Capitol query: HOW TO IMPROVE STANDING OF ADDICTION TREATMENT

WASHINGTON, D.C. -- Astronaut Buzz Aldrin held a Senate panel spellbound
last week as he described the stumbles and climbs in his recovery from
alcoholism -- through Veterans Administration programs, hospitals and
treatment centers.

"It took time and it took many exposures," Aldrin testified.

Does it follow that health insurers should write blank checks for addiction
treatment, giving alcoholics and drug abusers unlimited chances for
recovery? If so, how does that square with the drive to contain health costs?

Those are among the questions prompted by a call in Congress and on TV this
month for giving addiction the same standing as diabetes, heart disease and
other maladies.

Many insurers say they agree with the spirit of that call. But they counter
with their own call for efficiency and accountability from an area of
treatment that heretofore has been hidden in shame and the mysteries of the
brain.

"Our employers do philosophically agree that all diseases should be treated
equally, and our programs have been designed to do that," said Steve
Wetzell, a spokesman for the Buyers Health Care Action Group, which
organizes coverage for 28 Minnesota companies. "But even with parity, you
haven't solved the problem of knowing whether people are getting good
outcomes."

There is a near consensus that the key to getting the best value for the
health care dollar is to let medical experts -- doctors and clinicians --
decide what's best for each patient.

But the day-to-day reality is that doctors and clinicians aren't always
well-prepared to spot and treat addiction. And the treatment industry is
divided over recovery philosophies.

Rep. Jim Ramstad, R-Minn., wants to begin the debate at the bottom line. He
insists that we can't afford to let the problem slide because untreated
alcoholics and addicts incur health care costs at twice the average rate
and add tens of billions of dollars to the costs of crime, accidents and
absenteeism from the workplace.

The pile of research that Ramstad has gathered became too heavy for his
staffers to haul around Capitol Hill on his crusade for the bill he and
Sen. Paul Wellstone, D-Minn., hope to pass this year. It would require
group medical plans to provide the same levels of coverage for chemical
dependency as for other illnesses.

But the true weight of Ramstad's influence comes from his recovering
alcoholism. He has appeared this month on "Nightline" and C-Span with the
story that's well-known to Minnesotans: On July 31, 1981, he had the last
in a 12-year series of alcoholic blackouts. A Minnesota state senator at
the time, he was arrested and jailed for disorderly conduct.

The story and Ramstad's faithful attendance at meetings for recovering
alcoholics also are well-known on Capitol Hill. Members of Congress and
staffers routinely visit his office for discussions of their own addiction
problems, he said.

Now, Ramstad's office is flooded with messages from people throughout the
country responding to his call for a new national priority on treating
addiction. Ramstad's pitch coincides with a five-part series, "Moyers on
Addiction: Close to Home," that began Sunday on PBS.

Not since the late Iowa Sen. Harold Hughes fought for federal funding for
addiction treatment in the early 1970s has there been such a visible push
for congressional action on the problem. Hughes offered a lonely voice by
openly discussing his personal battle with alcoholism.

Stepping forth

Ramstad and Wellstone are backed by Partnership for Recovery, a coalition
that includes the Minnesota-based Hazelden Foundation and the Betty Ford
Center of California. The partnership recruited Aldrin and other
celebrities to testify about their struggles with addiction. Even the
normally secretive Alcoholics Anonymous is stepping forth.

"The recovery community in America is getting mobilized nationally for the
first time," Ramstad said.

They are spurred by a decline in insurance coverage for substance abuse
services and a parallel drop in treatment facilities.

The reaction from health insurers and providers is mixed. Allina Health
System in Minnesota favors the Ramstad-Wellstone bill because the state
already has a similar law, and "we welcome consistency between the federal
law and state law," said Jan Malcolm, vice president for public affairs.
The state law has expanded access to services for some people and has
raised premiums about 2 to 3 percent, she said.

Resistance doesn't come as much from health plans as from employers, she
said. As purchasers, they want to be assured the treatment is effective.
And they're more likely to raise questions about mental health and chemical
dependency treatment than about any other kind of medical care.

Some questions stem from the fact that treatment centers lobbying for the
bill stand to gain financially from the legislation.

"There are special interests who might push for mandates and might actually
be trying to protect revenue streams," said Wetzell of the buyers group.
"We get concerned when you put in mandates, especially ones that are
advocated by provider groups, because you're not quite sure whether it's
about protecting the patient or making sure the insurance companies pay for
services that may or may not be necessary."

There is a "stunning lack of data available to consumers and employers on
who has better outcomes" across the health care spectrum, Wetzell said.
When it comes to substance abuse, that's a particularly sensitive problem
because of a perception that quality standards have been lacking in the
treatment, he said.

Standards rise

Treatment experts are among the first to agree that their industry has a
checkered record.

"In the 1970s, a lot of for-profit treatment centers cropped up, and
insurance companies would pay for everything, no questions asked," said
David Hiers, who manages the in-patient chemical dependency program at
Fairview Recovery Services in Minneapolis.

Before that, most of the care for alcoholics came from recovering
alcoholics who may have been helpful but probably were not qualified to
counsel patients through complex problems, said Barbara McCrady, clinical
director of Rutgers University's Center of Alcohol Studies.

Standards gradually have risen. "Back in the old days, being a member of
Alcoholics Anonymous was the qualification," Hiers said. "Now, we are
requiring bachelor's degrees and licensure and much more training."

The industry's credibility also has been challenged by a highly publicized
debate over treatment philosophy. Bookstores display volumes debunking the
so-called Minnesota Model, based on Alcoholic Anonymous' 12-step approach.
But scores of counselors and recovering addicts follow the 12 steps with
nearly religious devotion.

A growing body of research shows that "these are treatable disorders" and
that an array of approaches can be effective, McCrady said. Recently, there
have been breakthroughs in the understanding of the genetic basis for
addiction and of the changes a brain undergoes during a high. And new
medicines are in the works.

For moderate alcohol problems, there is good evidence that brief
interventions of two to four sessions can at least reduce drinking and
related health and occupational problems, McCrady said. At the other end of
the spectrum, some people need comprehensive long-term treatment.

"Many people who have drinking problems deal with it successfully
completely on their own," she said. "I always try to get a message across
to individuals who are out there living with drinking problems that there
are multiple ways to change, and if someone said, 'Oh, I've heard about AA,
and I wouldn't want to do that . . . there are plenty of other options."

If one option or another doesn't help a given person, that's no
justification for giving up, she said. "Lung cancer has an 85 percent
mortality rate, but we don't say, 'Well, two shots and you're through,' "
she said. "What is it about alcohol dependence or drug dependence where we
say we shouldn't give them, maybe, three shots?"

Part of the problem

What's important for saving money and curing addiction, said McCrady and
other experts, is for physicians and other health care workers to determine
the best approach for each individual. But that's part of the problem. Many
doctors aren't seeing and treating signs of substance abuse.

"Some people think that chemical dependency treatment is not medicine,"
Hiers said. "It's touchy feely. It's not heart surgery."

Further, it is time consuming, McCrady said. "Patients don't come in
saying, 'I'm really worried about my alcoholism.' They come in saying, 'I
have a pain in my belly,' or 'I have this cough I can't get rid of.' The
assessment and diagnosis requires a lot of verbal interviewing . . . so
it's very hard for a physician who may have patients booked every eight
minutes to find the time to do that kind of assessment. And they don't get
reimbursed for that."

Insurers who took the long view of health care costs would build incentives
into their reimbursement plans for doctors to identify the problems and
start early treatment, she said.

© Copyright 1998 Star Tribune.