Jake Bernstein, ProPublica
It didn't take long for Lillian Imbert to conclude that her outpatient drug treatment program wasn't helping her recovery. Fellow patients appeared to nod out in group therapy sessions that she found repetitive and shallow. They begged her to sell them her clean urine to fool the clinic's weekly drug tests. The clinic itself was dingy and run down, and her counselors seemed harried trying to juggle heavy caseloads. Interactions with them were perfunctory. Outside the clinic, she said, a man she believed to be a patient openly sold drugs to those arriving for counseling.
Imbert said she desperately wanted to transfer to a program that took recovery more seriously. But she couldn't. With rental assistance from the city of New York, she was living in a "sober home" — a place where indigent alcoholics and addicts typically reside four to a room while they undergo treatment. Imbert said her landlord set the rule: Either she went to a specific clinic, New York Service Network (NYSN) in Brooklyn, or he'd evict her. Seeing no other option, Imbert complied.
"I felt trapped," Imbert said. "Most of the counselors were just going through the motions."
A ProPublica examination of NYSN and the taxpayer-financed system that sustains it shows that Imbert's experience isn't unique. In New York, a lack of affordable housing gives sober-home landlords extraordinary power over their residents, who often are forced to attend specific outpatient treatment programs that can be of dubious quality. It's a system that victimizes not only alcoholics and addicts — making an already challenging recovery more difficult — but taxpayers who pick up the tab.
Outpatient addiction treatment for the poor has become a mainstay of the social safety net, costing the federal, state and local governments $6.7 billion in 2009, the most recent figure available. The money pays for an estimated 1.5 million admissions a year, nearly three-fourths of them to outpatient programs like NYSN's, according to a study by the National Center on Addiction and Substance Abuse at Columbia University.
As Medicaid coverage expands under the new health reform law, millions more people are expected to become eligible for treatment. They'll be entering a system that many experts say is loosely regulated, rife with unskilled providers and open to fraud and abuse. As the Columbia study notes, the success rate is low: Of those who enter outpatient care, only two in five complete treatment.
In Massachusetts, authorities have won convictions against sober-home employees who were sending residents to get drug tests at a company that paid kickbacks to the homes. In South Florida, a federal task force last year prosecuted halfway house operators who accepted illicit payments for sending patients to clinics for unneeded procedures. And in July, California halted payments to 16 centers amid reports by CNN and the Center for Investigative Reporting about phony billing.
Oversight of outpatient centers is mainly left to states, which typically perform inspections and paperwork audits but don't necessarily delve deeply into clinic operations. Patient outcomes are self-reported by clinics, and counselors often lack medical training and are poorly paid. Clinics generally are compensated on a fee-for-service basis, creating an incentive to bill for as many visits as possible.
Some clinics "are just preying on people's desperation," said Susan Foster, director of policy research at the Columbia center. Foster served as the principal investigator for the center's 2012 report on the state of U.S. addiction treatment, which found "widespread system failure in health care service delivery, financing, professional education and quality assurance."