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Cleaning Up

Federal money is expanding drug treatment in Baltimore--and causing providers headaches.

Photographs By Christopher Myers
Baltimore substance abuse system's Greg Warren: "We're now about to do something that we've never had to do before, which is start an advocacy campaign."

By Edward Ericson Jr. | Posted 6/23/2010

The first of a four-part series

Read part 2, part 3, and part 4

Page 2 of 4.   1  2  3  4  

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."

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Medicalization is the hot new thing in drug treatment. Just like in 1970.

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Mortgage broker goes bankrupt, seeks mortgage modification as taxpayers face mounting bailout bills

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