WARREN TOWNSHIP, New Jersey – When Ed Fahy agreed to an addiction treatment in February 2016, he expected him to recover near his home and family in Warren Township, New Jersey.
Nearly seven months later, and a thousand miles away in Palm Beach County, Florida, he would overdose and die at the age of 28. After his health insurance plan repeatedly rejected applications to cover in-patient treatment closer to home, he ended up in Florida – in a sober house that was so bad that it was eventually closed down by law enforcement agencies.
Fahy’s mother, Maureen O’Reilly, knows who she blames: health insurance.
O’Reilly at her kitchen table.
She held her son Ed as a child.
Courtesy of the Fahy family
Fahy first tried to be hospitalized for his addiction to opioids, cocaine and alcohol in two different facilities in New Jersey. But his health plan manager, Horizon Blue Cross and Blue Shield, and his health care behavior manager, Beacon Health Options, repeatedly denied his allegations. Fahy’s family, after a desperate search, found a treatment that was covered in Florida.
Down south, Fahy got into what is today known as the “Florida Shuffle” – a swamp of inferior, poorly regulated addiction treatment centers and sober homes. In one of those sober houses, Fahy overdosed fentanyl and cocaine.
O’Reilly said none of this would have happened had Horizon and Beacon approved inpatient treatment in New Jersey instead of pushing Fahy to Florida. “You can not be torn away from this and that place and sent to the worst place in the United States to recover,” she told me as she sat in her kitchen.
O’Reilly now sued Horizon and Beacon for allegedly refusing medically necessary treatment. In the lawsuit, which was first filed in 2018, O’Reilly accuses Horizon and Beacon of violating their contract, allegiance and state law and causing Fahy’s “culpable death”.
Fahy was far from being alone with insurance issues. In interviews with experts and addicts, insurance is widely cited as one of the biggest barriers to obtaining treatment in the US. As part of Vox Rehab Racket, nearly 900 people completed a survey to share their experience with addiction treatment. Many of them are responsible for poor insurance coverage for lack of access and high costs.
Approximately 100,000 people in the US needed drug-addiction treatment in 2018 but could not receive it because their insurance either did not cover the treatment at all or did not cover the full cost, as the National Survey shows drug use and health.
In the midst of an opioid epidemic that has led to over 700,000 overdose deaths in the US since 1999, experts claim that bad insurance coverage leads to more untreated addictions and deaths.
Insurers’ payment reticence is inextricably linked to the two major problems of American addiction care: high costs and low quality.
The US addiction treatment system has largely emerged outside of the health care system. Addiction was considered a moral failure rather than a medical condition, and the supply initially came largely from community groups. Because addiction services were not considered part of general health care, health insurers generally refused to cover the treatment.
The effects continue to this day. Health insurers are still resisting coverage, although federal and state laws are trying to persuade them to do so. Insurers’ refusal to pay also means that they do not consistently offer any form of quality control – something they do in other areas of the health care system, for example, by ensuring that the money they spend uses for evidence-based practices which will actually improve the results.
For example, families might be forced to pay tens of thousands or hundreds of thousands of dollars out of pocket for care, as I’ve repeatedly reported for the Vox Rehab Racket Project. Or people seeking help are forced to switch from treatment to treatment, desperate to land on something the insurance ultimately pays off. Or they are not treated at all.
In the meantime, insurance companies can no longer afford to pay for a treatment that can be costly and cause costs for months or even years.
Insurers’ behavior is a “purely profit-driven thought,” said Ellen Weber, vice president of health initiatives at the Legal Action Center. “There is a sense [people with addiction] that will never improve.” There is a sense that they do not deserve health care. “
Horizon said in a statement that “the allegations made in a [O’Reilly’s] lawsuit are not true, unfounded and unfair.” Beacon declined to comment, citing ongoing litigation.
After Fahy’s death, O’Reilly got caught thinking about what should have been. “It’s just these thoughts that you have,” she explained.
With such thoughts, the check she had issued for Fahy’s funeral would have had to be a down payment for his first house. And that the people who gathered there in suits and dresses should instead disguise themselves for his wedding.
O’Reilly keeps a picture of her son Ed Fahy with her other son William Fahy in their backyard.
He wanted to be treated in New Jersey, but his insurance plan did not pay off.
Fahy took heroin for the first time when he was 19, according to his mother, as a sophomore at the Catholic University of America. After his roommate told her about Fahy’s heroin use, O’Reilly took him to a psychiatrist who prescribed buprenorphine. One of the drugs that has shown studies to reduce the mortality rate of opioid addicts by half or more. Fahy improved but fought back and forth for years with opioid, cocaine and alcohol dependence.
