Performance Review. Broward Addiction Recovery Center. Office of the County Auditor Evan A. Lukic, CPA County Auditor

Transcription

1 Exhibit 1 Performance Review Broward Addiction Recovery Center February 18, 2016 Report No Office of the County Auditor Evan A. Lukic, CPA County Auditor

2 Table of Contents Topic Page Executive Summary...1 Purpose and Scope.3 Background...3 Section 1: Evaluation of BARC s Performance....8 Section 2: Evaluation of BARC s Cost Recovery Practices..20

3 Executive Summary This report presents the results of our review of Broward Addiction Recovery Center (BARC). The purpose of the review was to assess BARC s performance in key efficiency and effectiveness measures: bed utilization, cost per client per day and successful completion of treatment. We also reviewed BARC s ability to recover costs through insurance and client fees. Our review primarily focused on BARC s performance over the past four fiscal years (FY 2011-FY 2014), but also considers overall progress since our previous review of BARC conducted in The results of our review in each of these areas is summarized as follows: Utilization Rates: Utilization rates for detoxification treatment services have remained consistently high in recent fiscal years, with the service continually operating at a near-full capacity, and exceeding the national benchmark. Over the past four fiscal years, utilization rates for the residential treatment facility average 12 percentage points below the national benchmark, even after BARC actions to reduce the number of available beds. Both programs have improved their utilization rates from the previous review period. Cost per Client per Day: Over the past four fiscal years, treatment costs per client per day for detoxification services range from 5-14% higher than the state benchmark. Over the past four fiscal years, treatment costs per client per day for residential services range from 2-14% higher than the state benchmark. Both programs reduced treatment costs per client per day since the 2008 review. Successful Completion of Treatment: Clients successfully complete detoxification and residential components of treatment services at rates consistent with national averages, and above the goals established by the Broward Behavioral Health Coalition. Successful completion rates for various components of outpatient services could not be verified during this review, due to issues with data replication. The most significant concerns were identified in BARC s billing processes. Historically, BARC s revenue recovery practices have been poor. Client fees have not been properly assessed in years. As a result, BARC is not in compliance with state funding requirements or the Administrative Code. Private insurance is not accepted. Recently, BARC has made progress in collecting Medicaid for services to eligible clients but the collection of client fees remains minimal. BARC is attempting to resolve issues with its client billing system; however, these same issues were identified in 2008, and the status of BARC s billing practices have remained substantially unchanged from that time. Specific findings and respective recommendations are found within the body of this report. 1

4 Purpose and Scope This report presents the findings of our performance review of the Broward Addiction Recovery Center (BARC), a division within the Human Services Department (HSD). The overall purpose of this review is to evaluate BARC s performance in key areas. To accomplish this task, we: Reviewed: o pertinent performance measurement and substance abuse treatment literature; o Office of the County Auditor s Program Performance Review of BARC report issued in 2008 (2008 Report); o performance measure attainment as reported by BARC to Office of Management and Budget (OMB) for fiscal years 2011 to 2014; o BARC contracts with the Broward Behavioral Health Coalition; and o Florida Statutes, Broward County Ordinances and Administrative Code pertaining to BARC s services; Analyzed information provided by BARC managers and staff relative to specific processes for tracking and reporting data; Gathered and analyzed performance data for BARC s operations; Toured BARC facilities; Interviewed and conducted meetings with BARC s management and staff; and Interviewed Broward Behavioral Health Coalition staff and members of the Substance Abuse Advisory Board of Broward County. Background Founded in 1973, the Broward Addiction Recovery Center (BARC) offers a comprehensive range of services for Broward County residents over the age of 18 who are affected by substance abuse. BARC is accredited by the Joint Commission for the Accreditation of Health Care Organizations (JCAHO), and BARC is licensed and regulated by the State of Florida as a substance abuse treatment program in accordance with Section , Florida Statutes. As such, BARC provides substance abuse treatment to residents and strives to promote successful recovery and reintegration back into the community. BARC provides a continuum of care for substance abuse treatment, divided into four primary service areas: admissions, detoxification, residential, and outpatient. The continuum of care is intended to meet client needs and provide opportunities for clients to step down to an appropriate modality as they progress through treatment. Service Locations BARC provides services in multiple locations throughout Broward County: BARC Central at 1000 SW 2nd Court, Fort Lauderdale, 2

5 Edgar P. Mills Multi-Purpose Center at 900 NW 31st Ave., Suite 2000 Fort Lauderdale, and Stephen R. Booher Facility at 3275 NW 99th Way, Coral Springs. Stephen R. Booher facility BARC Central Services provided at these locations include: Admissions: Clients seeking substance abuse services typically enter BARC through Detox or the Admissions unit located at BARC Central. At Admissions, BARC intake caseworkers and licensed clinicians complete a bio-psycho-social assessment and, in conjunction with the client, determine the most suitable level of care to address the individual s needs. Clients are then referred to the next appropriate service area. If Detox triage indicates an immediate need for detoxification services, and a bed is available, clients are referred accordingly, and receive a full intake assessment during treatment. Detoxification Services (Detox): BARC has a medically supervised 34-bed detoxification facility operating 24 hours per day, 7 days per week, for clients who are at risk of life-threatening complications from substance withdrawal as they begin treatment. During detoxification, clients receive medical assessments and services to ease withdrawal symptoms, as well as education and counseling. Detox also offers on-site Alcoholics Anonymous and Narcotics Anonymous meetings. Clients are discharged from Detox when a doctor determines they are medically stable and able to proceed with further treatment. Detox is located at BARC Central. Residential Treatment Services (Residential): Residential treatment services are provided at the Stephen R. Booher facility, which has a maximum capacity of 92 beds. This short term inpatient program provides clients with counseling, education, and medical care. In addition to its standard intensive residential treatment program, BARC also offers a perinatal addiction program, which provides treatment services to pregnant women, or the mothers of young children. The time that clients spend in residential treatment varies by program. Intensive residential treatment typically lasts for 30 days; the perinatal addiction program lasts for sixty days or, for pregnant women, until the birth of the child. 3

