Pubdate: Tue, 17 Apr 2007
Source: New York Times (NY)
Page: Front Page
Copyright: 2007 The New York Times Company
Author: Richard Perez-Pena
Bookmark: (Treatment)


With grim humor, some doctors in New York call them "frequent fliers" 
- -- addicts who check into hospital detoxification units so often that 
dozens of them spend more than 100 nights a year in those wards.

Through its Medicaid program, New York spends far more than other 
states on drug and alcohol treatment, including more than $300 
million a year paid to hospitals for more than 30,000 detox patients. 
One reason for the high cost is that $50 million is spent just on the 
500 most expensive patients, at a cost of about $100,000 a person. 
These patients check in and out of detox wards, on average, more than 
a dozen times a year -- a practice that experts say would not be 
tolerated in most states.

In the state's 2004 fiscal year, one patient was admitted to such 
units 26 times at 17 different hospitals around New York City, 
spending a total of 204 nights, Medicaid records show. In fiscal year 
2005, there was one patient who spent 279 nights in detox wards, at a 
cost of about $300,000.

New York State spends more than enough money to provide all the 
needed treatment, but "the dollars are being spent in the wrong 
settings," said Deborah S. Bachrach, the state's Medicaid director. 
In Gov. Eliot Spitzer's campaign to overhaul Medicaid, she said, 
"this is very high on our agenda."

George Epps, 59, was a heavy user of alcohol, cocaine and heroin and 
says he went through detox programs around New York City 20 to 25 
times over several years. "I would come out of detox and rent a room, 
squander my money on drugs and women, be homeless again for a while, 
and check back into detox," said Mr. Epps, who added that he had been 
clean for more than six years.

He was far from being one of the most extreme examples, but he says 
he understands the thinking of the repeat patient.

"I would tell myself I was just a brother who needed a rest, not 
somebody who had a problem," he said. "I could mimic what they said 
with such grace and conviction, they would swear I was cured."

Among state officials, doctors who treat addiction, service groups 
dedicated to helping the homeless and mentally ill, even the addicts 
themselves, there is remarkable agreement on why the treatment system 
in New York is overpriced and inefficient.

In other states, most addicts who go through detox programs do so on 
an outpatient basis, while in New York the vast majority are 
inpatients. Medicaid rules in New York also encourage hospitals to 
provide the most expensive kind of inpatient detoxification, though 
it is often not medically necessary, while many other states favor a 
less expensive form of inpatient treatment.

And in New York, when patients are discharged -- typically after 
about five days -- the needed transition to an outpatient treatment 
program often never occurs. That is one reason many patients do not 
fully recover from their addictions and return to detox wards, experts say.

The system suits the most frequent patients -- most of them homeless, 
mentally ill, or both -- who see the programs as a source of shelter 
and food. And the most expensive treatment, which usually involves 
some sedation, can reduce the discomfort of withdrawal better than 
other methods.

Some drug users, especially those on opiates, also set out to clean 
their systems so they can reduce the dose needed to get high, 
according to addicts and those who treat them. For a homeless addict, 
the cost of each dose is a major concern.

But at its core, experts say, the overuse of costly inpatient 
programs is connected to the lack of housing for homeless people. 
People are less likely to admit themselves to hospitals, and more 
likely to adhere to treatment programs, when they are not living on 
the streets. For more than a decade, the city and state have invested 
in such housing, including some that accept residents who are not yet 
drug-free, but demand for housing still far exceeds supply.

"For this small group of what are basically professional inpatient 
detoxification users, it's really a whole series of linked problems, 
and none of the parts of the system work very well," said Dr. Richard 
N. Rosenthal, an addiction specialist and chairman of psychiatry at 
St. Luke's-Roosevelt Hospital Center in Manhattan. "There's been some 
progress on each element, but not enough."