By 2015, Fahy had got a job as a chemist at NatureX, a botanicals company near New York City. But he started taking drugs again, which affected his performance at work and he was eventually released. Then he broke away from his girlfriend and moved back to New Jersey. His drug use accelerated.
“He was emaciated,” O’Reilly said. “He was not heavy before, but he was not skinny … I was shocked.”
On February 6, 2016, Fahy’s family got into a fight over whether to seek treatment – and he finally agreed to leave. He went to Sunrise Detox, a facility in Stirling, New Jersey, which he visited and liked on 7 February at 1 am for in-patient treatment.
O’Reilly was “euphoric” after dropping Fahy, she said. “I was so excited on the way home.”
At this time, Fahy was in the insurance policy of his mother due to her employment as a defender. She paid $ 700- $ 750 a month to keep Fahy on the map, but she thought it would be worth it. “I thought private insurance was the ultimate,” she said.
Ed Fahy, an animal lover, held one of the family chickens in his hand.
Courtesy of the Fahy family
Fahy at the New Jersey Shore a few years ago.
Courtesy of the Fahy family
The plan was self-funded, which meant O’Reilly’s employer, New Jersey, paid for Fahy’s caring. But the state hired the insurance company Horizon to manage which treatment was approved and which was not. For addiction treatment, most of these decisions were made by Beacon, Horizon’s behavioral health care manager. Self-financed plans generally have fewer rules than other types of health insurance. However, the plan should continue to cover the addiction care.
But two days after her son’s return, O’Reilly learned that Horizon and Beacon would not approve inpatient treatment at Sunrise Detox. For detoxification and in-patient care, this might cost O’Reilly more than $ 20,000 a month in his own pocket after calling the Sunrise Detox Admissions office.
On the recommendation of Fahy’s Sunrise Detox vendors, O’Reilly moved her son to another inpatient facility in Lafayette Township, New Jersey on the same day: Sunrise House, which has no direct relationship with Sunrise Detox. For 11 days Fahy did well there. Medical notes O’Reilly received after his death showed that he accepted the treatment, and O’Reilly found Fahy in a better mood when attending a family event at the Sunrise House.
But until February 20, 2016, it was clear that Horizon and Beacon would not approve further treatment at Sunrise House. Fahy’s family had to pay out of pocket for the rest of the stay – a full month of inpatient care could cost $ 15,000 today, based on a phone call to Sunrise House’s admissions office – or he had to leave.
In search of a facility that would house Fahy and approve the cover, the family ended up at the Transformation Treatment Center in Delray Beach, Florida.
Fahy has received the message badly. According to medical records, he did not want to leave his family – his primary support network – and complained that he did not want to switch to a “red state”. But it was the fastest option that Horizon and Beacon would likely approve of for coverage, so Fahy went.
In Florida, however, insurance problems reappeared. Horizon and Beacon would not agree to fully ensure the inpatient care desired by Fahy and its suppliers. Within a few months, Fahy fell back twice. When, after the second relapse in July 2016, he tried to get involved in transformations, even an intensive outpatient treatment was eventually denied. Later he was released from transformation, although his therapist said in a medical report of a “high risk of relapse”. He was urged to be treated in another outpatient facility – a facility was later closed by the law enforcement authorities.
Horizon and Beacon’s letters, in which O’Reilly refused to report, illustrate an obscure process of life-or-death missions. Horizon and Beacon would refuse Fahy to seek treatment and recommend a lower level of care. Instead, he would aim for a lower treatment level, and this too would be denied either entirely or a few days later. When reporting was approved, it often happened after several attempts. Horizon and Beacon sometimes approved coverage at the same level, previously rejected with little or no explanation as to what had changed, if at all.
This seems to be a common tactic for insurance companies: deny as much coverage as possible, in the hope that patients will give up. Insurers “rely on families and consumers who are unable to appeal these decisions,” Weber told Legal Action Center.
The result: Fahy could not be fully hospitalized, which he, his suppliers, and the review of Horizon and Beacon’s coverage decisions revealed needed. As one of Fahy’s doctors wrote in a medical note dated August 2016, “the patient is unable to achieve or maintain sobriety as an outpatient, and requires inpatient clinical therapy to prevent relapse.”
In the final weeks of his life, Fahy chose Living Right sober home and Palm Beach Recovery and Wellness for intensive outpatient treatment – both operated by the same owners in Palm Beach County, Florida.
He died in a sober house on September 3, 2016, after consuming cocaine and fentanyl in one of the house’s bathrooms. No one looked for him for eight hours before he was found dead, O Reilly said. Both the apartment and the treatment facility were later closed after their owners, who were unavailable for comment, were arrested in 2017 for referral.
