She wanted addiction treatment. She ended up in the relapse capital of America.

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Brianna Jaynes wanted help for her addiction to painkillers and heroin. She ended up trapped in a cycle that focused on running up big insurance bills and landing profitable kickbacks — not addressing her drug problem.

In 2015, when Jaynes was 20, she started her rehab search by calling a number she found through Google. The person on the other end of the line promised to get her help: She’d be fine, and she’d get into one of the best addiction treatment facilities in the country. Jaynes had little experience with addiction treatment, and, in a moment of crisis, it was exactly what she wanted to hear.

But what Jaynes didn’t know is that she was speaking to a broker who, despite his claims, wasn’t working with the best treatment facilities. Instead, she later found out, he worked with facilities that had promised him a kickback for sending them patients. The facilities, in turn, would bill the patients’ insurance for thousands, if not tens of thousands, of dollars.

Over the next six months, Jaynes went to more than a dozen treatment facilities in South Florida. Many of these places lacked basic forms of treatment; some allowed rampant drug use within their walls, including by staff. In one case, a staff member sold Jaynes drugs. In others, she was given drugs in exchange for going to certain facilities. Jaynes didn’t pay for the facilities herself, but her insurer, Independent Health, paid treatment providers more than $100,000 between December 2015 and May 2016, according to her insurance records.

Jaynes over time realized it was all wrong, she told me during an interview in her home near Buffalo, New York. But in Florida, a state that was new to her, and navigating a complicated addiction treatment system she was unfamiliar with, she tried to follow the lead of people — these brokers — who seemed to know better and seemed like they really were trying to help her. And as a person addicted to drugs, it was hard to get away from an environment awash in pills and heroin, much less get into sustained recovery.

Eventually, though, Jaynes had enough and went back to New York. But the experience scarred her — leading her to further drug use and crime before she began her full recovery later in 2016. “After Florida, I was so fucked up mentally,” Jaynes said. “I didn’t give a flying fuck what happened. I didn’t care.”

The scheme Jaynes and her then-boyfriend, Shane, were caught in was so common that it now has a name: the “Florida shuffle.” On the front end, treatment facilities in Florida paid brokers to refer patients with good insurance, finding patients through 12-step meetings, addiction conferences, phone hotlines, and online groups and encouraging them to get help in Florida.

Then the treatment facilities, many of which offered subpar treatment or none at all, cashed in themselves by charging the patients’ health insurance plans. Meanwhile, patients were led through a quagmire of treatment facilities and sober homes without ever getting real help. As Shane, who asked I not use his last name, told me, “I was using my insurance card as a hotel key.”

The scheme transformed South Florida from the “recovery capital of America” to, as some experts described it, the nation’s “relapse capital.” Jennifer Napolitano, owner of the sober home Full Circle Recovery (which Jaynes went to), told me, “It combusted overnight. People were dying on other people’s lawns. People were getting rolled out of cars. People were getting rolled in front of the hospitals.”

Khary Rigg, a behavioral health services researcher at the University of South Florida, argued there was a profit motive for patient brokers and treatment facilities to perpetuate a cycle of drug use: “The financial incentive is to get them to use, have a positive urine test, then now they can go back to the treatment center, and the [broker] or sober home owner gets a kickback from the treatment center.”

At least two of the facilities that Jaynes went to were shut down by law enforcement, in part for brokering and allowing drug use, and at least eight others closed for unknown reasons. And Congress, Florida lawmakers, and local officials have taken some steps to crack down on the shuffle by strengthening laws against patient brokering.

But experts, advocates, and providers argue that the shuffle remains a problem in much of Florida, with several telling me that officials have so far only caught the “low-hanging fruit.” They also warn that the shuffle and patient brokering more generally could spread to other states as long as addiction treatment oversight, regulations, and their enforcement remain weak nationwide, leaving room for bad actors to take advantage and bilk addiction patients in crisis for profits without providing anything close to evidence-based care.

