A snap decision by Google has begun to reshape the drug treatment industry, tilting the playing field toward large conglomerates — the precise opposite outcome Google had hoped to achieve.
The fateful decision was made September 14. Google faced pressure from an exposé in The Verge released a week earlier, documenting how shady lead generators game its AdWords system. High-cost ads based on rehab keywords referred users to phone hotlines that gave the impression of being independent information services, but were actually owned by treatment center conglomerates. Representatives, who reap large fees based on how many patients they sign up, employ high-pressure sales tactics to push people into their favored facilities, whether or not that facility is the right one for the patient.
This deceptive marketing can lead to substandard treatment and massive overbilling. It also made lots of money for Google, which was shown in the story actively courting addiction treatment advertisers.
And so Google made a quick call: It effectively stopped running ads from treatment facilities. At first blush, that may look like a happy alignment of the public good and a company’s need for good public relations, with Google taking a hit to make the world a better place in the midst of an epidemic.
But the problem of economic concentration is so deep in the United States today that peeling back one layer merely reveals another. Without ads, addicts or their parents are left only with the organic search results.
Guess who wins those?
It’s not Ben Camp. He’s the CEO of RehabPath, which bills itself as a resource for addiction recovery, connecting patients with quality treatment information. Camp has been a longtime critic of the fraud rampant in the treatment industry and felt that Google was operating from the right impulse, but got it wrong — to the detriment of smaller facilities.
“I think Google made a mistake,” Camp told The Intercept. “They’re putting rehab centers out of business that are doing good work. And if they come back in a month and say, ‘We figured this out,’ the centers will say, ‘Thanks, but we’re out of business now.’”
Addiction recovery during the worst drug epidemic in American history is expected to generate $42 billion in business by 2020. Insurers are required to cover substance abuse treatment under the Affordable Care Act, and some stays can cost up to $60,000 a month, making every patient extremely lucrative. And the majority of addicts or their parents — 61 percent, according to Google’s internal statistics — use the internet to find help.
The first click on that path is usually to Google, giving the search engine tremendous influence over how America responds to a public health emergency. Google ads gave preferential treatment to whomever paid the most, regardless of the standard of care. Kenneth Miller, who worked at community treatment centers in Florida for a decade (and, full disclosure, is my cousin), said his facility “spent an insane amount of money on advertising, specifically through Google. They used to give us flash drives with the Google logo on them.” Some facilities were spending $1 million a month on this type of advertising.
Many of those ads steered addicts to woefully substandard facilities that were little more than vehicles for insurance and Medicaid fraud. That’s been widely known and was even the subject of the industry’s 2016 conference.
But The Verge article touched a nerve, and Google responded by stopping all AdWords marketing for addiction treatment, a blanket policy that froze out every treatment center — good and bad. “We found a number of misleading experiences among rehabilitation treatment centers that led to our decision, in consultation with experts, to restrict ads in this category,” said Google spokesperson Elisa Greene in a public statement at the time of the announcement.
Screenshot of google search for “rehab treatment” with ads as results on Sept. 22, 2017.
Today, that restriction mostly remains in place. You can definitely find paid ads if you use certain obscure combinations of words in searches; Google has described the change as a gradual process. But a Google search for “drug rehab near me” yields no links with that ubiquitous green “Ad” box in front. It just shows organic search results, listing treatment centers in your area, as well as third-party referrers and locators.
The problem is that organic search is often dominated by the same sketchy treatment chains that were buying up the ads, because when it comes to search results, scale almost always trumps quality — and now the conglomerates no longer face competition from decent centers that were losing on search but at least could buy ads.
“Almost any result you find with a neutral query has some sort of tie-in,” Camp said. He gave the example of Rehabs.com, the top listing under Google Maps in the generic search The Intercept tested. (Test it yourself: Type in any combination of addiction-related keywords you can think of into Google, and Rehabs.com won’t be far from the top.) The website runs what appears to the consumer to be an unbiased, comprehensive directory of treatment facilities, with ratings, reviews, and helpful articles. Because the site has been featured on The Huffington Post, Business Insider, and other top sites, it maintains a high Google rank.
But Rehabs.com was purchased in 2015 by American Addiction Centers, a 1,200-bed conglomerate that owns 20 facilities, in a $60 million deal. In fact, AAC owns several websites with neutral-sounding names, like Recovery.org, MentalHelp.net, and Dependency.net, all through a subsidiary, making it hard to figure out what’s going on. This drives more users to its dedicated call centers, especially with AdWords out of the way and organic search as the only option for inquiring addicts.