6 Outpatient Services: Outpatient Services consists of three programs: Non- Residential Day Treatment (NRD), Intensive Outpatient Treatment (IOP), and Outpatient Treatment (OP): o Non Residential Day Treatment (NRD): NRD is a four-week daytime program for individuals who need more intensive treatment than that provided by typical outpatient services, and have completed, or are determined to be inappropriate for, Residential Treatment. Clients are assigned a primary therapist, and are given treatment goals focusing on their legal, medical, and psychological needs. Clients attend psychoeducational group sessions to learn about the basic principles of addiction and recovery. NRD services are provided at BARC Central. o Outpatient Services: Outpatient services are offered to clients who do not require more intensive treatment services, or as a step down for those who have completed other components of BARC services. Outpatient Services are provided at the Edgar P. Mills Multi-Purpose Center, and include a flexible schedule of day and evening meetings, individual and group therapy, and education. Clients attend sessions twice per week as they begin the program, and then transition to once per week, or monthly as they progress through treatment. o Intensive Outpatient Services: Intensive Outpatient services is a sixweek program, offering similar services as standard Outpatient services, but is more intense, as clients receive services three times per week. Intensive Outpatient Services are provided at the Edgar P. Mills Multi- Purpose Center. Currently, a new treatment facility is under development, which will replace BARC Central. This new facility will also be located in Fort Lauderdale, and will increase current capacity for Detox services, and will offer various outpatient treatment services. BARC administrative offices will also be located in the facility, which will contain meeting and training rooms. Clients Served BARC serves many clients each year across its various treatment components. According to BARC, in FY 2014, they provided services to 7,091 unduplicated clients; however, many of these clients may receive services in multiple areas, while others may only receive a detox triage or intake assessment, but do not return for recommended treatment. BARC estimates 4,500 clients receive ongoing treatment throughout the year. Exhibit 1 shows the various treatment services offered by BARC and the number of clients served in FY 2014, as reported by BARC to OMB. 4

7 Exhibit 1: In FY 2014, BARC provided services to clients across multiple treatment modalities. Type of Service Number of Clients Number of assessments conducted at Admissions 1,867 Number of detoxification screenings at triage 4,832 Number of clients who enroll in Detox 1,825 Number of clients who enroll in Residential Treatment Services 988 Number of clients who enroll in any level of 1,585 Outpatient Treatment Services Source: Office of the County Auditor representation of data from OMB FY 2014 Annual Performance Measurement Report. Although BARC clients may abuse multiple drugs, treatment services focus on the primary substance abused, which is also referred to as the drug of choice. In FY 2014, nearly one-third of BARC clients were admitted for alcohol abuse, as indicated in Exhibit 2. Other primary abuse substances include marijuana, and opiates and synthetics other than heroin. BARC Managers are also concerned about the growing use of Flakka, a highly addictive and dangerous substance, which has been associated with multiple deaths in Broward County. Exhibit 2: In FY 2014, a significant portion of BARC clients were admitted for alcohol abuse treatment services. Other Opiates and Synthetics 21% Other 10% Alcohol 30% Marijuana/ Hashish 19% Source: County Auditor presentation of BARC data Heroin 7% Cocaine/Crack 13% During intake, BARC collects client income information. This data is recorded and tracked by BARC staff and may later be used in fee assessment. Presently, client income is selfreported. As shown in Exhibit 3, the majority of BARC clients serviced in FY 2014 had minimal annual income. 5

8 Exhibit 3: According to data collected by BARC in FY 2014, the majority of clients served had income levels at or below $10,000 per year. $10,001- $20,000 15% $20,001-$50,000 11% Over $50,000 2% $0-$10,000 72% Source: Office of the County Auditor presentation of BARC data Funding, Expenditures and Staffing In FY 2014, BARC s total budget was $12,029,070. Exhibit 4 shows BARC s primary funding sources by percentage. The majority of BARC s support comes from General Fund Revenue. BARC receives funding from grants, including grants from the Broward Behavioral Health Coalition (BBHC). The BBHC receives funding from the Department of Children and Families (DCF) and acts as the local managing entity to partner with providers of substance abuse and mental health treatment. Exhibit 4: In FY 2014, BARC s primary funding source was General Fund Revenue. Grants $4,125,340 34% Source: Office of the County Auditor presentation of OMB data General Fund $7,903,730 66% 6

