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OREGON PUBLIC MEDICAID FUNDS MISSPENT FOR HEALTHCARE THAT HARMS

MANAGED CARE MALFEASANCE LINKS SELECTIVE FUNDING OF SHAM TREATMENTS AND PATIENT RIGHTS VIOLATIONS TO WORSENING OPIOID, MENTAL HEALTH,  SUBSTANCE USE, OBESITY, AND DIABETES EPIDEMICS

By Clark Miller

Published May 14, 2021

With opioid and substance use epidemics overwhelming public health response and continuing to claim lives – a half million predicted over the next decade for the opioid crisis alone – Oregon business-model managers (Coordinated Care Organizations, CCO) of public healthcare funds in one hard-hit rural area reject research-based practices and expert guidance of policy, instead support invalidated approaches with no evidence for benefit including coerced religious programming, managers privately acknowledging the lack of research support.

The picture that emerges is of remarkable incompetence,  ignorance and/or disregard of research- and evidence-based practices and behavioral health treatment models required to benefit the increasing numbers adults and youth trapped in chronic stress or depression, chronic pain, trauma-related and other problems driving compulsive behaviors and related obesity, substance abuse, and diabetes epidemics.

While the Opioid Crisis commands headlines daily, many more Americans are trapped in equally lethal and worsening epidemics including other substance abuse, child and adult obesity, and diabetes. Implementing effective prevention and treatment approaches will require fundamental change in healthcare, because the public health crises emerged under current treatment models, the opioid crisis for example mainly caused by the predictable and avoidable costs of treating an entirely non-medical problem with medical fixes. What can we say about the ability of healthcare systems to learn and change from predictable and avoidable outcomes like the opioid crisis?

Map of U.S. states by illicit drug use by young adults

Lessons from managed healthcare in hard-hit rural Oregon

Problem opioid use and its consequences in Oregon are among the most dire nationwide, and the rural counties of NW Coastal Oregon rank high as problematic among counties in Oregon, where the problem is described as a “public health crisis” and “epidemic”, with more prescription opioid pills (280 million) prescribed than in any other state and 150 deaths annually attributed to overdose by prescribed opioids. More recent findings identify Oregon with the highest rate of older adults hospitalized for opioid use problems.

In Oregon, use of Medicaid funds under the Affordable Care Act (ACA) to address the opioid crisis by selectively funding treatment approaches – including necessary mental health (MH), primary care (PC) and substance use (SU) services – is controlled by regional Coordinated Care Organizations (CCO) acting as insurance companies and plainly driven by business and medical models. In rural Oregon including NW Coastal Oregon most hard-hit by the OC those insurance payers include Care Oregon (CO), Columbia Pacific CCO (CP) and Greater Oregon Behavioral Health Inc. (GOBHI, for mental health funds), each taking a central role in determination and dissemination of clinical treatment direction to treatment providers and control of practices through allocation and withholding of public funds for selected treatment models for ACA Medicaid patients.

Against the profound threats posed by multiple public health epidemics generated under current models of providing healthcare, managed care organizations like Columbia Pacific CCO continue to support with public funds the decades-old approaches that got us where we are now, invalidated or lacking research evidence for effectiveness.

It’s time to start dissecting the problem, critical discourse by critical discourse.

For vulnerable Oregonians trapped in an increasingly lethal opioid epidemic and whose Medicaid health insurance benefits and options are controlled by Columbia Pacific CCO – failed treatment as usual (TAU) is the only option

As detailed in this post, programs overseen by Columbia Pacific to provide treatment services for problem opioid use are stuck in the harm-predicting sham treatments  – disease model; 12-Step; group modality; unqualified staff providing treatment – implemented over past decades as “treatment” within the addiction treatment industry and which predictably have resulted in a steadily worsening and lethal national substance use epidemic.

At OHSU Scappoose Clinic, patients in the MAT program are routinely referred to TAU outpatient substance use treatment programs in the area, like Columbia County Mental Health (CCMH) and Tillamook Family Counseling Center (TFCC) in Tillamook County, programs also provided clinical oversight by Oregon CCOs, and providing the same elements of traditional substance use TAU provided in residential (“rehab”) programs.

“What we simply need is a a nice bulldozer, so that we could level the entire industry and start from scratch . . . There’s no such thing as an evidence-based rehab. That’s because no matter what you do, the concept of rehab is flawed and unsupported by evidence.” 

