A Holistic Approach to Treating Addiction at Column Health
What does it take to break addiction?
Consider this scenario. You simply want to escape for an evening, so you reach for the leftovers of an opioid prescription you received for back pain. One evening becomes two, then three, and so on. Before long, you have a growing dependency, one that is beyond your control. You become less reliable at work. You lose your job and your health insurance. Within months, with no income and no savings, you find yourself homeless and relying on drug dealers to supply substances that prevent your sink into excruciating withdrawal.
At some point in this downward spiral, you resolve to turn your life around. You think that you are ready to do whatever it takes to get your old life back. But what exactly are your options?
You call a few numbers you see on ads but are told there are long waiting lists. Finally, you get an appointment, using street drugs to hold yourself over. When you arrive, you find yourself in a dingy and depressing clinic, spend just ten minutes with the doctor, and leave with a prescription for Suboxone. The office visit costs $150, which you must pay in full, and you’ll have to pay for the medication too. As you walk out the door you reflect that it feels a bit like you’ve just visited a different kind of drug dealer.
You try to navigate the medications and withdrawal symptoms on your own but it’s difficult. Increasingly cold, hungry, and withdrawing, you visit an emergency room only to be told that your condition is not acute or severe enough to warrant inpatient treatment. A new buddy, with more time in and out of drug use, suggests you try again but this time “just tell the nurses that you’re going to kill yourself if you can’t get clean.” So that’s what you do. The clinicians are clearly skeptical, but they admit you to a five-day inpatient “dual-diagnosis” program for your suicidality and your need for opioid detoxification to prevent painful withdrawal.
In at least a narrow sense, the detox is a success. You’re discharged from the hospital. For the moment, you’re not physiologically withdrawing, but you are homeless, unemployed, and surrounded by others with a history of substance abuse problems.
There is no easy path from here. All too often, folks like you end up falling into criminal behavior. But your crime will probably be poorly planned and executed. In prison, you’ll be surrounded by more drugs. You’ll also have plenty of motivation to suppress your individuality and lose sight of how you used to feel. You might even forget why you want to live.
During emergency room shifts in his psychiatry residency, Dan Karlin, MD, had plenty of exposure to individuals reporting suicidal thinking. He’d been trained that folks with addiction problems often claim to be suicidal just to gain access to inpatient units, but he sympathized with their plight. He understood how hard it was to get into treatment programs and detoxification facilities because he’d frequently made the effort to gain admission on behalf of patients. He saw that the patients were advocating for themselves as best they could in a system that presented them with no better options.
There are many system failures, starting with society’s confused attitudes towards addiction. Is addiction a disease or a crime? Does addiction reflect all-too-human fallibility or a lack of willpower? A confusing patchwork of regulations that applies only to addiction drugs complicates matters, as does the proliferation of single-drug clinics rather than comprehensive care models. There is also the strong correlation between addiction and poverty, which means impoverished patients have few resources in their fight to overcome addiction.
In the system’s failure to meet a massive and growing need, Karlin saw an opportunity. Within one year of finishing his psychiatry training in 2013, he was in deep conversations with his soon-to-be business partner Colin Beatty about launching a business that offered a better solution. Karlin had taken a job in drug discovery in the pharmaceutical industry. Simultaneously, he was working in an academic role where he met Beatty, an MBA with years of experience in health-care consulting. Beatty had a close connection to substance abuse issues; a relative of his had succumbed to addiction.
Before long, Karlin and Beatty had sketched out a plan. At first, their ambition was simply to open one clinic—a demonstration project—to prove that there was a better approach to addiction treatment, one that was insurance supported, profitable, and effective. The first barrier they confronted was finding a landlord who was willing to rent to them. Few landlords felt an addiction clinic would make their real estate more attractive to neighboring tenants. For much of 2014, they searched without success.
Finally, toward the end of that year, using essentially all of their available personal resources, Karlin and Beatty bought a house turned office building in Arlington, Massachusetts, and launched the first Column Health clinic. After several months of work to convert the building into a clinic, the new facility welcomed its first patient in the summer of 2015.
Karlin insists there is no rocket science behind Column Health’s approach. There is just a simple recognition that it takes a bundle of services to treat substance abuse; offering just one or two pieces of the bundle is ineffective. He elaborates:
Put all of the services necessary to get a patient to full recovery under one roof. And put the clinics in beautiful spaces—places people might want to be, instead of feeling forced to be. Coordinate the care. Use good information technology to keep patients connected to providers and providers connected with each other.
On their first visit, patients begin an intensive intake process. They spend 60–90 minutes with a psychotherapist who takes a thorough history. The history is shared with a colleague, a physician provider of medication-assisted therapy, who sees the patient next. The clinicians then collaborate on a diagnosis and treatment plan. Part of Column’s philosophy is to have at least two independent clinicians evaluating each patient, at least one of whom examines the patient with a broad lens on all mental health issues and another with a narrower focus on treating substance abuse. In Karlin’s view, treating substance abuse without addressing other mental health challenges is rarely effective.
Many patients will continue with Column’s most intensive program for the next two to three months, spending several hours at the clinic each week and seeing each of their providers. Each patient will also have a urine toxicology test weekly and will attend a weekly group therapy session led by the psychotherapists. Family counseling or couples counseling also may be added. Additionally, Column offers case management services, assisting patients with housing, food, transportation, and other personal challenges.
