For years, Baltimore's political leaders have lamented the shortage of drug treatment "slots" needed by the city's drug addicts. Even as state funding for treatment increased from $25 million to more than $60 million in the past decade, waiting lists remained the rule.
The long waits contributed to other problems, according to Del. Peter Hammen (D-Baltimore), chairman of the legislature's Health and Government Operations Committee. Addicts awaiting drug treatment continued to use drugs, overdose, and commit crimes, costing the state thousands of dollars in increased police, court, jail, and emergency room charges while helping devastate communities across Baltimore. Hammen realized that the federal Medicaid program could be tapped to pay for treatment if he could seed the process with a small fraction of the $125 million the state was already giving to county health departments and bSAS for drug treatment. With Medicaid reimbursements set at 62 cents for every dollar the state spends on covered treatments, "we were leaving so many federal dollars on the table," Hammen says.
Several years ago, Hammen set about making drug treatment a veritable right for the poor through a federally funded state program called Primary Adult Care, or PAC. Sometimes called "Medicaid Lite," PAC is available to anyone earning less than around $12,500 annually. The program already covered doctors visits, mental health services, some medicines, and lab tests, but not drug treatment. After several years of legislative wrangling and negotiation with drug treatment providers concerned about losing grant money, Hammen got PAC expanded to cover three types of drug treatment.
Politicians often discuss drug treatment in terms of "slots," as though any drug treatment program is like any other, but this is not so. There are multiple levels of treatment, beginning with Level I "outpatient" therapy, which includes two hours of counseling per week, and going up to Level III.5, or "high intensity residential," which includes a year's housing during which a patient receives intensive, all-day therapy sessions. Other alpha-numerical designations refer to detoxification, "medically monitored inpatient" treatment, and "opioid maintenance therapy," better known as methadone. Baltimore has only 160 Level III.5 slots, but it has hundreds of Level I "outpatient" slots and hundreds more at Level II, aka "intensive outpatient," which include about eight hours of talk therapy per week. PAC now covers Levels I and II outpatient, as well as methadone maintenance therapy. But PAC does not pay for the more intensive--and expensive--Level III slots, detox, or the city's vaunted buprenorphine initiative ("Wonder Drug," Feature, March 24, 2004; "Drug Disabuse," Mobtown Beat, Dec. 19, 2007), which is handled under different rules.
Thus PAC is part of a larger trend bringing substance abuse treatment under the umbrella of medical care. Since January, more than 1,700 men and women have signed up for drug treatment under the program in Baltimore, and that will expand. The federal health care bill passed a few months ago will by 2014 widen eligibility for Medicaid and increase state reimbursement to 90 percent, Hammen says.
Many drug treatment programs never had to bill anyone before, and the process is complex, so to help ease them through the transition period bSAS has allowed providers to keep their full state grant in addition to any money they've been able to bill through PAC. But when the new fiscal year starts on July 1, the grants will be cut dramatically, and providers will not be paid for their PAC clients unless their paperwork is in order and their services deemed "medically necessary."
PAC also makes it harder for bSAS to keep track of who is getting treatment, and whether that treatment is effective, which is one of the system's most important functions. Under the grant program, bSAS-funded providers must inform bSAS whenever a treatment slot is filled by a new client and when the client is discharged. The PAC program does not carry that requirement, and because the client can get services through "any willing provider"--and many providers are not in bSAS' system--PAC is making it harder for bSAS to track drug treatment outcomes in Baltimore.
"As soon as they shift to PAC, we don't see them anymore," bSAS board Treasurer Alan Woods says at the May 27 board meeting. "They could drop out [from drug treatment] a week later and we wouldn't know it."
The pros and cons of the new system are on display behind the glass-enclosed reception desk at Glenwood Life Counseling Center, a methadone clinic that also offers outpatient talk therapy in the Woodbourne-McCabe neighborhood of North Baltimore.