– Dr. Mark Willengbring, former director of treatment and recovery research at the National Institute of Alcohol Abuse and Alcoholism (NIAAA)

Under the clinical and medical direction provided by managed healthcare organizations in Oregon the regional “best practice” response to the opioid crisis, including a model MAT program “center of excellence” in fact reflects a profound ignorance of and profound disregard for current research outcomes and evidence-based treatment of substance use disorders, predicting no benefit or harm to individuals trapped in the  opioid crisis and seeking competent care.

As designed and implemented by professionals at these clinics  and professionals employed by the insurance companies – professionals who are out of scope of competence for evaluation of relevant research and for program development for use of evidence based practice (EBP) MH and SU practices for substance use disorders – neither program driven by clinical guidance from Columbia Pacific is providing any services constituting EBP for substance use disorders or opioid use disorder, instead treatment as usual (TAU), TAU established as predicting no benefit or harm by decades of established research.

Lethal Smoke Screen

Columbia Pacific CCO does not support healthcare practices that would support patient use of marijuana to assist, as supported by research, in managing pain without opioids while tapering off prescribed opioids, instead recommending policy in clinics that would abruptly end prescription of opioids if a urine drug test is positive for THC (an active chemical in marijuana), leaving patients – who generally were provided the opioids in medical settings overseen by CP CCO – at risk of turning to illegal, high-risk “street” opioids.

marijuana plant

neither program driven by clinical guidance from Columbia Pacific is providing any services constituting EBP for substance use disorders or opioid use disorder, instead treatment as usual (TAU), TAU established as predicting no benefit or harm by decades of established research.

At the same time, CP CCO ignores the established links between tobacco use and chronic pain, in turn to problem opioid use. The importance of research-driven effective responses to smoking as a public health problem and its direct and indirect effects is profound. Health care system and social costs of tobacco use eclipse those of opioids and illicit substances combined, and tobacco use is directly related to the opioid crisis, established as contributing to the causes of chronic pain conditions and to worsened perception of chronic pain.

Tobacco use is directly related to the opioid crisis – evidenced as contributing to cause of chronic pain conditions and to exacerbated perception of chronic pain:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202023/

and increasing risk of continued or return to problem use of substances including opioids (acting as a “gateway drug” for opioids):

https://www.sciencedaily.com/releases/2018/01/180125120439.htm

https://www.ncbi.nlm.nih.gov/pubmed/26375198

https://tonic.vice.com/en_us/article/vb3a3j/smoking-and-addiction-recovery

Columbia Pacific CCO uses public healthcare funds to exclusively support treatment as usual (TAU) for substance use problems, TAU established by decades of research to predict no benefit or harm for problem substance use and increasing risk of problem tobacco use. For example, TAU is wedded to and almost always incorporates 12-Step programming –a set of religious prescriptions completely unrelated to treatment for substance use disorders – and encouraged participation in meetings of the religious subcultures (like Alcoholics Anonymous and Narcotics Anonymous) identified with 12-Step practices. At those meetings, addictive use of tobacco – arguably the most lethal and addictive substance among public health threats – is encouraged in a variety of ways. At meetings, tobacco use is: socially reinforced; ritualized; normalized; sometimes rationalized; and rewarded when smokers are celebrated for being “clean and sober” while remining dependent on tobacco.

These aspects of traditional treatment (TAU) for substance abuse predict increased risk of use of tobacco directly through the dominance of 12-Step and AA culture in treatment programs and reinforcement of tobacco use at meetings of that religious subculture. In fact, participation in those religious meetings is often coerced or mandated, in violation of the constitutional rights of those trapped in treatment systems. As is common in the U.S., that’s the case in Tillamook County, Oregon, where community mental health (Tillamook Family Counseling Center, TFCC) colludes with local courts to violate constitutional rights of clients mandated to treatment by forcing participation in those religious programs.

These types of community addiction treatment programs provide traditional elements of substance use, TAU, that are established by longstanding research as predicting treatment failure and harm: 1) disease model; 2) group versus individual modality; 3) orientation to and promotion of 12-Step practices and AA/NA meetings; and 4) services provided by staff (addiction professionals e.g. in Oregon, Certified Alcohol and Drug Counselors = CADC) who are unqualified to provide treatment for any type of behavioral condition, let alone complex, life-threatening behavioral health conditions. 

Those four core elements of TAU – disease model; 12-Step; group modality; unqualified staff providing treatment – implemented over past decades as “treatment” within the addiction treatment/”rehab” industry predictably have resulted in a steadily worsening and lethal national substance use epidemic.