Until the moment she went to the funeral home to see Fahy’s body, O’Reilly said she kept hoping that it was someone else – that someone might have stolen Fahy’s identity. “But of course it was Ed,” O’Reilly said. “I touched his hair and his face. But he was so freezing cold. “
According to O’Reilly, Fahy loved the sprawling garden of his family. “We even have a stream that runs behind. Now it is more of a swamp, because there is still some work to be done, “she said.
Insurers often do not know what a good or necessary treatment is.
Addiction is so difficult to treat, and the quality of addiction treatment in the US is so uneven that it is difficult to say exactly what the situation would have been if Fayy’s inpatient treatment had been approved in New Jersey.
However, experts argue that insurers could play an important role in alleviating these problems by covering care and maintaining addiction treatment at a higher standard. One problem is that insurers often do not know what good or necessary treatment is because they have not been in use for so long and so much of what’s out there is of uncertain quality.
“Without figuring out who does a good job and who does not, it’s very difficult to take responsibility here,” said Richard Frank, a health economist at Harvard who deals with addiction treatment. But if insurers refuse addiction therapy because of their quality, they should “also offer a place that makes work better”.
In Fahy’s case, this did not happen, as he was eventually transferred to a facility that eventually closed due to patient referral. And the first two facilities for which Fahy has tried to get network coverage, Sunrise Detox and Sunrise House, were indeed on the net, but Horizon and Beacon continued to refuse network coverage.
O’Reilly also pointed to various issues with Fahy’s addiction treatment in general.
Fahy was well versed in the opiate addiction drug buprenorphine in his earlier life, and studies show that drugs are generally the most effective treatment for opiate addiction. However, buprenorphine was never offered to him for long-term care in 2016.
Fahy also struggled with depression for which O’Reilly never got proper care. In July 2016, he complained to then medical records of Transformations “as worthless, hopeless and often isolated”.
“They can not be swept away from this and that place and sent to the worst place in the United States to recover.”
As an atheist, Fahy also distrusted the 12 levels because of her demands, which he submits to a “higher power.” However, the 12-step approach was the addiction treatment method he repeatedly offered, including in New Jersey. (It is used in approximately 70 percent of US treatment facilities, with alternatives often hard to find.)
The treatment units are not error-free because their own problems provide evidence-based care. American Addiction Centers, part of Sunrise House, announces that it offers addiction and mental health treatments to meet patients’ needs. AAC also claimed to provide drugs for opioid addiction when deemed “appropriate by the medical provider investigating the patient.” However, when I called Sunrise House, the receptionist said she would prefer patients not to take such medications – to maintain the stigmatizing myth of getting medication, one drug is replaced by another.
Sunrise Detox has not responded to multiple requests for comments. Transformations declined to comment, citing O’Reilly’s lawsuit.
Part of America’s addiction care reform will require insurers to reject substandard drug therapies and push patients toward higher-quality services. If insurers “believe that there is a high probability that this person will get a treatment that will boost their bill and make them no better, then it is right not to join [the insurer],” said Frank.
However, Horizon and Beacon appeared to refuse medically necessary treatment based on review of coverage decisions made by one of Beacon’s own physicians and later by an outside agency – another possible sign that they did not really know which patients are dependent.
Initially, Beacon refused hospitalization and detoxification at Sunrise Detox on and after February 7, 2016 and Sunrise House on and after February 9, 2016. In two communications dated February 25, 2016, a Beacon employee who, as Dr. Kho was identified as having had to cover both inpatient and detoxification treatment at both facilities in New Jersey. Kho explained that Fahy had high withdrawal rates and “had a high risk of worsening withdrawal,” among other clinical factors justifying the level of treatment he had previously been denied.
At the time of the internal review, Fahy had already traveled to Florida. O’Reilly said she had not seen the review or knew until Fahy died when she requested his medical records.
Ed Fahy as a child (above) and one of his brothers (below). Fahy’s siblings tried to encourage him to seek addiction treatment.
Fahy’s guitar was returned from South Florida where he died. It’s in O’Reilly’s kitchen, where one of her other sons picks it up and plays it.
Regardless, a later report from the independent clinical reviewer MCMC, which O’Reilly had requested, overturned Horizon and Beacon’s decision to withhold cover for intensive outpatient treatment at Transformations on July 26, 2016 and beyond. There were several reasons why Fahy needed continued care, including “low sobriety motivation”. It added, “Once we have lifted the denial, your plan or health insurance issuer will now provide the service or make the payment.”
This review was conducted on November 17, 2017, more than a year and two months after Fahy’s death.
