Author Archives: Jeffrey Lynne

About Jeffrey Lynne

Jeffrey C. Lynne is a South Florida native, representing individuals and business entities relating to licensing, accreditation, regulatory compliance, business structure, marketing, real estate, zoning and litigation pertaining to substance abuse treatment facilities and sober living residences. Mr. Lynne has been recognized across the region as a leader in progressive public dialogue about the role that substance abuse treatment has within our communities and the fundamental need and right to provide safe and affordable housing for those who are both in treatment for addiction and alcoholism as well as those who are established in their recovery.

Pharmacy Benefit Groups Begin to Limit Opioids, Over AMA Objection

Express Scripts, the country’s largest pharmacy benefit manager (PBM), announced plans to roll out a new program nationwide that will limit the number and strength of opioid medications that doctors can prescribe to first-time users.

The program, which will begin on Sept. 1, is being put in place to help reverse the country’s opioid epidemic, according to the Associated Press. President Donald Trump last week said he was prepared to declare a national emergency to combat the deadly opioid crisis.

The move by Express Scripts was met with resistance by the American Medical Association, the largest U.S. organization that represents doctors. It said decisions about prescriptions and treatment plans should be made by doctors and patients, the AP reported.

In a pilot study of more than 100,000 members new to opioid therapy, the company saw a 38% reduction in hospitalizations and a 40% reduction in emergency room visits when compared to a control group during 6 months of follow-up.

The AMA does not support the program’s expansion.

Medicaid has implemented policies such as prescription drug monitoring programs, quantity limits on opioid dispensing, prior authorization requirements, preferred drug lists and patient review and restriction. In 2012, 15% of Medicaid enrollees had at least one prescription opioid claim, and the program paid more than $500 million for more than 34 million claims for opioid drugs.

Cigna also recently announced that it recorded a 12% decline in customers’ use of prescribed opioids in the last year, which it accomplished by leveraging its claims data to detect patterns of misuse and by working with doctors.

Why is the AMA is objecting is left to anecdote, conjecture and speculation.

Saying a “one-size-fits-all” approach regarding the number of prescriptions takes away physician discretion, Patrice Harris, M.D., who chairs the AMA’s Opioids Task Force, told the AP that doctors have already voluntarily reduced opioid prescriptions by 17% and are directing patients to other forms of pain management.

Teens Now Succumbing to the Opioid Epidemic in Record Numbers

A new report out from the CDC on Wednesday morning highlights the dramatic shifts in overdose deaths among teens ages 15 to 19.

After more than doubling between 1999 and 2007, the overdose death rate among that group dropped 26 percent between 2008 and 2014. But the rate dramatically rose in 2015.

Opioids — and specifically, heroin — were the primary cause of drug overdoses among adolescents in 2015.

Key findings from the National Vital Statistics System

  • The death rate due to drug overdose among adolescents aged 15–19 more than doubled from 1999 (1.6 per 100,000) to 2007 (4.2), declined by 26% from 2007 to 2014 (3.1), and then increased in 2015 (3.7).
  • The drug overdose death rate increased between 1999 and the mid-2000s for both males and females but only males had a subsequent decline between 2007 and 2014.
  • For both male and female adolescents, the majority of drug overdose deaths in 2015 were unintentional.
  • Death rates for drug overdoses among those aged 15–19 in 2015 were highest for opioids, specifically heroin.

Meanwhile, as the opioid epidemic rages on, the lawsuits against drug manufacturers and distributors continue to pile up. South Carolina’s attorney general just filed a lawsuit against OxyContin maker Purdue Pharma, alleging that the company used shady marketing tactics that contributed to the epidemic. And in Cincinnati, city officials are suing three major prescription drug distributors, alleging that they broke a federal law that requires them to report suspicious opioid orders.

At this juncture, we remain sadly pessimistic that the Trump Administration is not going to fulfill cornerstone campaign promises to tackle the epidemic head-on. The recent declaration of national health emergency did send an important message of acknowledgement, and hopefully will expedite access to resources and different tools to respond, those resources are often only available to the indigent and underserved areas. This could be used to staff up or train providers for medication-assisted treatment, which is considered the gold standard for opioid addiction care. Or it could be used to waive state licensing requirements for doctors, letting addiction specialists go into areas that currently don’t have enough access to such care.

