The Rise of the “Sunshine State Shuffle” by Christopher Dale

From Baggies to Billions: Can Florida’s Body Brokering Be Stopped?

In a state where criminals now turn patients – not pills – into profits, can one county’s fight make a difference?

Rehab. Relapse. Repeat.

Welcome to Florida, where a state that once birthed the opioid pill mill crisis is now at the epicenter of another treacherous trick: insurance scammers turning baggies of heroin into billions of dollars, one criminally orchestrated relapse at a time.

Ever the drug addiction trendsetter, Florida finds itself at a killer confluence. First, it has by far the most substance abuse providers per capita in the country. Second, it has a fentanyl epidemic that is picking off unknowing substance abusers.

Now, many of the same bad actors who fomented America’s chemical killing spree are finding another way to line their pockets, death and destruction be damned. It turns out fake pain and real addiction have something in common: the treatment is more lucrative than the cure. Enter the “Sunshine State Shuffle.”

“Rehab facilities have a financial incentive to keep patients in rehab for as long as possible,” said Alan Johnson, Chief Assistant State Attorney for Florida’s 15th Judicial Circuit in West Palm Beach. “And then, once their insurance runs out, healthcare insurance rules now incentivize return visits.”“The treatment-relapse-treatment cycle is highly lucrative,” said Johnson’s colleague, State Attorney Dave Aronberg. “Unfortunately, too many either leave the facility for the final time in an ambulance or, worse, a body bag.”

Can anything be done about it? One Florida county is at least trying.

The Fight to Clean up Clean Living

Since renamed Addiction Recovery Task Force, Palm Beach County’s Sober Homes Task Force was launched in 2016 to crack down on rehab centers preying on vulnerable victims for insurance-supplied profits. The Task Force strives to be a forward-thinking combination of law enforcement agencies, prosecutors, city and state agency representatives plus one key ingredient.

“Legitimate drug treatment providers,” said Johnson, “were a big part of getting this going. Their ability to help addicts recover is being impacted along with their industry’s reputation.”

If all this sounds like negligence rather than corruption, think again. Johnson and his colleague, State Attorney Dave Aronberg, shared examples of drug abusers being fully informed about their options upon departing a sober living facility – up to and including being handed $40 to get high, test positive, and re-enter expensive albeit fully-covered treatment.

Too often, these same patients never make it back into treatment because, considering their freshly clean bloodstream and Florida’s fentanyl-tainted drug supply, they overdose and die.

The Task Force showed some promising early results. An October 2017 article in the Palm Beach Post notes that, in the previous eight months, 28 owners and operators of drug treatment centers and sober homes had been arrested for buying and selling insured people with substance use disorder. Seven had already plead guilty upon the article’s publication, which also discussed a tactic common in narcotics law enforcement: dangling lower legal penalties to those willing to expose and testify against fellow bad operators.

The Task Force has recently expanded its focus to include facility-adjacent players such as pharmacies, physicians and even drug-testing laboratories.

“It’s incredible how far the fraud reaches,” said Johnson. “For example, we’re finding drug-testing labs running unnecessarily comprehensive tox screens to dramatically increase their billing. For instance, testing for caffeine and nicotine, neither of which are relevant in a drug recovery setting.”

As the Task Force evolves, Aronberg and Johnson have suggestions on both improving rehab facility ethics and reducing overdose deaths.

One approach is something Johnson calls a “longer-term, lower-level” model of addiction treatment. In essence, Task Force officials are currently working to convince insurance companies and both state and federal government entities to reimagine successful patient care.

“Our current system commits all the resources in a short-term treatment plan – inpatient rehab, intensive outpatient programs, etc,” said Johnson. “The problem is that is takes far longer to recondition an addict’s brain, and too many find themselves prematurely back where they began – unsupervised and with drugs readily available.”

Unfortunately, body brokering is encouraged by unintentional consequences of the 2010 Affordable Care Act, which gives substance abusers guaranteed coverage despite preexisting conditions. The ACA also eliminates per-diagnosis limits – meaning they can cycle through rehab indefinitely while the facilities make unlimited profits.

