REHAB CENTERS RUN DRY

By ELIZABETH GLEICK

FIVE YEARS AGO, SIERRA TUCSON WAS the model of a happy farm for substance abusers. Thousands of people from across the country came to the manicured 325-acre "campus" to deal with their addictions to alcohol, drugs, food, sex or gambling among the saguaros and sagebrush in the foothills of Arizona's Santa Catalina mountains. It was a Cadillac of the substance-abuse centers, and a company-provided Cadillac at that: employee health insurance routinely covered most of the costs of the standard 30-day stay there. Today, Sierra Tucson is a different place. Where there used to be 313 beds for people with a host of mental-health problems, now there are only 70. The management has added to its offerings Miraval, a holistic health spa along the lines of the nearby tony Canyon Ranch. Some of those who still visit Sierra Tucson to cope with addictions do much of their therapy in short, intensive workshops. And more than three-quarters of them now pay the $650-a-night tab out of their own pockets.

Welcome to rehab centers in the age of managed care. "It was like a cloudburst," admits Keith Arnold, Sierra Tucson's director of marketing. "It decimated the business. We've changed our marketing strategy and now go after the self-paying"--read rich--"client." These days, it is difficult to get in-patient coverage at all for detoxification. "The number of in-patient treatment programs has declined precipitously," says Monica Oss, editor of Open Minds, a behavioral-health-industry newsletter. "Between 1988 and 1993, the average number of patient bed days dropped from 35 to 17."

As a result, across the country facilities like Sierra Tucson have been forced to reinvent themselves. In 1994 the Hartford Institute of Living, in Connecticut, merged with Hartford Hospital to avoid extinction. The nonprofit giants, the Betty Ford Center in Rancho Mirage, California, and the Hazelden Foundation in Minnesota, have both increased the amount of financial aid they offer to needy patients. McLean Hospital in Belmont, Massachusets, a 185-year-old Harvard-affiliated facility, long ago famous as a haven for addled and addicted Brahmins, has seen its average patient stay drop from 57 days to 14 since 1989 and now fills 70% of its beds with Medicaid and Medicare patients.

When it comes to substance-abuse treatment, however, unlike other forms of medical care, many doctors and insurers have discovered a rare parcel of common ground: nearly all acknowledge that some of the changes being imposed by managed care are long overdue. "There was a lot of waste," concedes Dr. Michael Sheehy, president of patrician Silver Hill in New Canaan, Connecticut, who says that the arbitrariness of month-long stays "made no clinical sense." Dr. William Goldman, medical director of U.S. Behavioral Health, one of the largest companies in the country, agrees. "Most of the free-standing psychiatric hospitals in the '80s provided only one service--24-hour, acute hospital care," he says. "It became apparent to payers that treatment usually ended, particularly with substance abuse, when the limit was reached on one's insurance coverage. Patients always got better on the thirtieth day."

Though addiction specialists concede that some scamming went on in the for-profit recovery business, they nevertheless caution that for some patients, one month in a placid, nurturing environment, away from all the temptations of their old routine, is the best medicine. Dr. Frederic Schiffer, who recalls treating cocaine addicts at McLean, says he saw his patients four times a week for four weeks. "They needed the time to be held in a kind environment," he claims. "The grounds were very therapeutic. We would walk the grounds and talk."

As always, with managed care, it comes down to whose judgment prevails--the doctor or the insurer. Dr. Lloyd Sederer, senior vice president of Clinical Services at McLean, who believes that for the most part the benefit rollbacks have not caused undue harm, nevertheless is growing weary of the hours he spends dickering with insurance companies. "We have clinical responsibility but not the fiscal control," he says. "The next step is to give us a fixed budget and goals and then let us deliver our services to meet those goals."

Rehab facilities are now obliged to offer an array of treatment options. Some have patients live on the grounds, but with only round-the-clock supervision rather than round-the-clock nursing and medical care. Other patients attend therapy programs during the day but sleep elsewhere. "After 10 or 14 days of hospitalization," explains Sederer, "the staff know they must find other services, like partial hospitalization and ambulatory programs. The concept is continuous care."

But the wrong treatment choice can carry real risks. Silver Hill's Sheehy tells a story about an alcoholic patient who attended four to six hours of therapy a day, then retired to a nearby inn each night. One evening the patient bought a bottle of Jack Daniel's on his way home from the clinic, got drunk, then fell down the stairs, nearly crashing through a window. And for many addicts, detoxification is only the beginning of treatment. Often, substance abuse overlays a more serious psychiatric problem that needs lengthy treatment. In a short stay, says Jerry Spicer, president of Hazelden, "you can deal with detox, but you can't bring about a recovery. It comes down to trying to treat a chronic illness as an acute one." "What you lose," agrees McLean's Sederer, "is the ability to see patients to the next stage of recovery."

"He loses the ability to do that," counters Dr. John Ludden, of Harvard Pilgrim Health Care, an HMO, "but we don't." Ludden maintains that when done right, the new treatment protocols can still provide a safe haven for patients. But "the hospital psychiatrist is no longer the center of the universe," says Ludden, though even he acknowledges that "there are managed-care companies that perhaps have been overzealous in their intrusion." In some plans that make aggressive use of the "medical necessity" clause in their contracts, reports Sheehy, "we're clearly losing people we can't get in or keep in long enough."

Betty Ford Center president John Schwarzlose says it is routine to receive a call from the patient's managed-care company after five to eight days. Is the patient ambulatory? they want to know. Is he or she doing better? Then the struggle begins. Some companies refuse to divulge their benefit criteria, which also vary from plan to plan and state to state. "Our physicians talk to their physicians," says Schwarzlose. "Then we call the patient in to see our financial counselors," because, increasingly, the insurer's response to continuing inpatient addiction treatment, he explains, is to "just say no." But for now, at least, managed care has mostly succeeded in cutting the fat out of substance-abuse care, while saving the vital organs.

--Reported by Sam Allis/Boston, James L. Graff/Chicago and Jeanne McDowell/Los Angeles

With reporting by SAM ALLIS/BOSTON, JAMES L. GRAFF/CHICAGO AND JEANNE MCDOWELL/LOS ANGELES