The most intensive form of treatment, "medically managed" withdrawal 
takes place in a hospital, usually involves some sedation, and 
requires a great deal of care by doctors and nurses. The next level, 
"medically supervised withdrawal," can be done in a hospital, or 
sometimes on an outpatient basis, and requires less medical 
intervention and less staff.

In New York, Medicaid pays an average of more than $100 a day for 
outpatient medically supervised withdrawal, and close to $400 a day 
for the inpatient version.

But it pays more than $1,300 a day for medically managed detox -- and 
state officials estimate that more than 40 percent of that is profit 
for the hospitals. Hospital executives say the margin is not that 
high, but they concede that the most expensive form of detoxification 
is a significant money-maker.

As a result, many hospitals offer that program, but not the cheaper 
ones. By law, hospitals cannot turn away emergency patients, and drug 
or alcohol withdrawal is considered an emergency. So about 80 percent 
of the detox patients handled by hospitals in New York are treated at 
the most expensive level -- often because it is the only one available.

Federal officials say they do not keep state-by-state Medicaid 
records, but experts and state officials say it is clear that New 
York spends far more on drug treatment than any other state, because 
other states mostly provide outpatient treatment. Figures compiled by 
the Department of Health and Human Services support that claim, 
showing that New York has more hospital admissions for drug or 
alcohol abuse -- whether paid by Medicaid or someone else -- than 
California, Texas and Florida combined.

Of the patients in medically managed detox in New York, "about 80 
percent of them are uncomplicated and could be provided with a lower 
service," said Karen M. Carpenter-Palumbo, commissioner of the 
state's Office of Alcohol and Substance Abuse Services.

Spitzer administration officials say the state needs to pay less for 
the top level of care, and possibly pay more for the others, to spur 
the development of those services. That fits with the governor's plan 
to review what Medicaid pays for all services, with an eye to 
encouraging less expensive forms of care.

But those officials also know that when George E. Pataki tried twice 
as governor to change the detox payment system, the hospital 
industry, which has been losing money over all, persuaded the 
Legislature to protect one of its few sources of profit.

Everyone in the field agrees that drug treatment would be more 
effective and less expensive if a patient consistently went to the 
same hospital and the same set of doctors.

But in New York, a hospital has no way of checking a patient's 
history at other hospitals. The state has talked for years of making 
that information available right away, and requiring that patients be 
transferred to their "home" hospitals, but to no avail.

Beyond medically managed and medically supervised detox, there is the 
least intensive form, called medically monitored withdrawal, which is 
often done in a residential treatment center, to remove addicts from 
the influences that contribute to their drug use. The cost per day is 
comparable to outpatient detox, but patients can stay for weeks.

But under rules laid down decades ago by the federal government, 
which pays half of New York's Medicaid bills, Medicaid will not pay 
for drug treatment in a residential center, as opposed to a hospital. 
The state pays for a limited amount, using non-Medicaid funds.

In interviews, several current and recovering addicts who have also 
been homeless said they would happily accept less expensive forms of 
treatment, as long as they were given shelter. Sam Tsemberis, 
executive director of Pathways to Housing, a nonprofit group based in 
Manhattan, works with many such people.

"People use it instead of the shelter system," he said. "It's safer, 
you get three hots and a cot, the meals are better than a shelter, 
the beds are better, you get a clean change of clothes."

When patients are discharged from hospital detox wards, the hospitals 
are supposed to refer them to follow-up treatment, usually through 
other organizations.

"The handoff doesn't happen," said Shari Noonan, who was the acting 
commissioner of the state substance abuse office last year. "There 
are no incentives for the hospital to make sure it happens."

Medicaid records show that in New York State, 80 percent of patients 
do not have any form of outpatient treatment soon after leaving 
hospital detox. For almost half of them, the next drug treatment they 
get is another detox admission.

Ms. Carpenter-Palumbo said the state is looking into ways to correct 
those failings, providing incentives to hospitals to follow up, and 
assigning case managers to track patients. But again, such steps 
might require getting stable housing first. 
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MAP posted-by: Richard Lake