It was 2011 when Tommy McKay's family finally confronted him about his addiction. Over the course of four years, following a back injury from a car accident, the family had watched the 28-year-old take increasingly large doses of pain medication.

On the day McKay's mother and aunt finally confronted him in his home in Washington County, he broke down: He admitted he had a problem. He agreed to get treatment.

But what might have been a new chapter in McKay's life quickly degenerated into a new round of trauma for the family. As McKay's first pangs of withdrawal kicked in – vomiting, diarrhea, shaking and cold sweats – his family was told that detoxification centers across the county were full. A hospital in Pittsburgh turned McKay away because it didn't consider opioid withdrawal a life-threatening condition; a common policy among hospitals.

McKay spent a week in agony in his family's home. When he finally was admitted to a treatment center in Washington, his health insurance only covered him for three days of detoxification and 13 days of inpatient rehab – not enough time to heal a four-year addiction.

Within weeks of release, McKay began snorting heroin – which, like prescription painkillers, is a member of the opioid family. Eventually, in the pursuit of stronger highs, McKay began injecting the drug. It became a $160 per day habit. McKay stole jewelry from his family to keep feeding it. He was in an endless spiral.

"I wanted to be as messed up as I could be," McKay said.

There is never any certainty that an addict can be cured upon their first entry into treatment. In Pennsylvania, however, relapse is almost guaranteed due to systemic failures in the state's treatment system.

Owing to a complex array of public and privates interests, addicts face steep barriers to effective treatment in Pennsylvania at a time when the state is wrestling with an epidemic of opioid addiction. Certain insurers, like McKay's, are often reluctant to cover in-patient rehab and, sometimes, even detoxification. Uninsured addicts can face waits of days or weeks to get treatment through cash-strapped county offices – often ensuring they'll fall back into addiction before a bed opens up.

The result, drug prevention advocates say, is a system that costs Pennsylvania in two ways. The first cost is human: addicts who end up spiraling helplessly into addiction, tearing apart their families and potentially losing their lives. Nearly 3,000 Pennsylvania residents have died over the past five years because of opioid abuse.

The second cost is financial, borne by all Pennsylvanians. Without effective treatment, addicts such as McKay typically lose their jobs and cost the state millions in lost productivity each year. Untreated addicts are more likely to rely on welfare, commit crimes, crash cars, or become incarcerated. Meanwhile, treatment experts say, each failed attempt at treatment makes an addict less likely to seek help and less responsive to rehabilitation in the long term ­– further exacerbating the public cost to successfully treat an addict.

Deb Beck, president of the Drug and Alcohol Service Providers Organization of Pennsylvania, said it adds up to a system that fails both the taxpayer and the people who need it the most.

"What we have is a byzantine and labyrinthine set of steps that people have to take to get treatment," Beck said. "And sometimes they don't survive."

A statewide battle for inpatient rehab

One of the biggest concerns for treatment advocates is that opioid addicts such as McKay rarely get enough time in inpatient rehab to successfully quit opioids.

After a detox of three to seven days, a doctor will typically recommend that an addict spend time in inpatient rehab, followed by months or years of outpatient treatment. Within that regimen, inpatient treatment is particularly important for people addicted to opioids because of the strength of those drugs. Most need isolation from people and places that easily lead them to relapse.

"What opioids do is they rewire the brain," said Carmen Capozzi, president of Sage's Army, an anti-heroin advocacy group in Westmoreland County. "It can't be put back to normal until you have time."

There is no set prescription for how long that might be. Every addict has different levels of addiction and a varying desire to quit. However, the National Institute of Drug Abuse, a research institute for the federal government, says that stays of less than 90 days of inpatient care are rarely effective to rehabilitate an opioid addict.

But according to a PennLive analysis that involved interviews with more than a dozen treatment providers, former addicts, county officials and drug prevention advocates, opioid users are often lucky if they can get a health insurer or the public sector to cover more than 30 days of inpatient rehab in Pennsylvania – and many will get significantly less or none at all.

