)

The cost of treating addiction has declined over the past decade, said
Kieran Ayre, clinical director of High Focus Center in Sparta, which treats
patients from Morris and Sussex counties.

Ten years ago, he said, it was common to send an addict for six weeks of
inpatient treatment at a cost of $40,000. Now, the same person might get
three months of intensive outpatient care, at a cost of $3,000 to $4,000.
And costs are getting lower as treatment programs become more competitive,
Ayre said.

"The flipside is that if you have a serious case with a kid who needs
inpatient, it's difficult to get," Ayre said.

Some experts say managed care companies should be held accountable for the
kind of treatments they allow.

"I think there needs to be a set of quality standards, and the (managed
care companies) need to be judged," said Dr. Herbert Kleber, medical
director of the National Center on Addiction and Substance Abuse at
Columbia University.

"Most HMOs have to provide adequate care for cancer patients because the
public won't stand for any less," he said. "But they feel they can get away
with not providing adequate treatment for substance abuse."

Some relief may come from Trenton

A bill currently before the state Assembly Banking and Insurance Committee
could change that. It would require health insurers to provide mental
health benefits using the same guidelines used for other diseases.

However, a companion bill, which passed the Senate, stipulates that only
"biologically-based mental illnesses" apply, which would leave out
substance abuse treatment. The Legislature is expected to hammer out the
differences between the two bills.

Checked-by: Mike Gogulski