A lot of times, when people think about addiction recovery, they immediately think of live-in rehabilitation centers for hard drug users and Alcoholics Anonymous meetings for alcohol users, with not much in between. It’s unfortunate that this is the extent that people know about addiction recovery, because addicts considering getting help may feel averse to those structures and pass up assistance because of it.
However, in reality the programs for recovering addicts are varied to accommodate differing needs and situations. Generally, there are four main tiers of treatment programs. Patients are sorted into these programs based on evaluation of their addictions and lifestyles.
Or, rather, that’s the idea. However, insurance companies frequently do their best to keep patients from being able to get the treatment that they need.
Here’s a breakdown of the four tiers of addiction recovery programs, in order of descending intensity, as well as an explanation of the criteria by which patients are placed into each one and how insurers are involved in that process.
This is the most intensive variety of addiction recovery program, and typically is reserved for patients with the most pressing needs. However, before describing what this type of program does consist of, we should clarify what it does not consist of—specifically, this is not an inpatient program, though some centers mistakenly call it that. In Illinois, inpatient programs are only for mental health, not substance abuse, and it is illegal for a chemical dependence facility to lock the doors. Patients in these programs are always free to walk out the door should they so choose.
That said, patients in residential treatment programs do live at a sober living recovery facility. They eat there, sleep there, and spend their time participating in daily group and individual therapy sessions, as well as art therapy and educational lectures. Most residential treatment programs are 12-step programs, and many hold AA-sponsored events or send patients to AA meetings several times per week.
These programs last about 30 days on average, though research has shown that they are most effective when a patient remains for 3 to 6 months.
Partial Hospitalization Program (PHP)
Don’t let the word “hospitalization” scare you—this next tier of addition recovery services is actually less intensive than residential treatment.
For the most part, these programs are the same, with patients eating meals at the facility and attending various therapy sessions and other programmed activities throughout every day. The difference is that in a partial hospitalization program, or PHP, the patient returns home for the night just before dinner.
The length of these programs depends on whether this is an initial treatment or a transition phase. If this is the program the patient is initially placed into, it lasts on average about 30 days. If it is being used as a step down to transition the patient from residential treatment to reintegration back into their home and their community, then it may only last a week or two.
Intensive Outpatient Program (IOP)
An intensive outpatient program, or IOP, grants the patient a bit more freedom.
While the higher two tiers require patients to spend every day participating in all-day programming, an intensive outpatient program only requires 3 to 5 days of attendance per week. And rather than taking all day, the programming is a block of time either in the morning or the evening.
This allows patients to continue to go to school or work a job. Such a program is good for people not at risk of relapse in their own home, such as alcoholics who are only tempted when around alcohol in public settings but don’t keep any in the fridge, or anyone with a good support network at home. It typically lasts 6 to 8 weeks.
Finally, outpatient programs are the least intensive of the four tiers of addiction recovery programs.
Once per week, patients attend some recovery programming, perhaps a group therapy session, and go home at the end of it. At this point, it is most similar to what people imagine when they think of alcohol users attending AA meetings.
The patient usually continues with this from 9 months to a year.
How Insurers Influence Where Patients Are Placed
So, how is it determined which tier of treatment a patient receives? Well, the sorting process is based on a professional assessment conducted by a substance abuse counselor who figures out what the patient needs.
This assessment is based on guidelines set out by the American Society of Addiction Medicine (ASAM), which consist of six criteria for the counselor to consider. They are:
- Withdrawal potential and chemical history—What is the patient’s drug dependency like? Are they at risk of withdrawal symptoms? If so, they may need medical supervision and thus be sorted into residential treatment.
- Medical history and physical condition—Does the patient have any relevant health issues? For example, a patient with a damaged liver might experience liver failure and death if they drink and thus require high-tier treatment.
- Mental health and emotional state—Does the patient have any mental health issues that may be exacerbated by withdrawal? Do their cognitive or emotional frames of mind require special attention?
- Readiness to change—Is the patient ready and willing to follow through with what the treatment requires of them? How accountable are they?
- Relapse potential and history—Is the patient at risk of relapse? Have they relapsed before? A chronic relapse will be placed in higher-tier care than a first-time recipient of treatment.
- Living/recovery environment and support network—What is the patient’s life at home like? Are their family and friends also drug users, or are they supportive of the patient’s recovery? Are they at higher risk of relapse if they are at home, or is it a positive part of their recovery process? If the former, then they will be placed in higher tier programs, and if the latter, then they will be placed in lower tier programs that allow them more time at home.
The problem, however, is that while these are the accepted guidelines which substance abuse counselors use to evaluate patients, insurers have their own standards that are quite different. Because insurers are losing money whenever someone is receiving medical treatment, they push as hard as they can for patients to receive lower tiers of treatment and for less time.
For example, residential treatment has been shown to work most effectively when it lasts 3 to 6 months, yet counselors have to fight insurers every step of the way just to keep patients in it for the 30-day average. Every four days that the patient is there, the counselors must call the insurer and essentially fight to persuade them that the patient still needs that care. Often, it isn’t easy.
The insurer will, for instance, ask whether the patient wants help and wants to be in the program. If yes, then the insurer will argue that the patient is cooperative and can be moved down to a lower-intensity form of treatment. If no, then the insurer will argue that the patient will bail on treatment if it is too intensive.
And if a patient is a first time recipient of care, the insurer insists that since they haven’t gotten treatment before, lower tiers may be enough, even when it’s clear to the counselor according to the ASAM guidelines that it’s a high-risk patient who need a higher-tier program.
The fact that these insurance companies can deny treatment to those who desperately need it, especially amid a growing heroin epidemic, all for the sake of protecting their bottom line should be an outrage.
All we can do though is keep doing our best to get help to those who need it. That’s why New Directions Addiction Recovery Services continues to operate The Other Side, a sober bar in Crystal Lake, Illinois, as well as a variety of other services as part of a drug dependence recovery community. If you or your loved one is struggling with addiction, or if you would like to contribute to our efforts to get people necessary treatment, give us a call at (779) 220-0336. We care about every individual’s specific circumstances, and will always try to lend a hand to someone in need.