The driver behind that is cost. Inpatient rehab isn't cheap: It typically costs $300 to $500 per day for an addict in an average treatment center. For those covering the cost of treatment, be it the public sector or the private sector, it can appear cheaper in the short term to shift a patient from inpatient care to outpatient as soon as possible.

But, drug prevention advocates say, that short-term motivation to save money has ramifications across the entire treatment system.

The fight for self-insured care

One of the most likely groups to get inadequate inpatient rehab in Pennsylvania are the more than three million Pennsylvanians such as McKay who have health insurance through a union or company that self-insures.

Self-insurance means that an entity effectively funds its own insurance coverage for its employees rather than relying on a third party. They are particularly popular among large businesses. Most Fortune 500 companies, from Walmart to Macy's, self-insure.

For Pennsylvanian workers, the difference between a private plan and a self-insured plan will usually be imperceptible when it comes to coverage for physical health issues. But the differences are glaring when it comes to coverage for addiction treatment.

Under Act 106, a law originally passed in Pennsylvania in 1986, private insurers are required to provide minimum coverage for detoxification, in-patient rehab and outpatient care for drug and alcohol addiction.

But self-insured plans such as McKay's are exempt from Act 106 because those plans fall under federal jurisdiction. Consequently, self-insured provide limited coverage for drug addiction, treatment providers and drug prevention advocates say.

Mark Sarneso is the regional director for Gaudenzia, Pennsylvania's largest treatment provider. He said inpatient rehab is almost always a constant battle for the organization when it comes to patients on self-insured policies.

Under Act 106, insurers cover an addict in Pennsylvania for at least 30 days of inpatient rehab treatment if a doctor feels it's necessary. However, Sarneso said, on average self-insured plans cover opioid addicts for about 14 days of inpatient rehab at Gaudenzia's facilities.

Sarneso said that isn't enough time to rehabilitate.

"You can't do it with 14 days," he said.

The organizations making those coverage decisions for self-insured entities typically tend to be managed care organizations. MCOs are contracted by insurers to control costs, which often control the type and length of services that a patient receives. They are often thought of as "middle men" between a patient and insurer.

Sarneso said those MCOs are often reluctant to authorize inpatient rehab at all.

In some cases, Sarneso said, an MCO will claim that addiction treatment is not a medical necessity. In other cases, an MCO will say that a patient needs to first fail at outpatient care before it will approve inpatient care – a prescription that Sarneso said is deeply problematic because a patient likely will relapse and not seek further treatment.

"The public then views treatment as not being effective, not working," he said. "And it's really not that. There's more than enough research – drug and alcohol treatment is very effective."

Steve Roman, chief planning officer for the Greenbriar Treatment Center – which operates facilities in southwestern Pennsylvania – said in some cases addicts can't get detox at all. "Many managed care managers have taken the position that withdrawal from heroin isn't particularly dangerous," he aaid.

It's coverage decisions such as these that Greg Heller, a trial attorney in Philadelphia who specializes in bad faith insurance cases, said he believes might potentially be illegal.

Heller said self-insured entities, while not covered by Pennsylvania's Act 106, might still be breaking federal law. In 2008 Congress passed The Mental Health Parity and Addiction Equity Act, which requires health insurers to treat addiction with the same seriousness as any medical or surgical condition such as diabetes or cancer.

The problem, Heller said, is that there has been virtually no enforcement of that law at the state or federal level since its passage. For that reason, managed -are organizations, working for self-insured entities, have largely acted with impunity.

Problems still abound for conventionally insured

While the challenges are particularly steep for self-insured addicts seeking adequate treatment in Pennsylvania, addicts on conventional health insurance face barriers themselves.

For one, private plans are required to provide a minimum of 30 days of inpatient rehab under Pennsylvania's Act 106. But many insurers are reluctant to cover a stay beyond that period.

According to Sarneso, on average, a conventional insurance plan will cover an opioid addict for about 40 days ­of inpatient treatment at Gaudenzia's facilities – which, although markedly better than coverage on self-funded plans is still short of the 90 days or more that is recommended for treating opioid addicts.

