Fourth of a four-part series.
PART 1: Cleaning Up: Federal money is expanding drug treatment in Baltimore--and causing providers headaches. 06/22/2010
PART 2: Old Habits: Medicalization is the hot new thing in drug treatment. Just like in 1970. 07/27/2010
PART 3: "We Are Not In the Housing Business": Baltimore's recovering addicts need a clean, affordable, safe place to live. Somebody's making money on it--but don't ask who, or how
Statistically speaking, Shakarian D. Frazier is a drug treatment success story. A drug dealer and habitual felon, according to court records, the 31-year-old was convicted of dealing for the third (or fourth) time, sentenced to 20 years in prison, and, in December 2007, referred to Baltimore’s vaunted “Drug Court” for redemption. Frazier received acupuncture and graduated from his substance abuse treatment program in May 2009.
With a year and a half of successful drug treatment under his belt, Frazier was the kind of person to whom the treatment industry might refer a reporter looking for a good news story. But newspapers carried no good news about Frazier. Eight months after successfully completing drug treatment, Frazier was caught dealing heroin again, charged with gun possession, and sentenced to two years in prison. Released last month after having served about nine months, Frazier was charged with murder on Oct. 27. Police say he stabbed long-time girlfriend Mary Williams to death in front of four witnesses.
In Baltimore about 40 percent of those in drug treatment were referred there through the criminal justice system, and Frazier’s treatment got his 2007 prison sentence reduced. But people with substance abuse disorder are not necessarily—and not presumed to be—criminals, and the drug treatment bureaucracy takes no responsibility for the behavior of patients after they leave treatment. They are not tracked that way.
Even during treatment, individuals disappear into a statistical stew. With treatment success measured in days of reduced drug use, percentage of “completers,” or counts of those who still attend treatment services after six or nine months, cases like Shakarian Frazier’s are quickly forgotten—if they are noticed at all.
Not only are individual patients not tracked comprehensively, but there is no solid number for Baltimoreans who need treatment. According to estimates by Baltimore Substance Abuse Systems (bSAS), the quasi-public nonprofit that directs and monitors much of Baltimore City’s drug treatment effort, 74,000 Baltimore residents need addiction treatment. It is a loose estimate, based on telephone surveys, arrest data, hospital admissions, and other indirect indicators. It is also greater than a previous loose estimate of 60,000 addicts that had been bandied about by policy makers since the 1980s. That number was debunked by The Baltimore Sun in 2005 but repeated long after by drug treatment advocates seeking to drum up funding (“Scoring Data Points,” Mobtown Beat, June 14, 2006).
Taking the quasi-official estimates of 60,000 addicts and 74,000 addicts at face value, a decade of increased funding for drug treatment has resulted in 14,000 more Baltimoreans needing drug treatment.
Where Baltimore’s drug treatment industry is arguably most efficient is bringing in and tracking money. A key treatment system priority is encapsulated in the title of a consulting report done on bSAS’ behalf and released a year ago: “Baltimore City Substance Abuse: Strategies to Maximize Billing.” Asked how bSAS makes sure the nearly $50 million in government funds it receives is not wasted, Carlos Hardy, a bSAS spokesperson, replies that the city hardly ever has to give the state anything back. “Reversion has been less than one-tenth of 1 percent,” he says proudly. “We’ve been highly effective in spending every dollar that we get from the state.”
And that’s just the state-funded side of drug treatment. There is also an expanding private-pay system in which drug treatment providers answer to the state Department of Health and Mental Hygiene and the managed-care organizations (MCOs) it hires to dispense a mix of state and federal Medicaid funds. The MCOs are paid in part to deny care unless it’s proven to be “medically necessary,” but successful for-profit drug treatment businesses such as Baltimore Behavioral Health (BBH) have developed a number of strategies to maximize billing themselves.
Neither the state grant systems nor the Primary Adult Care (PAC) program—a sort of “Medicaid Lite” health insurance plan for poor people—are set up to advocate for patients or measure how well they do individually under the various types of care provided. Indeed, the data these bureaucracies generate and work from seem to measure everything except the patients’ long-term well-being. There have been recent efforts to tighten fiscal control and introduce more efficient therapies (such as “wonder drug” buprenorphine), along with sometimes heroic efforts from caring people up and down the chain of command. But at its very foundation, Baltimore’s drug treatment system is fractured, with each element geared toward its own self-perpetuation. That Baltimore can neither count its addicts with any precision nor document their progress in recovery on an individual basis means that every new treatment and addiction theory and every additional dollar spent funding them is an act of faith.
