WHO SAYS HOW LONG REHAB WILL LAST?

If you're fortunate enough to have health insurance, who should decide how
much treatment you need for a drug or alcohol problem? Your family
physician, or a medical professional who works for your insurance company?

Two years ago, Pennsylvania's state insurance department sent out a notice
that any licensed physician or psychologist could refer addicts and
alcoholics to a minimum 30 days of residential care and 30 days of
outpatient care per year, with a lifetime limit of 90 and 120 days,
respectively.

Insurance companies have battled that interpretation of Act 106 ever since,
saying they should decide what treatment is medically necessary so they can
keep costs down. The dispute ended up in Superior Court this year, but the
court told the parties, in effect, "we're not getting involved" because it
considered it an administrative issue.

Sam Marshall, spokesman for the Insurance Federation of Pennsylvania, calls
the treatment debate "a legitimate dispute within the medical community."

The appropriate level of treatment, he said, "is going to vary, and that's
sort of the whole point. Don't assume that 30 days inpatient is the best
for that patient and that the insurer is just trying to save money."

The fact is, though, that the disputes rarely involve an insurer pushing
for more treatment and, while an appeals process does exist, it is families
who get squeezed in the meantime.

In many instances, those families would be better off if they were poor and
qualified for medical assistance.

When Roberta Lojak, of Fawn, learned daughter Ashley Elder was using
OxyContin in April 2001, she immediately took her to a rehab program, which
told Ashley to leave after six weeks of outpatient care.

"They told me I need to save my benefits because I will need them down the
road," Lojak recalled. "I said, 'You're telling me she has a problem, and
that she needs more help, but you're sending her home?' " The family
continued to battle Ashley's addiction for several months and, at one
point, Lojak, a nurse, took a leave of absence to help her through a
withdrawal. Ashley always went back to using.

The family had Ashley committed to a 28-day program, which discharged her
after nine days. "They told me she'd completed the program," Lojak said.

Lojak picked Ashley up on a Saturday but, knowing her daughter wasn't well
yet, she arranged for her to start another program the next Monday.
Sometime Sunday night, Ashley got hold of some heroin and overdosed in her
bedroom. Her mother found her dead Monday morning.

Two weeks later, Lojak says she received a letter from the rehab program
inviting her to appeal its discharge of Ashley.

"You can't cure someone in a week. They need long-term treatment, to get
away from where they are and all the people," said Lojak, who hopes to open
a long-term program herself.

Marshall counters that so many variables come into play, such as the number
of previous relapses and what kind of support system a patient has at home,
that no set rule or minimum works for everyone.

"It's a chronic illness and I don't know if you're ever cured," he said,
"but it's a far tougher issue than saying, 'Jeez, the insurance companies
just want to save money.' "

Some question whether money should even be an issue.

When a New Jersey State Assembly commission looked at mandated drug and
alcohol health coverage earlier this year, it found that health care
premiums would increase only between 0.1 percent and 0.2 percent if
insurers had to cover addictions as they do other illnesses.

"Any insurance company that fears that expenses will go up with an expanded
benefit are proven wrong by history and experience," said David Mactas, the
New Jersey-based former director of the federal Center for Substance Abuse
Treatment.

"If you speak to health professionals, they would tell you the expense to
insurance companies is incredibly minimal. I think insurance companies just
don't like the idea of paying for addiction treatment because of the stigma
involved."

That's not just an issue for insurance companies, he acknowledged. Public
funding of treatment for addicts always will be a difficult sell, too, he
said, because "too much of the general population thinks they're not sick,
they're morally weak."