"Even with Act 106 it's a fight daily and constantly to get people the time in treatment that they need," he said.

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Sarneso said some MCOs, working for private insurers, often play games to pressure treatment providers to release addicts early from inpatient rehab. Workers for MCOs will claim they don't know what Act 106 is ­– despite the law being in place for more than 20 years.

In other cases, Sarneso said, insurers will repeatedly give the wrong billing address to try to force treatment providers to miss mailing deadlines and, therefore, to shirk paying the cost of a claim.

MCOs also have ways of creating incentives for treatment centers to limit the amount of inpatient rehab a patient gets. MCOs have preferred lists of providers where an insurer effectively promises a treatment center more patients and therefore more revenue if they keep average length of inpatient rehab for their patients within a certain limit.

And while those fights and tactics happen behind the scenes, away from the eyes of most addicts and their families, they have real impacts on the treatment system.

One of the biggest impacts may be to the cost of treatment itself. Sarneso said part of the reason treatment is so expensive is that 20 percent to 30 percent of clinician time is spent dealing with insurance companies. Meanwhile, one out of five of all the organization's staff is dedicated solely to that task.

"It's time consuming," Sarneso said. "It's costly because we have to hire staff to do that."

Kay Foltz-Brown, program supervisor of outpatient service for Gaudenzia, said that those fights for treatment create other barriers.

To preempt excessive questioning from insurers looking for reasons to limit treatment, Gaudenzia, like many treatment centers, requires addicts to fill out a large amount of paperwork before they begin treatment. At her organization, a patient might need to fill out more than 16 forms – an often dizzying amount of work for an addict in the throes of withdrawal.

"It's not uncommon for them to walk out and never come back," she said. "They say, 'no, I'm not ready. I can't do this.'"

Even once they've entered the treatment system, Foltz-Brown said, an opioid addict can't wait hours, much less days, to find out whether their insurer will approve their care at various stages of treatment.

"You try to go through the channels, the appropriate channels to approve a higher level of care and by the time it's approved, the client's gone," she said. "Or, god forbid, dead."

Insurance industry responds

Sam Marshall, president of the Insurance Federation of Pennsylvania, said he wasn't aware there were concerns about insurance coverage for inpatient rehab in the state.

Marshall said he couldn't speak for self-funded insurance plans, which are handled by individual entities.

While Marshall said he wasn't familiar with the average length of stay for inpatient rehab through an insurance plan, he said it was worth remembering that insurers had limits for care for physical ailments, just as they naturally would for addiction treatment.

"We have limits on how long you can go to a hospital for a heart attack," he said. "You may only get two weeks of inpatient coverage for a heart attack. That's why it's always a question of what somebody means. Policies have limits, they are not open-ended."

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If the marketplace demands unlimited lengths of stay for inpatient rehab, that is something insurers can supply. "The question is," he said. "What's the cost?"

But Heller, the Philadelphia-based trial attorney, said the irony is that if insurance companies covered sufficient inpatient rehab when an addict needed it, they would reduce costs to themselves in the long-term by preventing the relapse of their customers and by negating other illnesses that opioid addiction bears.

"But this long-term benefit does not seem to drive insurance companies that are focused on the current fiscal year or the next quarter," he said.

The beauty of the short-term strategy of insurers, Heller said, is that they are typically able to shift the cost of treatment to taxpayers.

By failing to successfully treat opioid addicts, many will spiral further into their addiction, lose their job and health insurance, and eventually become eligible for treatment coverage under Medicaid or through county-level assistance. In other instances, they'll wind up entering the prison system, where their addiction treatment will also fall upon taxpayers.

"And the sheer brilliance of it is that it's not just insurance companies making taxpayers pay for treatment that was really the insurers' obligation," Heller said. "The insurance companies are also weeding out sick people and getting them off the rolls, which is the holy grail of making money in the insurance business."