It’s not a new story: in states where treatment capacity is limited and waiting lists predominate, Florida — where treatment providers are plentiful — has become the end destination for families desperate to get their loved ones into recovery. In this article, we focus on one such provider — Banyan Treatment Center — and its marketing methods, which are not unusual for the field.
Banyan has a residential treatment center in Pompano and a detoxification facility in Stewart, and it recently opened an intensive outpatient program (IOP) in Naperville, Illinois. According to Eric Oakes, executive director, 95 percent of the patients in Florida have out-of-network insurance coverage. The other 5 percent are self-pay. “We don’t take Medicaid, we don’t have in-network contracts,” said Oakes, noting that very few Florida providers are in-network with insurance companies. The vast majority of patients go to Banyan with a primary diagnosis of opioid use disorder.
The fact that virtually all Banyan patients have out-of-network insurance is by design — out-of-network insurance is the best kind from the provider’s point of view, as there are no cost limitations based on contracts. The main referral source is in Illinois, where Tim Ryan operates as Banyan’s Midwest regional outreach coordinator, a full-time salaried position. Ryan told us that he refers people with good insurance to Banyan, because that’s his job. And in fact, this is an age-old marketing job for treatment programs — getting beds filled.
Some patients are referred to Florida, and some to the new IOP in Naperville, said Ryan. The IOP is a partial hospitalization program (PHP) that ultimately could treat up to 90 people but currently only has 20 housing beds, he said. “Some people don’t want to leave the state or are still living with Mom and Dad.” Only patients with “good policies” are referred to Banyan, he said. “It has to be PPO or cash pay,” he said.
PPO plans — which allow treatment out of network but frequently only pay a portion of that care as a way of encouraging patients to use in-network providers — are viewed as a kind of out-of-network plan. Treatment programs that do not collect the patient portion of the PPO coverage are subject to fraud charges.
Art VanDivier, executive director of La Hacienda in Texas, questioned Banyan’s business model of taking only out-of-network patients. “If you don’t have a contract, most insurance companies will say they’ll pay 50 percent of your rate,” VanDivier told ADAW. “Suddenly the rates become very high, and 50 percent of out-of-network is higher than an in-network contractor gets and the provider doesn’t even want to be in-network,” he said. “Insurance is cracking down on this because it’s an obvious abuse.” This is a “shaky business plan,” said VanDivier. “Is it illegal? Not technically. Is it unethical? You’re gouging the insurance company.”
It’s not unusual for a treatment provider to have a patient whose insurance doesn’t contract with the provider. “We all have those situations,” said VanDivier. “But to create a business that’s based on it? If I were an investor in that company, that would be scaring me to death, because managed care is going to come down on it. They’re keeping stats, and they know there’s money hemorrhaging.”
The vast majority of patients Ryan, who has no clinical credentials, refers to treatment have no insurance. He has a not-for-profit that, according to Banyan and Ryan, is independent of his work for Banyan, called the Man in Recovery Foundation. Through this, he attracts people who need treatment. “I put 300 people a month into treatment, but 98 percent have no insurance or have state insurance,” Ryan told ADAW. “I know how to maneuver the system whenever even if someone has state insurance, they can get treatment,” he said. “I know exactly where the beds are.” But, we pointed out, there are waiting lists all over the state. “I know when beds are opening up,” said Ryan.
Ryan, a former heroin addict who lost his 20-year-old son to a heroin overdose, just got out of prison two years ago. He does not refer patients to medication-assisted treatment (MAT) with methadone, and buprenorphine is only used in Banyan facilities for detoxification, said Oakes. The Naperville facility has Vivitrol, said Ryan.
Edward-Elmhurst Health, which has a substance abuse treatment program in Naperville, declined to be interviewed for this article.
The Florida Department of Children and Families (DCF) licenses and regulates substance abuse treatment facilities in the state. But the DCF “has no authority regarding provider marketing practices in Chapter 397, Florida Statutes,” said Jessica K. Sims, DCF communications director. The Office of the Attorney General (Pam Bondi) is responsible for enforcing the Florida Deceptive and Unfair Trade Practices Act and the civil provisions of the Racketeer Influenced and Corrupt Organizations Act, she told ADAW last week. “The State Attorney has enforcement authority over criminal cases,” she said.
Lack of MAT
The fact that the first-line recommended treatment for opioid use disorders includes medications — methadone, buprenorphine or naltrexone — is ignored in this Banyan philosophy — as it is in many rehabs, partly because of patient ignorance and mistrust. All counties in Illinois are experiencing a gap in capacity for treatment with buprenorphine or methadone, said Kathie Kane-Willis, director of the Illinois Consortium on Drug Policy at Roosevelt University. Methadone is still not covered under Medicaid in the state, she noted, adding that in 2017, it will be covered just as buprenorphine and Vivitrol now are. But there aren’t enough buprenorphine providers to meet the demand.
