A dramatic change in how Maryland pays for substance abuse treatment programs is leaving some providers short on cash and displacing more than 200 drug and alcohol addicts, even as the state's four-year transition to a new funding system has significantly increased the number of people getting help.
Providers say they're worried that the instability will cause recovering addicts to lose their tenuous grip on sobriety when at least three treatment centers close their doors this summer, as the facilities deal with the unintended consequences of a state effort to broaden services.
State officials say providers were told about the change in 2008 in order to give them time to prepare, and many are in position to take advantage of new resources as the transition winds down this summer.
But Susan Tangires, director of Epoch Counseling, said the nonprofit learned "essentially overnight" that it would have to close its Lansdowne center, eliminate five full-time positions and shuffle some 90 clients to its Catonsville clinic. Counselors at the Lansdowne office are tapering off services and expect to close the center by August, Tangires said.
Even though the distance between Epoch's Lansdowne and Catonsville centers isn't far, Tangires said the change could be a major deterrent to those in recovery.
"Anything that makes it a little harder, you stand the chance of losing that person," Tangires said.
Under the new system, the state will pay for more treatments through Medicaid reimbursements, a strategy that officials say will ultimately provide health care access to more Marylanders. Medicaid is the federal health insurance plan for the poor and disabled, and every state dollar is matched by Washington.
By some measures, the state's new strategy is already showing success. Nearly 20,600 more people are getting addiction help today than three years ago, state officials said.
Many addiction specialists agree that the move will eventually help more people, but right now they're trying to find ways to keep displaced clients in treatment. They knew the funding shift was coming, but few realized it would arrive so quickly. Now, centers are facing the loss of millions of dollars in grants.
First Step expects to close its Randallstown and Towson treatment centers this week and shift its clients to its Reisterstown and Cockeysville locations. The drug treatment program at Sinai Hospital is scaling back its services, and Gaudenzia's residential treatment center in Owings Mills may have to shut down.
The idea behind the funding change is that facilities would make up for the cuts by billing Medicaid, but providers say they're not able to recoup all of the money they lost. For instance, providers cannot bill Medicaid when an addict does not show up to a scheduled appointment, a regular occurrence that skews budget projections and curbs cash flow.
Kathleen Rebbert-Franklin, acting director of the Alcohol and Drug Abuse Administration, said providers must become less reliant on grant funding, and many have already done so. The state should not be paying for treatment that qualifies for Medicaid reimbursement, she said.
Rebbert-Franklin said the announcement of the change in 2008 was intended to give providers time to adapt.
Tangires said Epoch decided to consolidate the Lansdowne and Catonsville centers after learning in mid-May that it had six weeks to figure out how to juggle a more than $286,000 budget cut from the state effective Sunday with the start of the new fiscal year.
Frank Arthur, a 44-year-old mural and graffiti artist from Halethorpe, said counselors in the Lansdowne center are the reason he is sober today, 28 months and counting.
"These people are like my family, even when my own family didn't want to be around me," Arthur said recently from the lobby in the center. "So many people threw me away, or threw me in jail. This place right here was the foundation. I would be under a bridge somewhere in or in jail."
Arthur said he used cocaine, LSD, heroin and marijuana for 25 years. His counselor at Epoch "breathed new life into me," Arthur said. He rides his bike the two to three miles from his home to Epoch's Lansdowne office at least once a week to meet with the counselors and finds Narcotics Anonymous meetings to attend daily.
After the Epoch center closes, his bike ride to see the counselors will more than double, but he plans to keep it up.
The budget cuts varied by jurisdiction.
Baltimore's block grant was cut by $5.6 million. Baltimore County's was cut by $1.48 million; Anne Arundel County, $757,000; Harford County, $448,000; Carroll County, $350,000; and Howard County, $111,000.
State lawmakers shifted $6.7 million in this year's state budget to Medicaid from the Alcohol and Drug Abuse Administration, a division of the Department of Health and Mental Hygiene. The state's $6.7 million investment was doubled to $13.4 million with Medicaid's match from the federal government.
The problem, according to providers, is that they are not able to make up every dollar that the state took away from the blocks grants by billing Medicaid.