Many hours and many appointments—it is a big commitment for patients, and Column demands a big commitment soon after patients arrive. Karlin believes goal alignment in the very first session is a crucial step in gaining the necessary level of commitment from patients. Understanding a patient’s goal for himself or herself allows treatment to be tailored directly toward achieving those goals. Treatment is far more effective when it is explicitly directed at objectives that are meaningful to patients, whether that is improving family life or keeping a job or simply remaining free of the problematic substance. One theory that Column Health is testing is that requiring an effort to gain a strong time commitment early in treatment helps reduce the number of patients who show up with the intent to acquire a prescription for a drug that they can sell on the street. Once the commitment is made, Karlin feels the group therapy sessions are essential in sustaining the commitment. The sense of community and belonging is powerful; some patients ask to keep coming to group sessions after they have graduated to a level where group attendance is no longer mandated.
Column does not need to work hard to find patients; patients find Column—sometimes via a Google search, sometimes from an emergency room referral, sometimes through a pharmaceutical company website that promotes a particular addiction drug. The clinic sees as many substance abuse patients as it can given the size of its staff and its clinics. Intake is time intensive; there are only so many new patients the staff can see each week. Because Column’s various addiction programs do not completely fill every hole in the providers’ schedules, Column also sees a limited number of patients contending with mental health challenges but not substance abuse.
As of fall 2016, Column employed 8 psychotherapists and 10 physicians (including medication-assisted therapists and psychiatrists). To attract physicians, Column offers flexibility to work part-time. To meet the needs of patients, Column offers flexible hours that include appointments early in the morning, in the evening, and on weekends.
It is a point of pride for Karlin that Column’s clinicians are highly satisfied with their work.
We’ve trained our staff to do as much information gathering and data entry as possible before the patient meets with the clinician. The docs come in and can focus almost all of their energy on patients. We have a terrific electronic health record, so all of the information that they need is right in front of them. They do not waste time, and they also know that if they are unavailable to see a patient, another doctor can cover for them and have all of the same information.
But most critically, our entire staff are happy because our patients recover. The staff at every level, from the folks answering the phones to the doctors, see that every day. They see patients who start in darkness emerge into people who are present, happy, employed, and in a stable living situation.
If you engage Karlin in a conversation about Column Health, it won’t be long before he mentions Beatty. In Karlin’s view, their partnership works in great part because the two bring complementary expertise: medicine and business. Karlin also describes a relationship of deep trust, constant communication, and a habit of resolving disagreements quickly.
Even before opening Column Health, Karlin and Beatty were speaking with insurers about the possibility of new and nontraditional contracts for treating substance abuse. They found that insurers were eager to engage, especially with a clinic that had good data systems and could provide information about outcomes. Substance abuse was a growing problem and an expensive one. The insurers were under pressure to find better answers.
When Column saw its first patient, it already had multipart bundled payment agreements with two insurers. Column was paid a set amount per patient per month rather than a fee for each service provided. The agreements set three prices for three distinct bundles of services: high, medium, and low intensity. It was typical for patients to progress through all three bundles in sequence, from high-intensity to medium to low. The prices made the bundles profitable for Column though not significantly more profitable than traditional fee-for-service schedules. (A deeply appreciated side benefit for both parties was the dramatic reduction in paperwork and churn associated with billing.)
Karlin and Beatty preferred bundled payment agreements with all payers, but some moved slowly. A preliminary step was simply being added to the network on as many health plans as possible. The duo did what was necessary, as Karlin describes:
If an individual insurer rejected our bill, they would send a list of approved in-network providers to the patient. Our staff would get the list and call each provider on it. We end up sitting with the health plan executives saying, ‘Look, this provider’s dead, this one has moved to Oregon, this one has a waiting list a mile long, and this last one has never practiced addiction medicine. So who exactly do you want this patient to see instead of us?’
On many other calls, Karlin and Beatty explained how Column was different and how good outpatient care was far less expensive, and often more effective, than an inpatient admission. They made progress, one health plan at a time.
Early results and momentum left the partners hungry for more rapid growth. They were greatly encouraged by a few health plan providers that encouraged them to expand operations and even offered to discuss expansion planning and geographic targeting. Indeed, by mid-2016, Column had opened two more clinics in the Boston area.
Karlin and Beatty’s ambitions, however, extend far beyond the Boston area. They visualize a national network of clinics and are in conversations with investors to raise the necessary capital. Karlin may be the medical partner, but he speaks with an MBA’s enthusiasm about the possible economies of scale that a national expansion could confer. Column’s operations are technology driven and cloud based; clinics in every corner of the country could be centrally administered.
While thinking big, Karlin remains grounded in the day-to-day impact that Column is having. He tells the story of a recent patient who had just been released from his most recent jail term and had a history of dangerous overdoses. The patient was a long-term heavy opioid user; he presented with personality traits that might be labeled antisocial. In his early appointments with Karlin, he just demanded drugs in a threatening manner, suggesting that if he committed a crime because he couldn’t get the meds he wanted he’d go back to jail, that it would be Karlin’s fault, and jail was where he was most comfortable anyway.
Within a few months, he was sustaining an ability to not use substances, was employed, and had a safe place to live. He had transformed into someone who was funny and engaging and a pleasure to spend time with. One day, as Karlin and Beatty were walking up to the clinic, the patient very obviously “hid” behind a tree and at just the right moment, jumped out in front of the two and said, “Boo!” in a goofy, playful, and effectively comical manner.
Karlin’s interpretation: “He’s not afraid anymore.”