Adults sitting at an AA meeting

Tillamook Family Counseling Center, in Tillamook, Oregon, like programs across the country, as part of TAU outpatient “addictions treatment” colludes with judges of the County Circuit Court (as evidenced by reports of clients and by overt statements to that effect by the judge and by TFCC’s clinical director including in clinical staff meetings ) to violate the constitutional rights of vulnerable patients in order to force their participation, without allowance of secular options and under threat of legal consequences (bench probation violations), in overtly religious subcultures – e.g. Alcoholics Anonymous, Celebrate Recovery.

Exposure to meetings of those religious subcultures places vulnerable individuals in settings where continued addictive use of arguably the most lethal and addictive substance known (tobacco) is promoted by:

Normalization of smoking as something other than problem substance use

Celebration of tobacco dependent individuals as “clean and sober”

Ritualized group use of tobacco at meeting breaks, providing social reinforcement

Exposure to triggers for continued use

 

Through support of practices without evidence of benefit to smokers and support of traditional “treatment” for substance abuse – its practices invalidated, predicting no treatment benefit, and coercing participation in a religious subculture where tobacco use is reinforced – managed care in rural Oregon uses public healthcare funds in ways that worsen risk of tobacco use, that use linked to worsened risk of chronic pain, that risk linked to opioid misuse.

cigarette butts

Another harm-predicting program supported by Columbia Pacific CCO

is Helping Hands,  operating homeless shelters in five northwest Oregon counties.

In Tillamook County, HH partners with TFCC. There are no credentialed mental health professionals employed with HH and providing direct behavioral health services. Helping Hands organization runs homeless shelters in the region served by CP CCO, HH founder and Director Alan Evans apparently motivated and guided by a personal history of homelessness and involvement in the religious subculture Alcoholics Anonymous.

Services at the shelters for homeless and substance abusing individuals are described as a “Reentry Program”, but in practice, community members including homeless clients and healthcare professionals understand and refer to the shelters as comprising a “treatment program”(s) for homeless individuals with substance use problems.

The website describes activities provided homeless adults as including “Attendance at AA/NA meetings as needed”, but this description is false according to consistent direct reports of homeless clients there, of community members involved with the program, and of HH staff I have spoken with directly.

By those consistent reports, in order to remain in the program and avoid being evicted and homeless again (and to avoid return to homelessness for their children), adults must attend regular (daily or more frequent) meetings of the religious subculture AA and/or of more overtly Christian religious groups like those of Celebrate Recovery.

That practice of coerced religious programming by participation in 12-Step groups on threat of return to homelessness for the vulnerable Oregon men, women and their children in the shelters:

– Is established as a violation of their constitutional rights to freedom from religious coercion

– Strongly predicts harm to those individuals by triggering trauma-related symptoms and by exposure to the AA/NA religious subculture, established by evidence as countertherapeutic and increasing risk of return to problem substance use

– Particularly for the homeless, substance abusing populations, with high incidence of trauma- and ACE-related (Adverse Childhood Experiences) symptoms and traits, being forced to participate in anything, let alone stressful environments is the opposite of trauma-informed care, forcing individuals with high probability of traumatic histories into triggering settings where they are forced to hear stories of traumatic and/or disturbing histories and expected to “share” their histories. Key  features of PTSD include severe  anxiety, over-reaction and agitation triggered by reminders of trauma, of loss of personal control, of loss of ability to avoid reminders.

Evidence based therapies for addressing those effects are individual modality therapies provided by licensed mental health therapists, and the common features of history of ACE and adult trauma – including fearfulness in novel and social settings, dissociation (“spacing out”) and mental agitation in triggering settings e.g. where group members are recounting disturbing histories, avoidance of thoughts and reminders of trauma, with high risk of treatment disengagement – all indicate against group treatment, especially forced group participation.

Alan Evans, Director of Helping Hands and responsible for the coerced religious group participation on threat of homelessness and associated predicted harms to a vulnerable homeless population, as exemplified by the cases described below, was the featured keynote speaker at the third annual Opioid Summit sponsored by Columbia Pacific and Care Oregon CCOs, presenting the talk, “From Homeless to CEO: A Drug Addict’s Story”.

Mr. Evans, with no background, training, or credentialing in substance use or its treatment, has been recruited by Columbia Pacific and Care Oregon to serve on the Northwest Regional Substance Use Steering Committee (NWRSUSC) to assist in applying expertise to provide clinical guidance in addressing the region’s opioid crisis and substance use epidemic.

Victims of Columbia Pacific’s support for harmful sham treatment programs and violation of legal rights of vulnerable Oregonians

As a behavioral health professional with experience  working in community mental health in northwest Oregon during periods over the past decade, I worked directly with patients who accessed programs constrained in practice by Columbia Pacific CCO by control of Medicaid reimbursement to the programs,  including patients accessing or attempting to access shelter at a Helping Hands facility in one of the five counties. Some of their stories – with all potentially identifying information omitted or changed – follow. 

