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Utah seeks Medicaid rule waiver to cut addiction treatment waitlists


MURRAY — For several years, Bradley Hieb’s various drug addictions destroyed everything important to him.

Hieb lost his marriage, custody of his two children, his job, his home — and nearly his life to suicide.

“I had burned every bridge that I had ever known,” he said.

In early 2007, after hitting rock bottom in a bad fight with his “last friend,” Hieb was given a final chance to stay one night at his parents’ house. The next morning, he was greeted by a sight that roused something inside him: “When I had woke up, my kids were sitting there on the bed.”

They were staying with Hieb’s parents at the time.

“That was the closest thing to a spiritual experience I had ever felt,” he recalls.

In his most desperate moment, the sight of his children gave Hieb the nudge of hope he needed to seek treatment for his drug addiction, including heroin, meth and cocaine. Later the same day, he picked up the phone.

“I remember sitting outside on the phone just calling, trying to get in somewhere,” Hieb said.

The Division of Child and Family Services, with whom Hieb had been in contact intermittently because of his children, was able to coordinate a stay for him at the Volunteers of America detox facility in Salt Lake City.

Hieb stayed there for two weeks. Physically, he felt awful, he said, but he knew he needed to stay in detox or he would find the wrong sort of help for his withdrawals. Facing a hopeless future, Hieb clung to the treatment.

“I knew that whole time that if I left, I really had nothing and nobody,” he said.

After his stay, Hieb transitioned directly to a long-term rehabilitation program at Odyssey House in Salt Lake City. He lived there for 23 months and emerged a changed man. He became 10 years sober on April 15.

Hieb is now a program director at New Roads Behavioral Health, where he helps people whose shoes he’s been in. And he frequently reflects on just how close he came to never getting better.

“Even though it was really sobering to see my kids and (I) had that epiphany … if I wouldn’t have got into detox that day, I can’t say I would have survived,” Hieb said. “I had already lost everything too many times.”

Getting timely access

The moment he was desperate enough to change, Hieb got the help he needed. But he and others who work in the addiction recovery services field know that many addicts are relegated to waitlists, devastating their chances of being treated when their commitment to recovery is at its strongest, when a lack of money or insurance requires them to resort to residential treatment centers that are part of the social safety net.

“Addiction is a complex disease, and when people find that they want to get help, that window of them being able to access services is (critical). If there’s any type of barrier in the way, we might lose them,” said Adam Cohen, CEO of Odyssey House, a Salt Lake addiction treatment center.

Currently, the waitlist is anywhere from three to six months at Odyssey House, and most government-contracted residential addiction recovery programs in Utah that are relied upon to serve people who are unable to pay for the services, Cohen said.

But if the Utah Department of Health can obtain an exception to a little-known federal Medicaid rule, the floodgates to faster addiction treatment availability — as well as affordability — will be opened, Cohen said.

“If you were a Medicaid consumer … wanting to access addiction treatment, your waitlist would dramatically decrease overnight,” he said. “It’d be a very big deal (with regard to) getting access to necessary services (at) the time that they actually need them.”

The rule in question is a Medicaid regulation prohibiting the use of funds from the federal program in addiction treatment facilities with more than 16 beds. Last July, Utah became one of several states seeking a waiver of the rule.

Emma Chacon, director of Medicaid operations in the Utah Department of Health’s Division of Medicaid and Health Financing, said state officials believe the waiver will be granted.

The Trump administration has indicated “that they will basically approve the additional states’ (waivers) as long as it’s pretty much exactly the same thing” as the applications from states that have previously received the go-ahead, Chacon said.

“I think the new administration recognizes the value (of that), particularly with regard to the opioid epidemic and the prevalence of drug use just generally. (So) they’re making a concerted effort to simplify the process the states need to go through in order to get those waivers approved,” she said.

Chacon said the health department patterned its request after one submitted by California that received approval for a waiver by the Obama administration. The other states that have been granted the waiver are Maryland, Massachusetts and New York, while several others have joined Utah in the request phase.

Although Chacon said she feels confident about eventual success with Utah’s request, there’s still no clear timeline for when it will be formally processed.

“They have a very small staff that approves these,” she said of the Centers for Medicare and Medicaid Services.

Boon for providers and patients

The benefit of allowing Medicaid dollars is twofold, Chacon explained. On one hand, it greatly improves the dollars available to residential addiction treatment facilities by giving them access to Medicaid purse strings, she said.

Secondly, a person reliant on Medicaid insurance would have a greater range of options for residential treatment facilities, including already existing larger ones with more than 16 beds that currently are not allowed to accept their insurance, Chacon said.

“If we could draw down additional federal dollars, in theory that would make some more services available by putting more resources into the system,” she said. “And … for Medicaid (insurance) recipients, certainly that would make more services available to them.”