But for the balance of the nation, it may not mean much.

Pushback Against Plan to Medicalize Drug and Alcohol Treatment

Pressure has been mounting in Florida and across the country for state departments of health to take over regulation of public and private treatment providers, the thought being that we have for far too long bifurcated healthcare at the neck.

We had previously written about NJ Gov. Chris Christie announcement on July 11, 2017, of his decision to reorganize the $1.2 billion NJ agency (Dept. of Human Services) in charge of mental health and addiction services. In NJ, that agency is funded at a rate of approximately 10:1 as contrasted with Florida and other states, where the local humans services agency tends to be the least funded and the one with the lowest morale. (To that point, Palm Beach’s WPTV (NBC affiliate) ran a story on July 28, 2017, about how Florida’s Department of Children and Families’ employees were falsifying records relating to child welfare inspections simply because they were overworked, overburdened, and underpaid.)

Back to NJ, last week, experts appeared before legislators in Trenton to testify on how the plan, proposed by Gov. Chris Christie, to shift mental health and addiction services to the state Department of Health would create probable disruption for providers and clients.

“While we strongly believe integration of behavioral health and substance abuse is important to integrate with physical care, we believe this move is not a viable way of making this happen,” said Barbara Johnston, director of policy and advocacy for the Mental Health Association in New Jersey.

The shift could involve moving millions in state funding, a couple hundred employees and regulation changes between the two departments.

According to a copy of his reorganization plan, Christie said the shift would “remove bureaucratic obstacles to the integration of physical and behavioral health care, and effectively address substance-use disorder as the public health crisis that it is.”

A Physician’s Perspective

We interviewed Dr. Robert Moran, a well-regarded South Florida psychiatrist who specializes in addiction medicine. He is also the founder, CEO and Medical Director of the Family Center for Recovery in Boynton Beach, Florida.

Psychiatric illness means that an organ of the body is dysfunctional–the brain. It is silly and naive to think that a social service agency is capable of overseeing the licensure and quality of care of psychiatric treatment centers. It is also misguided to see the disease of addiction as something that should be treated differently than other psychiatric illnesses; that is, in a ‘rehab’. As a physician trained in medical school to diagnose all medical illnesses, I do not see brain illness differently from heart or lung illness with regard to the fact that we illicit symptoms, identify signs, make diagnoses and prescribe treatment. Of all the medical specialties, psychiatry is the most difficult and most sophisticated. [DCF has] no idea as to whether we are providing quality standard-of-care because they have no medical training. They may see that I have a patient on 7 psychotropic medicines and have no idea whether it is appropriate, but they will point out that one digit in the phone number for the abuse hotline is incorrect.

I, personally, am licensed by the [Florida Department of Health]. My psychiatric practice is under their auspices. The treatment that I provide to the patients in my facility should be monitored by that same agency.

Moving licensure and oversight to DOH is not only logical, it is absolutely necessary if we expect to get the opioid epidemic under control. DOH knows what standard of care is for all illnesses. It is able to recognize when a facility/practitioner is not meeting the standard. DOH would be able to identify that a licensed entity is not recommending anti-craving medicines which have been proven to decrease use of substances (almost all patients referred to us from other facilities have not been offered/prescribed proven anti-craving medicines at the referring facility).

The Perspective of Recovery Support Providers

The majority of speakers said they favored more integration but not at a time when community agencies are already undergoing a major transition from a contract-based payment system to a fee-for-service system.

Johnston and others said the timing for reorganization of the mental health division, which oversees community-based mental health and substance-use programs, the state’s four psychiatric hospitals and other behavioral health programs, could hurt agencies already struggling with the payment transition.

Debra Wentz, CEO and president of the New Jersey Association of Mental Health and Addiction Agencies, said on top of that, uncertainty on the impacts of what a federal health care repeal could do to mental health and addiction services in New Jersey is another reason for hesitation.

Others were hesitant to separate mental health and addiction services from wrap-around services such as housing, food assistance, employment, Medicaid oversight and others that currently exist within the human services department.

