HERRIN — The City of Herrin has a tradition of gathering to share Thanksgiving dinner with its residents and neighbors.
This year, dinner will be served from 11 a.m. to 2 p.m. Thanksgiving Day at Herrin Civic Center. Also, it's the first year in a long time that Bart Mann, the dinner's longtime organizer, wasn't a part of the day.
Volunteers have stepped up to fill the vacancy left by Mann’s untimely death in August. Darlene Floyd, who worked with Mann for 10 years, has filled the role of chairman, but said Mann did more than most people knew.
“He was such a good guy. He will be greatly missed. He didn’t only do Thanksgiving,” Floyd said. “Bart cared about the community in a lot of ways people did not realize.”
On Tuesday, Floyd rallied the volunteers and crews were working at locations across town to prepare for Thursday’s dinner.
Turkeys were roasted at the Fin and Feather Club. Preparations were underway at Herrin Civic Center, and volunteers prepared the cooked turkeys for the cooler at Herrin High School.
Floyd said most people only worry about proper cooking temperatures when cooking a bird for a family celebration on Thanksgiving Day. However, when cooking ahead of time, volunteers also have to make sure the turkeys cool down to safe storage temperatures within the proper time frame.
Cooked turkeys have to be at 70 degrees within two hours and below 40 degrees within six hours. The meat will go into ovens about 5:30 a.m. Thursday to bring it to 165 degrees by 11 a.m.
Volunteers John Burke, who cooks at Teddy’s in Herrin, Frank Brookhouse and Alice Ramsey worked skillfully to prepare the turkeys and broth for the coolers.
While they work, Mann was near to their minds.
“Bart did a lot,” Ramsey said.
Volunteers have stepped up this year, not only to fill a void left by Mann, but also to honor their friendships with Mann.
“I might have stepped up to take on everything that Bart did. I did that in honor of Bart Mann, but it takes a community to keep this going,” Floyd said.
Turkeys were cooked Tuesday. Floyd said workers were making 20 pies and 20 pineapple upside down cakes on Wednesday. The rest of the meal is being cooked Thursday morning at Our Lady of Mount Carmel and the civic center.
Floyd stressed that the meal is open to anyone who wishes to attend. Those who are less than fortunate are welcome, as is anyone from surrounding communities. Floyd said it is a great place to meet people from the Herrin area, enjoy good food and good company. Donnie Falknor will provide musical entertainment.
Floyd said some families attend, as well as people who are alone on Thanksgiving. She again stressed that everyone is welcome.
“You can get a lot of friendships at this dinner,” Floyd said. “It has really been a blessing to me.”
Floyd said it takes more than 100 volunteers working all week to prepare, set up, serve, deliver and clean up the meal. She added that it would not be possible without the generous donations of different organizations, churches, businesses and individuals in the community.
In addition to meals served at Herrin Civic Center and carry out meals, volunteers will deliver between 250 and 300 meals to those who are unable to get out.
“I really want to say thanks to the community. I don’t think people know what kind of community they live in,” Floyd said, adding that Herrin is a giving, caring community.
She believes volunteers are trying to make something good from the tragedy of Mann’s death.
“As we go through this Thursday, I would like people to focus on good things in life, like this dinner,” Floyd said. “It is good for the community to come together and be thankful.”
Painkillers are an expensive addiction, but for many users trying to quit, treatment isn’t much cheaper.
Insurance can defray much of the cost of counseling and medication to help with cravings. The Affordable Care Act, passed in 2010, made treatment for substance use disorder an essential health benefit, requiring that insurance companies cover it without yearly or lifetime limits, even for people with pre-existing conditions.
But when doctors don’t accept insurance or Medicaid, their patients find themselves in a familiar predicament — they’re stuck with an expensive draw on their money that they could have used for rent, food and a car, all essential items in maintaining a productive, and sober, life.
Patients who don’t have insurance or who use public assistance are the most vulnerable treatment population, said Tom Britton, president of Gateway Rehab, a drug rehabilitation center with locations in Southern Illinois, including Caseyville.
Gateway treated about 36,000 people in six states during the last fiscal year, Britton said, but because of what the company pays doctors, it’s common for them to maintain their own practices.
Dr. Rakesh Chandra, a licensed psychiatrist in Carbondale, started treating opioid use about three years ago after the Gateway center there called to say it wanted to work with him, he said. When he saw how big the problem was, he took an eight-hour training course and became certified to treat with buprenorphine, which helps manage opioid cravings.
“These are very fragile people who have gone through a lot,” he said.
Britton couldn’t determine how many people Chandra treated at Gateway, but Chandra knew there was more work to do, so he founded Rassik Complete Care in August 2015.