Over the past six months, City Paper has examined Baltimore’s drug treatment system, its history and plans, talking to practitioners, addicts, and officials both inside and outside bSAS’ network (“Cleaning Up,” Feature; June 23; “Old Habits,” Feature, July 28; “‘We Are Not in the Housing Business,’” Feature, Sept. 29). Though it is not possible to know everything about a decentralized bureaucracy employing thousands of people, several elements of the system now in place suggest that if the system continues on its current course, Baltimore’s addict population will not shrink, and may continue to grow.
The problem begins with patient tracking.
“Our data is by individual patient but only at two points in time—entry and disenrollment,” says William Rusinko, a research statistician for the Maryland Department of Health and Mental Hygiene who for more than 20 years has analyzed the jumble of numbers collected from drug treatment programs. Improvements in data collection are coming, he says, but right now even urine tests—the alpha and omega of drug treatment accountability—are published in aggregate.
“We can track individual patients, but we can’t track each individual service” the patients receive, Rusinko says. “That’s why it gets difficult to talk about, ‘This level of care does better than that level of care.’”
Indeed, the state’s data system is designed primarily to track drug treatment programs and allow them to justify their results. A system that instead tracked the progress of individual patients through various drug treatment programs could help state officials determine which levels of care—in-patient, out-patient, or residential—brought the best and most long-lasting results for the types of clients in a given area. The data show, for example, that suburban drug-abusers tend to leave residential treatment in droves while Baltimore’s addicts tend to stay. This is probably because many of the suburban folks have decent housing, while many of the city’s addicts are often homeless. But there is as yet no rigorous analysis of which treatment centers, or even which broad level of care, get the most people to stop using drugs.
Figures reported to Rusinko’s shop are not always trustworthy either. A 2003 performance audit of the state Alcohol and Drug Abuse Administration deemed four of the five reported performance measures “inaccurate,” with the final one still uncertified because, as auditors wrote, “unique client identification numbers were not assigned to each client.”
When auditors looked at drug treatment results in another program for ex-offenders in 2007, they found that the Department of Public Safety and Correctional Services’ division of Parole and Probation still had not assigned unique IDs to its clients. It had also claimed offenders had “successfully completed” drug treatment programs in which they had never enrolled.
“Specifically, we tested 35 of the 1,237 [Proactive Community Supervision] closed cases for which the offenders were identified as having satisfactorily completed treatment during fiscal year 2007,” the auditors wrote. “For 24 of the cases, there was no documentation to establish satisfactory completion of a substance abuse treatment program by the offender. Furthermore, for 16 of the aforementioned 24 cases, the offenders had not been enrolled in a substance abuse treatment program.”
That is, in nearly half the cases examined, Parole and Probation workers falsely claimed the offender had completed treatment that they had never even attended.
“As a result of those findings, supervisors and agents were reminded of the importance of certifying the accuracy of the data entered in the Division’s electronic case records and hard-copy files,” Department spokesman Mark Vernarelli wrote in an e-mail to City Paper. “The [Department of Legislative Services] audit uncovered issues within one office concerning the accuracy of the case closing data. The Division does not release internal audit reports or documentation.”
While state officials appear to regard such indicators of fraud and mismanagement as minor glitches in an otherwise solid system, that system is becoming even less accountable to its clients and less transparent to taxpayers. The growth of the state’s PAC program, promises to expand—and ostensibly make more available—services for patients. It also stands to enrich the larger, more established drug treatment programs that can effectively bill Medicaid. But once a patient leaves the grant-funded treatment centers Rusinko monitors, his or her success or failure is not usually reported. Enrollment in PAC takes drug treatment clients off of bSAS’ blurry radar screen, making it harder still to track client outcomes and thereby improve services over time.
It‘s not as if no one cares. Since his arrival in 2009, bSAS President Greg Warren has made sometimes wrenching decisions to get a handle on quality control. On May 15, 2009, he sent a letter to one of Baltimore’s most celebrated drug treatment providers, I Can’t We Can (ICWC), telling founder Israel Cason that his nearly $350,000 annual grant from bSAS would not be renewed.