John Lehman of the Florida Association of Recovery Residences brings a unique and educated perspective to this issue, particularly the interplay between treatment and recovery support services:

Though integration of SAMH [Substance Abuse and Mental Health] and Medical Healthcare continues to present challenges to New Jersey, Florida and many other states, the greater challenge is the profound failure of federal and state agencies to fully embrace recovery-oriented support systems. Contrary to much rhetoric, recovery support systems are largely ignored by payer systems. This results in what can be described as the Catapult Practice wherein persons exiting quality addiction treatment are launched towards mutual aid and other recovery support platforms in hopes they will make it across the relapse chasm. Over two-thirds fail to cross the divide resulting in either premature death or repeated and costly episodes of acute care. We must build bridges to recovery predicated on evidence-based practices and interventions appropriate for delivery by credentialed peers in nonclinical settings. One of the most appropriate settings from which to provide these evidence-based interventions is certified recovery residences measured to be complaint with NARR Quality Standards.

John Jacobi, Seton Hall director of the Center for Health and Pharmaceutical Law and Policy, said years of research and study on integration issues has shown that the fragmentation of health care delivery systems is one of biggest issues legislators have had to face.

Jacobi said regardless if the plan gets passed or not, integration between mental and physical health must happen, which should include a streamlined process where providers can get a single license to provide behavioral, substance and medical treatment.

“I believe, from our research, that behavioral health integration saves lives,” he said. “That reform of New Jersey’s licensure system for outpatient care is necessary, but the process for integration is a long one.”

The Florida Legislature Sends A Message To The Country-We Will Protect The Recovery Community

On June 14, 2017, the Florida Legislature sent to Governor Rick Scott for signature House Bill (HB) 807, which has unofficially been referred to as the “Practices of Substance Abuse Service Providers Act” and which comprehensive law implements several of the recommendations from the Palm Beach County Sober Home Task Force’s Proviso Committee and the Palm Beach County Grand Jury to address the problems within the substance abuse treatment industry. Effective July 1, 2017, HB 807 is a global approach to the regulation of the treatment and sober living industries which to date, have operated in a “grey zone” due to lack of clarity in existing laws as well as operated, by some, simply fraudulently.

Click here to read more.

Negative Press Causing Referrals to Florida to Come Into Question

The Portland Press Herald reported on July 19, 2017 in the article “Operation Hope stops sending clients out of New England for opioid addiction treatment” about how the Scarborough (Maine) Police Department’s Operation Hope has stopped sending clients out of New England for treatment for opioid addiction, largely because of negative media about alleged unscrupulous programs, especially in Florida (a story published in May by STAT, a health journalism website that partners with The Boston Globe, detailed alleged insurance scams and referrals to Florida clinics where patients were receiving little or no treatment).

Launched in 2015, Operation Hope was conceived as a way for police to channel addicts who sought help into a treatment program as an alternative to criminal prosecution on drug-related charges.

In most cases, getting help from Operation Hope meant flying out of state – to Florida or one of eight other states – because Maine lacked treatment opportunities. In the program’s first six months, four out of five Operation Hope participants headed out of Maine, mostly to clinics in Florida, Arizona and Massachusetts.

“We always wanted to help people closer to home, but we really had no other choice. That was the only way to get people help,” said Steve Cotreau, program manager at Portland Community Recovery Center. The nonprofit social support center for people in recovery has helped with Operation Hope placements.

With the current black-and-white approach that many law enforcement agencies are taking with regard to “regulation” of treatment providers, many good providers are electing to close up shop due to lack of regulatory guidance. When the only guidance available is a knock at the door from a detective claiming you have violated the law, when the lawyers themselves may disagree whether the law was violated, but it is to be “left up to the judge and jury” to determine one’s fate, many good providers are simply walking away.

There is an absolute vacuum of publicly-funded beds in Florida, and nationally. Even when there is some modicum of availability, these facilities are generally not accessible to persons who do not qualify as being impoverished, and are often staffed by persons who lack the experience or education to be administering what is becoming an overwhelmingly medical modality.

The ignorance from the regulatory bodies about how the private sector must be allowed to work is impeding innovation as well as necessary investment in technologies for growth. A truly progressive society would stop complaining and fully support the treatment industry altogether.

The apparent restriction of prosecutorial discretion for purposes of achieving popular political gains is not only short-sighted, but also has a significant negative impact upon the substantial legitimate employment that the industry provides, along with choking off the ancillary revenue that local businesses experience from developing recovery communities.