Both Johnson and Aronberg contend the current system contributes to relatively low rehab success rates, and that meting out resources on a flatter scale – a year’s worth of mentorship and “keep ‘em honest” tox screens, for example – could prove more effective. And since treatment regimens would be longer, the incentive for rehabs to continuously recycle relapsers into fresh monetary windfalls would significantly diminish.

Extending to rehabs the type of performance-based payment incentives enjoyed by hospitals and other traditional healthcare institutions would be a logical next step. Just as the goal of a cardiologist should be to keep his patients from suffering another heart attack, rehabs should be rewarded when its patients avoid relapse.

Further, making these results trackable would provide a clearer idea which rehabs are effective and which, potentially, are simply printing money on the backs of people with substance use disorder. Currently, sober homes are not federally regulated, and many states don’t have regulations or even licensure requirements. The Task Force would like to see that change in Florida and beyond. Restaurants get cleanliness scores; rehabs should as well.

Aside from facilities, Aronberg and Johnson contest that another simple yet politically tricky step could reduce overdose deaths: fentanyl testing strips, which are currently considered illegal drug paraphernalia in many jurisdictions.

“If you could walk into a pharmacy and buy a simple testing strip to determine whether the drugs you’ve purchased contain fentanyl, lives could be saved,” Johnson said. This approach acknowledges addiction rather than endorses it. An addict can’t get clean if he’s dead in the gutter.

There’s no tidy endgame here. People will continue dying, and criminals seeing dollar signs will always find other angles that hide behind veils of legitimacy. However, like recovery itself the idea is progress rather than perfection. Aronberg sees the Task Force’s role as providing some much-needed fluidity that allows law enforcement to stay current to the ever-evolving landscape – all toward the goal of harm reduction and lower overdose deaths.

“We’re not solely looking at this as prosecutors,” said Aronberg, “More than anything, we look at this as saving lives.”

All this is a noble effort. But the heroin-fueled headwinds may be too much to overcome.

Dirty Needles in a Haystack

Palm Beach County DA is fighting an uphill battle without sufficient weapons. Laws counteracting body brokering are sorely lacking, as is the political will to enforce them.

Shamefully, most states don’t even have body brokering on the radar, let alone the legislative agenda. While insurance fraud is, of course, a crime recognized by everyone, rules specific to rehab facilities and sober living homes are few, far between and largely toothless.

Florida’s rules are stricter than most, but still not nearly strict enough. Its Patient Brokering Act makes body brokering a felony with a minimum $50,000 fine – a drop in the bucket considering the lucrative practice. Another brokering hotspot, California, has a much weaker law that merely gives the Department of Public Health the authority to penalize licensed facilities and certified programs and counselors, with no specified fines.

The federal government isn’t helping much either. Despite what some described as “sweeping” opioid legislation from the Trump administration in 2018, 18 months later the number of prosecutions brought for patient brokering was exactly zero, per the Department of Justice. In 2021, a case was finally brought against Dylan Walker, who faced SIXTY-TWO years in prison – one for each count of body brokering.

The outcome? A plea deal with NO JAIL TIME and a $250,000 fine, which he easily forked over because, well, crime pays.

According to Johnson, The Sober Homes Task Force has made about 120 arrests since its inception, with 91 convictions. That’s a start… but it’s only putting a dent in a seemingly impenetrable problem. It’s clear far more resources are needed.

Among these are a clear, cohesive certification system for rehabs and sober living homes. In fact, despite being at the problem’s forefront, Florida has no firm licensure rules. In 2015, then-governor Rick Scott initiated a voluntary certification system through the Florida Association of Recovery Residences. But dissuading billion-dollar fraud with voluntary measures is like asking wolves to stop eating sheep.

Outside Florida, as of August 2021 six other states – Maryland, Massachusetts, Missouri, Rhode Island, Pennsylvania and Illinois – had begun voluntary certification programs of their own. Wolves, meet sheep.

Just three states – Arizona, New Jersey and Utah – require some form of official certification.

Like the opioid crisis before it, America is waking up to the burgeoning big business of body brokering way too late and far too tepidly. Penalties must stiffen. Treatment regimens must become less luringly lucrative. Healthcare laws must be altered to reflect a new reality. Certification systems must go from an optional maybe to an operational must.

There is little time and lots to do. Should we fail, we’ll likely look back on this period in patient brokering with the same question the decades-old opioid crisis now evokes: “How did we get here?”