With its political ties, up-from-addiction roots, and in-your-face promotion, ICWC was a star drug treatment program in Baltimore in the 1990s and 2000s, scoring Abell Foundation support and fawning media coverage, including a story in this newspaper (“Can Do,” Mobtown Beat, June 12, 2002). As part of ICWC’s tough-love, faith-based approach, Cason employed his clients at a family-owned restaurant, deployed them at political rallies, and housed them in often dilapidated, overcrowded homes he and his family owned.
Though nominally still operating, ICWC has not filed a federal tax return since 2007. Previous filings are spotty, claiming, for example, more than $1.9 million income from “rents” between 2005 and 2007, but where the form requests “Kind and location of property,” ICWC’s accountant provided no list of addresses, instead simply writing “residential.”
As of mid-2010, nine homes linked to Cason, his family, and/or ICWC were either in foreclosure or had already changed hands. Cason did not respond to numerous requests for an interview, but his nephew, ICWC’s Columbia University and Johns Hopkins-educated former chief operating officer, reluctantly granted one.
“My life is in transition right now,” Saafir Rabb says during an Aug. 5 interview, adding that he left his uncle’s organization four years ago. “I think they’re struggling,” he says. “With the loss of support from the city, it’s a challenge. This was a grassroots organization that was kind of boot-strapped.” (ICWC’s struggle has not dented Rabb’s career trajectory. The 34-year-old has styled himself a nonprofit business consultant, jetting around the world to lecture on cultural competency and other subjects.)
ICWC record-keeping had been problematic for years before bSAS pulled the plug, and its budget was augmented by political patronage. The program was a favorite of Gov. Martin O’Malley when he was mayor; ICWC even received a $280,000 yearly contract from the Department of Public Works to augment street cleaning in its Northwest Baltimore neighborhood. That contract, known to neither bSAS officials nor the public until now, ended in July 2008, according to DPW spokesperson Kurt Kocher.
Like other local treatment programs, ICWC never documented its success in getting people to stop using drugs, and was never asked to. But the cardinal sin in government contracting is failure to account for the money. Cason responded to bSAS’ funding cutoff with pickets outside bSAS.
More than a year after terminating its grant, Warren is still reluctant to talk about ICWC and its imposing leader. “I have a lot of respect for Israel Cason,” he says, carefully parsing his words during a Sept. 16 meeting. “To have a contract with [bSAS], you need to have an independent audit every year. You need to show us where you spent the money. The houses people live in have to be safe for human habitation.”
BSAS Chief Financial Officer Arnold Ross sums up ICWC’s problem during an interview in May: “[Cason] is a nice man and believes in recovery. [But] . . . it took a long time for Israel to put on his corporate clothes. I don’t think he ever got them all the way on.”
If ICWC’s seat-of-the-pants operation was the way of the past, the precise and professional corporate culture of Baltimore Behavioral Health, headquartered a few miles south in the Hollins Market neighborhood, points the way to the future. Like ICWC, BBH is family-owned and operated, with six of its officers and directors related by blood or marriage, according to a two-part investigation published in The Baltimore Sun this week. Unlike ICWC, BBH is beyond the control and oversight of bSAS. Under the new system of PAC-funded care, providers like BBH answer only to state regulators—who have been investigating the company since the spring.
Founded in 1997 on the ashes of a bankrupt, grant-funded drug treatment program, BBH grew rapidly in the 2000s to a size nearly 40 percent of bSAS itself. With several physicians on staff and a sophisticated billing operation on the third floor of its building, BBH received $20.4 million in revenue in 2008. None of it came from bSAS, says Terry Brown, BBH’s vice president of community relations.
Instead, BBH billed insurers—mainly Medicaid—through the managed-care organizations (MCOs) the government contracted to disburse its money as medically needed. Medicaid is not mandated to cover drug treatment, Brown says, but it does cover emergency room visits brought on by overdoses and other medical hazards of drug addiction.
During a May interview in his office at BBH headquarters, Brown says he negotiated Medicaid coverage for BBH patients. “It’s basic economics,” he says. “[The MCOs] realized that the patients were going back and forth to the emergency room. They looked at their bottom line” and realized that the cost of treatment at BBH was easily outweighed by the greater cost of one or two ER admissions, which they’d have to pay for under Medicaid’s rules. Drug treatment, in other words, saves money.
