As the executive director of a harm-reduction facility in the heart of Denver, Lisa Raville interacts with substance users constantly. Ask her about the state of inpatient treatment in the metro area, and she'll laugh, as if you asked her about a stairway to the moon.
Ask Julie Taub, an addiction medicine physician at Denver Health, about how often she gets patients into inpatient treatment, and she'll talk for 10 minutes uninterrupted about the impossibility of it. Three patients in three months, she'll say, and one of them required the rare use of involuntary commitment.
"At least half of the people I see are begging to go to treatment," she said, adding that 99% of the patients she sees in Denver qualify for inpatient rehab. "Some of them literally are begging. 'Don't send me back to the street, Im going to die, I'm going to keep using.'"
Bobby Harr is a case manager for the Colorado Coalition for the Homeless; he primarily deals with clients who are on or eligible for Medicaid, which 18 months ago began covering inpatient substance-use treatment. When a client comes to him ready to seek treatment, Harr will begin working through the short list of facilities that take Medicaid.
"By the time you get to the final list, it’s pretty small," he said. "You want to be pretty trauma informed, you want to give folks options. But there’s not a lot of options, not a lot of choice."
"If you have money, if you have programs, there’s all sorts of fancy stuff for what you can be doing," he continued. "All of it sounds very nice. But for us, it's 'Which is going to be the least uncomfortable for you,' instead of 'what's the most comfortable for you?'"
As Colorado, like the rest of the nation, grapples with an alarming increase in fatal overdoses, experts say the state has an understaffed and underfunded treatment system. While most people with substance-use disorders don't need inpatient treatment, those that do - particularly those on Medicaid - face significant barriers to entry here. Many spend anywhere from four to eight weeks on wait lists. Some stays are downgraded after as little as a week after subsequent Medicaid reviews.
The Denver Gazette spoke with more than 30 physicians, treatment providers, people in recovery, case workers and other experts to better understand a critical aspect of the treatment landscape in Colorado. Though many said the problem was improving, none said the system was sufficient, and nearly all told a consistent story of frustrating delays, missed windows for desperately sick users, and a system that needs money and personnel.
Many providers said Medicaid payments are too small to be economically viable for facilities with the most expansive services. As a result, some of the best inpatient treatment facilities in the state - costing tens of thousands of dollars - take few or no Medicaid patients. Meanwhile, some of the facilities that take an unrestricted amount of Medicaid patients make do with less.
The base problem - not enough beds, staff or money - predates Medicaid's arrival into the space. It also predates fentanyl, and many of the providers expressed frustration at the legislature's decision to spend hours debating incarceration, rather than improving the systemic problems limiting evidence-based solutions.
One current fentanyl user, an unhoused woman named Amber, referenced comments by legislators that the threat of incarceration would motivate users into treatment.
"OK," she said, "so where is it?"
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Substance-use treatment is a multi-layered, complex flowchart. How and where a person moves on that chart depends on a multitude of factors: What's their goal? What's their medical or behavioral health needs beyond the substance use? How long have they been using, to what extent, what substances? Have they had success or setbacks elsewhere before?
Experts said most people with substance-use disorders succeed with outpatient therapy. Fentanyl or heroin users can get medications like methadone or Suboxone to cut down on cravings and withdrawals; when that's paired with therapy and social support, medication-assisted treatment becomes the gold-standard for addressing opioid use. There are medications for alcohol users, too, and experts are hopeful that the equivalent top-tier treatment for meth users will become more available soon, too.
For opioid users, access to methadone or Suboxone is somewhere between acceptable and good, experts said, particularly for those living in the metro area. The needed social supports are tighter, depending on whom you ask. While there are strong frustrations with medication access - methadone remains tightly controlled - providers said that most users who want to start on a medicine can do so relatively quickly, regardless of income level.
For low-income patients for need higher levels of care and support, inpatient treatment is far less accessible. For a time, it was chiefly available through the criminal justice system, providers said, meaning many users had to be arrested before they could get access to inpatient treatment, something more broadly available at higher levels for privately insured or wealthier Coloradans.
It's a longstanding problem, and in January 2021, the state took a significant step to address it: Medicaid began covering inpatient substance-use treatment. Cristen Bates, the state's interim Medicaid director, said that Colorado went from zero providers in December 2020 to 56 now.
It's undoubtedly an improvement, experts said. But significant gaps remain. The reimbursement is too low to incentivize many providers, experts said, and the administrative burden is heavy, too. Jim Geckler, the CEO of the treatment provider Harmony Foundation, said he looked at joining the Medicaid program when it first launched.
"The documentation and the billing is very hard, and the reimbursement rates are really terrible," he said. "From a provider point of view, it’s really not enough to pay our staff. ... We hate to talk about revenue compared to mission, but it’s a reality of what we have to do. We have to keep the lights on."
Geckler said Harmony charges $1,000 a day for treatment. Private insurance covers between 60% and 80% of that daily cost. When he looked at the Medicaid rates last year, he said, they covered about 25%.
According to the state's Medicaid reimbursement rates, a provider gets paid a little over $15 for an hour of group drug or alcohol counseling. Individual or family therapy is roughly $25 per 15 minute period, and case management is reimbursed at $8.04 for the same time period.
The result trickles down: Fewer providers, like Geckler, are willing to take Medicaid for inpatient treatment.
"If you're privately insured or have $30,000 or your family has $30,000, you can find a treatment bed," said Sarah Axelrath, a physician who works for the Colorado Coalition for the Homeless. "The beds are there. The programs are there. The funding is not there."
