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Gateway founder laments managed care impact on substance treatment
Thursday, November 02, 2000 By Mackenzie Carpenter, Post-Gazette Staff Writer
As Dr. Abraham Twerski turns 70 this week, his friends and admirers are planning a festive celebration of yet another milestone for the physician and rabbi who founded Gateway Rehabilitation Center in 1972.
There's certainly lots to celebrate. Forbes Magazine once called Gateway -- which has more than 30 treatment facilities in the region -- one of the top 12 centers in the country. Former first lady Betty Ford, a Twerski friend who helped remove some of the stigma from alcohol treatment, is serving as honorary chairwoman of tonight's event at the Doubletree Hotel Pittsburgh, Downtown.
Twerski has even expanded Gateway's reach to Israel, where he recently established a center near Jerusalem, Shaar Hatikvah -- Hebrew for "Gateway to Hope."
But when asked how drug and alcohol treatment has changed in the past 30 years, Twerski, who now serves as the center's medical director emeritus, is anything but upbeat.
Managed care, he says, has wreaked havoc on the field. Inpatient stays of 28 days, which he believes allow many patients time to recover physically and mentally and to best benefit from therapy, are mostly a thing of the past -- except for people who can afford to pay their own way at Hazelden in Minnesota or the Betty Ford Clinic in California.
And that, he says, is a tragedy.
"People who could have better services and a better chance at recovery are being deprived of it. I believe every individual should be assessed so that their needs are addressed properly, but that's not what has happened. Many managed care companies and HMOs are refusing most inpatient care on the grounds that it's not necessary. They are making arbitrary judgments."
Grim words indeed, but Twerski, who has authored 32 books -- including four in collaboration with Charles Schulz, the late "Peanuts" cartoonist -- has never been one to refrain from speaking his mind.
And his colleagues at Gateway are even more blunt: The 28-year-old organization has been struggling financially, even as it has diversified its outpatient services to survive under the new paradigm of managed care.
In the beginning, Gateway's typical patient was a white, middle-class male in his mid-40s, employed, with addiction to alcohol, who would stay for 28 days at a residential rehabilitation center.
Not any more.
"A lot of those people today would be doing outpatient at our Green Tree or Fox Chapel facilities," said Dr. Neil Capretto, Gateway's medical director.
During the 1990s, more than half of the nation's inpatient centers closed after businesses and their insurers began to question whether the cost -- in the thousands for several weeks of hospitalization -- really brought results. Noting that the relapse rate in alcoholism is high -- up to 75 percent in the first three months -- they began demanding proof of success. Most treatment centers didn't keep careful records, however.
Gateway moved quickly to change with the times, establishing some 30 satellite outpatient facilities and halfway houses in the region.
And new studies began to show that outpatient care, along with counseling and self-help programs like Alcoholics Anonymous, could help people stop drinking.
"We were opening outpatient clinics before insurers even were willing to pay for them," recalled Capretto. "But there is still a population that needs inpatient care and that's the part that's suffering."
"Today, we're seeing people closer to age 30, plus a higher number of women and minorities. These people often have multiple addictions and complex medical and psychological problems, but often all they get are a couple of sessions in an outpatient program."
Two decades ago, only 35 percent of Gateway's patients were publicly funded; today, 80 percent of its patients are on some form of government insurance. Many of those who would have received some kind of private insurance coverage for substance abuse aren't getting it at all today, he noted.
In fact, expenditures for mental health and substance abuse treatment have shrunk to 7.8 percent of the more than $1 trillion dollars in all U.S. health care expenditures in 1997, down from 8.8 percent in 1987.
Public attitudes about addiction and treatment have played a role, noted Ken Ramsey, Gateway's CEO. All one has to do is look at today's news headlines: Betty Ford's successes aren't chronicled; Darryl Strawberry's failures are.
"The stigma about addiction has creeped back in after a period in the 1980s when it was almost fashionable to go into a clinic," said Ramsey. "But when people repeatedly fail, the public gets fed up, ignoring the fact that a large percentage do succeed when they seek help."
The biggest blockade to providing that help, Gateway officials claim, is Magellan Health Services, the nation's largest managed care company for mental health, drug and alcohol treatment.
"Blue Cross really took a step backward in contracting with Magellan," Capretto said, noting that his company's relationship with Blue Cross had been more positive until Magellan was signed on last year. "That decision has really pushed cost savings into unsafe areas. They won't admit to it, but anyone who's worked for any time period in the field knows about Magellan tactics in setting up obstacles to treatment so they can deny care."