Brown says BBH concentrates on “co-diagnosis” of mental illness. Indeed, the rise of the co-diagnosis in drug treatment is widely considered an improvement as it deals simultaneously with two conditions that often feed each other in many addicts. It’s a major step toward making drug treatment services medical care, as for any other illness. Co-diagnosis also means BBH often deals with two separate state bureaucracies—one for drug treatment and the other for mental illness. Each one releases money separately, and BBH bills them both for patients receiving both substance abuse treatment and mental health services. Brown estimates that 525 of BBH’s 600 patients are co-diagnosed with mental illness.
Brown says the state bureaucracy’s separate mental health and drug treatment “silos” are inefficient, and he wishes they would merge. “If we could get $225 a day for someone instead of the $300 we get, that would still be better because we don’t have to bill two [agencies],” he says.
Such inefficiencies have nonetheless helped BBH’s directors and officers prosper. CEO William Hathaway earned $347,089 in 2008 (up from only $166,000 earned two years earlier and more than three times the pay of then-bSAS President Adam Brickner). His wife Victoria made more than $40,000 in 2008 and $61,500 in 2009 serving as BBH’s “recording secretary” for 20 hours a week. Morris and Sandra Hill, BBH’s president and vice president for clinical services, respectively, earned $277,992 each.
BBH’s mastery of multiple, complex billing systems is the key to its financial success, but it is not total. In 2008, the Inspector General for the state Department of Health and Mental Hygiene went over BBH’s bills with a fine-toothed comb, discovering $128,000 worth of billing errors. BBH agreed to repay $108,000 of that. That same year, the Administrative Service Organization that Maryland contracts with to disburse money for mental health care discovered a $2.66 million overpayment to BBH, which has been paying it back at the rate of $65,000 per month interest-free—reduced from an original agreed figured of $110,000 a month—according to documents released to City Paper under a Maryland Public Information Act request.
The pay-backs, along with other state budget cuts brought on by the recession, have apparently crimped BBH’s ability to provide the promised “high rate of success” for its clients. Many of the recovery houses surrounding BBH have shut down (see “‘We Are Not in the Housing Business’”).
In the absence of actual information, theories about BBH’s issues run the gamut from fanciful rumors to malapropism. Keith Murchison gives his assessment.
“BBH lost funding ‘cause they were messing up. Big time,” Murchison says. “I think it was plagiarism.”
A few years ago, when he was a BBH patient, Murchison says he would have rated BBH an eight on a scale of one to 10. “If I was to give it a rating, I’d say maybe a three or four now,” he says.
It is Sept. 11, and Murchison is in Druid Hill Park for the fourth annual Recovery Walk and Rally, part of Recovery Month activities, a September spasm of marches, rallies, and advertisements sponsored by the federal Department of Health and Human Services to demonstrate that, as its slogan says, “Treatment Works.” There are hundreds of people here, and free hotdogs and sodas, a band, and lots of drug treatment counselors mixed in among the clients. Murchison, with a valentine heart tattooed on his right cheek, has the usual life story of long-time drug users, with burglary, armed robbery, assault, and various drug-dealing charges adorning his 18-year criminal record. He’s been at the east-side, for-profit, residential treatment center Powell Recovery Center, Inc., for two months, and says it’s the best place he’s ever been sent. (He is still drug free, as this story goes to press.) “Feels good,” he says. “Feels good to get up and not chase. . . .”
Though a drug treatment veteran, Murchison is still learning the aphorisms drilled into substance abuse repentants by their counselors, recovery colleagues, and therapists. But he has one ready for a reporter: He says he once told a psychiatrist who asked him if he had ever considered suicide that, actually, he practices it every day. Murchison says he’s tired of the streets and the chancy quality of the heroin available: “You don’t know what you get out there.”
In Baltimore, you can be sure that in drug treatment, at least, whether you graduate or merely attend counseling sessions for at least 180 days, that your experience will be distilled into numbers and deployed in the mission of expanding the funding and reach of the drug treatment industry. How it best serves you, or how it might serve you better if you relapse, will remain unknown, a matter of faith.
Bipolar and previously addicted to alcohol and drugs, two months into his recovery Murchison says in September that he is unable to work or seek work at the moment because he’s “on blackout” at Powell Recovery. He defines this as “a certain period of time you have to be there so [the center] can pull the money from the state.”