Post-acute care facilities in MA disproportionately reject referred patients with opioid use disorder

Post-acute medical facilities disproportionately reject referrals of hospitalized patients with opioid use disorder (OUD), according to a new study.

The study was conducted by Boston Medical Center’s Grayken Center for Addiction and was published in the March issue of Health Affairs. It looked at more than 2,400 hospitalizations at Boston Medical Center, a safety-net hospital, and 16,500 subsequent referrals to 244 private post-acute care facilities in Massachusetts and New Hampshire during 2018.

It found patients with OUD were rejected at more than double the rate as patients without the condition. Only 6 in 10 patients with OUD were discharged to a nursing facility. These rejections likely prolonged hospital stays as they limited access to medically necessary care. There were more hospitalized patients with OUD referred than those without the condition, and yet most (83%) of referrals were rejected, compared to nearly 66% of those without OUD. 

“To ensure that people with OUD have equitable access to post-acute care, it’s critical that state and federal governments enforce guidelines on equity and that nursing facilities follow them,” Simeon Kimmel, M.D., an addiction medicine and infectious diseases specialist at the Grayken Center who led the study, said in a statement.

The Massachusetts Department of Public Health has previously put out guidance against this practice, and the U.S. Attorney’s Office has settled with several facilities over these violations of the Americans with Disabilities Act. 

Facilities that accepted OUD referrals at higher rates got more of these referrals overall and were much less likely to have high rankings according to the Centers for Medicare and Medicaid. Meanwhile, nearly a third of facilities receiving a substantial volume of referrals did not receive any for people with OUD. This is “particularly problematic,” the researchers noted, and potentially indicative that many facilities may not provide any post-acute care for these patients. 

Most patients with OUD identified were receiving medications. They were significantly younger, more likely to be male, white or Hispanic and insured by Medicaid than their counterparts without the condition. Significantly more also experienced homelessness and required infection control precautions during hospitalization, though they still had higher odds of rejection even when these factors were controlled for.

The researchers concluded that the study likely underestimates how big a role a diagnosis of OUD plays in determining referral acceptance. Future studies should examine possible racial inequities and how clinical outcomes vary by type of facility.

Stigma, lack of comfort with or expertise in treating these patients and complex regulations around medication for OUD may all be contributing factors to these findings, the authors noted. These barriers could be overcome with more education, clinical capacity and leadership, as well as better collaboration between hospitals and facilities and regulations.