Such tactics include denying detoxification services to someone using 10 bags of heroin a day, said Capretto.
"Or we'll have a person on heroin who was struggling with depression, who was a recent suicide attempt, and after much struggle and a physician review, we'll get three days authorized after detox, and then I have to fight for another two days, and then they [the insurers] want to drop him into an evening program twice a week, even though our position is he needs two weeks before he has a fighting chance of going back on the street and staying sober."
Magellan and Blue Cross officials insisted that each case is reviewed on its merits.
Such decision making is "a very delicate balancing act," said Michael Weinstein, a spokesman for Highmark. "We're trying to satisfy our customers, the purchasers of health care, while at the same time trying to make sure people receive the appropriate treatment they need."
Magellan officials noted that they follow patient placement criteria as established by the American Society of Addiction Medicine (ASAM) and have a group of physicians experienced in substance abuse treatment reviewing claims.
Magellan focuses on individualized treatment planning that includes inpatient care ranging from a few days after detoxification to up to 11 days. But there are also many other treatment options available that are as effective as the old, 28-day hospital stay, noted Dr. Sam Donaldson, vice president of clinical services for Magellan and a licensed psychologist in Pittsburgh who once worked for Gateway.
"Traditionally, Pittsburgh substance abuse treatment has lagged behind the rest of the country in accountability," said Donaldson, "with an insistence that hospitalization is necessary without the research to back it up. Substance abuse treatment has been ideologically driven, almost by belief [rather] than by hard science."
In one major 1995 study by the American Psychiatric Association, inpatient hospitalization was not found to be a superior level of care, Donaldson said. Outpatient models were just as effective in many cases.
"A lot of people may not know that the person seen in an outpatient setting three times a week was something we didn't have in the 1980s. Treatment has gotten better for addicted folks."
"The idea that we sit around here and say, 'Let's delay treatment,'" is absurd, he said. "Financially, they [Gateway] have been impacted. They're running a business also," and to say otherwise is disingenuous. "They say it's all about patient quality and care, but they're looking at huge facilities they need to fill."
The two sides are not likely to improve their relationship anytime soon. Gateway claims Magellan has routinely recorded all its conversations with the center's officials, and now plans to do the same in return "to get their words on the record," says Capretto. Gateway also has begun referring cases to Attorney General Mike Fisher's office when it believes the company is illegally denying coverage.
"We don't tape record conversations with Gateway or anybody else," said Magellan's spokeswoman, Erin Summers. "We believe we're managing care appropriately on an individualized basis. We're disappointed they feel like that's not happening, but certainly it's within their rights to refer those cases to the AG's office or any other regulatory body."
These days, it seems, the best way to the best treatment is to be in jail or on welfare. Pennsylvania's Department of Corrections has been working with Gateway on an intensive 18-month program for inmates that is considered something of a national model. And Allegheny County's managed care program for welfare recipients, Community Care Behavioral Health Organization, CCBHO, generally provides for longer inpatient and outpatient treatment than private insurers.
"They recognize that if you put a Band-Aid on a 10-inch wound, it's going to come back," said Capretto. "County officials realize that many of these people can't get much lower before ending up in jail."
Businesses aren't completely to blame for the undertreatment of addicts, Twerski added. Medical schools still aren't committed to training their students in substance abuse treatment, and a recent survey of physicians found that the majority didn't believe alcoholism could be cured by medical intervention, he said.
"The people who should be making the identification, diagnosis and referral aren't doing it, in part because they don't believe it's a disease."
The "disease model" has divided the treatment field for years, Twerski noted, from the days of the temperance movement, whose leaders believed addiction was a moral defect, to attacks on Alcoholics Anonymous by those who felt it didn't stress personal responsibility sufficiently.
On the other hand, advances in research have found that alcoholism may be a genetically inherited condition, and new technology has made it easier to measure the impact of psychoactive substances on the brain, leading to advances in drug therapy that can actually ease an addict's cravings.
Twerski remains optimistic about the future -- on both new treatments and new approaches to paying for them.
"I don't get depressed from this because I'm an incorrigible optimist. When you've been in the field this long, you realize one of the things about being an alcoholic is being in denial; they don't realize how bad things are until some crisis occurs and they hit rock bottom.
"Right now, the insurance industry hasn't hit rock bottom. But when they realize that they've cut so far on one end that they're now paying at the other end with huge medical bills, then there will be a change, an end to that denial. I don't give up on alcoholics, and I'm not giving up on the health-care industry. They'll realize it some day."
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