Residential addiction treatment centers commonly request high up-front payments and admit patients before they’re clinically screened, according to researchers who posed as heroin users shopping for care, which the researchers say demonstrates the need for “greatly increased oversight” of the programs.

An article published Feb. 1 in Health Affairs presents evidence that both for-profit and nonprofit inpatient rehabilitation centers across the U.S. may be encouraging costly, questionable addiction treatment for people who might see better results from other care settings.

These findings, the authors wrote, should prompt licensing authorities to beef up supervision in order to ensure that vulnerable individuals are able to find effective addiction treatment that doesn’t needlessly break the bank.

“To our knowledge, this is the first truly national survey of addiction rehabilitation centers that shows how deeply troubled this sector is and how much it is in need of reform,” Michael Lawrence Barnett, an assistant professor at Harvard T.H Chan School of Public Health and co-author of the research, told The Academic Times.

Inpatient rehab is large and growing, according to the researchers. Studies show that rehab care now accounts for over 25% of national spending on substance use treatment, and centers nationwide admitted almost 1 million patients in 2018.

That rise is puzzling — and potentially worrisome — given that it isn’t clear rehab is the best option for individuals struggling with opioid addiction, the researchers wrote. Many people are better suited to outpatient alternatives that allow them to lead more normal everyday lives, and there isn’t robust evidence that residential programs ultimately lead to better outcomes for anyone.

Medications like buprenorphine and methadone, which can be prescribed and administered outside rehab facilities, offer proven benefits for a lot less money — meaning outpatient care is very likely the better route for most patients.

“As with any intervention in medicine, we need to [consider] the cost-benefit,” Barnett said. “If someone’s going to be shelling out potentially $40,000 to get this treatment, it sure as hell must be better than having a weekly appointment with an addiction specialist [for] medicines you pick up at a pharmacy, which would be an order of magnitude less expensive if you’re paying cash.”

To get a patient’s-eye view of rehab’s costs and recruitment practices, the researchers called 368 residential programs while posing as uninsured heroin users willing to pay cash for addiction treatment. The sample included both for-profit and nonprofit centers, and represented over one-quarter of the nation’s 1,436 non-federal residential treatment facilities, they said.

The researchers used information they gleaned from their audit calls to develop a systematic picture of the sector’s admissions, financing and recruitment techniques.

Callers were quoted steep prices and frequently asked to pay up-front, according to the researchers. For-profit facilities requested up-front cash 88% of the time, with an average price of $17,434 for a 23-day treatment course; nonprofit centers requested up-front money in 50% of cases, with an average price tag of $5,712 for 16 days.

The researchers noted that for many individuals and families, these costs could be unmanageable and may trigger long-term financial burdens for people who choose to cover the cost by going into debt or tapping their families’ resources.

For-profit programs were also likelier than nonprofits to use recruitment techniques like follow-up contacts or communications with a caller’s family members, using at least one such tactic in 65% of cases.

While it’s not necessarily wrong for residential programs to court treatment-seekers, the researchers said, it may well be inappropriate if they don’t also carry out rigorous clinical evaluations. For-profit rehab centers often offered the callers rapid admission and leveraged recruitment tactics to make patients commit before screenings, a discovery they said was a red flag.

“These findings raise concerns that residential treatment programs may be admitting a clinically and financially vulnerable population for costly treatment without assessing appropriateness for other care settings,” the authors wrote.

Yet for people who may truly need inpatient rehab, including individuals with other psychiatric problems, these same programs often make it difficult for them to access care. 

For-profit facilities were shown to be more likely than nonprofits to screen out patients with psychiatric comorbidities, a form of “cherry-picking of low-complexity patients” who also happen to constitute 38% of people with substance use disorder, the researcher wrote.

“These facilities are often screening out the patients who most need [inpatient] treatment,” Barnett said. “And the reason is pretty clear: Those people take more effort and resources to take care of, and [rehab programs] just want to collect their money and go.”

Two-thirds of nonprofits didn’t offer same- or next-day service and didn’t have vouchers to defray costs, the researchers found, potentially leaving these most vulnerable individuals without a good inpatient alternative.

Facility accreditation and licensing authorities must do more to ensure rehab centers aren’t taking advantage of patients, the researchers wrote.

“I’m very confident that regulations could clean this up,” he said. “It’s really a matter of state and federal lawmakers seeing the breadth of the problems in the sector and actually demanding accountability.”

He added, “There are lots of very difficult problems in health care and social policy that are not necessarily that easy to fix with policy alone. I don’t think this is one of them.”

The article “Admission Practices And Cost Of Care For Opioid Use Disorder At Residential Addiction Treatment Programs In The US,” published on Feb. 1 in Health Affairs, was co-authored by Tamara Beetham, Yale University; Brendan Saloner, Johns Hopkins Bloomberg School of Public Health; Marema Gaye, Harvard T.H. Chan School of Public Health; Sarah E. Wakeman, Massachusetts General Hospital; Richard G. Frank, Harvard Medical School; Michael Lawrence Barnett, Harvard T.H Chan School of Public Health.