In addition, Illinois lost 50 percent of its publicly funded treatment capacity between 2007 and 2012, before the budget impasse in the state even started, noted Kane-Willis.
Of particular concern is the stigma against methadone and buprenorphine. “I just spoke to a mom who had lost her child to an overdose,” she said. The mother said she would never have allowed her child to be on buprenorphine. “I think this speaks volumes,” said Kane-Willis, who said Ryan is contributing to the attitude that buprenorphine and methadone aren’t really treatment, but just “trading one addiction for another.” This stigma has become worse, not better, over time — ironically during the same period in which the opioid epidemic itself has become worse. And family members are prey for rehabs that avoid these medications, like Banyan.
“Since folks really don’'t understand what treatment is and their only frame of reference is Intervention and Dr. Drew, they tend to look for inpatient programs because they feel that that is what treatment looks like,” she said. “We are working hard to make simple videos to reduce the stigma related to these life-saving medications,” she said. “People tend not to believe the science, which demonstrates the efficacy of these medications,” she said.
However, people are more likely to believe those with lived experience, said Kane-Willis. “I know this because of my own experience,” she said. “I can quote the science until I am blue in the face. However, when I mention my own lived experience, the conversation changes completely. When we were working on the override of the governor’s veto on the heroin crisis bill, I was talking about methadone, and the general consensus from the advocates was ‘We don’t like that.’ When I told them that I had used it in my recovery, the conversation changed, completely.”
“We really need more people to come out regarding their positive experiences with these medicines,” said Kane-Willis, although she sympathizes with the fact that stigma makes this difficult. “People are doing well and are stable living their lives — no one would know that they were once heroin users,” she said. “But I really do hope people do start sharing their stories, as we know that these medications are the most effective treatments for opioid use disorders.”
Because of the bias against MAT in many treatment programs, however, it is the “rehab” that is the focus of the Ryan-Banyan arrangement. Gerald “Jud” E. DeLoss, outside legal counsel for the Illinois Alcoholism and Drug Dependence Association (IADDA), shared his views on the arrangement between Ryan and Banyan with ADAW.
“First, state and federal consumer protection laws govern paid endorsers or references,” he said. “If an individual is paid by a third party to provide an endorsement of a particular product or service, then that individual should disclose the financial relationship/incentive to potential consumers because the payment impacts the credibility of the endorsement.”
Robert Ryberg, managing partner with Peak Consulting Partners, an addiction treatment consulting company based in Colorado and Arizona, agreed. “I feel very strongly that someone’s integrity is in question when they don’t make their financial situation known to the client,” Ryberg told ADAW. “Tim and the entire group of Banyan folks, contract or not, are notorious for doing that,” he said. “I’ve had a lot of words with them about this.” Ryberg grew up in the area of Chicago where Ryan is operating, and got sober there. He has heard about the Man in Recovery Foundation’s “outpatient groups,” which are used as recruiting mechanisms for patients. “In no way, shape or form does the job they do resemble a typical clinical outreach representative in the industry,” he said. “They’re not clinical, and they’re not sending clients to the appropriate level of care based on need. This is predatory.”
The involvement of the not-for-profit Man in Recovery Foundation also concerned IADDA’s lawyer. DeLoss questioned “whether a not-for-profit foundation can legally or ethically refer business to a for-profit treatment center that employs the foundation’s leader,” he said. “It’s possible, but there are a whole host of tax-exempt issues that must be addressed.”
“These are predatory marketing tactics,” said Peter Palanca, executive vice president and chief operating officer of TASC, based in Chicago. “I don’t think there’s any question about that,” he told ADAW. “To prey on families who are scared to death, grasping at straws, terrified about their son or daughter dying” is wrong, he said. Ryan “has the credibility that a microphone gives someone,” said Palanca, who is on the board of the National Association of Addiction Treatment Providers (NAATP). “Large crowds are showing up for these presentations,” he said. Palanca recalls the days when he spoke about adolescent issues in the 1980s, and people would show up looking for care for their children — but the audiences were much smaller. And he was at the time linked to a specific program and identified himself as such. “I ran the first intensive adolescent outpatient program in Illinois,” he said. “We focused on kids who needed addiction treatment, and we were at that point in time where we would put every kid who came to us into IOP because there wasn’t anything else,” he said. “We quickly realized that it wasn’t the way to go.” Now, however, that is the scenario repeating itself.
DeLoss, who also represents treatment programs in Illinois and other states, also questioned the licensure, training or certification of Ryan. “There would likely be ethical if not legal restrictions on the use of a position of trust to refer clients to a specific treatment center,” he said.
In Illinois, treatment providers are already having difficulties contracting with certain health plans to become in-network, said DeLoss. “We believe that the limitations imposed by the plans may be violations of federal and state parity laws that prohibit plans from treating mental health/substance use disorder providers differently than medical/surgical providers,” he said. To the extent that there are waiting lists, it’s likely the fault of plans failing to contract with in-state providers to ensure sufficient coverage of areas of the state where there is a lack of capacity, he said.