C’s story

In my role as BH therapist in a coastal program, I began providing BH services to C. C’s history is not unusual: severe childhood abuse, neglect, and exposure to violence; chronic PTSD; severe problem alcohol use beginning early adulthood; multiple DUII convictions; history of alcohol intoxication and domestic violence; history of failed TAU treatment episodes including at TFCC in Tillamook County, “They always put me in classes” there, not therapy, and not experienced as helpful to C.   

C was sent to Bridges to Pathways detox center, a program provided clinical oversight and programming guidance by Columbia Pacific where, per C’s reports, C was recommended, referred, and encouraged by the director of that program  to a program of faith healing, Mountain Ministries Religious Center Church in Rainier, Oregon, where C  found C would need to commit to a year-long program of religious indoctrination, with only the Christian Bible allowed as reading material, and strict rules of conduct, experienced by C as programing aimed at C being “brainwashed” and “pretty much a cult . . . I left”.

S’s story

S was an elderly resident of an Oregon north coast community evicted from an apartment, homeless since then, sleeping in a vehicle or at times using dwindling savings to stay in a motel room. S is diagnosed with Opioid Use Disorder (OUD) related to misuse of prescription opioids, and with dementia, contributing to vulnerability along with homelessness, chronically disturbed sleep, social anxiety and alienation, and the memory and other cognitive deficits associated with dementia. S uses cannabis to aid with sleep, in Oregon a legally prescribed medication. S has over-utilized ED (Emergency Department) services and has struggled against cognitive deficits to reliably use prescribed medications including for hypertension. S has been the subject of clinical discussions of an interdisciplinary team to address the needs of particularly vulnerable elders in the area. The clinical director of TFCC, a community mental health agency that partners with Helping Hands, was part of the interdisciplinary meeting.

S has actively pursued stable housing since eviction, has not been successful to date gaining access to the very limited housing resources in the area. S has requested and been disallowed from using housing at Helping Hands, due to S’s use of marijuana, supported by research as effective in providing relief from chronic pain and to be associated with reduced need for use of opioid pain medication and successful taper off opioid pain medication. When I had last contact, S continued to use limited savings to persist, homeless and vulnerable in the community.

W’s Story

W accessed behavioral health (BH) services with me at a program, was diagnosed with a chronic psychotic disorder with symptoms including paranoia, confusion, social anxiety, and hallucinations. After housing with natural supports failed, W accessed a bed at Helping Hands in one of the NW Oregon counties where HH is present. Prior to disengaging from medical and BH services in the program where I practiced, W reported to me that W was increasingly anxious as triggered by forced attendance in the religious groups, consistent with complex and novel social stimuli commonly triggering agitation and anxiety for individuals with psychotic conditions like W’s. I contacted the HH case manager directly by phone, explained W’s clinical picture and needs, likely prognosis with exacerbated symptoms if W continued to be forced to attend the groups. The case manager explained that W would have to continue to attend, as part of requirements of HH programming.

W was evicted by HH and became homeless,  fears and symptoms of the disorder increasing, living in a tent in the woods, repeatedly arrested and jailed for nuisance crimes in the community, like property damage, related to W’s illness and diminished functioning. W’s functioning deteriorated, and W started to fail to appear repeatedly for medical appointments. W was accessing medical care reliably prior to eviction from HH.

homeless person sleeping

D’s story

I began working with D in therapy about after D had accessed follow up Emergency Room (ER) care after acute alcohol toxicity. D had a lifelong adult history of severe problem alcohol use, with repeated TAU treatment failure and decades of involvement in the religious subculture AA, without perceived or practical benefit. When D became homeless in our region, D was offered shelter at one of the Helping Hands programs, where D eventually took on roles as helping in the facilities by working in capacities with other residents. D became overwhelmed by the responsibilities and was abusing prescription sedatives obtained online through the mail, affecting D’s concentration, mood, alertness, and balance. Per D, HH administrators noticed D’s distress and asked D about it, then continued to require D’s assigned duties. D fell and was injured while under the influence of the illicit prescription sedatives, requiring an ER visit and revealing the drug abuse, HH administrators becoming aware. Instead of facilitating and referring D to legitimate treatment for substance use, HH administrators kept D working in a HH facility, with forced programming consisting of required daily meetings of the AA religious subculture, an activity that had not benefitted D over decades of severe alcohol use, by D’s accounts. D had to commute daily to attend the required religious programming. Within weeks, D ended up in the ER with acute alcohol intoxication.

