private pay treatment part 2: a critical look in the mirror

I wrote this series of posts on the private pay treatment world to explore ideas I’ve wrestled with over the past few years. My goal is to start an honest dialogue around the good, the bad, and the ugly of the private pay treatment industry. Additionally, I’m trying to elucidate hidden incentive structures and the tradeoffs we make by choosing to work in private pay healthcare.

If you haven’t read the first post (the good stuff), please check it out before continuing. I want to be clear: I greatly respect the people, programs, and referring professionals who make up the private pay treatment world. My thoughts on “the bad” parts of the private pay treatment world are meant to start a discussion about how we can grow and evolve as a field. Because I think so highly of the people and programs that make up this field, I believe we should be at the forefront of the behavioral healthcare revolution.

If we want to make parity a reality, we should embrace our rightful place in the healthcare system.

background

I never planned on pontificating about the future of healthcare. I just wanted to run a good program for young guys in early recovery. The conclusions I’ve drawn are, by nature, broad generalizations. The problems with private pay treatment listed below are items that we have (a) recently worked hard to overcome, (b) challenges we are currently grappling with, or (c) issues we plan to address in the future. If you don’t feel like the below problems pertain to you, kudos, seriously – you’re ahead of my organizations, Green Hill Recovery and Advaita Integrated Medicine. I believe that the private pay world is comprised of great people who can adapt and change to deliver more value to clients, families, and the broader community, and I hope this series helps move the conversation forward.

I neither went through a therapeutic program nor worked for one before founding Green Hill. My experience, or lack thereof, has been a blessing and a curse. There was a steep learning curve – I had to learn a lot about running a program, licensing and regulation, insurance contracting, building a team, and much more. On the positive side, I entered the field with a very philosophical orientation and no preconceived notions about what constitutes quality treatment based on personal experiences. So I turned to experts, research, and books on everything from corporate governance and talent development to evidence-based clinical interventions and the transdiagnostic approach to mental health challenges. While I’m relatively new to the field, I’ve thought a lot about how to use my resources to have the biggest impact possible.

So what are some of my gripes with the private pay treatment world? Read on.

the bad

There is a pervasive scarcity mindset.

Demand for behavioral healthcare is at an all-time high. Outpatient therapists, psychiatrists, and behavioral health providers are inundated with new patients, and in most organizations, the limiting factor for growth is provide recruiting/retention, not patient demand. In the private pay world, this isn’t the case. At Green Hill, seventy-five percent of our clients come from out of state, so we compete with programs around the country for the same pool of clients. Only so many families have the resources to send their children out of state for treatment that insurance doesn’t cover. A limited addressable market causes “clinical outreach,” aka “business development,” to be an exceedingly important function for any program. I don’t have the stats, but I’d bet that private pay treatment programs allocate a much higher percentage of revenue toward marketing and business development than any other type of healthcare organization.

*Proposed improvement: look for opportunities to evolve the underlying business model by serving the local community.

Clinical sophistication is secondary to referral relationship management.

Therapeutic alliances are critical, and I firmly believe in stakeholder alignment throughout the treatment process. That said, private pay treatment programs prioritize customer service and (referent) relationship management over in-depth clinical training. Whoa, Tripp, what gives you the right to say this? I’m an offender of this, too – we have a bigger budget for business development than clinical training, and that’s a problem. If you try to say that national conferences that offer continuing education units count toward your clinical training budget, you’ve proved my point. We all know that many programs provide incentive bonuses to therapists for direct referrals, which makes our field ridden with potential ethical pitfalls.

*Proposed improvement: Develop better means for measuring programs based on measures and services instead of relying on “inside scoop” or personal relationships. Programs should demonstrate how they are furthering clinical competence instead of just getting the clinical team out and about. Programs and processes should come before personalities and relationships.

We are a cliquey, incestuous bunch.

Cracking into the private pay treatment referral world is much more akin to “sitting with the cool kids” than “defending a dissertation.” As mentioned above, we prioritize relationship management over the development of clinical sophistication. Consequently, you are rewarded (both clinicians and non clinicians) for your ability to develop and cultivate relationships – aka, it’s about social currency. To be fair, part of the social currency equation is the perception that you do good (therapeutic) work, but that’s only a smidge. What gives me the right to say this? Well, I definitely used it to my advantage as a master code switcher: I learned the lingo and quickly developed referral relationships. Perception is reality, and we don’t have instruments finely tuned enough to gain accurate perception, so we do what we can with relationships.

*Proposed improvement: Increase exposure to non-private pay organizations, researchers, and providers. Instead of reinforcing our groups’ beliefs, we need to challenge dogma.

Mythology and storytelling often trump “the science.”

Placement and selection: The story of successful treatment is quite seductive and begins early on with the program placement and selection process. We place far too much emphasis on what I’ll call “milieu magic” and not nearly enough on standardized diagnostic criteria. This is ironic because I believe we also overly mythologize the data produced during the evaluation process, e.g., neuropsych testing. When discussing our program with referral sources and families, we spend a lot of time discussing the current milieu and client culture thus painting a picture that this client will “fit right in.” There is an implicit implication that a client should fit right in for it to be a successful therapeutic process. Not once has a referring professional (therapist, consultant, or otherwise) started a conversation about placement with The ASAM Criteria, which is the “most widely used and comprehensive set of guidelines for placement, continued stay, transfer, or discharge of patients with addiction and co-occurring conditions.”

Treatment and programming: When it comes to the actual treatment, I’m continually frustrated at our emphasis on “bells and whistles” and dubious claims about how skills are generalized. Is good treatment really about overseas trips and lavish excurions? Connecting with passion and purpose is great, but what does that really mean? Too often I believe private pay programs are looking for unique differentiators that are at best loosely correlated with increasing the therapeutic benefits. One of the most problematic myths that is continually pushed is the false belief in the generalizability of skills. For example, the natural consequences of poor planning in the woods will help a student manage their executive functions better in “real world” situations. Executive functioning strategies are incredibly context dependent, per the science. Yet, we all want to believe that Johny is going to remember to turn in his homework because he learned his lesson when his gear was soaked in the woods. We also make up stories to “fill in the gaps” in our knowledge. A few years ago I took my wife to an industry conference where there was a panel of therapists working with autistic students. Someone asked the panel how they handle picky eaters, and the response was basically, “they’ll eat when they’re hungry enough.” My wife, a speech language pathologist who specializes in feeding disorders, was flabbergasted that at a professional conference, we had individuals pontificating (incorrectly) about treatments that were outside their scope of practice. Humans are meaning-makers; we need narratives and want a beginning, middle, and end. To be honest, I’ve got a dog-and-pony show too. If you’ve spent enough time around me, you’ll hear some familiar stories that convey much more than my biography. Telling a good story is part of any profession, it just needs to be grounded in reality, not woo-woo.

*My proposed improvement is largely covered in the final point below.

Programs often lack strong, widely used theoretical frameworks.

How are we building (and evaluating) programs? What are the first principles of effective treatment? What are the sufficient and necessary elements of a “good” program? The below diagram isn’t theoretically sound, but it provides me with a starting point to evaluate whether the program(s) I’m building deliver services that are well-suited for the complex condition that is human nature.