We will simply go from one crisis, to another.

CMS Requests Proposals New Payment Models for Behavioral Health

CMS (Centers for Medicare & Medicaid Services) has issued a press release about its interest in developing a behavioral health payment model, but wants feedback from providers and the community.

The model is meant to improve healthcare quality and access and lower the cost of care for Medicare, Medicaid or Children’s Health Insurance Program patients who have behavioral health conditions.

CMS announced its intentions for the new model in a notice (PDF) for a public meeting in the Federal Register. The agency will hold an all-day public meeting to discuss ideas for the model beginning at 10 a.m. EST on Friday, Sept. 8 at the CMS Central Office in Baltimore.

The Center for Medicare and Medicaid Innovation Center will test the new payment and service delivery model, which aims to address the needs of patients who have substance use disorders, mental disorders in the presence of co-occurring conditions, Alzheimer’s disease and related dementia and behavioral health workforce challenges.

The federal government under the Obama administration helped to accelerate the shift to value-based payments with a goal to tie 30% of all Medicare fee-for-service payments to alternative payment models (APMs) by the end of 2016 and a 50% goal by 2018.

Although the Department of Health and Human Services met its 30% target by March of 2016, it was unclear whether the new White House administration would embrace value-based care. In recent months CMS delayed the start of new bundled payment programs and the expansion of others to January.

But in the Federal Register notice CMS said it wants stakeholders to come to the meeting with ideas for potential models.

The meeting will feature four panel sessions of behavioral health experts who will discuss behavioral health disorders. Attendees are invited to listen to the panelists’ experiences delivering care and their ideas for payment models. Attendees will be able to ask questions to the panels and make brief individual statements (two minutes per models).

The agency said the recommendations made during the meeting will help design a model test to address behavioral payment and service delivery. Those interested in attending the meeting must register online at​resources/​behavioral-health-paymentcare-summit.html by 12:00 a.m. EST on Aug. 25.

NJ Governor Seeks to Transfer Addiction Treatment to Department of Health

According to the Associated Press and other news outlets, NJ Gov. Chris Christie announced yesterday his intent wants to reorganize a $1.2 billion agency in charge of mental health and addiction services.

The reorganization — which the Republican governor said will take place within 60 days — is his latest effort to combat widespread opioid drug addiction. According to the governor, the changes will eliminate bureaucracy and improve health care, he said.

Lawmakers who chair committees on the state’s Human Services and Health department said Monday they intend to hold public hearings on the reorganization proposal, as they have concerns.

The health department has little operational experience, said Democratic State Sen. Joseph Vitale, who represents Middlesex County. The decision needs to be vetted, Assemblywoman Valerie Vaineri Huttle (D-Bergen) said.

State Health Commissioner Cathleen Bennett said all of the employees from the mental health and addictions division will move to her department, so the agency will still have the same leadership.

In the 16-page reorganization plan, Christie wrote that by giving chief responsibility for the agency to the health department, addiction will be better treated as a health care issue.

Christie also quoted from a recent research paper by Seton Hall Law School that found people with serious mental illnesses and addictions often suffer from physical medical problems that go untreated. People would be healthier if their medical providers kept watch over their mental as well as physical health, but that happens too infrequently.

But Sen. Joseph Vitale (D-Middlesex), who chairs the Senate Health, Human Services and Senior Citizens Committee, said he doesn’t understand how moving one agency to another will make things better for patients.

The health department would oversee addiction treatment and housing providers, and oversee the state’s four psychiatric hospitals which serve 1,500 patients, Vitale said. The health department runs far fewer services but licenses health agencies, he said.

In what has been called a “surprise move,” the proposal has triggered concerns among some lawmakers and advocates asking for more discussion, as it would involve the relocation of more than 200 state workers and some $975 million in state and federal funding for the Division of Mental Health and Addiction Services, or DMHAS.

In contrast to Florida, which has a rather robust and experienced Department of Health and its ancillary Agency for Health Care Administration (AHCA), it appears the NJ legislators are saying the opposite to be true. “You are taking away these services from the Department of Human Services and giving them to the Department of Health, which has no operational experience,” Vitale said.

Debra Wentz, CEO for the New Jersey Association of Mental health and Addiction Agencies, questioned the timing of the reorganization. On July 1 a new payment system went into an effect that has resulted in layoffs and cuts to services.

