Faulty therapy

Baltimore Behavioral Health, a West Baltimore substance abuse clinic, has managed to find a way to maximize the amount it bills from the state while minimizing its own costs, enriching the family that runs the facility in a way that hurts taxpayers and, potentially, the very addicts it's supposed to be helping. The investigation published yesterday and today by The Sun's Scott Calvert was shocking not just because of the practices it described at BBH but also because it revealed an utter lack of effective supervision from the state, even as the center sucked up more and more taxpayer dollars. The Department of Health and Mental Hygiene has been investigating BBH since this spring, but it also needs to look inward to figure out how the facility was able to operate so long with so little oversight.

Here's what's wrong with the way BBH operated: The center routinely diagnosed addicts with co-occurring mental health problems, often major depression or bipolar disorder. About 90 percent of BBH's patients have such a diagnosis, about triple the rate of all drug treatment providers in the state. Some of those patients are referred to the center because of their dual diagnosis, but others walk in off the street and are diagnosed with a mental health condition while still on drugs, contrary to accepted medical practice.


The reason that's a problem from a medical perspective is that drug addiction and withdrawal can often create symptoms that mimic those of mental illness, so until an addict is clean, it's impossible to know for sure whether psychiatric treatment is necessary. The anti-depressants and other medications patients were prescribed as a result of their BBH diagnoses are not without side effects — or substantial cost to the state — and a false diagnosis can often complicate recovery from addiction because it can allow the addict a way to rationalize a relapse.

In fairness, the center did more than just put its patients on psychiatric medications; it also provided them with hours and hours of therapy every day. For some, it certainly worked. And a dual diagnosis is one way to make sure the state will pay for drug treatment — Maryland's public mental health system covers drug treatment if a patient's primary diagnosis is a psychiatric disorder.


But the problem from the state's perspective is that the intensive therapy offered by BBH is far more expensive than ordinary drug treatment. The intensive outpatient therapy BBH provides costs the state $125 a day, and partial hospitalization costs $197. Drug treatment for those without psychiatric disorders comes from different (and more limited) pots of public money. Classic 28-day programs in Baltimore cost slightly more per day — about $140 — but those slots are rare, and in any case, BBH used to keep its psychiatric clients in treatment for nearly twice as long on average, 52 days. Long-term residential drug treatment costs about $75 a day, and halfway houses cost about $60 a day. Intensive outpatient drug treatment, involving nine or more hours per week, works out to about $450 a month, or about one-eighth the cost of intensive outpatient psychiatric treatment.

If the goal is to get as many people off drugs as possible, the state needs to be funding the least costly effective treatments, not the most expensive.

Furthermore, it's not at all clear that BBH's approach is generally effective. It has no statistics to validate its claims of success, and it is not subject to the same scrutiny as drug treatment programs funded in the more common way through grants administered by Baltimore Substance Abuse Systems. And elements of its treatment model are questionable at best. About 150 of the center's 800 outpatients live in houses rented by BBH, places where former residents say drug use was common. (BBH would not answer Mr. Calvert's questions about its drug testing policy for clients while they are in therapy.) Moreover, instead of having trained professionals to manage the homes, BBH tasks clients who have been sober as little as 60 days with overseeing them — and keeping the keys to the medicine cabinet. That's a recipe for disaster.

BBH officials have referred to the housing program as "charitable services" on the grounds that it is impossible to provide effective drug treatment to people who otherwise might not have a place to stay. That may be true, but the free housing is also an inducement for people to go to BBH and stay there, a profitable proposition for the non-profit center. BBH was paying about $200 per person per month for the housing and billing the state thousands for their care. That was certainly a beneficial arrangement for the center — even before it recently began charging clients $150 or $200 a month in rent. Having clients manage the homes meant they didn't have to pay a trained professional to do it.

The result is that BBH went from billing the state $2 million in 1998, its first year of operation, to $17 million in fiscal 2009. Meanwhile, the six members of the family that runs the center and controls its board were paid a total of $1.4 million last year.

The most troubling thing from a public policy perspective is that it took the state so long to figure out something was fishy. As early as 2004, BBH's billings had begun to spike as more and more of its patients were steered into expensive treatments, but state officials acknowledge it took them three years to notice and another two to do something about it. The houses BBH rents for its clients are not regulated by the state in any way, and the state doesn't actually require intensive outpatient psychiatric programs like BBH to test their clients for drug use. Once the health department completes its own investigation into BBH, it needs to seriously consider severing ties with the organization altogether.

But it also needs to answer how it allowed the situation to get so out of hand. BBH officials may have established a therapeutically questionable business, but the state allowed it to happen and paid them handsomely for it. The legislature needs to hold hearings on the matter to determine how BBH slipped through the regulatory cracks and to provide the health department with the regulatory muscle it needs to make sure this doesn't happen again.