There, he treats the rest of his patients with opioid use disorder, which are capped by law at 275. Unlike Gateway, however, Rassik doesn’t accept insurance or Medicaid. Everyone must pay cash.
Because there aren’t many doctors who treat opioid use disorder in Illinois, Chandra is supplying a much-needed service for a neglected population. However, some of Chandra’s colleagues disagree with his business model and say it puts profits ahead of patients.
By accepting only cash, Chandra avoids lower rates set by insurance companies and the often slow pace of Medicaid reimbursement. But for the people who can’t afford treatment without third-party payers, it means they have to go somewhere else.
Despite this, Rassik is thriving.
“Spots fill up quickly,” Chandra said, and over the years he’s had to say “no” to a lot of people who wanted treatment because his clinic was at capacity.
After he was approved to treat addiction with buprenorphine products, which include Suboxone and Subutex, Chandra quickly reached the first-year limit of 30 patients, he said. In his second year of treatment, he applied to treat 100 patients, but those spots also filled up, so in his third year, he applied for the legal maximum, 275.
Dr. Jeff Ripperda, who treats opioid use disorder in nearby Murphysboro, said several of his patients transferred from Chandra because his treatment is too expensive. According to them, Chandra schedules a $250 appointment every two weeks, and that mandatory counseling and medication cost extra.
“I’ve not had a single patient who told me of a positive experience with this type of arrangement,” Ripperda said in an email. “It reeks of profits before patients. I see the arrangement as just another barrier to treatment.”
Chandra would not say how much treatment at Rassik costs, but he considered it reasonable.
“It’s a free enterprise system,” he said. “This is our model.”
At Ripperda’s practice, out-of-pocket fees are much lower, in part, because he spaces out appointments more, depending on how well patients are doing, and because he works at Shawnee Health Service, a federally qualified health center that works with medically underserved communities and accepts private insurance and Medicaid.
According to Rachel Rector, Shawnee’s revenue cycle director, patients with opioid use disorder who have private insurance pay $30 out-of-pocket for an office visit and another $30 for medication. On average, the most they pay out-of-pocket a year is $300, although some patients reach $500 and $700.
At the same time, Medicaid patients typically pay less than $5 out-of-pocket for appointments and less than $5 for medication, and their yearly out-of-pocket expenses mostly stay below $150 for all expenses, including appointments, medication and counseling.
“I don’t have a yacht or a vacation home in the south of France, but I am certainly making a comfortable living with my clinic’s business model,” Ripperda said in an email.
Although Rassik refuses third-party payers, the clinic states on its website that it is “happy to provide a receipt and help you fill your insurance claim forms.”
For small practices like Rassik, working with insurance companies can be hard because they have less leverage to get good reimbursement rates, Rector said. But, it can be even harder for patients, who often can’t navigate the paperwork and are reimbursed less than what they would have been had their medical providers accepted insurance.
“I’ve heard of a few clinics doing that for state employees because the state is so behind on paying its bills,” Ripperda said, referencing Illinois’ two-year budget stalemate, “but I haven’t really heard of it in any other circumstance.”
Rassik likely is not the only cash-only addiction clinic in Illinois, but rather it is part of a trend.
“Sometimes called direct pay … this sort of business model was once seen as the perquisite of rich folks and medical tourists from foreign lands,” Time magazine wrote this year. “But nowadays many of the people seeking cash-based care are middle-class Americans with high-deductible insurance plans.”
The Time story focused on a $19,000 knee replacement; however, opioid use disorder can require lifelong treatment with medication, according to the Substance Abuse and Mental Health Services Administration, or SAMHSA. A patient going to Chandra’s clinic would spend that amount on appointments alone in a little more than three years.
So far, the number of addiction treatment providers who don’t accept insurance is small enough that it hasn’t attracted the attention of the Illinois General Assembly.
“I cannot comment on the business practices of a particular doctor,” wrote Rep. Lou Lang, D-Skokie, in an email. Lang led the push for the 2015 Heroin Crisis Act, which went on to strengthen some laws to help the opioid crisis.
“However,” he wrote, “it is my view that medical people who will not serve patients in need do a disservice to the profession. I understand that the state is slow (to) pay. Nevertheless, patients who are addicted need help. I can only hope patients are finding the access they need.”
Legislative insurance committees also aren’t aware of the issue.
“(This) is the first time it’s come to me,” said Rep. Laura Fine, D-Glenview, who chairs the House’s Insurance Committee. “(But) just because I haven’t heard of it doesn’t mean it’s not going on.”