On a Thursday morning in early June, George Lincoln, the administrator at Glenwood Life, is downstairs with the staff that processes clients who are milling about in the lobby and in front of the building, smoking cigarettes and conversing jovially at volumes normally encountered in a sports stadium. "I'm down here looking to see if things are going smoothly," Lincoln says. "They aren't."
Dressed casually in a white shirt and a blue ball cap, Lincoln exudes the relaxed attitude of the computer expert (he has managed the information technology here since his hiring 18 years ago). Lincoln got Glenwood's billing duties a bit more than a year ago. "Even without PAC, it was overwhelming," he says. "Billing is easy. Collection is hard."
Collection is hard because of the population Glenwood serves, he says. Poverty and addiction make its clients less reliable than the average person. Nick Usher, a case manager who has been signing up clients for PAC for the past five years, says 85 percent of those who walk through his door lack the Social Security card or other identification paperwork required by the state to confirm eligibility.
Once they get eligibility, he says, he can get them PAC coverage in a few weeks--if they don't move away from the address they gave him during that time. He says about a quarter of his clients do move, and as a result don't get the packet the state sends them. If and when they get PAC coverage, they must reapply via the same process every nine months, he says.
While Usher signs up new PAC clients, Lincoln manages those already on the rolls. Because of the vagaries of PAC insurance rules, "We have to check at least weekly--it really should be daily--every client's eligibility," he says. "Our clients are not prone to come to us and say, 'Ya know, I just got insured,' or, 'Ya know, I just lost my insurance.'"
So Lincoln--or someone, most likely his intake coordinator, Aredenia Langley--has to go to a state government database and key in each client's name and ID number to discover if their PAC insurance status has lapsed or changed. "It's about 60 seconds per name," Lincoln says, adding that he can't make a computer program to automatically check the names. Sixty seconds times 600 patients is about 10 hours of work each week--a quarter of a normal work week just to check eligibility.
Eligibility is actually easy compared to authorization.
Just because someone has PAC insurance doesn't mean a particular service is covered. First, it has to be "authorized" by the managed care organization (MCO) that administers the PAC insurance. (PAC is publicly funded, but managed by private health insurance companies such as United Healthcare, which decide whether to pay for a particular service based on whether the claim form is "clean"--filled out correctly--the service is "medically necessary," and the client is both eligible and authorized to receive the service.) If eligibility is like a nine-month rail pass, authorization is more like a monthly bus ticket. Or sometimes a 13-week ticket. Sometimes it's 26 weeks, Lincoln says. It depends on the rules of the MCO.
Lincoln says he underestimated the billing process, much of which initially fell to an assistant who was quickly overwhelmed by the task. He reluctantly let her go, and from July of last year until February of this year, Lincoln picked through insurance denials totaling more than $200,000, he says. That is more than 20 percent of the grant funding Glenwood is scheduled to receive this coming year. He is currently battling over another $20,000 in bills he says United Healthcare misrouted.
Glenwood has traditionally had about two-thirds of its patients on grant and one-third on insurance of some sort--mostly public plans like Medicaid. Under PAC that ratio is supposed to flip--one-third grant and two-thirds insured.
On July 1, Glenwood Life Counseling Center will have 230 grant-funded slots. Right now, Lincoln still has 275 on the grant rolls--45 more than will be covered by the grant in three weeks. "I can guarantee you this 45 will not have insurance by then," Lincoln says. "So, July 1, we're gonna be losing money. How much, I can't tell you. But we're gonna be losing money."
Methadone programs such as Glenwood are better adapted to PAC, because opiate-assisted treatment has been, "and I hate this term, 'a billable service,'" says Lillian Donnard, the clinic's executive director. Yet even with long experience dealing with MCOs, Glenwood has chafed under the new program. In the early months of PAC, Donnard says, one of her staff counselors "canceled a couple of group therapies because his treatment plans were all due." If the treatment plans were not submitted to billing, Glenwood Life could not be paid. The extra step costs the counselor hours, and hours cost more than money, she says. "If you got to fill out the paper to get paid, it doesn't take an idiot to figure out that that's time you spend that you would have spent doing something else."