Cohen said Odyssey House and others like it would plan to expand services at addiction recovery residential facilities because the waiver would fundamentally change their abilities to do so in a financially feasible way.

“It would make it more cost-effective for them to be willing to serve individuals with that funding source,” he said.

In turn, the expanded scope of services would naturally reduce the length of waitlists, Cohen said.

Jeff Marrott, spokesman for the Utah Division of Substance Abuse and Mental Health, said the Utah Legislature set the health department’s request in motion in early 2016 as part of HB437, the bill that expanded Medicaid coverage for some additional Utahns.

Plenty of larger residential treatment facilities can be used with no waiting list but cannot accept Medicaid insurance primarily because of the 16-bed rule, Marrott explained.

“It’s put a lot of needy people in the position where they cannot get access to care because the publicly funded system is so strapped for cash,” he said.

The private organizations that contract with counties in Utah to act as a safety net — including Odyssey House — are burdened with waiting lists because of resultant excessive demand, Marrott said.

Cohen said the waitlist for most publicly administered residential addiction recovery centers currently is anywhere from three to six months. That’s plenty of time for a person’s life to take a turn for the worse or for their commitment to the idea of treatment to falter, he said.

The waiver would cut down that time significantly, Cohen said.

“It would certainly affect waiting lists and allow for more individuals to access services,” he said. “That would allow a lot more people to access funding (via Medicaid) to get into treatment.”

A difficult dilemma

Now working to rehabilitate addicts, Hieb also knows referrals and treatment aren’t as quick for many others as it was for him.

“I try to get people in now and (the response is), ‘Keep calling,'” he said. “Like, ‘Good luck.'”

Chacon and Cohen said Medicaid was initially designed with its addiction treatment facility bed limit in place because of concerns about institutionalizing the mentally ill and drug- or alcohol-addicted people in large facilities designed to warehouse them out of the eye of society.

But a person who needs treatment at a facility primarily because of addiction has much different needs than a person whose main issue is failing mental health, Cohen said. The reason for that is the profound way in which individuals with addictions have been proved to benefit from settings that emphasize peer-to-peer interaction, Cohen said.

“It wouldn’t make sense to have more than 16 schizophrenic patients in one location, but it does make sense to have more than 16 addiction patients in a treatment center,” he said. “A larger population is (considered beneficial) for an addiction treatment setting.”

Under the parameters of Utah’s waiver request, the treatment that residential facilities would provide is considered shorter term and less restrictive than most types of in-patient medical care, Chacon said.

Adults at an addiction residential treatment facility with more than 16 beds would be allowed a 90-day stay, with the possibility for an additional 90 days if the facility can provide documentation showing a patient is progressing and needs the treatment, she said. Juveniles would be granted a 30-day stay at such a facility, with the possibility for another 30 days.

Kathy Bray, president and CEO of Volunteers of America-Utah, said addiction treatment providers across the country can face an almost impossible dilemma posed by the obscure Medicaid regulation.

One choice is to treat all addicts that easily fit into a facility and lose Medicaid funding by going over the 16-bed limit. The other is to artificially cap the number of patients at 16, despite a far greater capacity at the facility, and keep the Medicaid funding.

“That’s a shame,” Bray said.

On a new path

Hieb said he’s convinced that his ability to get into treatment without delay saved his life.

“If everything hadn’t lined up the way it did, I wouldn’t have been able to follow through on any of it,” he said. “There weren’t any more chances.”

If Hieb had been made to sit on a waiting list or otherwise couldn’t get treatment at a detox center due to lacking the right referrals and resources, “I don’t think I ever would have made it in, to be honest with you.”

“I was lucky to have (state and) county funding, Medicaid, and family drug court funding come together to get me into treatment,” he later added.

Because of Hieb’s own experience, the prospect of making it possible for a greater number of people to get timely help is exciting for him.

“Any access for more beds would be a crucial resource and would be quickly utilized,” he said.

If he hadn’t received timely treatment, Hieb would have lost out on a future much happier than his past, seeing as he began his road to recovery just in time to salvage his family life. Near the end of his stay in detox, he was able to call the juvenile court overseeing his kids’ case to submit a claim requesting that his children not be assigned to permanent foster care.

They were two days shy of getting that designation when he called.

“My story, every time I talk about or share it with anyone, I realize how crucial the timing of everything that happened was,” Hieb said.

Later, after his treatment at Odyssey House, Hieb qualified for full-time custody of his children, now 16 and 13. He remarried and studied at the University of Utah to become a licensed addiction recovery counselor, leading to the job he has now running the dual diagnosis program at New Roads Behavioral Health.

And this year, Hieb had a home built in West Jordan — “a huge milestone” for his family, he says. He credits his new existence to the moment he found the frame of mind to get treatment, and the caring professionals who sustained the momentum of that wakeup call.

“I had a huge reality lesson (about) what my life would be in 20 years if I kept doing the same thing,” Hieb said.



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