Rehab Specialists Struggle to Navigate Health Reform, New State Certification Process

Ellen Ahn, right, at work at KC Services, one of Orange County's first drug and alcohol rehab programs to begin treating patients referred by Medi-Cal under the Affordable Care Act. Photo: Caitlin Whelan.
Ellen Ahn, right, at work at K.C. Services, one of Orange County’s first drug and alcohol rehab programs to begin treating patients referred by Medi-Cal under the Affordable Care Act. Photo: Caitlin Whelan.

It’s a brave new world for Ellen Ahn of K.C. Services, which provides addiction treatment in Fullerton.

Ahn’s agency is among the first rehab programs in Orange County to begin serving patients who enrolled in California’s low-income health program under the Affordable Care Act.

Ahn and other providers are trying to figure out how to offer addiction treatment under new state certification rules and the federal health law, which is designed to provide greater coverage for addiction services.

“This is still fresh,” Ahn said. “I’m a traditional substance abuse provider that is learning how to do all this.”

So far, the challenges have been mostly bureaucratic, with a key hurdle at the state level.

California’s Department of Health Care Services is required to certify rehab programs seeking to treat Medi-Cal patients. Providers say the certification process has been slow and frustrating in the wake of last year’s reports involving fraud at clinics in Los Angeles.

In the aftermath of the scandal, the department has mandated that all existing providers apply to be re-certified under “new, more stringent, certification requirements,” said spokeswoman Carol Sloan.

Sacramento County sees huge increase in demand for addiction services. See that story here.

Providers who are new to the program, called Drug Medi-Cal, are finding it hard to complete first-time certification amid the re-certification crackdown. The delay could leave patients in need of treatment with fewer places to turn.

Sloan said she could not provide a count of how many providers statewide are also seeking new certification because the re-certification of existing providers is happening at the same time, and the data are not up to date.

Meanwhile, longer-term questions remain unresolved about addiction care under the ACA, which is rolling out at the same time that industry leaders are embroiled in a debate about what constitutes optimal treatment for drug and alcohol abuse.

“The ACA is coming down in the midst of a debate,” said David Sack, CEO of Elements Behavioral Health, which operates the Promises Treatment Center in Malibu. Because demand for addiction services is expected to continue to increase, treatment providers will “have to become more efficient and look at what the best settings and strategies are,” he said.

Health reform changing care

Health reform is expected to expand addiction care in a number of ways. It expands Medi-Cal to include more people, including single uninsured men, the population most in need of addiction services. And it guarantees coverage of at least some substance abuse services — though precisely which are still being worked out — to people enrolled in Medi-Cal, the state’s low-income health program, as well as insurance plans on the open-marketplace exchange.

But getting services to the people who need them hasn’t proven easy so far. The backlog in processing new enrollments in Medi-Cal under the Affordable Care Act has caused delays.

Meanwhile, demand for addiction services is expected to increase. Health reform enables Medi-Cal’s primary doctors to screen patients for substance abuse problems, stage brief interventions and refer them to specialists.

With growth anticipated, an emerging concern is that these newly referred Medi-Cal patients won’t have a place to go — due to certification delays but also a shortage of substance abuse providers in general.

“If there’s no provider, no clinic, no hospital, no counseling program that provides the service… it’s not a real benefit yet,” said Keith Heinzerling, of the UCLA Center for Behavioral and Addiction Medicine. “There’s got to be an increase in capacity of the system to provide services,” he said.

Heinzerling believes primary-care doctors need more training in addiction, and he thinks physicians and addiction counselors should combine forces rather than operating separately. Two options, he said, might be for outpatient rehab programs to bring a physician on board, or for rehab counselors to work with community clinics.

Counselors and doctors sometimes at odds

Bridging the traditionally separate worlds of rehab counseling and doctors’ offices is complicated though necessary, providers say.

For example, the lack of communication sometimes means that clients who are in rehab for pill addiction are at the same time being prescribed painkillers by their unknowing physicians.

There are also generally some philosophical differences between doctors and rehab counselors. Rehab counselors often have a bias against medical treatments, such as methadone or a newer medication, Suboxone, which are themselves addictive. Doctors, meanwhile, often believe replacement drugs are safer opiates from which patients can wean themselves.

But the larger issue may be that the culture of Alcoholics Anonymous, which informs traditional rehab treatment, primarily values abstinence, whereas the medical community sees progress along a continuum. For example, doctors see some success when a patient significantly reduces the number of days of active drinking in a month.

Alcoholics Anonymous has been criticized recently, as researchers and addicts question whether the 12-step program is the best method of addiction treatment. Some addicts don’t like the references to a higher power, and others simply don’t do well in group settings.

The treatment program can be life-changing, but it’s not right for everyone, and forcing people to attend meetings can be counterproductive, Heinzerling said. Meanwhile, the legal system remains Alcoholics Anonymous-oriented, with judges mandating addicts to attend meetings — in severe cases as many as 90 meetings in 90 days.

Quality of care can vary

The professional background of treatment providers is another wedge. Unlike physicians, rehab providers can have advanced degrees in psychology or simply be high school graduates with certification in addiction counseling.

One concern is that counselors aren’t always equipped to handle patients with mental health disorders.

But Ahn said that former addicts who have become counselors often have a unique understanding of patients that doctors lack. “Some doctors are the worst drug and alcohol drug counselors,” she said. “Our addicts just don’t identify with doctors.”

Finding the right mix of services — medicines, therapies, support groups – and offering them to addicts according to their needs is an emerging approach that experts on both sides of the addiction debate say they endorse.

In Orange County, public programs include traditional residential rehab, long-term counseling and medical treatment, said Mitch Cherness, a program manager in alcohol and drug abuse services at the county’s Health Care Agency.

For Cherness, addiction care is a personal as well as professional calling. His stepdaughter died of an overdose in 2012 after a lifetime of substance abuse that prompted numerous rehab stints and medical interventions, he said.

She lived her life surrounded by loving, supportive friends and family, but it wasn’t enough. “That’s how powerful this disease is,” he said.

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