“Undertaking a major systemic change could be a significant disruption that could impact people on the ground,” Wentz said.

Health Commissioner Cathleen Bennett said some of the concerns may prove to be unfounded. All of the employees from the mental health and addictions division will move to her department, taking with them all their expertise.

“It will be the same senior leadership team continuing,” she said.

Bennett also pointed out the department has worked closely with the 116 federal qualified health centers to work on temporary projects to integrate mental and medical care. She will expand on those experiences, she said

“If you have a substance abuse issue and an underlying medical issue, you [currently] need to go to separate locations,” Bennett said. “This provides a pathway where physical and mental health can be addressed.”

Under the current system, the DOH oversees public health programs like immunization and maternal health efforts, licenses and regulates hospitals and nursing homes, supports local health offices, and gathers data and coordinates efforts to address certain diseases or health disparities, among other responsibilities. The department is slated to spend nearly $1.6 billion this year and, with 1,100 employees, is one of the smaller agencies in the state, according to the plan.

In stark contrast to Florida, NJ’s Department of Human Services (DHS) is the state’s largest department, with some 11,000 workers and a roughly $12 billion budget – much of it from federal sources. It operates Medicaid or FamilyCare; oversees programs and residential facilities for developmentally disabled, blind, deaf and elderly residents; and coordinates a host of welfare programs, in addition to its work through DMHAS and other efforts.

While the proposed move came as news to advocates last week, Christie’s office said both departments were involved with the proposal, which drew heavily from last year’s Seton Hall report by Prof. John Jacobi, funded by the Nicholson Foundation. The study faulted bureaucratic hurdles and a lack of coordination between DHS and DOH for barriers in providing integrated care to vulnerable patients and said that while some efforts have improved coordination, more remains to be done.

The reorganization plan Christie proposed last week appears to put several of these recommendations into action and underscores how addiction services in particular should be combined with other population health initiatives overseen by the DOH. The plan also notes that the department recently received national accreditation for its public health work.

“Transferring the provision of mental health and addiction services to DOH is necessary to improve health care, remove bureaucratic obstacles to the integration of physical and behavioral health care, and effectively address substance use disorder as the public health crisis that it is,” the proposal notes.

DOH Commissioner Cathleen D. Bennett agreed the shift made sense. “This reorganization recognizes that mental health and behavioral health problems in general, and opioid addiction in particular, need to be treated as illnesses no different than infectious diseases such as Zika virus or chronic conditions such as hypertension, heart disease, diabetes, or obesity,” Bennett said, stressing the need for prevention efforts, especially when it comes to addiction.

“Only through such a public health approach can we overcome the stigma that for too long has characterized efforts to treat addiction as something that must be cordoned off from the rest of healthcare,” Bennett added.

The move also seemed appropriate to officials at Human Services. “DHS has cultivated a robust behavioral health system of care that will evolve with and benefit from the public health and regulatory expertise offered by DOH,” noted spokeswoman Nicole Brossoie. “DOH is the state’s point agency on research and prevention and therefore, perfectly positioned to address the public health crisis of opioid addiction facing so many of our residents.”

But Carolyn Beauchamp, president and CEO of the Mental Health Association in New Jersey, said the two departments have vastly different roles: DOH plays a largely regulatory function, while DHS has vast experience running contract-based community programs. Another concern she and others have is that DHS will still be responsible for Medicaid, which funds care for a majority of people seeking local behavioral health services. Separating this function from the work of DMHAS only creates another division, she said.

“It doesn’t meet the people’s healthcare needs,” Beauchamp said. “It will do nothing but slow (service delivery) down. I’m concerned that it will not serve our clients well.”

Sen. Joe Vitale, (D-Middlesex), longtime chair of the health committee and sponsor of a bill that would address some of the concerns about integrating mental and physical care, also raised serious questions. Such a significant change should involve some consultation with lawmakers, he said.

“We do need better integration” of physical and mental care, Vitale said, “I just don’t know whether or not this is helpful.”

Florida Telemarketing Update: Substance Abuse Marketing Service Licenses Now Available

After speaking with the Department of Agriculture and Consumer Services (DOACS), the new licensure application for a “Substance Abuse Marketing Service” is now being accepted.