9 In addition, BARC generates a small amount of revenue through reimbursement of its treatment services via Medicaid, and client fees. Exhibit 5 shows the amounts collected by BARC in FY Private insurance is not accepted by BARC at this time. Exhibit 5: In FY 2014, BARC collected approximately $185,000 in revenue from Medicaid and client fees. $100,000 $94,799 $89,285 $75,000 $50,000 $25,000 $- Medicaid Source: Office of the County Auditor presentation of OMB data Self-Pay In FY 2014, BARC s actual total expenditures were $11,956,952. Exhibit 6 summarizes BARC s self-reported expenditures by operational area for FY BARC allocates administrative personnel expenses proportionally across treatment areas. Exhibit 6: In FY 2014, Residential and Detox each represent approximately onethird of BARC s total expenditures. Outpatient, $2,330,933 20% Admissions, $1,472,041 12% Detox, $3,988,136 33% Source: Office of the County Auditor presentation of BARC data Residential, $4,165,841 35% As a client-focused service agency, the majority of BARC s expenses are for staffing. According to BARC, in 2014, there were a total of 150 staff positions, covering a wide range of classifications from administrative support, case workers, cooks, and medical personnel. Exhibit 7 shows BARC s total numbers of employees in each service area, 7

10 plus Administration. To supplement the services provided by direct employees, BARC also has contracts with outside vendors for activities such as nursing and food supply. Exhibit 7: In FY 2014, a total of 150 employees provided services across various treatment areas. Residential 47.5 Employees 32% Administration 18.5 Employees 12% Admissions 16 Employees 10% Outpatient 28 Employees 19% Detox 40 Employess 27% Source: Office of the County Auditor presentation of BARC data Findings and Recommendations This report is divided into two sections. The first section provides an evaluation of BARC s performance using key performance measures. The second provides a review of BARC s efforts to recover costs through billing clients and other available resources. At the end of each discussion area, findings and recommendations are provided, as applicable. Section 1: Evaluation of BARC s Performance We evaluated BARC s efficiency and effectiveness using performance data for various measures. These measures were benchmarked against research or other providers, as well as considering BARC s own performance over time. In completing this section of our review, we sought to answer the following questions: How does the utilization of BARC s inpatient facilities compare to other providers? How do BARC s inpatient service costs compare to other providers? How does the rate of successful completion for BARC s clients compare to other providers? 8

11 For each of the above performance areas, we assessed BARC s performance over the past four fiscal years, and compared FY 2014 attainment levels to the previous 2008 Report. Efficiency: Bed Utilization Rate An important measure of efficiency for inpatient residential programs is bed utilization rate, or the percentage of available beds that are actively used for client services. A facility s bed utilization rate has a direct effect on its relative efficiency. This is true because certain costs of operations (salaries, computer systems and equipment and utilities) generally remain constant regardless of the number of clients served. Therefore, when there are more clients being served in a treatment facility (i.e., a higher utilization rate), these costs are spread over a greater number of clients, resulting in a lower cost per client per day. Conversely, lower bed utilization generally will result in a higher cost per client per day. Bed utilization rate is calculated by dividing the total number beds filled by the total number of available beds. In reporting this measure to OMB, BARC gathers the total number of beds filled for each day in the quarter from BARC s client data management system, ECHO, which tracks clients through treatment in each of BARC s programs. The bed utilization rate for each quarter is then averaged for annual reporting. The maximum available bed capacity for Detox and Residential is 34 and 92 beds, respectively. The total number of actual beds available for each day is tracked internally by staff in a spreadsheet, and varies somewhat from the maximum capacity each day, based on daily bed availability due to repairs, hospitalizations or other factors as may be determined by BARC. To evaluate BARC's utilization rate against peers, we identified the 2012 National Survey of Substance Abuse Treatment Services (N-SSATS) as a benchmarking data source. This study is published annually by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). The N-SSATS includes data on the location, characteristics, services offered, and number of clients in treatment at alcohol and drug abuse treatment facilities at public and private facilities throughout the 50 states, the District of Columbia, and other U.S. Jurisdictions. Based upon the 2012 results of this study, the average combined bed utilization rate for detoxification and residential facilities in Florida was 92%. As BARC operates and reports on its Detox and Residential treatment facilities individually, the following analysis applies this 92% benchmark rate against each area separately. Detox Bed Utilization As shown in Exhibit 8, for each fiscal year (FY) from 2011 through 2014, based upon data provided to our Office, BARC s Detox facility either met or exceeded the 92% benchmark. For both FYs 2013 and 2014, BARC has maintained a 97% utilization rate, indicating a high demand for services. 9

12 Exhibit 8: For FY , the utilization rate for Detox has consistently remained at or above the 92% benchmark. 100% 90% 96% 92% 97% 97% 80% 70% 60% 50% FY 2011 FY 2012 FY 2013 FY 2014 * Red line indicates average percent of detox and residential beds utilized in the state of Florida in Source: Office of the County Auditor analysis As shown in Exhibit 9, the FY 2014 utilization rate of 97% represents a significant improvement from the previous 2008 Report completed by this Office, which demonstrated an average utilization rate for Detox of 80% in Exhibit 9: The utilization rate for Detox has increased from FY 2007 to FY % 97% 90% 80% 80% 70% 60% 50% FY 2007 FY 2014 Source: Office of the County Auditor analysis 10