When I last worked in therapy with D, D no longer was attending the religious subculture meetings, instead was provided evidence-based practice (EBP) therapies for chronic PTSD and other conditions by me, was at that time without problem alcohol use since beginning EBP treatment about 8 months before we separated.

B’s Story

B accessed therapy with me at  a behavioral health program in the region while a resident with two children at a Helping Hands shelter in a coastal county, B with histories of adult victim of domestic violence and chronic PTSD. B presented with significantly exacerbated anxiety, overwhelmed, including by the high needs of the children for social and mental health services. Stressors included: a child  with history of multiple mental health diagnoses  at risk of losing school specialized (IEP) status and support, with a nearing deadline for providing supporting documentation; worsened sleep with regular nightmares; fears of being evicted from HH and being homeless again; another younger child with history of likely abuse, struggling at school and with emotional dysregulation, “crying, puking”.

On top of those stressors and demands on B’s time, B was required to daily attend two different types of religious meetings that “stress me out” or be evicted from Helping Hands . 

In a therapy visit, B reported frustration, explaining a recent arrest for a minor, non-person crime and short jail stay, the 2 children placed in state custody.  B had never committed that misdemeanor crime before, and it was an impulsive act per B, B’s mental state agitated at the time, angry, with intrusive thoughts of the type overwhelming B as reported in a prior visit, about a month ago, “angry . . . going through everything in my head”:

“I’m tired of everything piling up”

“I’m not used to doing all this . . . piled on with chores”

B felt overwhelmed with keeping up with appointments for B and B’s children, requirements from DHS in order to continue to receive TANF, on top of that, demands from “the Shelter” (Helping Hands homeless Shelter) to complete work (“chores”) sometimes morning and night and participate daily in meetings of a religious subculture, on top of that 10 hours of volunteer work weekly.

B explained that B thought it was reasonable to be required by DHS to look for work and to provide 18 hours of volunteer work each week in order to continue with TANF. What overwhelmed B were the extra requirements from “The Shelter” (HH): an additional 10 hours of volunteer work per week; multiple hours of “chores” at the Shelter, mornings and/or nights; and daily meetings of the religious subculture AA or similar religious programming.

B affirmed earlier, reliable reports that B had never struggled with or been treated for a substance use disorder, so the required attendance at the AA meetings, ostensibly related to substance use, seemed arbitrary and counterproductive. B affirmed that being in the AA group meetings, where participants are expected to talk about chaotic and distressing events in their lives, exacerbated B’s anxiety. Those demands have stressed and overwhelmed B, in the context of a history of violence and chronic symptoms of PTSD.

Toward the end of the last  session we were able to have B reported, “I have to admit it was a relief in a way to go to jail”, to get away from all of the demands that were overwhelming B. B added, “I love my kids, don’t get me wrong, but my parenting skills are not great”. B was not offered help with parenting skills through Helping Hands.  

When I last had contact with B, because of the minor, non-violent and non-person  charge, B and B’s children were being evicted from Helping Hands, “I have to find a different Shelter . . . they kicked me out due to the [charge]”.

Helping Hands represents another program supported by public funds with practices likely unknown to the public: coerced religious programming on threat of eviction to homelessness; intentionally attempting to positively orient residents to participation in religious subcultures like AA where addictive use of the lethal substance tobacco is socially reinforced, increasing risk of chronic pain and acting as a gateway drug for opioids and alcohol.

What about treatments for tobacco use?

How are public funds being used by managed care to guide effective approaches for tobacco cessation, given the lethal connections to pain and opioid use, as well as the diabetes epidemic?

Columbia Pacific CCO provided clinical trainings to medical clinics and staff to disseminate “best practice” clinical practices for tobacco cessation, provided by CCO “experts”.

I’m personally and/or professionally acquainted with each of the insurance company staff members represented by Columbia Pacific as “experts” and placed in a position to determine best practices for a life-threatening substance use problem, in this case tobacco use.

None of the four insurance company employees have credentialing, formal training, or expertise in areas critically required to determine “best practices” in this area:

Training and background in research methods and design to analyze, vet and interpret the relevant research

Nature of substance use disorders and experience in EBP treatment program development

Comorbid underlying mental health conditions and their effective treatment.

Placing in context research findings based on direct practice clinical experience providing EBP therapies to substance dependent patients

That is, none of the insurance company employees has competence in the areas required for this task, let alone expertise.

young woman smoking a cigarette

I was glad to support use by the CCO of a clinical tool I developed at our clinic comparing treatment options for tobacco use disorder (TUD) for use by patients, and I provided by email updated information on relevant research to behavioral health colleagues and to CCO staff preparing and providing the clinical trainings.