“Finally, I am aware of treatment centers utilizing separate not-for-profit foundations to fund the travel of clients to out-of-state treatment facilities,” said DeLoss. These foundations are supported by the treatment centers, which pay for the transportation of patients, so the costs of treatment itself are similar to what they would be if treatment were delivered in Illinois. These arrangements would be prohibited if the patient has Medicare or Medicaid, under the anti-kickback law. State laws impose similar restrictions on private insurance, said DeLoss. “It is possible to structure such an arrangement legally but it is complex and an unsettled area of the law,” he said.
“I have no problem with an individual being compensated as long as they are transparent,” said Bob Ferguson, founder of Jaywalker Lodge in Colorado. He said the transparency issue is paramount. “I am very careful when I walk into a room that people understand I am a full-time employee of Jaywalker Lodge, that I represent Jaywalker Lodge, that I’m not a licensed or trained counselor in any way, that I am not trained or equipped to make clinical recommendations, and that I do serve on the board of directors of nonprofits, including one called A Way Out, which provides treatment scholarships — and that those scholarships don’t go to Jaywalker,” he said. When a marketer is working for a program, that person “can’t switch hats,” he said. “I have no problem with anyone being employed for an organization as long as they represent themselves as such,” he said.
But “switching hats” is exactly what Ryan is doing — he is taking some patients for Banyan. Others — those without good insurance — are referred to other programs, to mutual support groups and to the Salvation Army.
“I’m not familiar with what Banyan is doing or their business practices, and I’ve never met Tim Ryan,” said Rosecrance President and CEO Phil Eaton. But he recalled how the Rockford-based treatment program, which started more than 100 years ago as a mental health provider, began marketing addiction treatment in the 1980s. “We advertised in the Yellow Pages and trade magazines,” he told ADAW. “We had marketing staff who would talk to clinicians and hospitals that were in our catchment area — traditional, transparent relationship marketing.”
Now, however, treatment organizations around the country “overpromise and underdeliver,” he said. “There are SEOs and outfits that are middle men brokering referrals,” he said, noting that some organizations steal Rosecrance’s website and put their own 800 number on it.
Compared to the internet scams, having a real person like Ryan who has a commitment to recovery and tries to get people into treatment may be a step up. Banyan is a real treatment program, with its own website and Ryan clearly listed as a staff member.
Rosecrance has just survived a NIMBY (Not in My Back Yard) battle over a licensed 24-hour staffed recovery home (see ADAW, February 8, October 26, 2015). And Eaton is concerned about “getting lumped into the sober living effort where some guy has a house and no oversight,” he said.
Eaton is also concerned about the offers of Florida programs to fly patients there for free, and if the patient goes, the treatment program will forgive the copay (questionable legally, as DeLoss said). “We’re very concerned about the high costs of urine drug screens as well,” he said.
The National Association of Addiction Treatment Providers is working aggressively to rid the industry of these abuses in order to protect the integrity of the industry. “My concern is that consumers are getting swept up by these programs,” said Eaton, who has served on the NAATP board. “These are often organizations that are not accredited by the Joint Commission or CARF, that are unlicensed, that have skirted around zoning requirements and are often not accepted in the communities where they are.”
Uneducated, panic-stricken consumers
“The sad thing is, someone sees a TV show [Ryan was recently on Steve Harvey] or a video [Ryan has several], and they make that call,” said VanDivier. “It’s an uninformed panic-stricken consumer out there, and that’s what these guys take advantage of.”
John Lehman, president of the Florida Association of Recovery Residences, told ADAW that lack of education among patients and family members is the systemic problem. “They go Google, and boom, they make a decision,” he said. “As an industry of ethical operators across the country, we should be building an infrastructure that supplants their SEO methods and gets them to a site that educates them on the levels of care, on the appropriate care for the individual, how you go about choosing a program,” he said.
“My dad used to say, ‘Let’s check with the Better Business Bureau,’” recalled Eaton. “Now, I would tell consumers, go to the NAATP website and check the program out. Are they licensed? Are they accredited?”
Meanwhile, back at Banyan, Oakes defended Ryan and the arrangement. “He is primarily an ambassador for recovery,” he said. “He’s not a treatment broker. He runs the Man in Recovery Foundation, he speaks publicly and privately about trying to save lives from addiction, and if someone needs a treatment program and is willing to come to Banyan, that’s an option,” said Oakes. “If he can get someone clean in the rooms, that’s his primary goal,” he said. “If he can get someone to talk to him and put down the needle, he’s fine with that. His primary goal is not to serve Banyan.”
Banyan is not a member of NAATP.
A mix of a forceful speaker-marketer, family members uninformed about appropriate treatment and a for-profit Florida rehab is an example of the out-of-network business model at work.