13 Residential Bed Utilization Exhibit 10 shows the utilization rate for Residential Treatment services, as reported by BARC, for each FY from 2011 through Over the four years, the reported utilization rate for this facility has averaged 80%, 12 percentage points below the 92% benchmark. Exhibit 10: During the four years from FY 2011 to FY 2014, the utilization rate for Residential has increased, but remained below the average 92% benchmark. 100% 90% 86% 80% 78% 76% 79% 70% 60% 50% * Red line indicates average percent of detox and residential beds utilized in the state of Florida in Source: Office of the County Auditor analysis Exhibit 11 compares BARC s Residential utilization rate in FY 2014 with its utilization rate in FY 2007 as reported in our previous BARC performance review. At 86%, the 2014 rate represents a significant increase over the 2007 utilization rate of 67%. Exhibit 11: The utilization rate for Residential has increased from FY 2007 to FY % FY 2011 FY 2012 FY 2013 FY % 86% 80% 70% 67% 60% 50% Source: Office of the County Auditor analysis FY2007 FY

14 Number of Available Beds at Residential In considering the reported utilization rates for Residential, it is important to note that beginning in FY 2013, BARC modified its methodology for calculating the total number of available beds. As previously noted, BARC s residential facility has a maximum capacity of 92 beds; however, in 2013, BARC began calculating the utilization rate with a baseline capacity of 82 beds. BARC Managers explained that they capped themselves at this lower rate due to funding cuts. An agenda item presented to the Board on 12/11/12, acknowledges a $100,000 reduction in BBHC funding and states, Residential services is being reduced as these services have less of an impact on the community due to recent trends in utilization. BARC Managers also note that during this time, they were considering the possibility of converting these beds to transitional housing, and generally removed them from consideration of their total available capacity. However, BARC staff note that these plans did not materialize, and the facility remained able to accept up to 92 clients, if at any given time, services were needed. Additionally, BARC staff acknowledge that on occasion during this timeframe, the facility served clients in excess of the 82 bed baseline capacity. If the utilization rate for Residential services is re-calculated for FYs 2013 and 2014 using the maximum available capacity of 92 beds, the bed utilization rates would be lower. Specifically, as shown in Exhibit 12, the utilization rates for 2013 and 2014 would decrease to 71% and 77%, respectively. This utilization rate is significantly lower than the statewide benchmark of 92%, and the utilization rates BARC reported to OMB. Exhibit 12: Using a baseline of 92 Residential beds, FY 2013 and 2014 utilization rates are significantly reduced. 100% 90% 86% 80% 79% 77% 70% 71% 60% 50% FY 2013 FY 2014 Residential Utilization Reported by BARC Residential Utilization based on 92 beds * Red line indicates average percent of detox and residential beds utilized in the state of Florida in Source: Office of the County Auditor analysis 12

15 This perspective is important because based upon BARC s Managers feedback, there is a somewhat decreased need for Residential treatment services in the community relative to BARC s actual capacity to provide services. As a result of this disparity, Residential services will likely continue to operate below optimum efficiency, and the cost per client per day (see next section) will not be as low as it would be with a higher utilization rate. To improve its performance in this area, BARC will need to serve additional clients. In discussing Residential services client utilization rates, BARC Managers also identify the following challenges in their admissions processes which may contribute to lower utilization rates: Restricting admissions to clients with valid identification (ID) and proof of Broward County residency: The Administrative Code specifies that BARC services are to be provided to Broward County residents. To ensure compliance with this directive, BARC does not admit clients to Residential who do not have a current ID and proof of Broward County residency. Managers note this is sometimes problematic, as many potential clients are homeless, and do not have, or have otherwise lost, their identification and also have difficulty proving Broward County residency. To assist clients in overcoming this obstacle to admission, BARC Managers state that recently a Department of Motor Vehicles representative has been available on site at BARC Central once per month. Reduced referrals for Perinatal Addiction Program (PAP): BARC Managers acknowledge challenges in receiving consistent referrals to the PAP program from local hospitals providing detoxification services to pregnant women. This could have an impact on utilization rates as pregnant women are allowed to remain in the program for several months, pending delivery. Clients with severe mental health issues are typically not admitted for Residential treatment services: While there may be a need for substance abuse treatment amongst potential clients with co-occurring disorders, BARC does not specialize in this type of treatment service, and does not provide services for persons with more severe mental health illnesses. Refusal to treat individuals with private insurance: As BARC does not have billing agreements with private insurers; BARC typically does not admit potential clients with private insurance; instead these persons are referred to other facilities. Findings: 1. BARC s Detoxification facility has maintained a high utilization rate, meeting or exceeding the statewide benchmark over the past four years. 2. BARC s Residential facility four year average utilization rate is 12 percentage points lower than the statewide benchmark. 3. BARC is internally reducing its available capacity for Residential treatment based upon apparent community needs. 4. Both Detox and Residential services have increased bed utilization rates in FY 2014 compared to FY