Columbia Pacific’s lead clinician replied to my material by email (email exchange available by request), indicating that the CCO group disseminating “best practice” clinical practices to area clinics had not reviewed the research prior to validating, promoting and recommending continued use of nicotine replacement therapy (NRT = gum, patches for nicotine replacement) for tobacco use. It turns out they  could not have competently reviewed the research or would have been aware of emerging best evidence pointing to no benefit from NRT, see highlighted research summary.

Effects for positive outcomes with NRT have always been small for example “number needed to treat” NNT to provide one positive outcome, in this study NNT = 29 = 97% failure rate: 

http://www.bmj.com/content/338/bmj.b1024

Newer research and meta-analysis point to no tobacco cessation benefit (no difference in cessation rates compared to no treatment) from NRT:

http://www.jclinepi.com/article/S0895-4356(16)30184-6/fulltext

http://www.jclinepi.com/article/S0895-4356(16)30075-0/fulltext

http://tobaccocontrol.bmj.com/content/early/2012/01/03/tobaccocontrol-2011-050129.short

Herd, N., Borland, R. and Hyland, A. (2009), Predictors of smoking relapse by duration of abstinence: findings from the International Tobacco Control (ITC) Four Country Survey. Addiction, 104: 2088–2099

If the designated experts had reviewed current evidence

related to effective treatment of tobacco use, they would also have become aware of the body of research that establishes that urges per se to use substances, specifically tobacco, do not predict return to problem use (“relapse”), instead other factors do (e.g. Herd, Borland and Hyland, 2009, cited above). The assumed and invalidated effectiveness of medications and NRT for quitting tobacco use is based on the assumption – false – that urges to smoke are the primary trigger and cause of relapse.

Provision of NRT and other medication-based interventions to patients trying to stop smoking, with no or clinically insignificant benefit, is associated with additional harm due to reinforcement of patient belief in the invalidated disease model of “addiction” (NRT provided by medical providers in medical settings and perceived as a medical treatment for addiction), because research establishes belief in the fictional disease model as a primary predictor of relapse.

Effective use of public funds to treat tobacco use disorder is critical because: 1) health care system and social costs of tobacco use eclipse those of opioids and illicit substances combined, and 2) tobacco use is directly related to the opioid crisis – evidenced as contributing to the cause of chronic pain conditions and to worsened perception of chronic pain:
and increasing risk of continued or return to problem use of substances including opioids (acting as a “gateway drug” for opioids):

In that research context – of multiple evidenced links between tobacco use and worsened risk of development and effects of problem opioid use –

the private acknowledgments (request the email string here) of Columbia Pacific CCO’s Clinical Coordinator importantly highlight the continued harms perpetuated by managed care and Oregon CCOs against vulnerable Oregonians and associated abuse of public funds. Those acknowledgments include that: 1) tobacco use disorder (TUD), like any substance use disorder, is not a “disease” or medical condition with effective medical treatments, 2) the required, indicated EBP interventions that predict success are (individual therapy) behavioral health (BH) treatments including Motivational Interviewing (MI) and Cognitive Behavioral Therapy (CBT), 3) NRT and medications (bupropion, varenicline) are not significantly effective treatments, certainly not on their own.

Publicly and in contrast, Columbia Pacific CCO avoids reference to and recommendation of EBP therapies for tobacco use instead promoting and funding practices – visits to medical professionals, phone counseling, NRT, medications –that predict no clinically significant benefit for the life-threatening disorder, constituting apparent abuse of public funds and perpetuating public harm.

Further, those acknowledgments – specifically that the indicated, effective EBP treatments for smoking are BH therapies, not other interventions – point also to the false, deceptive, and harm-predicting promotion by Columbia Pacific of their employees as “experts” tasked with disseminating credible clinical practices for smoking cessation to health care professionals – individuals without credentialing, training, or research or practice experience in the area of EBP BH therapies for substance use disorders are presented by CP as “experts” but possess neither expertise nor competence in those areas of healthcare practice.

Those CPCCO experts, out of scope of competence, failed to review the relevant research prior to disseminating direction for clinical practice to regional primary care programs, promoting misuse of public funds for Nicotine Replacement Therapy, indicated by evidence as predicting no significant benefit for smokers.

So far – not good,

public funds consistently mismanaged due to clinical incompetence or malfeasance by business-model managed care to provide at best no benefit, or harm, to patients trapped in substance abuse and other public health epidemics.

At least it probably can’t get worse. 

