Poster #13 - Closing the revolving door: The effect of state legislation on patient brokering in substance use treatment

• In Event: Friday Poster Reception

Abstract

As insurance reform increased coverage for mental health conditions and the opioid epidemic raged on, the inflow of new funding sources and increased desperation for services created a  ‘wild west’ of health care. In this expansion, unethical and predatory practices plagued expensive treatment for substance use disorder with high insurance reimbursement rates. Vulnerable patients who failed to find accessible treatment were susceptible to predatory referral practices by patient brokers. Patient brokers are independent brokers or treatment center employees who offer cash, transportation, or other inducements to recruit (often out-of-state) patients into treatment, sometimes encouraging relapse in order to generate additional reimbursable stays (Clingan et al 2024). In response to public scrutiny and the worsening opioid crisis, nine states have enacted laws targeting patient brokering and related unethical practices in SUD treatment (Garrido et al). Yet there is limited evidence on whether these laws change how patients enter treatment or improve their treatment experiences and outcomes. In this project, I seek to measure the effects of state legislative action targeting patient brokering on referral patterns, treatment completion, and evidence-based care in residential substance use treatment.I use the Treatment Episode Data Set–Discharges (TEDS-D), a national dataset of discharges from substance use treatment facilities, covering 2014–2023. I use an event study approach to exploit staggered adoption of state patient brokering laws beginning in 2017. The model uses the Sun and Abraham estimator, with state and year fixed effects and standard errors clustered at the state level. Outcomes include referral source, treatment completion, and receipt of medication-assisted treatment among patients with opioid use disorder. Together, these measures capture whether the laws alter potentially brokered pathways into treatment, improve retention, or increase access to evidence-based care.Preliminary findings suggest that these laws have not produced detectable changes in proximate treatment outcomes. I find no clear evidence that state patient brokering laws reduce potentially brokered referrals, increase treatment completion, or improve receipt of evidence-based treatment. These null findings are consistent with the possibility that formal legislative changes alone are insufficient to alter treatment market behavior in the absence of robust enforcement, monitoring capacity, or broader changes in treatment system oversight (Davoust et al) . They may also help explain why prior work has found limited effects of these policies on downstream outcomes such as hospitalization and mortality (Garrido et al 2025).These results have important implications for federalism and state policymaking. As states assume greater responsibility for protecting vulnerable populations, it is essential to understand when state policy innovation meaningfully improves well-being and when it may fail. In the context of SUD treatment, laws targeting unethical practices may be a necessary first step, but are not sufficient to improve patient experience. Effective regulation may require stronger enforcement mechanisms, data systems, and complementary oversight of treatment facilities and referral networks. This study contributes new evidence on the limits and promise of state action in addressing exploitation within a fragmented treatment system.

Author

• Nadia Bell, Harvard University
  Presenting Author