Some services offered by providers aren't eligible for reimbursement — case management, for example — and despite the fluctuations in Medicaid funding, they still have to carry the same fixed overhead costs, such as rent and electricity.
The treatment centers also work to get individuals enrolled in the Medicaid program, but the providers have to bear the cost to treat them before they're accepted into the program, and most of the time providers can't recoup those costs.
Health care in Maryland is in transition, as more individuals gain access to insurance through the Affordable Care Act and steps taken by state officials. In 2007, for instance, the state expanded Medicaid eligibility by including parents with a higher income level than was previously allowed. In 2010 the state added substance abuse benefits for adults without children.
"Substance abuse is a public health issue of epic proportions in some areas," Rebbert-Franklin said. The consequences of substance abuse extend beyond those who are addicted, to families who are less stable and communities that are less safe, she said.
More than 84,000 people got substance abuse treatment from the state over the past year.
Tangires said Epoch, like other providers, had been aware of the state's shift to the new billing plan, but she said the size of the cut for the coming fiscal year was much greater than expected.
"All year we have been overextended," she said. "We have more demand than we can meet. Having such a short period of time to implement a cut like that, there was really no choice. We had no time to prepare."
Jim Perrone, chief executive officer for First Step, said his organization also could have benefited from more lead time. First Step was slated to lose $450,000 in the new budget.
"That's not the kind of money you save with cutting back on office supplies," Perrone said.
First Step's Randallstown and Towson treatment centers served 85 and 41 clients, respectively. The organization had to layoff five workers and will leave another two positions vacant, he said.
Still, Perrone said blending grant-based funding and fee-for-service reimbursements from Medicaid makes good sense.
"While this has been a dramatic shift for us, I also understand some of the economics of it," Perrone said. "While it's tough, I am not angry about this. It's a blow; it's not devastating."
Perrone said he does worry about the people who will lose access, because of transportation issues, especially from the Towson to Cockeysville locations. But not all the addicts who will be displaced by the closures will fall through the cracks, Perrone said.
"We have people, they come to depend on us, and we are sort of an anchor in their daily routine," Perrone said. "Breaking that routine could mean they find another place to get it or they say, 'Oh, what the heck,' and go back to seeking drugs, getting drugs."
Gale Saler, director of the Chesapeake region for Gaudenzia, said the nonprofit alcohol and drug treatment provider might also have to close its Owings Mills residential center, because of $187,000 in budget cuts. Residential centers, unlike outpatient treatment, are not eligible for Medicaid reimbursements under the expanded program in Maryland.
Suzanne Harrison, director of psychiatry for LifeBridge Health, which owns Sinai Hospital, said the hospital's treatment center on its campus in Northwest Baltimore is curtailing services due to a loss of half a million dollars in funding.
Slots for Sinai's addictions recovery program dropped from 328 to 204 with the new fiscal year. The program will also shave two hours off its regular hours and its medication services will drop from seven days a week to six, Harrison said. Additionally, the program will lose six positions and client-staff ratios will rise from 1-to-42 to 1-to-50, and in turn patients could see longer waits and less one-on-one time, she said.
Harrison said the consequences of the budget decisions are grave. People who need treatment tend to look for it in areas that are convenient and close to their homes, she said.
"In an environment like Baltimore, you're basically denying care to a population that desperately needs it," Harrison said. "You're putting up yet another barrier for people who have very little resources."
Dave J., a 63-year-old retired printing press operator, said many long-standing treatment centers have become staples in Baltimore communities and to disrupt services could mean individuals won't get sober. He declined to provide his last name, citing anonymity as a cornerstone of his 12-step program.
Dave said he depends on regular Alcoholics Anonymous meetings at Epoch Counseling Center in Lansdowne to resist the urge to reach for a drink, and it has worked for him for 12 years. The group will lose its meeting space when the center closes, and its members are scrambling to find a new location.
The meeting room at the Lansdowne center was been a consistent place alcoholics have turned to for help.
"It's a responsibly, a commitment that we all made that we show up every Thursday and have the doors open for the newcomer or the old-timers," Dave said. "To me, it's a matter of life and death. The clientele that goes to Epoch, when they send them into the room, coming into the room might save their life."