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Cash only clinics have gotten a bad reputation in the news lately. It is true that some cash-only Suboxone clinics charge outrageous fees from $250-$400 a month. Unfortunately, the high cost does mean better care. Patients who have been to these clinics tell me the doctor visit lasted a few minutes. They left feeling cheated and angry. Clinics like this are labeled “ pill mills”. The definition of a pill mill is a clinic or doctor who prescribes narcotics for non-medical reasons for bribes. These cash-only clinic doctors prescribe Suboxone for medical reasons, but brief assessment and high-cost cost arouses suspicion within the Drug Enforcement Administration and the general public that these providers run a clandestine operation. It is easy to understand how the public, in general, lumps all cash-only clinics into this category.
Are all cash-only Suboxone clinics tantamount to a criminal organization? Should cash-only clinics be outlawed or strictly regulated as some state legislatures believe? Members of our community suffering from opiate addiction need accurate information about different approaches available to treat Opiate Use Disorder. This group of people stand to benefit most from a wide range of treatment options. The DEA, state legislature, and insurance companies threaten to limit choice of treatment options for Opiate Use Disorder using Suboxone. Just in western Pennsylvania, the DEA and US attorneys office have shut down many outpatient cash-only Suboxone clinics. Insurance companies do not fairly reimburse outpatient Suboxone clinics that do not meet their idea of proper care. Government officials have attempted to pass laws to require individual therapy delivered exclusively from a licensed drug and alcohol clinic for every person in treatment for opiate addiction. This requirement for individual therapy exclusively from a drug and alcohol clinic violates a person’s right to choose their own treatment. By mandating therapy in a state-licensed drug and alcohol clinic, these laws conflict with the original intention that Suboxone treatment be delivered in a doctor’s office so as to decrease the stigma associated with going to a drug and alcohol clinic.
Physicians want to help patients with opiate addiction. Patients look to their physicians to help them make informed decisions regarding treatment options. They want to know the benefits of different treatment options as well as the drawbacks. Most patients want to have a say in what treatment they receive. Consumers of medical services similarly want to have a choice in who provides those services. Traditionally, friends or family members offer advice about doctors or hospitals they prefer. Word-of-mouth referrals are common for those seeking help with mental health problems and addiction. The problem with seeking good care for Opiate Use Disorder is that people who need help are too embarrassed to ask friends or family advice. Likewise, people who have received excellent care for their opiate addiction prefer to keep this information private. Folks who carry valuable information about the quality of care available in the community for opiate addiction fear being stigmatized. Accordingly, critical information about providers of treatment and treatment methods cannot easily be accessed. This opens the door to criticism and bias against cash-only Suboxone clinics as described above based on limited data.
We have a solid reputation in the community for delivering effective, patient-centered and affordable care. This reputation is supported by patient reviews, patient satisfaction surveys and reliable outcome data gathered over 10 years of operation. We are a program with a heart for those suffering from addiction. To better understand the philosophy and mission of South Hills Recovery Project and why we are cash-only, I will tell the story of how it was born.
I started practicing psychiatry in Pennsylvania 20 years ago. Fresh from giving my Hippocratic Oath “into whatever house I enter, I will enter to help the sick”, I trained at the University of Cincinnati and Yale. During those formative years, my professors ingrained in me a life-long habit of caring for those who need help irrespective of ability to pay. My first job in Pennsylvania was a staff position at Sharon Regional Health Center. At Sharon Regional, I treated seriously ill adults and children in the hospital and office. Sharon Regional was a community hospital whose mission was to serve the community regardless of insurance status. I had the privilege of attending patients whether they could pay or not. Most of the children I saw came from disadvantaged families. After six years at Sharon Hospital, I moved 2 hours away to Pittsburgh for family reasons. Despite the long commute, I continued to see children in Sharon, PA for the next 2 years. Children with medical assistance insurance had difficulty finding a psychiatrist who would take this insurance.
In 2005, I joined the staff at Southwood Hospital, a child and adolescent psychiatric hospital as a medical director. In addition to inpatient treatment, Southwood owned long-term residential care home for children with severe psychiatric problems. Most of the children living at the residential care home were from poor families. These families had few resources and struggled to get help for their children. It was at Southwood Hospital that I became increasingly disenchanted by the healthcare system and the medical insurance industry. I naively believed that these organizations served the patient. Instead, I saw insurance companies that denied appropriate treatment, and accreditation organizations tasked with ensuring quality care focused on paperwork over patient satisfaction.
