(This is the second of a two-part series on drug testing and treatment centers.)
Jeffrey Lynne, a lawyer based in Florida who represents treatment programs in zoning and other issues, says it’s about time that some drug testing arrangements are being cut back by payers (see ADAW, May 11). Lynne, who is a partner with Weiner, Lynne & Thompson in Delray Beach, said that insurance companies are suing treatment providers to get their money back for excessive and unnecessary testing in “clawback lawsuits.” He tells his clients that if they submit such claims, insurance companies will say it’s insurance fraud.
“You don’t need a clinician to tell you how many times you need to test someone,” Lynne told ADAW. “If you’re coming into my detox, I need to test you once to see what you’re on and how much of it.” For patients who are in residential treatment, under 24-hour supervised care, testing is necessary only if a patient is acting strangely, he said. “But if a patient is under your care 24 hours a day, seven days a week, why would you have any reason to test them?” he asked.
On the other hand, outpatient programs, as well as sober living residences, are doing the testing. Many sober living residences require patients to be tested once a day in order to live there — and if patients test positive, they’re kicked out.
Treatment centers and sober homes want to have their own lab so they can send their patients to it and get the money. For Medicaid and Medicare, this is a violation of anti-kickback law, but there is no such law that applies to private payers that are out-of-network (not contracted).
Desktop analyzers and more
The lure of the testing income was so great, Lynne related, that it first led programs to buy desktop analyzers so they could satisfy insurance company requirements for accuracy. Then, when they learned that a lab would have to perform the quantitative confirmatory test, they had to lease the costly machine that could do the confirmatory testing. Centers “shared” the machine. Other companies wandered into the market saying they were turnkey and would do everything for the center — but wanted a cut of whatever got billed and collected.
Billing companies were driving this trend, said Lynne. “Some billing companies say not only do you need to do the desktop analyzer but also the confirming test. And apparently you can bill one hundred dollars a panel at 15 substances per test per patient,” he said. “If I have a sober house with eight residents, and I can bill fifteen hundred dollars a day for each, you do the math.”
Unfair competition for labs
James Fratantonio, Pharm.D., manager of applied clinical research and education for Dominion Diagnostics, a lab based in Rhode Island that was recommended as a source by Marvin Ventrell, the executive director of the National Association of Addiction Treatment Programs (NAATP), said that labs performing clinical tests on patients need to be approved by CLIA and the College of American Pathologists, and must be audited. “You can’t just rent out machinery,” he said. “You need a lab director, you are regulated, your lab director needs a Ph.D. or an M.D.”
Fratantonio is concerned about the desktop analyzers with unregulated operations. “I do think this is going on, and I do not think that the competition out there is fair,” he told ADAW.
Drug testing is a clinical tool, which means it should be individualized to the patient, said Fratantonio. It would make sense to test a patient who was admitted for a cocaine use disorder for cocaine, but if the patient comes in showing symptoms of sedation, it would be good to test for benzodiazepines and opioids as well.
There are also esoteric drugs — and drugs that contain substances that are entirely unknown, such as “Spice” or “bath salts” — which won’t necessarily show up in standard tests, he said. “Nobody knows what’s in them,” he said. There are tests that can be run, but these are more costly. And they’re not likely to be done by anybody but a reference lab like Dominion Diagnostics.
It’s also important to test for therapeutic medications, to make sure the patient is taking them and not diverting them. This is true for buprenorphine, methadone, and opioids prescribed for pain as well. While there is no evidence to correlate urine drug levels with therapeutic range, “we can make judgment calls based on pharmacokinetic principles,” he said.
The value of testing
Sean Murphy, M.D., medical director of the Harmony Foundation (where the NAATP’s Ventrell is business manager), mainly uses testing for new admissions. Murphy has been providing treatment in residential detoxification programs for about 25 years — 14 in Colorado and, before that, 11 in California. “The technology has changed a lot over this time,” he said. “Ten years ago we sent everything to Texas, and the results were good, but it was a very slow turnaround time.” It took a week to get results back, so the testing just “wasn’t that useful,” said Murphy. “It did give a clear picture of their overall drug use pattern,” he said, noting that it clarified for a counselor what patients were really using. “The history the patient gives isn’t completely reliable — if you ask a diabetic what they’re eating, you’re not going to get the right answer.”
Now, Murphy uses Dominion Diagnostics, and the turnaround time is less than 24 hours — even though this time the samples go from Colorado to Rhode Island. The test results “help me treating people for their withdrawal,” he said. “With the narcotic explosion, there are so many types of drugs, with people using this and that — they can’t even remember what they’re using,” he said. “Someone may mainly use oxycodone, but took a couple Suboxone, chewed a fentanyl patch — they just don’t remember.”
Drug tests can also help Murphy’s patients who come in with alcohol or benzodiazepine dependence. Because withdrawal from these two substances can cause seizures, knowing what the patient was taking can inform Murphy’s treatment and help prevent seizures, he said.
Most of the testing Murphy does is for new admissions. As for ongoing testing, he only does it on a random basis, as a deterrent, due to costs, he said. The kind of random testing he does is more similar to workplace rather than clinical testing — two patients’ names a week are drawn at random for testing, saving money in testing costs. However, the down side is that because the patients are chosen at random, these aren’t really clinical tests, and Murphy doesn’t bill either the insurance company or the patient for them. It didn’t seem fair, said Murphy, to give a patient a bill for $300 because he or she was randomly selected to be tested. “We don’t want to pass the cost on to someone, and the insurance companies won’t pay for it,” he said. “But we can’t spend $25,000 a year on this anymore.”
There is really no good option other than a clinical lab, however. “Part of the problem is that the dipstick testing is not very reliable,” said Murphy. “We’ve been through six brands — and they all have a 50-percent error rate.” Murphy gives every new patient a dipstick test, to see if it confirms the patient history. Then, he sends the sample to the lab.
Laboratory testing is expensive, said Murphy. “We’re still searching for some other alternatives, for some lower-cost testing,” he said. “But it might be slower; we might have to give up a little accuracy.”
The Harmony Foundation doesn’t contract with any insurance companies, so there is no specific assigned lab that pays for each patient’s tests. The struggles reflect the considerations of a physician who is trying to give the best clinical care to his patients — and that, says Lynne, should be the only purpose of drug testing. “People need to know that urinalysis testing should not be viewed as a source of revenue,” said Lynne. “It should not be part of the business plan.”
Fratantonio’s final advice to treatment centers looking at urine drug testing as a profit center: “If you think that something is too good to be true — it is.”
Drug tests should enhance a patient’s care, not a center’s profit.