By Jim Kreitler, MS

Last year I wrote an article for this publication entitled “Are Arizona Addicts for Sale?” focusing on existing ethical issues in the field, in particular patient brokering. Now, 12 months later, are things better, worse or just the same?

Although a case could be made things have improved, Arizona is not nearly where it should be. If we look at the four areas of awareness, enforcement, current level of unethical activity, and the future of ethics in addiction treatment, it is clear that we are still in the process of solving this problem. 

We in Arizona have come a long way in recognizing these emerging ethical issues and dedicated professionals on all levels are getting involved in the discussion. The response to the ethics articles has been staggering. It has created vigorous, ongoing dialogue and a surprising number of people have reached out individually with offers to help, indicating that this issue is clearly not only my passion, but that of many others in the field. 

In the past year, several Arizona Addiction Advocacy Coalition luncheons focusing on ethical issues, organized by Arizona professionals Melissa Thornburg and Peter Thomas, have been held and were well attended. Numerous invitation-only Facebook groups dedicated to ethics in addiction treatment have emerged and are sparking important conversations. I also had the pleasure of participating in a panel discussion on ethics hosted by Behavioral Healthcare Magazine. 

On the national level, major associations like NAATP (The National Association of Addiction Treatment Providers, www.naatp.org) are on the cutting edge of discussion about what constitutes ethical treatment practices. These associations are moving beyond pledges to enforcement, but that only affects membership in the organization. Public awareness has increased, mainly from salacious news articles and stories. 

The troubling practices in south Florida have been the subject of almost weekly reports by the Palm Beach Post. Several major networks have broadcast stories that educated the public, but also put the entire industry in a bad light. NBC’s Sunday Night with Megyn Kelly aired “How to Find a Good Drug Treatment Program and Avoid the Bad Ones.” 

The show provided good information, and the video detailing the loss of life in Florida due to patient brokering and overdoses was heartbreaking. 

The bottom line is that, on all levels, discussion and awareness have significantly increased.

There is wide discrepancy in the enforcement of ethical practices across the country. We know of Florida as a hotbed of unethical and fraudulent activity, but to the state’s credit, that is also where most of the arrests and enforcement have taken place, and also where the strongest legislation was passed barring these practices. Unfortunately some of those unsavory programs now seem to have moved to sunny Arizona, where legislation and enforcement are lax.

MyPalmBeachPost.com reports that as of June 15, 27 people had been arrested by the Palm Beach 

County Sober Home Task Force for ethics violations. That includes Kenny Chatman, who was sentenced to 27 ½ years in prison in May for violations at Reflections Treatment Centers with charges including HealthCare fraud and money laundering. It seems as if there is an announcement weekly concerning new arrests in South Florida.

The FBI, which has been active in the Florida investigations, made a big splash in California by serving warrants to several programs operated by Sovereign Health. So far, no charges have been filed and Sovereign denies any illegal activity. 

Jeff Sessions and the DOJ announced that they are filing charges related to health care fraud against 412 individuals working in the prescription and distribution of opiates, as well as a treatment program in Palm Beach.

In Arizona, there seems to be almost no enforcement with regard to patient brokering. Effective enforcement requires strong laws, a motivated legal system, and a dedicated government to intervene. As of yet, efforts at legislation have been stymied. According to Angie Geren of the advocacy program Addiction Haven:

“In Arizona’s 2017 Legislative season, HB2333 was introduced by Representative Campbell which would have banned patient brokering and made any offenses a felony. Unfortunately the bill was assigned to a committee chaired by Representative Farnsworth who was not in support of the bill and refused to hear it even upon the insisting of Maricopa County Attorney Bill Montgomery, Yavapai County Attorney Sheila Polk, and other high officials in government. While advocates were frustrated with the lack of progress this season it has not stopped them from continually educating legislators surrounding the need for a ban and that Representative Campbell will introduce this legislation again in 2018. Most recently 60 individuals and organizations signed onto a letter to Gov. Ducey and leaders asking for immediate action to ban patient brokering.”

On the hopeful side, an AZ state law was passed that grants cities the authority to regulate sober homes, which have been identified as part of the problem in Florida. Prescott is one city that took advantage of this new law. Since being enacted, the previously large concentration of sober homes in Prescott has been reduced by two thirds. But current efforts to increase regulation in Phoenix and Scottsdale are making well-run homes nervous, as this would reduce the availability of this critical component of the recovery process. Unfortunately, sometimes the pendulum swings too far the other way. 

It is expected that the new Florida law known as Practices of Substance Abuse Service Providers Act HB 807, which became effective July 1, 2017, will significantly reduce, if not eliminate, bad practices in the state; however, it will also likely reduce the number of people who get treatment there. As this Florida law may become a template for legislators who are working on laws for their own states, I am concerned that subsequent regulations may also go too far and prevent many patients from getting the help they need. Again with that pesky pendulum!