“The Florida shuffle isn’t the Florida shuffle anymore. It’s just the shuffle,” John Lehman, a consultant for the research agency Recovery Outcomes Institute, told me. “I think these bad guys are looking for a home. There’s money to be made here.”

How the Florida shuffle works

Jaynes had struggled with addiction for years. She had respites, particularly when she got pregnant with her daughter and then started a career in nursing. But she gravitated back to opioid painkillers and, eventually, heroin. In late 2015, she had enough. She called a hotline, getting led down to Florida — for the first time — by a patient broker.

Jaynes recalled the broker, who she knew only as Justin, telling her she needed a positive drug test to be admitted: “Go ahead and get high tonight,” she recalled him saying. “Do whatever you got to do.”

After a failed stint at the Gardens Wellness Center Detox in Miami, which is now shut down, she went back to New York. She quickly relapsed. In January 2016, she got Shane, her then-boyfriend, to go with her for a second try.

Over the next four months in Florida, Jaynes and Shane were approached by several brokers, who would persuade them to go to treatment facilities and sober homes around the Miami, Palm Beach, and Broward County areas by promising cash, clothes, drugs, and other free stuff. Much of this was technically illegal, but the laws were barely enforced — so brokers operated in the open on hotlines, in online groups, and at 12-step meetings and addiction conferences.

In one case, a broker directed Jaynes and Shane to Good Future Recovery, a treatment facility in Delray Beach, by giving the couple heroin and promising cash later on. At the facility, drug use was widespread. Jaynes herself would hop a fence, go to a nearby Western Union to get money, and buy heroin. She never got real treatment there.

But for the brokers and other people guiding the couple through the system, money was put above all else: By attracting patients with some freebies, the brokers could make a profit from kickbacks — in the hundreds or thousands of dollars — that they got from the treatment facilities and sober homes. Then the facilities made money by billing insurance companies for treatment that sometimes wasn’t even actually offered and drug tests that weren’t necessary or even looked at.

“I’m failing drug screenings at this place, and they are not saying one thing to me,” Jaynes said of Good Future. “I’m getting tested every day to every other day. You would think they’d say something.”

Good Future was shut down by law enforcement in 2016, and the owner, Daniel Kandler, and other staff were accused of taking part in various patient brokering schemes. (Kandler’s attorney didn’t respond to a request for comment.)

But perhaps the worst of the facilities, Jaynes told me, was Safe Haven in Miami. Jaynes and Shane were driven to the facility in a beat-up car driven by two people who were “obviously high out of their minds,” she said. As they stood outside of the facility, they were unsure if they should even go in. Then, Jaynes said, a tech from Safe Haven came out and offered to get them heroin, telling them they could come inside after they got high.

For the tech, it was both personal and professional, Jaynes explained: “She wanted to make the $20 off the lick,” and the couple could be admitted with a positive drug test.

Jaynes and Shane agreed. But once inside, it was even clearer that the facility wasn’t going to help them. A former staff member, who spoke to me only on condition of anonymity, described Safe Haven as a “shitshow.” That same staff member told Jaynes, she recalled, that she needed to get out and find a place that would actually help her, warning her she’d die at Safe Haven.

Federal law enforcement last year shut down the facility for allegedly allowing drugs and fraud. According to the Department of Justice, Safe Haven submitted “false and fraudulent claims to health insurance plans for addiction treatment services that were not provided as billed and laboratory tests that were not medically necessary.” (Safe Haven’s former owners didn’t return requests for comment.)

Jaynes said that she deserved half of the blame for how things went down in Florida, telling me that she chose, at some level, to continue using drugs. Still, she argued that, at a bare minimum, treatment facilities and sober homes are supposed to try to provide a drug-free environment for people in recovery — and it’s no wonder if people relapse when drugs are everywhere.

