Quick Fix

After years of financial neglect, the state is hoping a shot of privatization will cure Dallas County's addicted and mentally ill population

Just like people who have private insurance, Northstar clients will select a plan, either Magellan's or Value Options', and a primary-care physician. Once enrolled in the program, the patients have the option of switching between plans, and they are free to change their primary-care providers. In an attempt to avoid costly emergency-room visits, patients will also have 24-hour telephone access to nurses who can answer medical questions.

If it works, the new system will make a world of difference to patients, who have historically been bounced from one county agency to the next, seeing different doctors unfamiliar with their medical history and unable to provide consistent care. Patients found the bureaucracy all the more difficult to navigate because they were often sent to doctors whose offices were too far away from their homes.

If patients didn't make it to the doctor, for example, they couldn't get their medications, their symptoms would grow worse, and they might ultimately end with a costly visit to Parkland Hospital's publicly financed emergency room. Once the patients were stabilized at Parkland, getting follow-up treatment depended on whether they qualified for Medicaid. In the end, Wanser says, many patients were sent home, and the cycle would begin anew.

Michael Hogue

The New Place's Carolyn Tartaro conducts the last group session inside the New Place. The first drug treatment center of its kind in Dallas, the New Place became the first casualty in a new experiment in managed health care for Dallas County's low-income addicts and mentally ill residents when it closed its doors on October 15, 1999.
Mark Graham
The New Place's Carolyn Tartaro conducts the last group session inside the New Place. The first drug treatment center of its kind in Dallas, the New Place became the first casualty in a new experiment in managed health care for Dallas County's low-income addicts and mentally ill residents when it closed its doors on October 15, 1999.

"Any rational person who doesn't have a vested interest in not seeing things change would agree this is not a sensible way to go. The idea of having coordinated systems of care that aren't redundant makes perfect sense," Wanser says. "For the consumer, [Northstar] starts to level the playing field so you don't have treatment ghettos."

From the perspective of consumers, the greatest potential benefit of Northstar is its promise to give them a watchdog authority over the companies that are supposed to help them get healthy. Unfortunately for them, the review board that's supposed to wield this authority is at the moment stalled. Initially, Dallas Area Northstar Authority (DANSA) was supposed to be fully operational by September 1998, but its board did not begin meeting until after the first of this year, and they didn't hire an executive director until May.

Under the old system, Dallas County's MHMR delivered health care for the mentally ill and Dallas County provided oversight of that care via the MHMR board of trustees, whose members were appointed by the county commissioners. When things went wrong, patients had nowhere to turn except the board, where they often found that their concerns fell on the deaf ears of political appointees who were more interested in protecting their reputations than in investigating consumer complaints.

The problem was last illustrated in 1997, when state auditors reported that the department was rife with financial mismanagement that had festered under the watch of the trustees, who were too busy to notice because they were micromanaging staff and clashing with advocates of the mentally ill during public meetings.

As conceived, DANSA would mark the first time that an independent board made up of Northstar patients and their advocates would be responsible for policing the public-health-care system. Even though DANSA is still in its infancy, spats have broken out regarding who should sit on its board. Mental-health advocates fear the board will be stacked with political appointments, breaking the state's promise to make the board more consumer-friendly.

If DANSA had been up and running on time, it might have been flooded with complaints. An unexpected delay in obtaining federal approval caused tremendous difficulties in getting patients enrolled in Northstar and pushed the deadline for enrollment back three months. Of the nearly 200,000 people the state expects to enroll in Northstar, only 50,841 have applied for membership so far, says Rudy Villarreal, the regional manager at Maximus, a Virginia-based company the state hired to handle enrollment for its managed-care pilots.

Once everyone is enrolled, state officials hope, a new computer database will enable them to better track patients through the system. As part of the new system, the managed-care companies will enter information that details everything from whether patients showed up for an appointment to what medications they were prescribed. While state officials have always tracked how the counties have spent their funds, they are hoping the database will enable them to discern whether a patient actually improves.

"Northstar gives us the ability to look at things at a larger policy level," says Patrick Gillies, the Northstar contract manager and Wanser's right-hand man. "In the past, monitoring contracts was about [asking providers], 'Are you spending money properly?' Now we're asking questions we haven't historically asked."

Whether Northstar will truly improve patients' health remains to be seen, but already the project has made the state's job of buying health care infinitely easier.

Prior to Northstar, the Texas Health and Human Services Commission took money out of the state's Medicaid budget and gave it to county-run agencies like the Dallas County MHMR, which spent the money in accordance with contracts they signed with the state. The state managed similar contracts with various private doctors who agreed to accept Medicaid patients.

Since Medicaid did not cover the cost of most drug treatment programs, the state used a separate funding stream for indigent addicts. The Texas Commission on Alcohol and Drug Abuse (TCADA) funded a network of drug treatment centers, which worked hand-in-hand with various county agencies but were nonprofit organizations under contract separately with the state.

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