16 Recommendation: 1. To continue to improve the utilization rate for Residential services, BARC should: a. Address identified challenges in Residential admissions process to facilitate client access to available services, or b. Decrease bed capacity to a level that is indicative of the need in the community for their services. Efficiency: Cost per Client per Day Cost-effective organizations aim to control cost, while maintaining quality, to achieve maximum efficiency. Unit costs provide better information as to an organization s operating efficiency than total costs. This is true because a change in total costs can be affected by multiple factors (e.g. utility or grounds maintenance costs), and may not be directly related to the level of services provided (e.g. number clients served, number of individual counseling sessions provided). Similarly, a change in the number of clients served may not have a direct or significant effect on total costs. Therefore, unit cost, such as the cost per client per day, is often used by managers in assessing operating efficiency. This data can be used to analyze operating efficiency over time, as well providing a basis for comparison to peers. BARC collects unit cost data for substance abuse treatment services and calculates the cost per client per day for both Detox and Residential services. Our Office used BARC s data to compare its service costs to the costs of other similar facilities in Florida. Specifically, we compared BARC s detoxification and residential treatment services cost per client per day to state averages published in the 2012 study, The Economic Cost of Substance Abuse Treatment in the State of Florida. 1 The study s findings are based on a review of 175 programs in Florida which accept government funding. This study considers the total cost of operations, including typical expenses such as staff salaries, rent, utilities, insurance, security, maintenance, food, and medications. Expenses between program types can vary, therefore, detoxification and residential treatment programs were considered separately by the study and in the following analysis. As this study presented costs for 2009, we adjusted the 2009 base amount for inflation, using the Consumer Price Index for All Urban Consumers for Miami-Fort Lauderdale, FL. In reviewing the cost data provided to our Office by BARC, we noted inconsistencies in the cost elements included from year to year. Therefore, to ensure consistency in the comparison of these costs over time (FY ), as well as comparability to the peer study, it was necessary to make two adjustments to the information provided. First, BARC began including Human Services Department management personnel as part of their overall cost structure in FY 2012; therefore, these expenses were added to the analysis for FY Second, expenses for maintenance and security contracts were transferred 1 The study was published in 2012 by Sage Publications, and was written by individuals from the University of Miami, Johns Hopkins University, and Nova Southeastern University, in partnership with DCF to determine the economic costs of publicly funded substance abuse treatment in Florida. 14

17 from BARC to Facilities Management Division in 2012; therefore, these expenses were also added to BARC s overall costs for FY in the following analyses. Detox Cost Per Client Per Day As reflected in Exhibit 13, BARC s cost per client per day for detoxification has been higher than the state average developed in the 2012 study. Specifically, in FY 2014, the average cost of BARC s detoxification services is $386 per client per day, which is 14% higher than the state average of $340 per day (as adjusted for inflation). Costs in FY 2012 and 2013 were lower, at only 5% above the state average. Exhibit 13: In FY 2014, BARC s cost per client per day for Detox was 14% higher than the adjusted average cost per client per day in Florida. $500 $400 $394 $352 $350 $386 $300 $200 $100 $- FY 2011 FY 2012 FY 2013 FY 2014 *Red line represents the adjusted average cost of treatment per client per day in Florida. Source: Office of the County Auditor analysis Residential Cost Per Client Per Day As displayed in Exhibit 14, BARC s average per client costs for Residential were also higher than the study s state average. From FY , costs were 2-14% higher than the adjusted state average. In the most recent year, FY 2014, BARC s residential treatment cost per client per day was $185, approximately 4% higher than the adjusted state average of $178 per day. 15

18 Exhibit 14: In FY 2014, BARC s residential treatment cost per client per day was 4% higher than the state average. $200 $192 $197 $185 $175 $150 $100 $50 $- *Red line represents the adjusted average cost of treatment per client per day in Florida. Source: Office of the County Auditor analysis While BARC s current costs are higher than adjusted costs for its Florida peers, it is important to note that overall, costs for both Detox and Residential services have decreased over time. In the 2008 Report, costs per client per day for Detox and Residential Services were $458 and $261, respectively. As shown in Exhibit 15, improvement is observed for both programs over the seven year period. Specifically, over this period of time, costs for Detox reduced by 16%, and costs for Residential were reduced by 29%. Exhibit 15: From FY 2007 to FY 2014, BARC reduced its costs per client per day for both Detox and Residential services. $500 FY 2011 FY 2012 FY 2013 FY 2014 $458 $400 $386 $300 $261 $200 $185 $100 $- Detox Residential Source: Office of the County Auditor analysis FY 2007 FY

19 Based on this information, it appears that BARC Managers have made progress in reducing operating costs for both programs. Further, BARC s current operating costs are close to the inflation adjusted costs of their Florida peers. Findings: 5. Over the past four fiscal years, BARC s cost per client per day for Detox and Residential services remains close to, or slightly (2-14%) higher than the Florida average for government funded treatment facilities. 6. From 2007 to 2014, BARC has reduced its cost per client per day for both Detox and Residential treatment services. Recommendation: 2. As feasible, BARC should continue practices that have been effective at controlling its costs. Effectiveness: Percent of Clients who Have Successfully Completed Treatment One of the main goals for clients in substance abuse treatment is to complete treatment. While the ultimate treatment goal is to become sober and discontinue drug and alcohol use long-term, this is difficult to measure once clients leave a program. Therefore, in measuring successful treatment of clients, BARC states that they consider the completion of each area of treatment as a valid measure of success. BARC reports attainment of successful completion of treatment to OMB for Detox, Residential, Intensive Outpatient (IOP) and Outpatient (OP) services. Successful completion of services is also reported to BBHC. Our Office was unable to fully validate the attainment levels reported by BARC to OMB from FY During the course of this review, we requested BARC provide source data used to report successful attainment in each service area. However, BARC Managers state they did not keep records of the data reported to OMB; therefore, in response to our request, BARC generated new reports for these time periods. In reviewing this data, inconsistencies with previously reported attainment levels were identified, particularly for IOP and OP. Specifically, we noted variations in the numbers of clients considered successful in the client data reports provided to us against the figures reported to OMB. These variations ranged from 15% less, up to 33% more successful clients. In response to our questions regarding these differences, BARC Managers indicated that due to changes in how successful completion is considered, and data entry concerns within their CMIS system, the previously reported results cannot be replicated at this time. 17