While on staff at Southwood Hospital, I worked evenings at a psychology practice that accepted insurance. Based on how insurance structured payments, I was scheduled patients every 15 minutes. After a while, I found this approach problematic. Patients’ problems did not fit conveniently into 15-minute appointments. Children required more time because it took time to make them comfortable enough to open up. The child’s family needed time to discuss their concerns. Insurance companies expected doctors in their network to see every patient asking for treatment irrespective of the doctor’s caseload. My caseload grew to the point that I had a 3-month wait for new patients. and 3 months wait for a follow-up appointment. When a patient had an unexpected problem, I squeezed them in an already overflowing schedule. I became frustrated, patients waiting room were annoyed and I regularly left the clinic late at night. I contacted several insurance companies asking to see patients for 30 minutes. I learned that the amount of documentation required to bill for a 30-minute appointment required at least 15 min. I eventually left wondering how a doctor could provide good care in today’s healthcare environment.
I had to find another way. People in the community needed good psychiatric care. In 2009, I left Southwood Hospital to start an outpatient practice. The challenge was to deliver good mental healthcare for an affordable fee. I wanted to see anyone who asked for help regardless of financial resources. With the help of my wife, Natalie, we went to work.
We expected to the practice to grow slowly. The opiate epidemic was starting to hit our area hard. When I learned that Suboxone was an effective treatment of Opiate Use Disorder, I started offering Suboxone in the office. I did not anticipate the demand for this service. In the first few years, we managed ten calls per day from patients desperately needing treatment for opiate addiction. My wife and I studied opiate addiction, read everything written about treatment, and attended conferences. We regularly asked patients about their treatment experience both in our clinic and others they attended. With an electronic records system, we carefully monitor treatment response and patient satisfaction. We continuously improved our treatment process. As we grew, we hired doctors and counselors who shared our vision and passion for exceptional patient care.
Today, South Hills Recovery Project has exceeded my expectations. By any measure, we have been able to consistently deliver high-quality, affordable, and effective treatment for people suffering from Opiate Use Disorder and related mental health problems. We have been able to see new patients within 48 hours, be responsive to patients’ work demands and busy lives. Without the paperwork required by insurance companies, we can invest more time inpatient care. We are available after clinic hours when needed. Most importantly, patients have more control of their treatment plan.
I invite you to review our “Report Card” available on this website. Take a moment to read our Google reviews. The lesson for me and the staff at South Hills Recovery Project was that by putting the patient back in the center of the process, affordable, effective and convenient treatment for Opiate Use Disorder is possible.
Are Suboxone clinics that accept insurance less interested in profit? Are clinics that require individual therapy, weekly visits, and group counseling doing so because it is medically necessary? Clinics that take insurance typically make up for lower reimbursement by seeing you more often. For the first 3-4 months, they may require you to be seen weekly. This visit with the doctor is a few minutes. The clinic may receive $60-75 for the visit. Most of the treatment for addiction is done by counselors. If you are required to be seen weekly for group, the clinic can charge around $50 dollars for each person in the group. The larger the group, the more money per hour for the clinic. If the clinic requires individual therapy, then they may receive $75-85 per week. The problem comes with the required co-payments that must be paid by the patient. Co-payment can range from $20 dollars up to $50 dollars per visit. As you can see, weekly co-payments can add up to $150-$200 a month. If you add all the fees collected for one patient per month, clinics taking insurance usually make 2-3 times more than a clinic that charges a monthly cash fee. Compare the monthly revenue for a clinic that takes insurance per patient, around $1000, to our fee of $175 per month.
Clinics that require more intensive treatment as described above are needed for some patients. They must miss work, take time off and travel frequently to get the results they request. However, do all patients require this intensity of services. No one knows the answer. The definitive studies have not been done. It is up to the patient and doctor to discuss the treatment options using the best evidence available. After a discussion, it is the patient’s right to choose which option would be best for them.
I hope this article sheds a little light on the complexity inherent in finding a Suboxone clinic best for you. Many forces are at work, many agendas and considerable misinformation. Patients, law enforcement and our legislatures need to look carefully into how doctors treat Opiate Use Disorder today. The lives of our family, friends, and co-workers depend on it.
