Thursday, August 26, 2010

Limitations on Health Care

A Grand Experiment: Limiting Detox to Once Per Year

The newly united Alcohol and Drug Addictions Board and the Mental Health Board took a huge hit by the state in the last round of budget cuts. The ADAMHS Board decided that they would work on limiting costs by only paying for one stay in detoxification for narcotics and other drugs per calendar year. Even if you leave a day after beginning detox, you cannot return for 12 months. Beginning October 1, 2010, the Board will pay for detox services only once per 12 months unless the women in need is pregnant or the individual is in active or impending alcohol withdraw. They held a public meeting last week to talk about these issues and a few activists and practitioners attended. Sounds boring, I know. I have to say in listening to all the statistics and the rationale, this all seems like some big experiment without a lot of proof that this will work. I was not even sure what the goals were for this program after listening to the staff of the ADAMHS board.

The Board was not looking for comment or public scrutiny. They were just asking to explain why they were taking these actions. ADAMHS Board Director William Denihan could not make it, but Dr. Christina M. Delos Reyes was able to provide some passion to defending and explaining the policy. Charlotee Still Noble, ADAMHS Board chair was also in attendance, but she did not say much. It must be noted that the policy was introduced earlier this year, and was criticized by many so they went back and revised it to not include pregnant women and those attempting to rid themselves of alcohol. The main defense was that they are trying to better meet the needs in the community, because of the long waiting lists that exist now. They are trying to better integrate the treatment programs with the detox programs so that people leave detox and get priority within the treatment programs. Dr. Delos Reyes talked about the budget cuts, and specifically the disparity that exists in how the medical system deals with alcohol and drug issues compared to other health care issues. This was an important point that she championed and should be shouted in the halls of the state capital.

The statistics provided by the board were not very convincing, and said to me that the Board does not do a very good job of understanding the full landscape of alcohol and drug services. They presented only the numbers from detox services that were reimbursed by the board, which I do not believe is a fair reflection of the need in the community. There are plenty of other programs, hospitals, and places that do not get reimbursed but provide medical detox. How many "frequent fliers" go through multiple detox sessions, but only one was paid for by the County? We also do not know how long people are in fact waiting for detox. Are they finding a waiting list at one of the three programs that are reimbursed by the County ADAMHS Board, and so they go somewhere else (like the emergency room)?

Then when pressed by those attending the meeting, it was found that the board has no ability to gather these other statistics. This means we do not know how this new policy will impact our community. We do not know if this will increase the number of people using the emergency room. We do not know if this will increase alcohol related deaths or even if this will increase the amount of care that the other providers must pay for out of their own pockets. It seemed to me that this was a rationing of health care, based on a small amount of data without any attempt to figure out the impact that this will have on the community. They could have rallied the community against tax cuts, a change in state budget priorities, or a focus on public policy instead of just corruption scandals. Instead we were treated to anecdotes and platitudes like, "This is not about waiting lists; this is about make the services available."

Stella Maris detox program staff claimed that they spent $209,000 in uncompensated care in 2009 and $59,000 in uncompensated care in 2008. I have to believe that this new policy will only push more uncompensated care onto community organizations like Stella Maris or the Salvation Army because it is so difficult to turn people away from detox. This is the first step into the treatment program, and so groups understand that they do not want to turn people away from this first step out of fear that they will never see them again. I applaud Dr.
Delos Reyes comments about treating these addiction issues as we treat every other health care problem with emergency care and a "do no harm mentality" as a guiding principle. Too often decisions within behavioral health are made based on economics and not what is in the best interest of the individual. Too often behavioral health problems are addressed with "consequences" for misbehavior by the addicted individual. I have never heard of discharging a patient being treated for diabetes/high sugar levels in the hospital because they had a friend bring in a milkshake. Relapse with a drink while in treatment and they will send you on your way without hesitation.

While some communities are passing special taxes on beer and wine distributors in order to pay for treatment on demand, we are going the opposite way in Cuyahoga County. The brave new world of rationing detox is upon us.


PS: I hate this photograph and the message contained on it, but it is a perfect example for why we need detox. This is why we doctored the photo to discourage people from copying it and using it as negative propaganda against homeless people. The composition of the photo by Cheryl Jones is very good, but the message is horrible. I mean begging for money is offensive, but then publicly admitting that you have a drinking problem is even worse. I have talked to Nate, the subject in the photo, about this but he thinks humor brings in the bucks. It just seems like to me a black guy doing a minstrel show for pedestrians downtown and asking for some dollars in exchange for making himself look like a fool. It is highly offensive, but the message delivered by the ADAMHS Board in rationing health care is just as troubling.

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