That something else might turn out to be more important than the higher-ups in the drug treatment industry had imagined.
Since 1995, bSAS has funneled state money to the 50 or so treatment programs it funds according to a fairly simple formula: serve more people, get more money. "Say you have 60 outpatient slots--you get a set number of dollars to treat 60 people per year," bSAS chief of operations Christina Trenton says. The yearly grants--which for some programs (like Glenwood Life) have supplemented their billing for other services, and for other programs have been basically the sole source of funding--had three main advantages. First, they were simple to administer, requiring an annual requisition and some monitoring to make sure the clients were receiving the services. Second, they allowed bSAS to develop a pretty good system to track clients in the system to see how effective programs are in keeping clients from using drugs. Finally, they allowed the programs flexibility in deciding how best to serve each individual client. The attitude at bSAS, Trenton says, was "you figure it out--we're paying you for this service, you do it."
As more clients are funded through PAC, things will be different. Treatment programs "need clinicians paying attention to billable hours," Trenton says. In the old system, a client might drop by and a counselor might spend a few minutes catching up with her, seeing how things are progressing. Now, Trenton says, "every minute of your day is scheduled for a billable service."
One of the non-billable services missing under the PAC paradigm is outreach to the people who need the services, according to the director of a small Southwest Baltimore treatment center.
"Advertising is not outreach," snaps Lena Franklin, the director of Recovery in Community (RIC), when told about the upcoming "advocacy campaign" announced by bSAS. "Outreach is phone calls, home visits." Outreach is going into the streets and finding someone with the disease and talking to them about recovery. It's telling that person that you care, and being able to back that up. And outreach is crucial, Franklin says, to any system that hopes to improve the outcomes of patients who need drug treatment the most.
Franklin is proud of her program, which she says has helped address some issues in the neighborhood where David Simon and Edward Burns' The Corner was set. At 60 years old, she has the fearlessness of a missionary and the sharp laugh and rolling eyes of a cynic. She says she has known Warren, the bSAS chief, "since he started as a counselor at St. Agnes Hospital. I don't try to take advantage of that." But she doesn't feel the need to bow too deeply to bSAS, either.
"They tell us there is all this great money that we can make" with PAC, Franklin says in her office in a church building that itself looks as though it could use some rehab. "But in order to make that, you need to be seeing patients"--not out on the street coaxing someone into the clinic. "They don't understand outreach," she concludes.
Recovery in Community began 10 years ago with outreach as its central mission. Serving some 60 clients as a "Level I" treatment center offering outpatient therapy, RIC was funded originally with grants from the Abell Foundation (which took a guiding hand in its founding). After its Abell grant ended around 2003, the center turned to bSAS for funding and has struggled ever since to maintain staff and services on a budget that, when it wasn't flat, was cut.
BSAS officials say that for the past several years they have used the utilization data they have collected under the grant program to determine which treatments are most effective, and adjusted the grants accordingly. BSAS Chief Financial Officer Arnold Ross says the organization had $4 million dedicated to intensive outpatient care by 2005, and it was underutilized. "People voted on outpatient treatment by not coming to it," he says. "It took us years to adjust our [funded programs] to the demand for those services." That this initiative came during a time of budget austerity (bSAS's grant from the state peaked at $60 million in 2003, and was pegged at $48 million in fiscal 2010) made the decisions more difficult, bSAS officials say.
"When bSAS started this whole thing about 'performance-based'--we lost $200,000," Franklin says. "We went from like $535,000 to like $350,000."
Franklin cut where she could. "My staff has been on furlough since 2008," she says.
