Secret Addiction Treatment Shoppers Log Hard Sell Tactics At Some Residential Programs

Luxury rooms, help with travel, pressure to enroll and requests for family contact info.

These were some of the recruitment tactics encountered by callers posing as uninsured heroin users when they reached 368 residential addiction treatment programs across the U.S. seeking help. The callers documented a range of questionable practices with admissions and costs in a study published Monday by Health Affairs.

Researchers called the recruiting techniques used by 43% of the programs “surprising” and “troubling.” The hard sell often happened before callers were screened to assess their need for treatment and determine if the program might be helpful. In fact, a third of callers were offered a spot in an addiction program before they even had a clinical evaluation.

“If a hospital was admitting anyone who walked into the emergency room regardless of how sick they are, giving them treatment that may or may not help them, we’d find that absurd,” said Dr. Michael Barnett, the study’s senior author. “But for some reason we tolerate it in this residential rehab community.”

Resident addiction treatment is big business. According to the study, a national survey found nearly one million admissions in 2018. And there are calls, even during the coronavirus pandemic, to create more beds for people who want to stop using drugs. This option may not be the most effective treatment for a substance use disorder. It is almost always more expensive than an outpatient program.

"If a hospital was admitting anyone who walked into the [ER] regardless of how sick they are, giving them treatment that may or may not help them, we’d find that absurd."

Dr. Michael Barnett

Daily costs quoted to the callers ranged from $357 to $758. About 74% were told they’d have to pay up front, amounts as high as $17,434 at a for-profit treatment center. In addition, 14% of programs encouraged the callers to pay with a credit card, and 15% offered to create a loan plan, with interest. Barnett called that outrageous at such a vulnerable time in a patient’s life.

Of the rehab centers reached by the secret shoppers, 72% have national accreditation. But Barnett said these findings, combined with a prior assessment of evidence-based treatment programs, highlight the need for changes.

“We need stronger regulation of the type of care that’s provided by these facilities, and the screening of which patient is most appropriate,” said Barnett, an assistant professor of health policy management at the Harvard T.H. Chan School of Public Health, “because the typical cost of a residential rehab stay would put the average American into enormous financial debt.”

The National Association of Addiction Treatment Providers said it has been working to address many issues identified in the study.

“This has included educating our membership on best practices, raising membership standards and enforcement through our Code of Ethics, Quality Assurance Guidebook, and Complaint Process, and working to educate patients and their families as they seek care,” said Peter Thomas, NAATP’s director of quality assurance, in an email.

Addiction treatment providers say some of the problems encountered by the secret shoppers in this research would not happen in Massachusetts for several reasons: most treatment programs are non-profit, the state requires an assessment prior to admission and the state funds addiction treatment for many people who are uninsured.

“The findings on problematic practices are not surprising given what we have heard from colleagues in other states where licensing may be more lax or for-profit entities more prevalent,” Association for Behavioral Healthcare CEO Lydia Conley said in a statement.

But the study fueled questions about residential care and insurance coverage, even in Massachusetts.

“We are deeply troubled by the findings in the Health Affairs report,” said Lora Pellegrini, president and CEO of the Massachusetts Association of Health Plans, which cover “a broad range of medically necessary behavioral health care services.”

But Pellegrini added that “while patients may be directed to residential treatment facilities, such programs may not be covered by commercial medical insurance as these facilities are providing services that are primarily custodial in nature.”