To examine things a bit closer, key provisions of this bill include:

• Facilities cannot pay marketers directly or indirectly for referrals, including a bonus.
• It is illegal to write off deductibles, co-pays, etc.
• Facilities cannot pay for flights for patients to and from treatment.
• Marketers can be charged for providing any benefit, even as little as buying a perspective patient a pack of cigarettes. 

This new law could have a chilling effect on business in Florida. Marketers who violate any of these provisions when sending a patient for treatment in Florida, even those based out of state, would risk being charged. They could not forgive co-pays and deductibles for active addicts who qualify for financial assistance. Even gestures such as buying a pack of cigarettes for an addict who has been on the streets would be disallowed. All this can seem pretty severe, but whenever an industry does not self-regulate and the government has to step in, the result often is over-reach.

I’d like to think that the amount of agreement among addiction professionals on ending unethical practices would have significantly reduced this activity in Arizona, but I am hearing otherwise. I do believe that some well-meaning people and programs have adjusted to new information about proper conduct, and I applaud those who have changed questionable practices and cleaned up, but others seem to have just gone deeper underground, and the reputations of many new programs, including plenty owned by Florida companies, are not good. 

While it is true that I currently have days when I don’t have the pride in our industry that I would like to, I remain optimistic that we can, and will, change and adapt. I see my patients change every day at the worst points in their lives, and I know our industry can meet this challenge. I remain hopeful. 

Addiction professionals are asking tough questions such as: 

How much sobriety time should be required of a former patient before they are hired? What are appropriate compensation structures for marketers working for one program or a family of programs? Can I accept a cup of coffee or a lunch from someone at another program? What assistance can we provide to eliminate barriers to treatment or to help an individual with no money, home or support? 

We have to, and we are, challenging familiar practices.

I admit that I occasionally buy, out of my own pocket, clothes or haircuts for patients that come in off the street and need those things. My wife understands that I take on these expenditures because I am uncertain how appropriate it is to ask my company to pay for them. The answers aren’t always clear, but we are working together and moving in the right direction.

In addition to professional dialogue, many sources are providing guidance to clients on how to find an ethical program. 

Jay Crosson, CEO at Cumberland Heights, a well-respected non-profit program in Tennessee, wrote a piece called 12 Questions to Ask Before You Choose an Addiction Treatment Program. 

Those questions are:

• How long has the program been in operation? Providers in operation over 10 years typically aren’t seeking quick profits.
• Is the program licensed by the state?
• Is the program accredited by the Joint Commission, an independent nonprofit which certifies health care organizations and programs in the United States, or the Commission on Accreditation of Rehabilitation Facilities (CARF), an international nonprofit accreditor of health and human services?
• Is the program a part of the national trade organization for addiction treatment? Is the program contributing to the community, including taking the NAATP ethics pledge which has been in place for five years?
• Is the program In Network or Out of Network? For-profit or Nonprofit? While not all Out of Network or For-profit providers are bad it’s nearly impossible to be dishonest from a billing standpoint if you’re In Network with insurance payers.
• How frequently does the program perform lab testing like urine drug screens? Does the program have financial ownership or receive incentives from the lab company?
• Does the program have a family component or family participation? Is there an extra charge for this service?
• What levels of care does the program provide?
• Does the program have placement criteria? Do they refer patients to alternative facilities when they don’t fall into their area of expertise? What are those criteria?
• Does the program offer airline tickets, free rent or other inducements? Offers of free rent or other benefits may be evidence of illegal patient brokering or in some states fraudulent inducement.
• Does the program have a strong alumni base? Do they offer alumni services such as Aftercare?
• If seeking a sober home, are referral fees paid to the sober home from a treatment center if residents enroll at that center? If so, it suggests the presence of an illegal kickback scheme.

I cannot emphasize enough that, “It is absolutely possible to recover from a life of addiction. I’m living proof. That’s why the information gathered while seeking treatment is the most important research done for the benefit of someone struggling with addiction. We see the miracle of recovery every day at Cumberland Heights, but it’s important to keep your eyes open and make certain you’re well informed when making decisions which will set the trajectory for your loved one’s life from this point forward.”

I want clients to be to be informed and to ask questions. And we need to be able to answer them. 

On Saturday, September 16th, 2017, at the Art of Recovery Expo, I will be moderating a panel of experts on ethics in addiction treatment, including Angie Geren of Addiction Haven, reporting on current legislation and advocacy efforts; Tom Heritage, LPC of Cigna, representing payers from a national perspective; and Peter Thomas of the National Association of Addiction Treatment Providers NAATP, providing an update on the efforts of his association.