20 Therefore, the attainment levels reported to OMB for IOP and OP could not be validated and are not included for discussion within this report. We researched drug abuse treatment completion rates to identify benchmarks for comparison to BARC s reported attainment levels. We noted the federal government provides national statistics regarding discharges from substance abuse treatment services in a study entitled Treatment Episode Data Set (TEDS), which is published annually by SAMHSA. We used the TEDS study issued in May 2014 which summarizes 2011 data and provides completion rates for detox, residential and intensive outpatient treatment areas for comparison to BARC s reported results. BARC considers clients to have successfully completed treatment when they have completed their program or treatment plan, or have transferred to a lower level of care (i.e. a client completing detoxification services and then transferring to residential services would be considered successfully completing detoxification, even though they still remain in a treatment program). Therefore in reviewing the TEDS study, we considered successful completion in the same manner. BARC also reports successful completion to BBHC for the clients receiving grant-funded services. For FY 2014, BBHC standard for successful treatment is 51%, across all levels of services (Detox, Residential and Outpatient). We compared BARC s reported client completion rates to BBHC s standard. Detox Treatment Program Effectiveness Compared to National Average In 2011, the national average completion rate for detoxification services was 78%. As shown in Exhibit 16, over the past four years, BARC has reported similar levels of successful attainment for its Detox clients. Exhibit 16: Between FY , BARC s clients completed Detox Treatment services at a rate consistent with the 2011 national average. 100% 80% 80% 78% 80% 81% 60% 40% 20% 0% FY 2011 FY 2012 FY 2013 FY 2014 * Red line indicates 78% detoxification completion rate benchmark from SAMSHA TEDS study. Source: Office of the County Auditor analysis 18

21 Residential Treatment Program Effectiveness Compared to National Average In 2011, the national average completion rate for residential treatment services was 70%. As shown in Exhibit 17, over the past four years, BARC s reported attainment for its Residential clients averaged 67%, close to this threshold. Exhibit 17: Between FYs , BARC s clients completed Residential services at a rate close to the 2011 national average. 100% 80% 66% 67% 68% 68% 60% 40% 20% 0% * Red line indicates 70% detoxification completion rate benchmark from SAMSHA TEDS study. Source: Office of the County Auditor analysis Detox and Residential Treatment Effectiveness Compared to BBHC Standard In FY 2014, BARC s contract with BBHC establishes a 51% completion goal across all types of services. As shown in Exhibit 18, BARC exceeded this goal, with 81% and 68% of Detox and Residential clients successfully completed treatment services. Exhibit 18: In FY 2014, both Detox and Residential services exceeded the 51% treatment completion goal established by contract with BBHC. 100% FY 2011 FY 2012 FY 2013 FY % 60% 81% 68% 40% 20% 0% FY 2014 Detox * Red line indicates 51% treatment goal established by BBHC contract. Source: Office of the County Auditor analysis 19 FY 2014 Residential

22 The completion rates for Detox and Residential services clients indicate BARC is effectively providing these services. Challenges with data collection and reporting were identified for Outpatient services and as result an assessment of the effectiveness of these services cannot be made at this time. In this regard it is important to note BARC has made progress in data collection and reporting since our evaluation of BARC in At that time, successful completion of treatment could not be assessed or verified for any of BARC services due to issues with obtaining data. Findings: 6. For FYs , client success rates for Detox and Residential services are similar to national averages in In FY 2014, both Detox and Residential services client completion rates exceeded goals established by BBHC contract. 8. Data reliability concerns inhibit verification of client success rates reported by BARC to OMB for various Outpatient services. Recommendation: 3. To improve data reliability and management s ability to monitor client progress through treatment services, BARC should a. Develop and employ a consistent methodology for the tracking and reporting successful attainment of important performance measures. b. Ensure its client management systems are properly configured to accurately capture necessary client information. c. Ensure its client management system is able to generate reliable client reports. Section 2: Evaluation of BARC s Cost Recovery Practices The second part of this report examines BARC s practices in recovering its cost to provide treatment services. Often government agencies establish and collect fees for services to reduce their reliance upon tax dollars. By ensuring available funding sources are utilized, and to the extent possible, clients pay for services, agencies can increase the proportion of expenses funded by direct users, potentially expand services as appropriate and/or increase recovery of General Fund expenditures. The following sections of this report examine BARC s practices in recovering its costs through sources such as Medicaid, Medicare, Private insurance and direct client fees for services. Fees for Services Section (2), Florida Statutes, requires clients receiving substance abuse services from state funded facilities to contribute to the cost of services. Therefore, as required, BARC maintains a fee schedule, which specifies the costs of various treatment services, 20