Sen. John Mulroe, D-Chicago, who heads the Insurance Committee in the Senate, also said he hadn’t heard of cash-only substance use treatment.
“(It) should be something the medical profession should be concerned about,” he said.
Sen. Bill Haine, D-Alton, the former chair of the Insurance Committee, said it would be difficult to legislate how doctors get paid.
“You’re opening up a Pandora’s box of controversy with that,” he said.
Haine recommended speaking with the Illinois State Medical Society to find out what it recommends doctors do.
The ISMS declined to comment.
The Illinois Psychiatric Society also doesn’t have a hard position on cash-only addiction treatment clinics. At an Oct. 23 meeting of the group’s Addictions Committee, some members thought that some clinics price addiction treatment too high and bordered on profiteering, but in the psychiatric world, cash-only practices are common, said Dr. Chris Stewart, the committee chair.
“That’s almost not even an issue, really,” he said.
The business model stems to the 1980s, when insurance companies put limits on mental health treatment by covering a limited number of therapy sessions, Stewart said. Even though the Affordable Care Act later abolished those limits, other issues still discourage psychiatrists from accepting insurance and Medicaid.
One includes funding: National politics are making insurance markets more unstable, so medical professionals don’t want to change their funding models if they’re about to change again.
Another reason includes the ways insurance companies sometimes manage reimbursement by requiring reviews and prior authorizations, varying reimbursement rates and even purposefully putting administrative staff on hold while they discuss reimbursements over the phone.
“There needs to be more access to treatment,” Stewart said, but lots of psychiatrists are resisting it. “The only way you change this is you get someone who sees a lot of Medicaid patients ... and they start treating with Suboxone.”
Although Chandra said he does not accept Medicaid, records from the Healthcare and Family Services Division show that he was reimbursed by the program as recently as fiscal year 2017.
He performed a psychiatric evaluation, gave a shot and later had a short bedside visit at a nursing facility. He was paid $655.38.
It is difficult to estimate the number of people who have opioid use disorder, but it is easy to see that the number of doctors who treat it is not enough.
Extensive surveys by SAMHSA show that only 11.7 percent of Illinoisans aged 12 and older with illicit drug dependence or abuse — about 29,000 people out of a total population of 248,000 — received treatment on average from 2010 through 2014. However, this estimate takes all drugs into account, including cannabis, hallucinogens, cocaine, heroin and other substances. More detailed results from SAMHSA don’t separate heroin from prescription painkillers.
Doctors often have waiting lists of people seeking addiction treatment. As of mid-September, there are just 909 medical professionals in Illinois who treat opioid use with buprenorphine, according to SAMHSA data.
Of those, only 569 Illinois medical professionals have made their contact information searchable on SAMHSA’s treatment locator website. Together, they account for 37,005 available treatment spots in the state. The other unlisted 340 doctors make up the remaining 14,155 spots. But the real number of treated patients is likely lower — just because doctors are allowed to treat a certain number of people, it doesn’t mean they do.
By comparison, tens of thousands of other doctors fail to seek certification to treat with buprenorphine.
There are approximately 44,000 physicians and surgeons with a controlled substance license, according to the Illinois Department of Financial and Professional Regulation. It is unlikely that surgeons would commonly treat opioid use disorder, but the department does not separate the two categories. Still, if just 10,000 doctors treated 30 people for opioid use disorder, it would more than cover the number of Illinoisans who depend on or abuse all illicit drugs.
Recognizing the lack of access to medication treatment, Congress in 2016 expanded buprenorphine prescribing privileges to nurse practitioners and physician’s assistants, of which there are approximately 10,600 in Illinois with a controlled substance license. If all of them took addiction treatment training, they could prescribe to 30 patients apiece, increasing the number of patient spots by another 300,000 — eclipsing the 248,000 people with all illicit drug dependence or abuse a second time.
Chandra, who said he used to hear patients called “druggies” and “junkies,” is familiar with the medical community’s aversion to treat with buprenorphine, and he estimated that today only 10 percent of patients who need addiction medicine receive it.
“(It’s) the tip of the iceberg,” he said.
For some users, it’s the high cost of treatment that makes them relapse, Ripperda said.
“Several patients have told me that their heroin habit cost them less than Dr. Chandra’s program,” he wrote in an email. “For an addict, the choice between expensive recovery and cheaper addiction will frequently lead to a relapse.”
While Chandra treats more people for opioid use than most doctors in the state, even he acknowledges that his treatment may be out of reach.
“Some of them don’t come to us because they can’t afford it,” he said.
BENTON — With mixed results from the forensic audit his office ordered in June, Franklin County Circuit Clerk Jim Muir is ready to move on as an office.