“It’s like Consumer Reports being owned by Toyota,” Camp said.
Other companies have parroted this technique. Addiction Campuses, which owns four large facilities, also owns DrugRehab.org, another online aggregator. “Some of the people who were most aggressive with AdWords are the most scaled-out as an organization,” said Marcello La Rocca, director of Sandstone Care, which runs two substance use facilities in Colorado. “They put money into organic ratings.”
Facilities could buy their way onto the aggregator sites, but that’s a far more costly option, and one without quality controls.
Meanwhile, taking out an ad and hoping for a click is a relatively simple process for the tiny IT and marketing staffs of smaller facilities, compared to battling large players for the top of the Google rankings. “It’s hard to get patients in South Florida regardless, we have a reputation as a sewer. This will make it worse,” said Miller, who now works with a small 10-bed facility, referring to South Florida’s well-earned reputation for being a haven of fraudulent rehabs.
Google’s approach to the business of drug treatment is being crafted in consultation with the nonprofit group Facing Addiction, Google spokesperson Elisa Greene said, referring The Intercept to the heads of the organization.
Jim Hood, the co-founder and CEO of Facing Addiction, confirmed to The Intercept he’s been in regular contact with Google and applauded its interest in solving the problem. The ban on ads, he said, was a good first step, though he thinks there is more work to be done. “They’re trying to work with people who have no axe to grind,” said Hood, referring to his organization’s nonprofit status. “It’s problematical if Google turns to any player within the treatment industry. It’s a cesspool.”
Facing Addiction launched in the fall of 2015 with a celebrity concert on the National Mall and has drawn criticism for aligning itself with what’s known as an abstinence-only approach to drug treatment and recovery. The American treatment industry in general has been deeply resistant to opening itself up to an evidence-based approach, even as the medical establishment and federal regulators insist on the efficacy of medication-assisted treatment.
The medication buprenorphine has been shown in repeated studies to be a far more effective approach when it comes to length of recovery and reduction of overdose deaths, but many treatment centers remain committed to in-patient, 30-day abstinence programs developed around Alcoholics Anonymous, despite challenges in adapting the program for opioid use disorders.
Hood said his organization is still developing a consumer guide to treatment centers and that if future evidence shows the medication to be effective, he may include a section on it. But as of now, his group treats all approaches equally.
Camp decided to put Addiction Campuses to the test. He performed an organic Google search for “alcohol rehab center in Wisconsin,” purportedly looking for help for his father. The first link went to a list on DrugRehab.org of the 10 top rehab centers in the state. All of them directed users to the same phone number. So Camp dialed the number and recorded the call.
Ben Camp’s call with a helpline operator at DrugRehab.org.
For 20 minutes, the helpline operator “Jamie” persistently tried to steer him away from the Wisconsin facility he chose, claiming she could find him something better out of state. “Most of the time when you go to rehab, close to home is not the best idea,” Jamie said. “It’s more of a commitment when you get on an airplane.”
Jamie instead recommended an Addiction Campuses site in Massachusetts called Swift River — “It’s basically a resort” with a five-star chef, fitness center, and rock wall, she said. Stays at Swift River can cost $25,000 for 30 days. The facility recently went from 48 to 112 beds. The Intercept called the facility intake and asked if Suboxone, the leading medication for addiction that contains buprenorphine and naloxone, was allowed. “We prefer you get off that stuff,” the operator said, medical advice offered without knowing the situation.
When Camp pushed back on Swift River’s treatment plan, Jamie suggested another high-end Addiction Campuses site in Dallas, the Treehouse.
Even when Camp said that his father didn’t want to travel and asked if there were any good facilities in Wisconsin, Jamie said no, they catered to heroin abuse, not alcohol. Camp asked about Illinois, a neighboring state, and Jamie said she couldn’t find any open beds. “This is going to save his life,” she said, pivoting again to Addiction Campuses sites. “He needs the best possible place for him. The best might not necessarily be the closest.”
Photo: John Moore/Getty Images
The lack of AdWords means that search engine-optimized aggregators leap to the top of the page, funneling vulnerable addicts and their families to their services. That’s not only true of the organic search, but in what might be expected to be a more neutral source: Google Maps.