Horizon defended his decisions in a statement, claiming “coverage was scheduled for well over 100 days of [substance use disorder] treatment”. A spokesperson for Horizon wrote: “Beacon authorized [substance use disorder] treatment both inside and outside the network.” -the-network-provider that complies with mr fahy’s health plan and [American Society of Addiction Medicine] criteria, based on the clinical information provided by the treatment facility at the time. “
Commenting on the internal and external reviews of reporting decisions, the spokesman added, “We do not know what additional information Dr. Kho may have gotten in performing his retrospective review. It does not seem that the MCMC review has directly or in any way used Beacon or Horizon, nor has it been used as part of an administrative complaint, so we can not speak with its procedures or findings. Regardless, Mr. Fahy was admitted at the time of his death for one [intensive outpatient program] until September 6, 2016. “
However, Horizon and Beacon seem to be aware of a bigger problem. Together with several other insurers, they have partnered with Shatterproof to develop better standards for addiction care.[19459078ExpertensagendassolltenVersicherertun”Wenn[insurers] should pay for treatments, they must look like modern health care, “Frank said.” That raises the bar, that may not raise the bar to the level we want … but I think it drives us in the right direction. ”
Existing laws could improve the coverage of addiction treatment, but are under-enforced.
America’s addiction treatment system is said to be a major line of defense against overdose crises like the opioid epidemic. However, the story of Fahy shows where this treatment system and the insurance apparatus to be paid for it can be neglected, even if federal and state legislators say they now view addiction as a public health problem and funding for start the treatment.
Two federal laws – the 2008 Parity and Addiction Equality Act on Mental Health and the 2010 Act on Affordable Care – seek to impose parity between physical and mental health care: at a level that also covers mental health and addiction care, Mental health and addiction services should be covered at the same level as physical health care. Several states, including New Jersey, have passed their own versions of these laws.
Beacon has previously been in trouble with these laws. In 2015, the New York Attorney General concluded that the company, previously known as ValueOptions, falsely denied state mental health dependence and protection. According to a statement by the then Attorney General, Beacon, which is proposing 40 million customers nationwide, had to “drastically reform the claims investigation process and pay a fine of $ 900,000.”
In general, however, the laws are poorly enforced. A study by consulting firm Milliman found that insurers paid more than 21 percent more on primary care in 2015 than on behavioral services, including addiction. Behavioral Care has been out-of-network up to 5.8 times more likely than physical or surgical care – making access more expensive and more difficult.
About 100,000 people in the US needed drug addiction treatment in 2018, but could not receive it because their insurance either did not cover the treatment at all or did not cover the entire cost
The White House Opioid Commission, in its 2017 report, dedicated a section to better enforce the Parity Laws, demanding that the US Department of Labor “have real powers to regulate the health insurance industry” and that insurers violate parity laws To be held responsible. “
Insurers seem to pay more for addiction care than they used to. According to the Health Care Cost Institute, commercial insurers spent slightly more than $ 17,000 on an average drug-using disorder in 2017, compared to just under $ 13,500 in 2008. This is likely partly due to the opioid crisis, but also probably The parity laws adopted and implemented since 2008 indicate that such measures may have an impact.
The concern is that, given the scale of the opioid crisis, insurers still do not pay enough and do not pay for the right things. Since insurers have long refused to pay for addiction care and have therefore avoided assessing the quality of such treatment, they are cautious that anything they pay in this area can be an ineffective waste of money. However, they can only solve this problem by seriously engaging in addiction treatment, be it by law or by will.
Part of the problem is that the laws that require the involvement of insurers are really hard to enforce. They require the decision of what is medically necessary, a concept that is abstract and largely interpretable.
It is also more difficult for supervisors to question these claims than for insurance companies to ask them. Regulators must request, obtain and review time-consuming and resource-intensive medical records and internal reviews.
“The problem is that there is no algorithm for [enforcement],” said Sherry Glied, health economist and dean of the Robert F. Wagner Graduate School of Public Service at New York University. “You have to go in somehow after the fact and see what’s going on. Nobody really came up with a good way. “
Some states are trying. For one thing, New York has tried to outperform parity, said Rob Kent, general counsel of the State Office of Addiction Services and Support. New York has tightened its enforcement. Insurers must use a standardized tool to decide what level of patient care is needed and proactively inform regulators of how they comply with the law. But Kent acknowledged that New York still has much to do to build its staff and better monitor insurance companies.
In New Jersey, Governor Phil Murphy (D) signed an enhanced parity law earlier this year, which includes a new obligation for insurers to submit an annual compliance report to the State Department of Banking and Insurance.
The New Jersey Department of Banking and Insurance cited the law in response to a request for comment on O’Reilly’s case, adding that it “takes complaints seriously.”
Still, Weber told the Legal Action Center, “I do not think there’s a state insurance department that works well in [enforcement].”
Meanwhile, some families, like O’Reilly, take matters into their own hands. Throughout this story, I spoke with several family members of addiction patients who sued insurers – some of whom could not speak on the record because they were prevented from doing so by their settlement agreements.