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