Wait lists follow. Nearly every provider interviewed for this story said wait lists of at least six weeks are common for Medicaid members trying to get into inpatient treatment. For patients who are unhoused, any delay is significant, and inpatient - plus step-down residential care - is critical to get them off of the street and into supportive environments. Providers said they desperately want to capitalize on the moments when a patient is ready and in their care.
Rob Archuleta, the chief officer of operations and innovation at Crossroads' Turning Points, which offers inpatient treatment to Medicaid patients, said that bottleneck can be primarily attributed to delays in assessing patients before they get in the door.
The situation is further complicated for patients who have substance use and medical issues. While more expensive, fully private treatment facilities have physicians and medical staff regularly on hand, other providers, with less financial reserves and fewer resources, are hesitant to take more complicated cases. Some facilities are resistant to keep patients on methadone because of its higher regulatory burden, despite it being required by law, several providers said.
"If we see a person that is medically or psychiatrically sick, even mild or moderately, and they meet the criteria for residential treatment for their addiction and they are on Medicaid, it is death sentence," Taub, the Denver Health physician, said. "Because they aren’t going to get treatment. Ad they’re going to die of their disease because they’re not going to get the treatment they need."
For patients who do get in, stays are often cut short, Archuleta and several other providers said. Providers must repeatedly demonstrate the patient has a medical necessity to be at a certain level of care, and Medicaid and private insurance will re-evaluate and move patients if they determine they're stable.
Archuleta and Jacob Frye, of Sobriety House, both said their teams will try to find ways to continue paying for a patient's stay if Medicaid determines they don't meet the criteria after a short stint. Archuleta said providers used to know they'd have patients for 30, 60 or 90 days. Now, it's a constantly moving target. West Pines, a Wheat Ridge-based treatment center, now centers its programming around a 14-day stay, an official there said.
"It's good and bad," Archuleta said. "It’s helped our clinicians sharpen our skills. It’s bad because it does put us in a box where a lot of people could perceive us as letting Medicaid dictate treatment."
Frye said that the opioid crisis, and particularly fentanyl's introduction into it, have worsened what's been a longstanding problem: More people now need higher levels of care than before.
It's unclear, providers said, how a patient could qualify for the highest level of care on day one and then qualify for something lower a week later. Taub said sending patients to lower levels of care too early will just cost more money while hurting patients.
Bates, the interim Medicaid director, explained it as a multi-faceted problem: Medicaid is a massive slice of the state's budget, and the state has to monitor those costs. Some can be explained by providers and Medicaid officials needing to work together better on assessing patients. And, she and another Medicaid official reiterated, some patients are truly ready to step down into lower levels of care earlier than might be expected from the outside.
To Bates' point about Medicaid officials working with providers to streamline the process, Frye said things have improved and that some patients are being approved for 30-day stays upfront. But others are still getting approved in seven-day increments, he said, and then providers are pressured to transition them out to a community- or outpatient-based program.
"It’s like, if somebody meets criteria for (a high) level of care," he said, "they’re not close to transitioning."
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Like the rest of the broader health care system, the treatment world has not been immune to significant staffing troubles. But that, too, predates COVID-19 and the recent workforce struggles that have plagued the rest of the industry.
In 2020, before Medicaid began covering inpatient substance-use treatment, Colorado changed regulations for staffing qualifications. As a result, many counselors - who previously could rely on hours of work in the field to substitute for formal academic training - are blocked from advancing upward. An existing crunch on substance-use counselors, physicians and treatment providers exacerbates the crunch.
The longstanding problem feeds back into reimbursement rates and the overall backseat status substance use and mental health treatment have endured in the health care field, experts said. The pay is low, the hours are long, the population difficult. Providers often come from a substance-use background themselves and are personally motivated to get involved.
"We’re in dire straights when it comes to finding people that are credentialed and licensed," Archuleta said. "A lot of people are really entering our field as a labor of love. ... I go speak at colleges to try to recruit kids, they have to be passionate about it. Looking at cost analysis, a student asked me, 'Why would I start my life with a mortgage? Why would I enter this field?'"
Rob Valuck, the executive director of the Colorado Consortium for Prescription Drug Abuse Prevention, said it speaks to the broader problem: Substance-use treatment - and substance users - have been shunted to the side in favor of more lucrative and attractive fields.
"You can get somebody who has a heart attack on Mt. Yale at 12k feet - there helicopter's there in 12 minutes, whisks them away to Colorado Springs, they have (treatment) within 45 minutes on the side of a 14-er," Valuck said. " ... We can do that with cardiology. We can't get somebody into treatment if they walk in and beg. 'I would really like to stop heroin now, can I get treatment?' 'Sorry we don't have anything for you, and you might overdose and die tonight.'"
Overall, access and availability of treatment in Colorado is improving, he and others said. There was optimism that reimbursements would improve and that other issues with Medicaid would continue to smooth out, as well. State officials have discussed efforts to improve staffing levels, and several providers said the arrival of the Behavioral Health Administration was encouraging.
Frye said the success stories he sees at Sobriety House help to balance out the cynicism he sometimes feels about the treatment field. Others similarly said the local wins help them keep moving forward.
But the frustration endures, and the road to get the state's treatment infrastructure to an adequate place is long.
"At each step, we don't do as well as we should," Valuck said. "We’re making progress. The good news is we’re making progress on a lot of these things. But progress is slow. It's hard to train the workforce. Hard to get payment systems in place, paying at a reasonable rate. It’s slow going. It’s climbing a very long hill, taking a very long route. You just can't go straight up the hill and say, 'We’ll be done in two years.'"