23 such as detox or residential treatment services (to be billed as daily bundled services), individual or group counseling sessions, and ancillary services such as urinalysis. During our review, BARC Managers informed us that the fee schedule in use was created by staff in 2014, and was put into effect in December 2014, pending adoption by the Board of County Commissioners. 2 According to the fee schedule, provided to us by BARC, the amount clients are charged for services is based on a sliding scale, which assesses fees according to annual income and family size. Exhibit 19 lists the current maximum fees for key services. Exhibit 20 shows the income levels and portion of fees assessed to clients for those services. Exhibit 19: BARC s fee schedule specifies maximum charges for various services. Service Maximum Fees Bio-Psychosocial Assessment $ (Part 1) $ (Part 2) $ (Update) Detox $212.22/day Residential $180.00/day Non-Residential Day Treatment $19.75 per hour Individual Services $103.24/hour Aftercare Group Services $22.94/hour/client Specimen Collection and $30/screening Testing Source: Office of the County Auditor presentation of information provided by BARC Exhibit 20: Client income levels are assessed in relation to federal poverty level to determine the percentage of fees a client will be charged. Income Level of Client (Percent of Poverty Level) Percent of Current Maximum Fee Client Shall Pay 0 to 149% 5% 150 to 199% 10% 200 to 249% 20% 250 to 299% 30% 300 to 349% 40% 350 to 399% 60% 400 to 449% 80% 450% and above Full Fee Source: Office of the County Auditor presentation of information provided by BARC These two schedules are used together to determine the portion of fees that may be charged to clients. For example, a client with income at 175% of the federal poverty level (or $20, for a single person) who receives seven days of detox services, will be 2 BARC managers acknowledge the fee schedule was not yet approved by the Board, but was in use effective December

24 responsible for approximately 10%, or $148, of the cost of their treatment. 3 Although BARC asks for proof of Broward residency prior to providing services, occasionally, BARC may provide services to clients who are not residents. Exceptions are made for clients at Detox as providing this service is considered to be a medical necessity. BARC Managers state it is their practice to charge these clients the full fee for services provided. ECHO Client Management Information System (CMIS) To better understand BARC s current client billing practices related to the above fee schedule, it is first important to understand the historical development and role of its CMIS system, ECHO, in recording client service episodes, which form the basis for billing. On September 24, 2002, the Broward Board of County Commissioners approved an agreement between Broward County and ECHO for computer application software for a Client Management Information System (CMIS) for BARC. The CMIS system has two main components: the Revenue Manager application and Clinician s Desktop application. The Clinician s Desktop application manages client medical records, while the Revenue Manager application is responsible for generating billing invoices. The Revenue Manager component has had functionality issues for years, and was still not fully operational as a billing system as of the close of our fieldwork in August According to BARC Managers, following the original installation of the ECHO software, BARC staff made modifications to the system in an effort to transition from paper to electronic records. As a result of these over-customizations, BARC experienced significant issues with recording and reporting client data. Consequently, the Revenue Manager application has been non-functional as a billing system (at least since 2012, or longer), and is unable to automatically generate accurate invoices to clients, or credit payments received to client accounts. In 2013, responsibility for managing the ECHO contract has transferred from BARC to the Human Services Department (HSD), and a work authorization was issued to ECHO to resolve over-customization issues. As of August 4, 2015, BARC and HSD state that Revenue Manager was functional for vendor and Medicaid billing, but was not able to create accurate invoices to clients. Furthermore, once ECHO is functional, it will not be able to generate invoices for previously delivered client services. As a result of these ongoing issues, minimal client fees have been collected over the past four years. As illustrated in Exhibit 21, in 2014, total client fees collected were less than $100,000, representing less than 1% of BARC s 2014 budget. According to BARC, these fees were collected primarily in instances when a client or other source such as Veteran s Affairs or an employer volunteered to pay, in which case a bill would be manually generated. 3 Daily fee for Detox is $212.22; $ x 7days = $1,485.54; $ x 10% = $

25 Exhibit 21: Over the past four years, BARC has collected approximately $500,000 in client fees, with $89,285 collected in $175,000 $159,300 $150,000 $125,000 $131,483 $110,265 $100,000 $89,285 $75,000 $50,000 $25,000 $- FY 2011 FY 2012 FY 2013 FY 2014 Source: Office of the County Auditor presentation of BARC data The above collection amounts are consistent with our 2008 review; in 2007, only $51,765 in client fees was collected. At the time of that review, BARC Managers cited problems with client fee collection such as the perception that services are free, and cited plans to discuss fees at intake, complete verification of client income, and provide clients a bill upon discharge. Based upon the current status of BARC s fee collection practices, it appears minimal progress towards these objectives was achieved. To better understand the potential lost revenue caused by the dysfunctional billing system, we worked with BARC to develop estimates of potential client fees and collections. For the month of April 2015, BARC was able to track the number of service episodes for treatment services such as detoxification, residential, admissions and outpatient programs for self-paying or DCF funded clients. 4 In total, there were over 5,700 treatment services delivered, with potential maximum client fees of $783,495. After applying DCF payments and the sliding fee scale, the estimated fees billable to clients for the month approximate $65,000. Extrapolating this monthly amount to an annual basis results in $780,000 in potential billable fees per year, and by extension, an estimated $3.2 million in client fees over the past four years. It is recognized that not all fees would be collected; however, even a 50% collection rate, yielding $1.6 million, would be a significant increase in revenue over the actual $500,000 collected in fees since DCF funded clients were included in this analysis as according to Florida Statutes and contract they are responsible to contribute to the costs of their services 23

