Body Brokering: Less Outrageous Than It Should Be
The addiction treatment industry is known for a number of unethical and illegal practices. Today we're looking at "body brokering," also known as "patient brokering," because it is getting Mainers' attention for what to my knowledge is the first time.
Body brokering is providing money or in-kind inducements, to an individual or a business, for referral of a patient. It is a form of "kickback" health care fraud and seems to have spread in addiction treatment since insurance plans became required to cover it as an essential benefit (in 2008 and 2010 federal legislation). At its most predatory, it looks like brokers approaching people in evident distress and promising them free travel, food and lodging en route to a luxurious treatment program somewhere far from their current location. If the patient agrees, the "treatment program" (which may not even exist) starts billing their insurance but never provides appropriate care, or any care at all. No support or transportation back home is provided at the end of "treatment," which may come abruptly whenever the insurer discovers the fraud.
I first heard of body brokering more than ten years ago, in context of Florida's infamously sleazy addiction treatment culture. Last year an episode of We The Unhoused (podcast) explored the lived experience of being brokered in California. And last week, beginning with Bangor, we learned it is happening in Maine.
Obviously, this is disgusting. But as with so many other crimes and scandals, the most disturbing aspect is the normal(ized) political, legal and economic context: the conditions that gave rise to the depravity and ensure that it will keep happening. To elaborate, here are some excerpts from the Portland Press Herald (linked above), with my annotations.
(The director of a street outreach program and shelter in Portland) said clients are vulnerable to scams because they don’t have enough access to resources or safe shelter, leaving them in a position to be preyed upon. He said many people want to get help for substance use disorder but don’t see a clear pathway that includes housing and treatment that is accessible and affordable.
Correct. And in my experience, addicted and unhoused people are exceptionally alert to strangers and the risks they pose, because they are constantly making real-time calculations for their own safety. We should read people's willingness to hop into a car with a purported outreach worker who won't even give their full name or employer as a sign of desperation, not naivete.
The Statewide Homeless Council is advising community groups to encourage clients, if they are approached for out-of-state placement, to instead connect with Maine service providers. The council said in its announcement that local providers “play a critical role in helping people navigate treatment options, access recovery supports and connect with appropriate care.”
First of all, the term "out of state" keeps showing up in Maine authorities' alarms about body brokering. This reflects how problems in Maine are always blamed on contamination "from away." Everyone and everything needs to come from Maine and to stay in Maine. In this case, "out of state" implies that providers in other states are automatically suspect...and that providers in Maine are all above board. Neither is true.
And do you see the contradiction between the second quoted paragraph and the first? This isn't a gotcha since these statements come from two different sources. But check it out: first we hear that people submit to brokering because they can't access housing or treatment, then we are told that people should contact local providers to get their needs met. Wouldn't it seem that they already exhausted the more obvious local options, hence their desperation?
I suspect the fundamental problem is the long-term, now almost complete shift away from residential addiction treatment. This is a complicated story that could make a post of its own, but to summarize: residential care– where you are provided a bed, food, and medical monitoring along with psychosocial treatment– tends to have long waitlist for Medicaid patients, and may not be accessible at all without insurance. Instead everyone is funneled into counseling-based outpatient programs like the ones I have worked in. Theoretically, this is to provide patients maximum day-to-day autonomy, but it is also definitely to save insurers money.
Outpatient may be ideal for people with stable housing and material conditions. But for those without, it means an expectation to consistently show up at the program office while potentially hungry, lacking needed medical care, and living outdoors. This is why urging desperate, unhoused people to contact Maine providers rings hollow to me. The only quickly accessible referral will be to an outpatient program that can't meet these people's needs, and they know it. They may well even have already attended such a program.
Rosalie Genova
Warnings about body brokering also tend to associate it with for-profit treatment organizations only. But I think we should examine all quid-pro-quo referral systems throughout the industry, including in nonprofits. (Nonprofit treatment agencies' business structure tends to be indistinguishable from for-profits anyway; I have worked for both.) Here are some practices reported with body brokering and analogues I've seen in legal, respectable, and nonprofit work contexts:
False promises: Treatment marketing often bears no resemblance to what a facility actually offers. The most common lie is about how much individualized attention the person will receive– just the same as how body brokers often deceive their victims. The promises made to desperate families of people with addictions can also be grossly manipulative: We can save their life. We can change them forever. You can stop worrying.
Expected exchange for referrals: In my experience, treatment organizations who send referrals very much expect referrals in return. It's not cash kickbacks, but it's not all that different either? When "Amy" relapsed as my outpatient, I was chastised for not referring her back to the (upscale nonprofit) residential facility from which she had come. Yes, we could say they offered "continuity of care" since she had already been there. But Amy herself wasn't asking to go back– or to go anywhere. The facility just felt they had dibs on her for another round of residential billing.
Encouraging patients to use drugs to qualify for care: This might be the most upsetting ploy of all: body brokers reportedly telling people to resume drug use or to use particular drugs to qualify for their programs. But the same thing happens in regular nonprofit treatment admissions. My patient "Zach" needed opioid detox but had to "show up drunk" because only alcohol detox was covered by his insurance. My patient "Carrie" was told her date of last drug use was too long ago to qualify for residential, but she could get in by demonstrating new use. So she used drugs on command at a time when she didn't want to. Carrie did then go to residential and complete treatment, but think of all the other ways that story might have gone.
One can hardly be too cynical about patient recruitment in addiction treatment. People whose lives are systemically devalued are being moved around like game pieces. I certainly urge everyone to be alert to body brokering and to warn people you know who could be targeted. But the system-level problems it illustrates are accepted and normalized, and I wish people were more concerned about that.
