As the nation's addiction crisis deepened, Tamara Beetham, who studies health policy at Yale University, set out to answer a simple question: What happens when people try to get help?

Her first step was to create a kind of undercover identity – a 26-year-old, using heroin daily. Using this fictional persona, her research team called more than 600 residential treatment centers all over the country.

"We'd kind of call and say, I'm looking to, you know, start treatment and kind of go from there," Beetham said.

For people suffering addiction, this can be a life-or-death moment. Studies show that getting high-quality medical care can make a huge difference, leading to long-term recovery and a healthier life. So what Beetham's team found was troubling.

According to their peer-reviewed study, published in the February issue of the journal Health Affairs, many for-profit rehab programs charged inflated fees and used misleading sales practices to attract patients without evaluating their actual medical needs.

It turns out the people answering the phones at for-profit rehab programs when Beetham's team called typically weren't nurses or therapists. They often weren't asking medical questions at all.

They were sales people using aggressive marketing tactics to get credit card numbers while demanding a lot of cash up front, averaging more than $17,000. Researchers found the sales pitch at for-profit clincis often focused on things that have nothing to do with medical care.

"It used to be a spa for the rich and famous," a rehab program sales person told one of Beetham's researchers, according to notes of the conversation provided to NPR. "It's got all this extra stuff, outdoor and indoor pools, five-star chef, massage, acupuncture."

Despite the high price tag, however, Beetham's team found most programs don't provide evidence-based care using medications such as buprenorphine and methadone.

"We actually found less than a third of the programs offered medication maintenance treatment, which is the gold standard of treatment," she said.

These findings, based on data collected in 2019, come as far more Americans are dying from drug overdoses during the pandemic — more than 81,000 last year, according to the Centers for Disease Control and Prevention.

An addiction gold rush

Experts interviewed by NPR say this problem — residential rehab programs operating more like luxury spas or used car dealerships — is an unintended result of the Affordable Care Act.

A decade ago, the ACA mandated that private insurance programs cover people suffering addiction. It's a widely praised reform that helped many patients find healthcare as the opioid epidemic exploded.

But it created a kind of addiction gold rush, says Dave Aronberg, state attorney for Palm Beach County Florida.

"You had all these bad actors descend on the legitimate recovery community to take advantage of people in recovery and exploit them for their insurance," Aronberg said.

So many for-profit rehab clinics and "sober homes" opened in his area of south Florida that Aronberg created a taskforce to investigate allegations of corruption, insurance fraud and other abuses.

"It's the wild west," said assistant state attorney Alan Johnson, who leads the task force. "The good providers were being driven out of business by these rogue bad actors."

Johnson described a case he investigated in 2017 in which parents sent their daughter to south Florida for treatment.

"She was in Florida for seven months, and she overdosed and died," Johnson said. "They got their statement at the end of the year. Their insurance company was billed for $660,000."

Fear, greed and little government oversight

Experts say there are many good recovery programs, but families and desperate patients trying to find help say it's often impossible to tell legitimate rehab programs from unethical ones.

"It's a very hard system to navigate," said Ryan Hampton, who spent years trying to get help for his addiction to prescription opioids and heroin.

He said his family "was preyed upon by unscrupulous treatment centers." He said they borrowed money and maxed out credit cards to pay his rehab bills.

Hampton has been in recovery for six years and works now as an advocate for people with substance use disorders. He said much of the industry is still shaped by two forces: greed and fear.

"You've got a highly unregulated addiction treatment industry on the greed side," he told NPR. "And then you've got fear on the other hand which are families, people who need help right away."

In recent years, some states including Florida have tightened regulations on rehab programs, but rules and requirements vary wildly from state to state.

Academics, recovery advocates and government officials told NPR that roughly half the states provide little or no meaningful oversight over the industry.

The federal government, meanwhile, plays little role setting or enforcing professional or medical guidelines for residential addiction care.

Many rehab programs are "accredited" by private companies that review their operations in exchange for a fee.

But The Health Affairs study found many of those rehab programs still use hard-sell marketing practices.

"We actually found ones with accreditation were more likely to recruit patients with inducements and without full clinical evaluations," Beetham said.

Efforts at reform within the industry

"The addiction treatment industry is really suffering from a lack of standards," said Dr. Paul Earley, president of the American Society of Addiction Medicine.

He said many care providers, along with advocacy groups, are working to improve and standardize addiction programs to be more science-based.

"We believe once ethical well-meaning treatment programs begin adopting these standards, it will eventually marginalize bad actors in the treatment field," Earley told NPR.

But there's frustration over the pace of change.

In 2019, a trade group called the National Association of Addiction Treatment Providers published a report acknowledging "a severe ethical crisis" in the recovery field.

Ethical standards at many rehab programs were so poor that the organization purged "numerous members of the association at considerable financial loss," according to the report.

Peter Thomas, NAATP's director of quality assurance, said the new study in Health Affairs shows there's still a lot of work to be done.

"I do think that it's still a problem," Thomas told NPR. "The hard sells, the deceptive marketing practices, fraudulent billing."

Some who have worked in the for-profit rehab industry agree the culture is still often driven by profit rather than proper medical care.

"It's horrific, there isn't really any reform," said Dr. Howard Samuels, who ran high-end rehab clinics in California until last year. He still maintains a private therapy practice for people in recovery.

According to Samuels, it's often impossible for patients to know which programs offer appropriate care for their type of addiction.

"You don't know what you're going to get because when you call the admission for treatment centers they'll tell you whatever you want to hear," he said.

Samuels said his programs did provide high-quality recovery care. But he acknowledged charging high rates for spa-like amenities — horse-back riding, fine cuisine and swimming pools — with no proven therapeutic value.

"I'm one of the first people who created that," Samuels told NPR, noting that rates at his in-patient programs ran as high as $60,000 a month. "You have to seduce the client in by having nice accommodations."

In fact, studies show for many patients, far less expensive non-profit residential programs or even outpatient addiction care can be equally as effective.

Where are the doctors?

Many of the experts interviewed for this story point to one needed reform: expanding the role of doctors, physicians' assistants and other trained medical professionals in addiction care.

"The addiction treatment industry is a cottage industry," said activist Ryan Hampton. "We need full integration into the health care system."

The idea is that doctors should guide patients suffering substance use disorder, just as they would individuals facing other life-threatening illnesses.

This view has grown rapidly in recent years, as research-based treatments have gained ground in a field long dominated by programs based on spiritual and ethical concepts.

"Addiction treatment is health care, and it should be obtained in the same way that other specialty services are — you should get a referral from your primary care doctor," said the NAATP's Thomas.

But despite scientific advances and far better insurance coverage for addiction care, this rarely happens.

After decades of being treated separately from mainstream health care, studies show many physicians are still unwilling, or lack the training, to treat patients suffering substance use disorders.

"That's part of the stigma of addiction," said Dr. Earley with ASAM. "Addiction is a treatable brain disease. When you look at physicians, the amount of training and education they have with this illness is marginal."

For now, experts say that means many people who fall into addiction wind up going it alone, navigating a rehab system that too often pushes them into debt without helping them heal.

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