After three months into her second round in Florida, Jaynes decided to give treatment one more honest try, calling up facilities on her own instead of relying on a broker. But nothing stuck, and she returned to New York in May 2016. Shane soon followed.

Florida was primed for the shuffle

By the time Jaynes left Florida, she had been to at least 14 treatment facilities. Ten of them have since shut down. Four are still open. Among those that remain open, only Florida House Experience in Deerfield Beach and Full Circle Recovery in Lake Worth responded to requests for comment.

Susan Roy, chief strategy officer of Florida House Experience, told me her facility disavows patient brokering. “We really have a very strong commitment to ethical treatment and to a very high level of medical and clinical care,” Roy said. “There were a lot of abuses in our industry. And there was no way to not be touched by those. And good centers just tried to hang together with one another.” (She also said Florida House Experience follows a clinical and scientific model. But the facility doesn’t offer buprenorphine, a medication that experts say is a gold standard for opioid addiction treatment.)

Napolitano, of Full Circle Recovery, took a similar line: “I pride my career on helping correct the industry that was exploiting people at their most vulnerable and their families. I’m very proud of the business that I’ve built and of the work I’ve got to participate in in improving it.”

Jaynes, for her part, said Full Circle was the only good facility she went to, because it made her go to 12-step meetings and get a job to “pay rent the right way.”

From Napolitano’s perspective, the shuffle has been horrifying — one that, in her view, was so widespread that even the better treatment and recovery facilities would struggle to keep it away.

“People would, for lack of a better word, poach clients that lived at our house — and it was really scary and dangerous when that was happening,” she said. “I knew that people that were being targeted for their insurance policies were being led to a dangerous situation, and we would do our damnedest to get them from going. But $0 a week and using drugs sounds a lot better than $200 a week and having to work a job and work steps and be sober. So it was hard to compete with that. … We saw a lot of vulnerable people exploited.”

There are reasons the shuffle took off in Florida first. The state’s southeast corridor was already widely known as the “recovery capital of America.” The warm weather and nice beaches made it inviting to health care tourists; as people repeatedly told me, no one would want to stay in cold, dreary Detroit or Buffalo in the winter when they could go to Miami.

“Pill mills,” which handed out opioid painkillers like candy and fueled much of the initial opioid crisis across the country, also once thrived in Florida. Many of these places also used patient brokering, said Rigg, of the University of South Florida: “Pill mills would pay these folks to find patients, and they would break them off $100 if they brought in a patient who’d pay cash for the visit, pay cash for the pills.”

But in the early to mid-2010s, Florida cracked down on pill mills. It’s perhaps not a coincidence, Rigg argued, that addiction treatment facilities adopted many of the same tactics as the pill mills shut down.

In the nearly four years since Jaynes’s experience, officials in Florida have taken steps to crack down on the shuffle. Dave Aronberg, the state attorney in Palm Beach County, and Al Johnson, head of the local sober home task force, have arrested and locked up dozens of bad actors in the treatment industry. The state, with the support of the sober home task force, has enacted new laws to stiffen penalties and improve enforcement for existing laws against patient brokering. The feds have gotten involved, taking the lead especially on cases of fraud, like Safe Haven’s.

“We’re very proud of our work down here,” Aronberg told me. “I believe our law enforcement efforts, our sober homes task force, has become a model for the rest of the country.”

Others are less enthusiastic. On and off the record, providers and activists said that there are still major problems in Florida. For one, Aronberg’s jurisdiction is limited to Palm Beach County — and as Jaynes and Shane experienced, the shuffle encompasses facilities in Broward County and Miami, too.

Even in Palm Beach County, some brokers have been pushed further underground but are still actively recruiting patients for treatment centers and sober homes. And the task force still meets bimonthly and regularly announces new arrests, suggesting that the problem is ongoing.

“It’s still a major problem,” Rigg said. “I don’t think this is going to be going away anytime soon unless there’s something a little more comprehensive.”

