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Substance Abuse and Teenagers

HMOs, the healthcare industry, and the nation as a whole all struggle to find a solution to teenage substance abuse. This study highlights 25 families who turned to their insurance policies for help and hit a wall--denied either inpatient care (ten cases), residential treatment (12 cases) or intensive outpatient (3 cases).

According to a report by the Committee on Child Health Financing and the Committee on Substance Abuse of the American Academy of Pediatrics (the committees), access to substance abuse services decreased during the last 10 years while the numbers of children, adolescents, and families affected by substance abuse increased. The decrease in access to treatment is probably due to inadequate insurance coverage, managed care controls, and low reimbursement rates, the committee said. In cases where coverage is available, it is usually short and capped at an inadequate number of visits, the report found. Moreover, a larger problem arises when dealing with inpatient care, for this service is usually excluded or covered only for "acute detoxification purposes."(1)

IROs in Texas overturned more than half of the cases involving teenage substance abuse, but rarely overturned a recommendation that teens try outpatient treatment before an inpatient admission. Eight out of the ten opinions on inpatient care agreed that the patients should be treated in an outpatient program. Reviewers recommended outpatient care because the patients had either shown insight into their illnesses, had not changed their medication or attitudes, or had inadequate records. The two denials the IROs overturned involved patients whose additional psychiatric problems complicated their recovery.
About half of the appeals concerned access to residential treatment rather than inpatient care. In these instances, if the patient had already tried an outpatient program and failed, the reviewer was likely to overturn the denial. For example, an Envoy reviewer held that a 16-year-old boy's residential treatment was medically necessary. The boy was described as a polysubstance abuser who also suffered from major depression. The reviewer noted that the severity of the boy's substance abuse had become dangerous. In addition, the boy had already attempted outpatient treatment and failed, prompting the reviewer to determine that he should remain in a residential treatment facility.(2)

Additionally if it appeared that the teenager was at a "high risk" of relapse, the reviewer would overturn the HMO's denial. An Envoy reviewer overturned a Magellan Behavioral denial of residential treatment coverage for a 17-year-old girl, who had been running away from home as well as prostituting herself for drugs. The reviewer maintained that she was at a high risk for relapse since she indicated a strong desire to use drugs, proved resistant to treatment, and had depressed and irritable mood swings. The reviewer concluded that the girl should remain in a residential treatment facility until her physician determined she was stable enough to leave.(3

In addition, if the teen had a history of running away or had serious conflict with other family members, reviewers would determine that the patient's enrollment into a residential treatment facility was medically necessary. According to a TMF reviewer, a 17-year-old girl's stay was necessary for her recovery because she was impulsive and did not completely grasp the program. Furthermore, the girl's family conflict and the presence of drug paraphernalia at home did not provide an ideal environment for recovery.(4)
Families with teenagers that have court orders to obtain treatment for their substance abuse, but whose insurance will not cover that cost, face an extra burden. Not only could the teenagers fail to meet their court orders, but they may also fail to get the treatment necessary to combat their present substance abuse problem and prevent future use and criminal behavior.

In two cases, the HMO denied coverage because the teenagers experienced a period of enforced sobriety just prior to admission. A 15-year-old female with a two-year substance abuse problem tried an outpatient program from Aug. 3 through Sept. 9, 2000. In March 2001 she entered a juvenile detention center for a probation violation. A judge in May ordered her directly into a residential treatment facility for her polysubstance abuse problem. The HMO denied coverage based on the fact that she had remained sober for two months. The reviewer disagreed, stating that she was only sober because she had been in juvenile detention. "Apparently, communication from the insurance company non-certifying her stay led to a precipitous discharge...with the parents angry at the insurance company," wrote the reviewer. "It is disappointing that her progress was terminated by this non-certification, which was clearly medically justified."(5)

A different IRO upheld an HMO denial in a similar case. The teenager had been clean for seven weeks prior to the time he would have had to fulfill his court order by enrolling in a residential treatment program. The review decision does not state whether he spent those weeks in detention, but most residential treatment programs will not accept court ordered patients who are not sober upon entry. But the period of sobriety appeared to disqualify the teen for coverage.(6)

HMOs will sometimes deny residential treatment ordered by the court even if outpatient treatment has already failed. A judge ordered a 15-year-old boy into a 24-hour residential treatment program, but the HMO denied coverage for this level of care. Because his attempts at sobriety had failed in outpatient care, an Envoy reviewer ruled that this residential treatment was medically necessary.(7)

The committees of the American Academy of Pediatrics concluded that:
l states should extend substance abuse treatment services for those on Medicaid or the State Children's Health Insurance Program (CHIP);

• private insurance companies reduce cost-sharing requirements for substance abuse services and widen benefits to include substance abuse prevention, assessment, and treatment services;
  
  
• improve preauthorization and utilization review criteria to be consistent with national standards on the treatment of substance abuse among youth developed by the American Academy of Pediatrics, the Substance Abuse and Mental Health Services Administration, the National Institute on Alcohol Abuse and Alcoholism, and the American Society of Addiction Medicine.(8)
  
  

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Footnotes:

1. "Improving Substance Abuse Prevention, Assessment, and Treatment Financing for Children and Adolescents," Pediatrics, Volume 108, October 2001, pp. 1025-1029.

2. Envoy, IRO Decision Letter, Magellan Behavioral Health, 8/14/2001.

3. Envoy, IRO Decision Letter, Magellan Behavioral Health, 9/5/2001.

4. Texas Medical Foundation, IRO Decision Letter, Blue Cross Blue Shields, 7/24/2001.

5. Independent Review, Inc, IRO Decision Letter, BCBS, 7/2/2001.

6. Texas Medical Foundation, IRO Decision Letter, Fortis, 5/31/2001.

7. Envoy, IRO Decision Letter, Humana, 8/6/2001.

8. "Improving Substance Abuse Prevention, Assessment, and Treatment Financing for Children and Adolescents," Pediatrics, Volume 108, October 2001, pp. 1025-1029.