PAC could fill some of the gap, but not in a way that will allow RIC to serve its clients the way it has in the past, she says. As a Level I outpatient facility, RIC is paid to provide two hours of counseling each week to each client. The clients at RIC receive 20 hours per week of therapies, classes, acupuncture, lunch, and HIV counseling, Franklin says, plus referrals for more intensive therapies when needed. "About 90 percent of our clients have mental health issues," she adds.
"Our clients are here Monday, Tuesday, Wednesday, and Friday, 11 to 3," she sums up. "BSAS never funded us for what we were doing in the first place."
Carlos Hardy, bSAS's spokesman, doesn't argue the point. "There wasn't any case where we were documenting these added services," he says. "It wasn't something we were tracking."
PAC may be a step forward in providing treatment overall, but it specifically funds the two levels of treatments--Level I and Level II outpatient treatment--that, statistically, have been shown to be least effective in keeping people away from drugs.
The state Alcohol and Drug Abuse Administration has tracked the outcomes associated with different levels of drug treatment in the different counties over time. According to its latest full report, Outlook and Outcomes at a Glance 2008, Level I outpatient drug treatment programs consistently retain less than 60 percent of patients for at least 90 days, the minimum time clinicians regard as effective. Baltimore City's 90-day retention rate was only 51 percent, lagging behind all but Prince George's County. (Baltimore City's 90-day retention rates for Level III.1, "low intensity residential," is 61.3 percent, a bit higher than the state's 55 percent average.)
Baltimore City is by far the largest drug treatment system in the state. It serves more than twice as many clients as Prince George's and nearly three times that of Montgomery County. But the report shows that the clients of the city's treatment programs are more likely than those in other counties to use drugs before, during, and after treatment. Among Maryland jurisdictions, Baltimore City drug treatment clients have the second highest illegal substance use at discharge (behind tiny Caroline County, with 186 clients) and the second lowest percent change, or reduction in use, again trailing only Prince George's County.
"The answer you always get when you confront city providers is they're dealing with much tougher patients than anyone else," says William Rusinko, a research statistician with the Department of Health and Mental Hygiene who has prepared and analyzed this data for 30 years. "And in truth, there is no adjustment for patient mix."
Baltimore City's providers tend to think they've got the toughest cases."We're like Mikey," Glenwood Life's Lillian Donnard says, referring to the old Life cereal commercial: "'Give it to Mikey, he'll eat it.'"
Statewide, more than 43 percent of all drug treatment clients are referred to treatment through the criminal justice system. With the threat of jail hanging over their heads, they tend to complete treatment more often than "self-referrals," according to the data.
PAC is designed specifically to allow more self-referrals into, statistically speaking, less effective programs.
So PAC will bring less motivated clients to more stressed-out counselors, who will be spending more of their time creating PAC-mandated paperwork and less time interacting with clients. And PAC does these things while removing its clients from the system that allows monitoring of outcomes.
The result still may be good news for those Baltimoreans suffering with addiction, says Usher, the Glenwood case manager who says he has signed up some 200 clients for PAC since January, as opposed to just 50 last year. "PAC has really helped us a lot here in terms of helping our clients who don't have anything to pay for their health care," he says. "They can go to mental health doctors, they can get checkups.People don't have to worry about how they're going to pay for medication. It helps their recovery."
Across town, Benita Dock, Recovery in Community's data manager, turns down the gospel music playing on the radio so she can talk. Her desk features a computer with a flat screen but her work is a stack of pages with a client's name on top and counselor's name on the bottom, in the middle is a form with a lot of numbers--one set corresponds to the procedure or service provided. Then there is a dollar figure. Then there is the provider number and EIN. It's all written in ball-point pen.
"The quantity of clients is not a great big quantity," Dock says. So three days a week, she gets the progress notes from the counselors and the billing forms and fills them out and faxes it to the billing person who, in turn, does the hard work of extracting the money from the managed care organizations. "It takes the majority of the day, because I'm handwriting this stuff," she says. "It's not tedious, but it's time-consuming."