For Jaynes, the trauma of the Florida shuffle — not just the failure and hopelessness of the treatment she sought, but abuse and disregard for other people that she witnessed — set back her recovery for months after she left Florida. When she went back to New York, she relapsed again; this time, she committed crimes, including fraud and robbery, to get money to buy drugs.

By September 2016, police caught up to Jaynes, arresting her. She was placed in drug court later that year, getting addiction treatment in New York. She stopped using drugs, and the courts largely dropped the charges against her. She completed a licensed nursing program, finishing above a 90 percent average. Today, she works full-time as a nurse at Chautauqua Nursing and Rehabilitation Center.

The shuffle isn’t a problem exclusive to Florida

While Florida was the first to get national attention for its problem, many of the factors that produced the Florida shuffle are national problems. Aronberg, the state attorney, said that his office has fielded calls from other states asking for help — and some, like California and Arizona, have been motivated to change their laws.

One California group, Advocates for Responsible Treatment, argued that the shuffle is hitting the area in and around Los Angeles, particularly Orange County and Malibu. Laurie Girand, a member of the organization, said her group has tried to draw attention to the issue, but not enough has been done yet. Her organization maintains on its website a long list of problems at treatment facilities and sober homes, ranging from crimes to violence to drug overdoses.

In 2017, the Orange County Register reported that brokers in California would “troll Alcoholics Anonymous meetings, homeless camps and drug courts to find people they can send to rehab — for kickbacks from the centers. Often, when they have a prospect, brokers will call several rehab centers and seek competitive bids. Highest bidder gets the business.” This would feed what locals call the “rehab riviera.” While state lawmakers have made some changes, Girand argued the changes haven’t been enough.

The shuffle “is absolutely going on in other states” besides Florida, Girand said, citing cases she’d heard of in California, Pennsylvania, and Massachusetts. “It’s pretty much anywhere where a criminal can open a facility and call it something that it’s not and therefore get an income stream from insurance.”

One problem: In most states, addiction treatment remains underregulated. As one example, treatment facilities often don’t need even a single medically licensed professional on staff. The lack of oversight allows shady, unqualified treatment centers to open up shop with little to no supervision.

At the same time, there have been concerted efforts to get insurers to pay for more addiction treatment. But in part because insurers have refused to pay for treatment for so long, they haven’t developed standards for addiction treatment — and frequently don’t know if what they’re paying for is any good.

With the opioid crisis in the background, all of this has created a situation in which bad rehabs and sober homes can easily take advantage of patients and families in desperate need of care. The Florida shuffle took off after federal parity laws and the Affordable Care Act simultaneously expanded access to health insurance and required health plans to more thoroughly cover addiction treatment. Jaynes and Shane were able to stay on their parents’ health insurance thanks to the law’s requirement that they cover children until they turn 26.

But Richard Frank, a health economist at Harvard focused on mental health and addiction services, cautioned against blaming the shuffle’s growth on expanded access to insurance.

Insurance coverage and better regulation are two separate issues, he said, and it’s important not “to hold hostage one for the other.” In his view, efforts to expand access to health care, including addiction care, need to continue; after all, federal data shows that only 1 in 10 people with a drug use disorder gets into specialty treatment, in part due to lack of access. Separately, he said, regulators and health insurers should also do much more to hold addiction treatment programs accountable — making sure they offer evidence-based care and track health outcomes.

For decades, addiction treatment in the US has avoided the government regulations and insurance-enforced accountability measures that are prominent in the rest of health care. Treatment modalities with little to no evidence behind them, like confrontational approaches or equine therapy, have been allowed to flourish, while evidence-based care, like medications for addiction, is widely rejected. A common quip I heard as I reported this piece is that all it takes to open a sober home in most of the US is to hang up a sign at your front door claiming to be a sober home.