It is available online from the Department of Agriculture and Consumer Services and can be found here.

As stated before, this governs anyone who is providing “substance abuse marketing services”.

DOACS is presently interpreting this to mean third-party providers who are actively engaged in marketing.

Passive platforms for which there are simply ad buys (such as a radio station itself) do not presently require licensure.

All of this is subject to change in the future as the Legislature further examines how this is rolled out; when DCF undertakes rulemaking in October; and as DOACS itself begins rulemaking for this new class of entity.

DOACS has also confirmed that any nexus with the State of Florida will require licensure, meaning if you are a: (1) marketer physically located in Florida; (2) marketer advertising for treatment and/or housing providers located in Florida; or (3) marketer actively advertising to Florida residents, you are subject to licensure.

Notwithstanding, all parties (providers; residences; marketers) are still subject to the new criminal penalties under new ss. 397.55 and 817.0345, Fla. Stat., for misrepresentation as to location, services, etc., whether required to be licensed by DOACS or not.

Again, DOACS is now accepting applications at the present time and there are criminal penalties for marketing without appropriate licensure.

Please consult your own legal counsel for more information.

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Cities Demand Sprinklers for Sober Homes, Condo Owners Cry Foul

For many years, Florida law mandated that the State Fire Marshal and the Department of Children and Families coordinate the establishment of rules and regulations governing fire and life safety for treatment centers and their associated components, which would include sober living.

In 2015, at the same time when the Florida legislature started down the road of licensure of recovery residences, they also required such residences to pass a “fire inspection.”

Nothing wrong with that at all.

Except that the State Fire Marshal and DCF never coordinated over drafting the regulations. Ever.

At the same time, in 2015, the Florida legislature then repealed the mandate of coordination. Meaning, if you ask those two governmental entities to get together to talk, they will not, because they do not have authorization to do so.

As a result, today, local cities and counties randomly determine on their own what level of “safety improvements” are required.

However, since 2015 (and for a period before), fire departments across the State of Florida have been speaking with one another and have determined that they are NOT residential uses but rather classified as “Residential Board and Care” facilities, which under the NFPA 101 (the National Fire Protection Association fire code adopted for life safety and evacuation), are the equivalent of Assisted Living Facilities.

This reclassification requires anyone who provides a sober living residence to now install fire sprinklers at a phenomenal cost, notwithstanding that everyone is otherwise capable of evacuation, self-preservation, and escape. Ironically, perhaps, while we have asserted that sober living residences should be required to maintain Narcan onsite and have all operators and managers certified in CPR, the state is simply worried about fires.

Now, in another moment of irony, the State of Florida this last legislative session tried passing a law to DEFER the mandatory installation of fire sprinklers and other modern life safety systems in Florida’s aging high rise condominiums, where a large portion of independent yet elderly residents retire to live. Think 9/11 on a small scale. How are they going to escape a fire? Running down the stairwells?

The strong lobby by law firms representing condo associations complained about cost and lack of need, and unlike recovery residences, the state agreed that condos were exempt, but recovery residences were not.

However, in a moment of clarity, Florida’s governor vetoed that bill and require all such buildings come into compliance by 2019.

And the response from the condo commandos?

Association leaders, condo lawyers and residents called the veto a bad deal, while those in enforcement noted that owners have had more than enough chances to install upgrades mandated nearly two decades ago.

Pio Ieraci, president of the 16,000-resident Galt Mile Community Association in Fort Lauderdale, said the veto will force buildings to spend millions of dollars on sprinklers and other equipment, leading to expensive special assessments — $15,000 to $25,000 per owner, in some cases.

He said many residents in older buildings are on fixed incomes and could lose their homes in foreclosure if they can’t come up with the money. And he said the assessments could jeopardize the financial stability of condo associations, reduce property values and make it harder for owners to sell individual units.

“It’s unconscionable and unbelievable,” Ieraci said. “The impact is huge.”

Eric Berkowitz, 67, who lives in a three-bedroom Galt Ocean Mile condo, said he and many of his neighbors live on modest means and wonder whether assessments will force them to leave.

“We’re frightened, is basically what it comes down to,” he said. “I live on a pension and Social Security. Most of the people here are not masters of the universe. We can’t afford something capricious like this.”

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