Tuesday, April 17, 2007

New York spends $$$ on Addiction

Kevin MD linked to a New York Times article describing the huge amounts the New York Medicaid program pays for addiction services:

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.

Addiction services cost so much in New York for several reasons:

1. lack of outpatient follow up care- 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.

2. addicts going on drug holidays to reduce their tolerance - 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

3. homelessness 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.

4. New York medicaid rules encouraging expensive inpatient treatment- 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. ...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.


Mother Jones RN said...

We see this type of stuff going on in our hospital all of the time. Addicts come in for "three hots and a cot," and then they get nasty with the staff when they don't get what they want on their dinner tray. It's getting harder to deal with everyday.

By the way, I love the bookcover you used in your post.


Anonymous said...

I wish I lived in New York. I really feel the stigma of being addicted and so ill. SO much so..I am dying rather than face the attitudes of people who write things like mother jones did. This is some of my story...

I am someone who is always in pain and is now physically addicted to both Oxycontin (8 years) and Xanax (21 years.) IN addition I have numerous chronic health problems ~ such as pulmonary fibrosis (thought to be MAC related although I am HIV -), Hep C , prior TIA, prior hypertension, depression, etc.

I also KNOW I am dying. I am now 106 lbs and 5'9. (I weighed 243 lbs for about 8 yrs or so prior to Jan. 06.) I am in my early 50's.

I have horrid insurance (Med. & Medicaid) and no car, nor do I know anyone with a car.

I have only been outside 5 times since Jan 06 as well...one of those trips to my PCP who in hindsight "dumped me" by telling me he was afraid I was dying and told me to go find a big hospital in the city who took NIH funding. He then added that his pratice and all of his referall specialists loathed and did not take my "new" secondary insurance due to the Medicare Advantage fiasco that occured abruptly for dual-eligibles in my state in Jan. O6.

I told him our car was dying as well and he reminded me there was no public or medical transportation anyway. [I had moved in Sept. 05 from a quiet middle-class county to the nearby "budget busted" big city.] He was correct as I called every specialist and none took my secondary and confirmed by phone that the trans. was in-city only.

In July of 06 ,I know..(the worst time possible) I did go to "supposedly" one of the TOP 10 hospitals in my state that got a LOT of NIH funding as my PCP suggested. I was admitted but they were at 110% capacity. I was only kept 2.5 days (1.5 of it in the ER) and the care was ~to be kind ~ "frenetic." I rarely saw a nurse and if I did..I was spoken at, not to. I was healthier then and 167 lbs. (Although I had lost over 70 lbs. in 7 months.) My addiction(s) were not as bad as they are now. Then I was only taking 5 Xanax daily. They discovered the pulmonary nodules.

I actually ended up begging the brand new attending (who always appeared very frustrated and overworked)to be allowed to stay but was abruptly discharged at 4 PM on a Friday anyway..never seeing their "promised" social worker or recieving any coherent follow-up care. I had wrote up a list of questions but the "team" was always in a hurry and rushing in and out. I never could get any of them to answer or even look at my papers.

My PCP's office staff messed up the OP referrals 3 times and then refused to try again. TO be fair.the OP ref.'s were done by a brand new resident and were not done correctly.

She set me up with clinic appointments with "more brand new residents" (instead of putting down an actual hospital doctor) so the coding was somehow meaningless or non-existant. Neither the hospital nor my old PCP would call each other and I got lost in the middle.

After 10 months or so of trying to get some type of home care, psych care, transportation or to find a new PCP who would accept both my insurances (which I never could), I gave up. Even attempting to just get basic correct information from this "new wretchedly thrown together" MedAdv. Plan was so ludicrous..I stopped calling out of frustration. They "outsource" their MH/D&A to a state 15 hours away who have no knowledge of this area. Temps constantly would answer the phones at the new MedAv and make things up. Supervisors were always too busy to come to the phone,etc. As for my secondary insurance..the welfare office knew nothing as far as docs who accepted it. The state said to call my local welfare office...they knew everything. The welfare office said to call the state back. I could go on and on. It was and still is disheartening and unorganized!

Now 9 months later,I can barely stand more than 2 minutes at a time , nor can I perform any ADL's. Sadly, I also have no family or friends except my grown son who is also an addict. Chronic constipation is so bad, I literally have to bite on a washcloth to prevent screaming from URQ back pain attempting to defecate, so I rarely eat and a decubitus ulcer is surely next as I am skin and bones. All my hair has fallen out and I have no one to bathe me. (My son does not know how to care take at all.) Always alone and never able to sleep or lie in any position for too long w/o pressure from being so frail -my Xanax use has spun wildly out of control. For 20 years I had always taken it as directed.

I am dehydrated and void about 2 ounces a day if I am lucky. I never did have good veins from previous hospitalizations..so I have daily nightmares of having to go to an ER that is probably already short staffed and having to beg to be throughly washed first. ( I know I would most likely need a central line and ding ding.instant infection.)


