Many private post-acute care facilities explicitly discriminate patients with substance use disorder

A new study shows that 29 percent of private post-acute care facilities in Massachusetts explicitly discriminated against hospitalized individuals with opioid use disorder, rejecting their referral for admission. Led by researchers at Boston Medical Center's (BMC's) Grayken Center for Addiction, the study showed that 15 percent of the rejections among patients with substance use disorders were denied due to a substance use disorder diagnosis or because they were being treated for opioid use disorder with buprenorphine or methadone.

These denials included documented and explicit discrimination. Published in the Journal of Addiction Medicine, the results demonstrate the urgent need to eliminate discrimination in order to ensure patients taking a medication to treat opioid use disorder get access to the ongoing medical care they need.

In 2016, the Massachusetts Department of Public Health issued guidance to post-acute care facilities in the state, advising that individuals taking buprenorphine or methadone to treat opioid use disorder who were otherwise eligible for admission could not be denied admission because of their opioid use disorder medication status. In 2018 and 2019, the United States Attorney's office for the District of Massachusetts settled with two different private post-acute care organizations for their discriminatory practices of denying admittance of patients taking an opioid agonist therapy, putting them in violation of the Americans with Disabilities Act.

As clinicians who treat individuals with opioid use disorder, we frequently encounter issues getting our patients accepted to post-acute care facilities. Given the landscape in Massachusetts, we wanted to take a look at the data to determine the reasons why this continues to be an issue."

Simeon Kimmel, MD, MA, an addiction medicine and infectious diseases specialist at the Grayken Center who serves as the study's corresponding author

Researchers analyzed electronic health record data (EHR) from BMC patients over the age of 18 diagnosed with opioid use disorder to track their referrals to private Massachusetts post-acute medical care facilities in 2018. They categorized the stated reasons for the rejections, singling out those who noted substance use or receiving an opioid agonist (methadone or buprenorphine) as discriminatory. In 2018, there were 219 hospitalizations at BMC associated with opioid use disorder that resulted in 1,648 referrals to 285 private post-acute care facilities in Massachusetts. Of those referrals, 81.8 percent (1,348) were rejected. Among those rejections, 15.1 percent were deemed discriminatory based on the reasons cited: 105 were rejected because the patient was treated with buprenorphine or methadone, and 98 were rejected because the patient had a substance use disorder diagnosis.

Of the facilities included in the study, 29.1 percent (83) had at least one discriminatory rejection based on information they included in the patient's EHR. Interestingly, the study's data showed no differences in the proportion of discriminatory rejections made by post-acute care facilities before and after the 2018 settlement between the U. S. Attorney's Office, District of Massachusetts, and a post-acute care facility organization.

"This data demonstrates a troubling pattern of explicit discrimination aimed at patients with substance use disorders who need post-acute medical care, despite the guidance from the Massachusetts Department of Public Health and being in violation of federal law," said Kimmel, also an assistant professor of medicine at Boston University School of Medicine.

The study results also show that only two of three patients with SUD referred to post-acute medical care are ultimately discharged to one for further medical treatment, including wound care, physical and/or occupational therapy, as well as medical care for other underlying conditions. This is another example of the health care system further stigmatizing individuals with SUD, creating barriers to accessing care.

"These facilities are telling us openly that they are discriminating and violating the law, and many more are likely engaging in the same practices but not documenting it as openly for us to see," added Kimmel. "We need to have more coordinated efforts to enforce the state and federal policies that prohibit these practices from occurring so that people are no longer being denied medical care."

The study authors note that future research should focus on the specific regulatory, behavioral and technical barriers that exist in order to better understand and determine the best approaches to remove those barriers and reduce discriminatory practices. The Massachusetts Department of Public Health funded an ongoing project in 2019, which provides training and technical support to increase access to medications for opioid use disorder in long term care and skilled nursing facilities.