26 Medicaid, Medicare and Private Insurance In addition to collecting revenue through directly billing clients, Medicaid, Medicare, and insurance companies can also be invoiced for eligible clients and the services they receive. The points below discuss BARC s current billing practices for these additional payment sources: Medicaid Medicaid is a low income eligibility based assistance program for qualified individuals. Historically, BARC has been able to recover some costs for treatment from Medicaid for clients receiving Outpatient services. However, the Florida Medicaid system has recently undergone many changes. In 2011, Florida passed legislation to transition most Medicaid recipients from traditional fee-for-service Medicaid to Managed Care Medicaid. Within Broward County, there are four Medicaid Managed Care organizations for substance abuse and mental health. Presently, BARC/Human Services Department has been able to execute interim agreements with two of the four organizations, Psychcare and Concordia. As of the close of our fieldwork in August 2015, BARC Managers state they have been invoicing Medicaid eligible clients and services, which, may include detox and residential, with pre-authorization. Further, a limited number of clients have remained eligible under traditional Medicaid and BARC states that they will continue to invoice for these client services as well. Exhibit 22 displays the revenue amounts received by BARC from Medicaid for FYs Presently BARC does not have procedures in place to assist potentially Medicaid eligible clients to apply for coverage. Assisting more clients with the application process may yield higher revenue collection in the future. Exhibit 22: BARC s revenue collected from Medicaid has improved in FYs 2013 and $150,000 $133,944 $125,000 $100,000 $94,799 $75,000 $50,000 $25,000 $39,508 $46,218 $- FY 2011 FY 2012 FY 2013 FY 2014 Source: Office of the County Auditor presentation of BARC data 24

27 It is noted that these amounts represent a significant improvement from the 2008 report, which indicated that only $1,182 in Medicaid reimbursements was received in 2005, and no monies were received at all in FYs 2006 and Medicare Medicare insurance typically serves persons over the age of 65, or persons with disabilities. BARC has not historically billed Medicare for client services, but Managers state they plan to start, once the Medicaid billing process is fully implemented. Private insurance Historically, BARC has not billed health insurance companies and has instead referred these clients to other treatment providers. BARC Managers state that BARC may want to look into accepting insurance in the future. Presently it is unknown how much potential revenue may be lost in this manner. Findings: 10. Inadequate functioning of the CMIS systems has inhibited BARC s ability to accurately invoice clients for services for at least five years. 11. BARC does not have an automated or proactive billing system; manual billing is available upon request. 12. BARC will not be able to generate accurate invoices for any services delivered prior to the date Revenue Manager becomes fully operational. 13. Delays in Medicaid Managed Care contract execution have inhibited BARC s ability to invoice for eligible clients. 14. BARC does not accept private insurance; as a result, unknown numbers of clients and potential revenues has been referred to other providers. 15. In 2015, BARC used a fee schedule which was not formally approved by Board. Recommendations: 4. To maximize potential available revenue, and offset some costs of providing treatment services, BARC should: a. Ensure ECHO Revenue Manager is fully functional and able to generate accurate client invoices, and properly credit clients accounts upon receipt of monies. b. Ensure client income is verified during early phases of treatment, and clients are aware of their financial obligations. c. Ensure fees for services are appropriately assessed and collected. d. Continue efforts to execute long term agreements with Medicaid carriers. e. Proactively develop agreements with additional private insurers. f. Ensure systems are in place to invoice insurance carriers for all eligible services, inclusive of obtaining pre-authorizations when applicable. 25

28 g. Develop procedures to assist potentially eligible clients to apply for Medicare and/or Medicaid coverage as applicable. 5. To ensure that BARC is following Board direction, BARC should immediately take action to ensure Board approval of any client fee schedule in use. 26

29 Office of the County Auditor Board Action Agenda Item #61 June 7, 2016 A. MOTION TO FILE Performance Review Broward Addiction Recovery Center (Report No ). (A member of the public pulled this item.) ACTION: (T-3:21 PM) Approved. (Refer to minutes for full discussion.) VOTE: 6-0. Commissioner Bogen was not present. Commissioner Ryan was out of the room during the vote. District 3 is open. ACTION: (T-4:20 PM) Commissioner Ryan requested being shown voting in the affirmative. 61. VOTE: 7-0. B. MOTION TO ADOPT County Auditor s Recommendations. (A member of the public pulled this item.) ACTION: (T-3:21 PM) Approved. (Refer to minutes for full discussion.) VOTE: 6-0. Commissioner Bogen was not present. Commissioner Ryan was out of the room during the vote. District 3 is open. ACTION: (T-4:00 PM) Commissioner Ryan requested being shown voting in the affirmative. VOTE: 7-0. Attachments Exhibit 1 - Performance Review Broward Addiction Recovery Center (Report No. 16-4) Exhibit 2 - Management's Response