I read these blogs and all the doctors and nurses write about these days is money. [Or your dislike of Medicare/Medicaid/problematic patients.] I read too much..to the point that I suffer daily rather than even attempt to go to an ER again.

The thought that I would not be believed or either just detoxed way too quickly or just right off of 20 Xanax 0.5 a day [and around 80 mg. of Oxycontin] is worse than dying this way. Or how do you do a colonoscopy or bronchoscopy on someone so addicted? Why is everything pushed toward outpatient when I have no one to help me at home? Would I be rushed out the door of any hospital or dumped to some horrendous nursing home in a ghetto (my insurance IS that bad) with roaches and most certainly undertrained, understaffed and most likely uncaring staff?

I called the three lone drug detox's in my area that even take my insurance and as expected, they are located in the worst neighborhoods imaginable. You get 3 to a maximum 7 days if you are lucky. Their protocols are "horrendous" according to guidelines supported by the better tx centers, 300 page addiction treatment protocol commission reports I have read or the recent HBO's "Addiction Series" board's guides and choices information [geared obviously for people who can afford to choose.]

I am way too sick now to even walk..let alone attend groups or be in a facility with no truama hospital staff. My seizure risk would be so high even 30-90 days out if I did not go totally insane from "reverse anxiety" first from the Xanax WD alone. Also, having read extensively on addiction I know that a 3 or 7 day program in my condition would or could not work...esp. with no family, friends or transportation for aftercare. I can not even walk more than 10 feet now without getting severely lightheaded.

I believe my abilty to even be this cognizant after 16 months of almost total isolation [except the 4 hours or so daily I see my son] speaks to the things I have not yet lost..my high level of intrinsic intelligence, acute awareness of the current state of mind of physicians and the grave disparities in medical care that sadly exist today and my own knowledge of my personally difficult medical and psychological condition(s).

I KNOW that you all appear to categorize everyone who uses drugs or deteriorates like I have as "non-entities" or not worth treating.

In reality I was and in many ways still am a warm and caring person. I am also very sensitive...which makes the thought of being "hated upon sight" or "judged harshly" even worse than suffering daily this way. I DO suffer.

SS for writing so much.. I just wanted to REMIND everyone here that not all people are drug seekers ( I have a safe full)..some of us are also very ill and have an ounce of pride left. That pride I retain inside somewhere (coupled with shame and guilt) keep some of us upon reading all of these blogs and articles from even attempting to seek care.

I don't know why I am still alive but I certainly hope it ends soon. I see no way with the way medicine is structured now how I could have ANY realistic chance [or even be alotted the necessary timeframe it would take] at this severe point in my med history to recover.

thestoryofhealing said...

I'm still learning. So this is very informative. Thanks, Dr. Rack for sharing this.

Anonymous said...

Well I am anonymous who wrote the second comment above. I posted my story here and on two other medical blogs. Not one of the three doc's who blog I commented in even answered my comment . Did you even read what I wrote? To me, that speaks volumes to how I am not a human being anymore but just a "thing."

Everything I wrote then was true then.it still is.

Now I am 98 lbs. and even less cognizant than before. I need help but truly do not know where to turn.

I just spent the last four days unable to sit up for long periods due to my feet sweeling or trying to lie down..which I can barely tolerate due to being virtually skin and bones.

Does ANYONE care at all?

Michael Rack, MD said...

To anonymous:
yes, I read your post. I don't have good answers to your questions but I'll try:
" Or how do you do a colonoscopy or bronchoscopy on someone so addicted?"
Not sure about the bronchoscopy, but performing a colonoscopy should be fairly simple. You would just need more sedation than the average person due to your high tolerance.
"Why is everything pushed toward outpatient when I have no one to help me at home?" It doesn't appear that you require long-term medical hospitalization (at least for your non-addiction issues). I'm not sure what state you live in. In some states there are longer term detox programs available in psych hospitals. If you lived in Mississippi, you might be elgible to stay on the chemical dependency ward at Mississippi State Hospital for 1-2 months.

"Would I be rushed out the door of any hospital or dumped to some horrendous nursing home in a ghetto (my insurance IS that bad) with roaches and most certainly undertrained, understaffed and most likely uncaring staff?" This depends a lot on where you live.

"Does ANYONE care at all?" You posted an anonymous comment to a blog. It could be totally true or 100% lies- I don't know you at all. Don't look for caring on the internet. I'm sorry you didn't have a better experience with your pcp.

Michael Rack, MD said...

"I also KNOW I am dying"
Have you looked into hospice care??

Anonymous said...

Inorder to help my friend who was even less cognizant than before and need help but truly do not know where to turn.This site will be useful for him.



Addiction treatment and recovery resources for the addict and their families. http://www.addictiontreatment.net

Vijay said...

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