Google searches for restaurants or retail businesses typically show a map in the vicinity of a particular Zip code. However, Marcello La Rocca of Sandstone Care explained that business listings can be effectively hijacked by interlopers who can request changes to phone numbers, re-routing traffic to their call centers. “We’ve had our phone number changed, all our calls were getting diverted,” La Rocca said.
The hijacking scheme is nothing new: The New York Times recently ran an exposé about shady call centers for locksmiths. Indeed, the original Verge article and other news outlets have highlighted scam rehab marketers changing phone numbers in Google Maps, or renting a P.O. Box in a certain city (or even listing a street corner as an address) and using that to pop up in local search. The dumping of AdWords makes local search and Maps that much more critical, magnifying these forms of abuse. “Google needs to make sure the listings are authentic,” La Rocca said.
A Google spokesperson told The Intercept that the company has “significantly reduced fraud with treatment center listings on Google and are committed to continuing to eradicate this type of fraud on our platforms.”
While Google has been accused of waiting too long to shut down the AdWords scheme, savoring the healthy profits it provided, it claims its intentions for the crackdown after the fact were noble — which may indeed be true. But that’s beside the point: Google’s dominance in search gives it quasi-governmental power to shape how the addiction treatment industry operates. And the technology giant doesn’t have the same incentives as a government would. “They’re not trying to do evil, they’re just not aware,” said Matt Stoller of Open Markets Institute. “It’s not clear that whatever would come up in Google’s natural search is in the public interest.”
That puts a heavy burden on vulnerable individuals seeking help to make sure they’re not being scammed, forced to fact-check themselves. “How are they going to be able to do that when they’re on heroin in Ohio?” wondered Miller.
The Substance Abuse and Mental Health Services Administration maintains a treatment services directory, a neat tool that lists all facilities in an area, with detailed information and direct phone numbers. But the SAMHSA directory doesn’t rise to the top in generic searches for rehab; instead, the conglomerates have the lead. And SAMHSA does not regularly inspect the thousands of facilities on the list, so while it is neutral, it is merely a list.
Google wouldn’t comment on how it plans to handle rehab searches and advertising in the long term, referring questions to Facing Addiction. For small treatment centers that have a handful of beds and little cash flow, even a month of waiting to optimize a new system could be too late.
La Rocca, whose Sandstone Care centers are integrated with local social workers in Colorado, thinks the change won’t affect his business as much. But he worries about how patients might be affected. “There’s so much stigma and shame around folks struggling with mental health or substance use,” he said. “Google can be an important resource for families, but unfortunately unethical organizations take advantage.”
Unethical organizations are forever on the lookout for ways to exploit cracks in the system. The discovery of Russian agents purchasing presidential election ads at Facebook and now Google has created the impression that the problem with tech monopolies is inadequate self-policing leading to an exploitable Wild West online. But that’s not quite right. The size and influence of these platforms means that any decision they make carries large ripple effects and unintended consequences. Facebook and Google’s sheer size gives them the ability to influence a presidential election whether they choose to act or not — far too much power for a company to have.
And in the case of treatment centers, America has outsourced public policy on the opioid epidemic to a private, for-profit search monopoly — which may have good intentions but has no idea what it’s doing.
And underneath that, it has allowed Wall Street-funded conglomerates to hoover up small treatments centers and corner the market on a service that is needed to save lives and funded by either government or private insurance. It would be hard to design a system more ripe for a ripoff.
So if Google wants all that power — and whether it does or not, it has it for now — then with it comes public responsibility. Hood said he sympathizes with Google’s dilemma. “It’s hard to play God when there are 15 or 16,000 data points,” he said.
It might be hard but, when it comes to the lives of people seeking help for a potentially fatal disorder, Google is now God. So they better figure it out fast.
That the company took any action at all could be seen as an encouraging sign. But when asked to comment on the fact that their search results send people to the same types of call centers they hoped to shut down with their ad ban, the enthusiasm for action diminishes. First, the Google spokesperson asked for evidence that, in fact, search results were sending folks to call centers. Then, she provided this statement.
We are deeply committed to delivering useful and relevant search results to our users. A site’s ranking on Google Search is determined using hundreds of factors to calculate a page’s relevance to a given query, including things like PageRank, the specific words that appear on websites, the freshness of content, and your region.
In other words, you’re on your own.
Ryan Grim contributed reporting.
Top photo: An attendee uses a computer to sign in for the Google I/O developers conference on May 15, 2013 in San Francisco.