A special project of the CCO was to implement and pay for with Medicaid funds a series of group sessions promoted as providing treatment for smoking, “Practice of Health”. POH is a proposed group-session “treatment program”, without curriculum or elements registered or supported by research as evidence-based, or as treatment at all, advertised to Medicaid patients by Columbia Pacific CCO as treatment for tobacco use disorder (see the flyer here) with public (Medicaid) funds allocated for payment by CPCCO.

Instead, POH as envisioned is made up of elements of New Age spiritualism and “Integral Transformative Practice” from the Esalen Institute.

Again, public funds dedicated by managed care to practices with no treatment benefit for a lethal substance use disorder, predicting harm to patients who would be encouraged to believe and continue to act on the beliefs that the components of POH constitute treatment of some type for life-threatening substance use problems.

mystical image

This is not encouraging. But hey, lighten up.

There must be some areas where managed care is able to act with clinical and ethical competence to manage public funds to provide effective healthcare for vulnerable Oregonians. Integrating behavioral health with medical clinics is considered a crucial improvement in delivered healthcare, they’re probably getting that right.

Right?

Primary Care Behavioral Health (PCBH) – a fictional clinical “model” predicting harm, supported by public health funds

The primary site of contact and identification for vulnerable Oregonians who have been overprescribed opioid medications, or otherwise are at risk due to problem opioid use, other mental health problems, are primary care clinics (PCC), where behavioral health services have traditionally not been available on site. An important current trend is to provide “integrated” BH services (functioning as part of team care with medical staff) at those sites to identify need and effectively provide substance use and mental health services within PCCs, because the large majority of patients seen in PCC and referred for those services elsewhere will never follow through and access effective care.

In the NW U.S. and the rural Oregon region where public health funds are controlled by Care Oregon, Columbia Pacific, and GOBHI, this fictional (never having been supported by a research base) and invalidated treatment “model” Primary Care Behavioral Health (PCBH) for integrated care has been and continues to be implemented and pressured for use in medical clinics by Columbia Pacific and Care Oregon, despite the complete lack of a body of appropriate research to support the “model” and by its being invalidated by longstanding research (copy of analysis of relevant research provided to Columbia Pacific by request, contact me).

As recently summarized:

“People who review the PCBH outcome research, including proponents of the model, agree that PCBH uptake has occurred on a foundation of limited effectiveness and efficacy research, especially patient-oriented clinical outcomes findings.” (emphasis added).

“evidence or no, PCBH (uncredited) and some of its aspects are now baked into our medical home standards in Oregon.  Seems the consensus for integration evidence is actually around the collaborative care model (CCM)  . . .”

          – Andrew Huff, Columbia Pacific CCO Innovation Specialist

That’s a misleading, overly-positive account,

because in fact, there are no RCTs (randomized controlled trials – the standard in research for confident conclusions about the experiment), let alone a body of RCTs, to support the practices described in PCBH. Its radical departure from standards of practice and EBP for the fields of Behavioral Health and Substance Use practice predict harm to patients and would require clinicians to practice unethically and illegally.

The model absurdly dictates the provision of, for example, 3 or 4 20-minute sessions, occurring about once each month, as “treatment” for an opioid use disorder, as well as for mental health disorders in general. Dr. Safina Koreishi, Medical Director of Columbia Pacific CCO, in a clinical staff meeting stated her understanding that this type of practice indeed does constitute “treatment” for substance use disorders and other mental health conditions.

These absurdly and grossly substandard practices appeal to payers (insurance companies) who, like Care Oregon and Columbia Pacific, use threat of withholding of public funds to attempt to coerce implementation. In our region, CO/CP staff have been made aware of the lack of validity of PCBH and continue efforts to mandate its implementation.

As Columbia Pacific Innovation Specialist Andrew Huff acknowledges:

evidence or no, [emphasis added] PCBH (uncredited) and some of its aspects are now baked into our medical home standards in Oregon. Seems the consensus for integration evidence is actually around the collaborative care model (CCM) . . .”

Mr. Huff adds:

“Nonetheless, I think that your points also highlight some questions about
• What is the role of innovation in healthcare
• What is the role of evidence in innovation?”

Mr. Huff is CP’s lead member in using public funds to coerce compliance with the invalidated PCBH model, despite his acknowledgment that PCBH is not supported by evidence and that there is “consensus” against this invalidated model compared to alternatives. In the face of an opioid crisis with a mounting mortality count, he seems to ask whether health care practices should require an evidence base.

