In 2019, Florida’s Department of Children and Families (DCF), the state agency charged with licensing and regulating addiction treatment providers, created a new definition within the Florida regulations governing addiction treatment providers. This definition was intended to standardize “best practices” for addiction treatment and place health insurance providers on notice that Florida was demanding evidenced-based treatment for its citizens and those who come to the state seeking the best addiction healthcare in the country.
Though that new definition remains somewhat nebulous, DCF’s requirement – that providers maintain “best practices” – is a great start to instituting qualitative and quantitative standards for the delivery of clinical services.
“Best Practice” means the combination of specific treatments, related services, organizational and administrative principles, core competencies, or social values designed to most effectively benefit the individuals served. Best Practices also include evidence-based practice, which is subject to scientific evaluation for effectiveness and efficacy. Best Practice standards may be established by entities such as the Substance Abuse and Mental Health Services Administration, national trade associations, accrediting organizations recognized by the Department, or comparable authorities in substance use treatment. [Rule 65D-30.002(7), Fla. Admin. Code]
It therefore comes as somewhat of a surprise that DCF has given its blessing to the filing of a new law (HB 1081 and its parallel SB 1554) in the Florida Legislature that will phase out one of the state’s “PHP” licenses, known in Florida as “Day or Night Treatment with Community Housing” or nationally as the “Florida Model.”
The “Day or Night Treatment with Community Housing” license requires a facility provide no less than 5 hours a day of outpatient services, and at least 25 hours of such services per week. Under ASAM criteria, this license provides services at level 2.5 of the ASAM continuum, Partial Hospitalization or “PHP.”
At this level of care, treatment and housing do not take place in the same location. The “Community Housing,” or sober living, component is an inextricable part of this level of care, required to be provided under the license.
By eliminating this license, we believe the real-world impact of this decision will be felt immediately and will be irreversible.
Here is the “bad”:
- Clinical Services Will Suffer: Eliminating this license will create a significant gap in the continuum of care that is not otherwise replaceable – the “next license in line” only allows for a mere 12 hours, as if the two were clinically similar or interchangeable. That is, the license providing the “highest” level of outpatient addiction treatment services available in Florida would require no more than 12 hours a week of services. Any quantum of services beyond the maximum 12 hours will be at the providers’ own risk of non-payment, or worse, under constant threat of insurance company audit or clawback for “underbilling” or “down coding.” There will exist a monumental, crater-sized hole in the continuum by eliminating this medically necessary level of care and not replacing it with something substantially similar. At present, no replacement is suggested.
- Transitional Housing is a Recognized Clinical Necessity: Failing to provide for temporary low cost (below fair market value) or free transitional housing of any sort may increase homelessness, as not all patients who complete detoxification or inpatient residential treatment have the means to immediately pay for rent, food, and basic life essentials required at the outpatient levels of care. Many spend their last dime simply getting to treatment. These out-of-pocket costs will only be available to those patients with additional financial means; others, who have insurance but not the separate means to cover these expenses, may be denied the clinically-recognized and essential sober living services, which insurance does not cover.
- Any vestige of “free room and board” will be eliminated, which will end the debate over whether free room and board was being used as an illegal inducement at this level of care (i.e., “you can live and eat here for free, so long as you attend ‘X’ treatment program”). As a result, any remaining unfair competition between providers may be removed, as everyone would then be on an equal playing field.
- The complete decoupling of clinical services from any form of concurrent peer-supported housing will require all sober homes to become certified by the Florida’s regulatory authority for recovery residences (FARR/Florida Association of Recovery Residences), rather than carving out an exception from certification for those who happen to have a PHP license, as it currently the case.
What needs to be understood is that PHP programs that resemble the “Florida Model” have become a cornerstone of many addiction treatment programs over the past 10 years, due in very large part to the shifting by insurance companies away from inpatient/residential care to outpatient models. Florida was one of the few, if only, states that had this “linkage” between clinical services and necessary recovery residential housing. However, the “Florida Model” was not originally a Florida creation.
Connecting treatment with housing originated back in 1949 and emanated from the prestigious Hazeldon treatment center in Minnesota (today, Hazeldon Betty Ford). In fact, it isreferred to as the “Minnesota Model”:
The year 1949 is significant because it marked the beginning of the Hazelden Foundation. What started as a “guest house” concept for alcoholic men has grown into the prevailing method of treating addiction: the Minnesota Model. More importantly, this historic innovation offered alcoholics a new alternative to jail, mental wards, or homelessness.
It’s easy to forget that the Minnesota Model represents a social reform movement. The model played a major role in transforming treatment wards from abysmal pits into places where alcoholics and addicts could retain their dignity.
Hazelden began with the revolutionary idea of creating a humane, therapeutic community for alcoholics and addicts. Once this idea was ridiculed; today it is seen as commonplace. The story of how this change has evolved is in large part the story of the Minnesota Model.
As a matter of historic practice and custom, providers of this level of service have not charged patients for room and board (with the full knowledge and the implicit blessing of all regulatory agencies).
It was understood that, at this “partial hospitalization” level of care, patients are not in a position to take on meaningful employment such as to cover the overhead expenses that we expect of “functioning” society.
That said, there is nothing about the Florida Model where rent was ever free, as a function of law.
But in our opinion and experience, there is a better way than the current “just tear the Band-Aid off” policy being proposed by DCF. Such knee-jerk reactions will come at the expense of current clinically-recognized standards of care, for which no alternative has been offered. We are “throwing out the baby with the bathwater,” as the saying goes.
So, what would be a better result? Rather than taking the most expedient method, for which no known impact analysis has been undertaken by DCF, the agency and the Legislature should seize this moment to pause and recognized the exceptional opportunity they have to identify and redefine 21st century clinical standards for the triumvirate of addiction medicine, clinical services, and recovery services. This can be readily accomplished without delay by assembling Florida’s exceptional selection of local addiction treatment professionals, elected officials, attorneys, politicians, and parents, to determine and define what are the “best practices” for the PHP level of care.
All stakeholders should be included, primarily those with medical and clinical experience.
And that “working group” already exists – the Palm Beach County Sober Homes Task Force.
As each state sets its own standards for addiction treatment, they also set the standards for health insurance. Florida is in the driver’s seat to set those national standards. As Florida goes, the rest of the country has proven to follow in this space.
If passed by the House and Senate, this law will take effect July 1, 2020 and will affect 102 addiction treatment providers in the State of Florida.