And although regulators and insurers closely track outcomes in traditional health care facilities and use those outcomes to decide what treatment is working and worth paying for, the majority of treatment facilities in the US don’t track even the most basic results of their approaches on a consistent basis — making accountability difficult if not impossible.

“Part of [insurers’] job is playing the unpopular role and saying ‘no,’” Frank told me. “The issue is that in some cases ‘no’ is completely justified and we should be supportive of that, and in other cases ‘no’ is basically a way of getting rid of people and that’s uncool. Making sure that we’re vigilant in distinguishing between those two is an important public policy job.”

Insurers are aware of this problem, teaming up with the advocacy organization Shatterproof to develop better standards for addiction care.

There’s also a dearth of research on addiction treatment and what truly works, particularly for addiction to stimulants. As long as that’s true, fraudsters and even well-intentioned but misguided actors will be able to pop up, promising miracle cures and treatments, said Sherry Glied, a health economist and the dean of New York University’s Robert F. Wagner Graduate School of Public Service.

“Part of the reason that we stopped having as many bogus cancer treatments is that we got better at treating cancer. Once you get better at treating cancer, there’s less incentive for people to go seek magic treatments because they’ve given up on everything else,” Glied told me. “We’re not there yet on substance use and mental health. So there’s a lot of space for charlatans to come in with all sorts of crazy things. And people are desperate.”

Jaynes’s previous insurer, Independent Health, declined to comment on the Florida shuffle, saying it needed “to ensure the integrity of current [Special Investigations Unit] investigations.” Shane’s former insurer, Empire Blue Cross Blue Shield, didn’t respond to a request for comment about the Florida shuffle.

Cathryn Donaldson, a spokesperson for America’s Health Insurance Plans, told me in a statement that “insurance providers are extremely concerned about what the industry often refers to as ‘body brokers’ who target and exploit vulnerable individuals by targeting insurance companies to bill for treatment and tests that may or may not be clinically appropriate or actually even be provided.” Insurers, she said, are working with regulators, policymakers, and treatment providers to address the issue.

To stop the shuffle from spreading, advocates demand reform

It’s unclear what, if anything, will get lawmakers to act on this issue. Congress passed a strengthened anti-kickback law in 2018 as part of broader opioid legislation. Beyond that, advocates — including addiction treatment providers themselves — have called for more regulation on and oversight of addiction treatment facilities, particularly those that receive federal funds.

“One, it involves better licensing. Two, it involves better accreditation. Three, it involves better measurement of performance,” Frank, of Harvard, said. “And then four, it also means when you put those first three things into place, and people depart from them, you have serious consequences as a result.”

But the treatment industry has resisted such efforts, and lawmakers have yet to make moves toward significantly more regulation.

Looking forward, Jaynes said she hopes to transition to a career in addiction recovery and treatment, but continues to be aware of problems in the industry like those she experienced in Florida.

While we were talking in her home, she got a phone call. Declining to take the call, she remarked, “I think that’s a patient brokering guy.” She explained that as she’s done more work in addiction recovery, she’s tried to avoid associations with treatment facilities — out of fear they might try to loop her into some sort of shuffle-like scheme. But she occasionally still gets a shady call or email.

Still, she’s trying to improve things. In 2018, her sister, Whitney, died of a drug overdose. In the aftermath, Jaynes launched Breaking Chains: The Whitney Project on YouTube to interview people in recovery and share their stories more widely. She’s also a professional public speaker, focused on addiction. And she plans to start a job as a recovery coach later this year.

For her, it’s about righting some of the wrongs she saw in Florida. But it’s also, she added, a bit therapeutic.

“You have to find something that you love more than drugs. You will love drugs more than you love anything in your life,” Jaynes said. “Once you give yourself meaning for the time being, it doesn’t make you so focused on anything else.”

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Photographs by Libby March, an independent documentary and editorial photographer, based partly in Buffalo, New York, and partly in Michigan’s Upper Peninsula.