In short, in the midst of mounting opioid and substance use crises, Oregon CCOs managing public health funds have “baked in” to their use of those funds to coerce clinical compliance, a fictional, invalidated “model” that: 1) is described by its authors as a “radical” departure from standards of practice; 2) has no evidence base (not a single supporting RCT); and 3) is invalidated, with predicted harm to patients, by decades of research establishing requirements for effective practice and outcomes in behavioral health.

The example of PCBH – like that of Columbia Pacific clinical practice experts tasked with understanding and distilling research to identify and promote effective EBP healthcare practices – points to something troubling. In both cases, Columbia Pacific staff responsible for clinical practice guidance acknowledged privately that the adopted clinical models are not supported by research as valid – at the same time that those models and practices are being promoted and directed for use by the insurance company and funded with public healthcare money.

On every count, from all lines of evidence, the business-model managed healthcare system, allowing insurance companies to use control of public healthcare dollars to drive and determine clinical practices, is failing to support effective evidence-based practices for vulnerable Americans trapped in the opioid and substance use epidemics, failing egregiously in rural Oregon hard-hit by the opioid crisis.

“People who review the PCBH outcome research, including proponents of the model, agree that PCBH uptake has occurred on a foundation of limited effectiveness and efficacy research, especially patient-oriented clinical outcomes findings.” (emphasis added)

           – Mauksch, Peek & Fogarty. 2017. Family, Systems & Health. 35: 251–256.

evidence or no, [emphasis added] PCBH (uncredited) and some of its aspects are now baked into our medical home standards in Oregon.  Seems the consensus for integration evidence is actually around the collaborative care model (CCM)  . . .”

          – Andrew Huff, Columbia Pacific CCO Innovation Specialist

These results may be predictable based on consideration of the values, competencies, and orientations of professionals selected and employed by and functioning in coordinated care (managed care) organizations. From all appearances, employees of Columbia Pacific CCO and Greater Oregon Behavioral Health Inc (GOBHI, managing mental health dollars) simply lack competence, let alone expertise, in the key areas of behavioral health, substance use treatment, and related research analysis and synthesis required to provide clinical guidance, are operating, in effect, in a clinical and ethical vacuum.

Connecting those points of malfeasance, incompetence, and abdication of public and professional responsibilities provides a picture of misuse of public healthcare funds and threats to wellness of vulnerable Oregonians.

Protecting the health of vulnerable individuals and families trapped in opioid, addiction, and other generated epidemics will require exposing and taking apart, dismantling, that web of misinformation and malfeasance, critical discourse by critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.”

– Pierre Bourdieu  Outline of a Theory of Practice (1972)

In Bourdieu’s Theory of Practice, heterodoxy is dissent, challenge to what “goes without saying” – the accepted, constructed doxa, “knowledge”, reality, that goes without saying precisely because it “comes without saying”, without real scrutiny, untested, unquestioned. The function of doxa is not knowledge or truth or promotion of the collective good, but to protect and serve the interests of those with the power, the cultural capital, to create it.

Unforgotten – Are the Kids Alright?

We’ve been focused on healthcare system malfeasance as it harm adults, so far ignoring an even more vulnerable and underserved population – children. They’re facing their own ongoing and latent epidemics: obesity; diabetes; and the lasting effects of adverse childhood experiences (ACE), those effects generated by problems in the home environment (like substance use, violence) that change developing brains and predict onset of the most common health ailments from anxiety to substance use to diabetes, obesity, and risk of suicide.

More about all of this to come, in posts here.

obese child

Preview

We know that ACEs are forms of stress and create baseline anxiety, that stress-eating is driving a childhood obesity epidemic,  obesity driving a looming diabetes crisis, and those effects partly caused and worsened by nicotine, which directly contributes to risk of diabetes and is delivered in e-cigarettes, booming in popularity with kids.

Prevention of ACE is the key, something we’ve known for a decade or so. In our region, driven by managed care, there are efforts to better serve kids through the Oregon Pediatric Improvement Project (OPIP), identifying kids with signs of developmental challenges and getting them to effective services.

OPIP, under managed care, is driven by a medical model and medical decision making, but the vast majority of children with signs of early problems are struggling due to effects of ACE,  including abuse, neglect, other forms of trauma – psychosocial issues demanding family and psychosocial, not medical, treatments and interventions. The inappropriate medicalization and medical treatment for another non-medical problem, chronic pain, is what gave us the opioid crisis. 

The most vulnerable population . . . pathologically incompetent business model healthcare system . . . managed care . . . medical model for non-medical problems  . . .

Kids in the way of harm demand of us a critical discourse.

children in pool

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

Pierre Bourdieu - Outline of a Theory of Practice 1972

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