Muir said the final audit report was returned to him late last week and he came to a simple conclusion — there simply was not enough information to make heads or tails of what happened in Fiscal Year 2016.
“We got the (2013), (2014) and (2015) audits caught up then we tried to do the 2016 audit and that’s where we ran into trouble,” Muir said. “What the audit found was that there was a lack of information and material documents … needed to finish it. It’s the exact same thing that we ran into.”
The audit report was written by Kevin Tepen, a partner at Alton-based firm C. J. Schlosser & Co. In it, Tepen paints a plain picture of his team’s findings.
“It appears that we ran into the same difficulty of locating pertinent information such as files, computer reports and other supporting documents that you and the audit firm encountered in trying to locate information and close out the prior audit. Without having access to the missing information and being able to locate information we cannot be certain that funds were indeed missing and it is likely to remain unknown if there was any mishandling of funds,” Tepen wrote.
Because of this, he said his team is not able to definitively say whether further work would find illegal financial activity in the office during Fiscal Year 16.
“At this point there is doubt as to whether any additional work would reveal any significant wrongdoing. This work is very time consuming and the cost/benefit doesn’t appear to be on the positive side,” Tepen wrote.
Muir went to the Franklin County Board in June to request a forensic audit for fiscal years 2013, 2014, 2015 and 2016. Muir said he needed the audit to help his office establish a good footing moving forward — after nearly six months on the job Muir said he was still not able to complete an exit audit. The forensic audit that was approved was estimated to cost the county between $25,000 and $35,000.
At the time, Muir and Franklin County Board Chair Randall Crocker said it was possible this audit could render findings indicating more fraud from previous administrations. This is in response to the criminal charges leveled against a former Franklin County Circuit Clerk's Office employee, Kindra Eickelman, who pleaded guilty to official misconduct in 2016 for stealing more than $10,000 but less than $100,000 from the office between 2012 and 2014. She was ordered to pay $37,403 in restitution.
“I’m not saying that there has been any wrongdoing. I’m just saying that there is a mess we’ve got to clean up,” Muir said in June, adding that it would take fresh eyes, particularly those of an auditor, to clear up any questions that are lingering about the office’s previous internal record-keeping.
When Muir ordered the audit in June, he sent a letter to Franklin County State’s Attorney Evan Owens. In it, he compiles a long list of missing or incomplete files — daily bank deposit tickets for 2015 and 2016, daily vouchers for 2015 and 2016, bond reports credit card receipts/records from June through November 2016, e-pay receipts/records 2015 and 2016, monthly general ledger sheets, monthly bank reconciliation worksheets, monthly fee disbursement reports and QuickBooks transaction detail reports.
“I am sending this information to you to ask for your help in referring this matter to an independent investigator/prosecutor to conduct an investigation concerning the possible theft and/or destruction of government documents, Muir wrote in the letter.
Owens said they complied with Muir's request and the Franklin County Court appointed a special investigator out of the Attorney General's Office. However, Owens said they said they would not move further with the investigation until an audit report was prepared from an independent auditor. Owens said now that this has been completed, he will send the information to Springfield for the AG investigator's review.
Muir presented the auditor's findings to the county board Tuesday during their regularly scheduled meeting. Board Chair Randall Crocker said he was pleased with the overall experience of working with Muir on the project. He said he thinks Muir will “take what we learned and making it a positive."
As to the possibility of wrongdoing going unaccounted for, Crocker said this has been in the back of his mind for years and not just with the circuit clerk's office. However, he said the recent audits have put Muir in a good place to move forward.
“I think this here puts Jim in a lot better position to monitor all that,” Crocker said.
After Tuesday's meeting, Muir said he has been incredibly pleased to work with the board. He said coming in as a "novice," the board has been a pleasure to work with as he got his bearing in his new position.
Muir said he and the county have done the best they could to get the office in compliance and wants to move forward.
“It’s troubling to me what happened but we are moving on,” Muir said.
Muir said though he is disappointed there couldn’t be a more solid result from the audit, he is proud of the work he and his office have done in the last year. Muir said the office’s revenue will come in at about $161,000 for the year.
“We beat last year $13,500 a month,” he said, adding that the comparison was apples to apples — there haven’t been any big fee increases or the like to throw off the numbers. Muir attributed this to a competent staff and even more simply, just “ watching what’s going on.”
Key to this success Muir said has been Cathy Dial, his office’s bookkeeper.
“She’s invaluable to me,” Muir said, adding the he is pleased with his entire staff and how the performed during such a stressful year.
With the end of year approaching though, Muir said one thing can be counted on — his audit will be “very good” and be done right as well as on time.