Office of Budget and Evaluation

Progress Report on NorthSTAR Program

411 Elm Street, 3rd Floor, Dallas, Texas 75202
E-mail: • Fax (214) 653-6517

I  -  Background

The NorthSTAR managed care program was implemented on July 1, 1999 with approximately $5 million of  County discretionary funding. The program has now been operational for approximately ten months. The purpose of this report is discuss various aspects of the rollout and make recommendations for the future direction of the program.

II  -  Outline of this Report

The progress of NorthSTAR will be discussed in the following categories:

Overview of Program- this section will include a review of the purposes of the program and the intended benefits.

Overall financial posture of the program - this category includes the costs of service paid out by the two BHOs as compared to the state's projections, and discusses the likely corrective actions to be made by the state and BHOs to create long term solvency.

Service Delivery in the Seven County region - because the managed care system has caused a major change in the financial posture of various service providers, including a major downsizing at Dallas Area Metrocare, this section will discuss the overall level of service being provided to citizens as compared to the pre-North STAR configuration.

Program Data Flow - one of the largest single weaknesses of the program to date has been the inability of local officials to judge its progress by looking at reliable management information. This section provides a recommendation to improve this data flow for the second year.

Items specific to the County Contribution and the County Agreement - the County's contribution was expected to provide "zero gain" services, with no costs transferred to or from the County to NorthSTAR. A certain portion of the payment was retained until an analysis could confirm that these transfers were not occurring. This section will concentrate on the services previously provided by County agreements with MHMR and TCADA, and will provide a recommendation relative to the funds retained by the County to protect against cost transfers to the County taxpayer. This section will also contain a point-by-point evaluation of the agreement made among the state, the BHO s, DANSA,  and the County, with a summary of compliance with this agreement.

Role of DANSA - This section will examine the role of the local board appointed by the respective Commissioners Courts, and make a recommendation for its future.

Conclusions/Recommendations - this section will summarize all conclusions drawn in the previous discussion.

III - Overview of the Managed Care Plan

The design of North STAR contemplated the concentration of a substantial portion of all public funding from several sources into one pool to be administered by two Behavioral Health Organizations selected by the state after a competitive bid process. The two selected organizations (Magellan and Value Options) would eventually compete for patients and disperse funds from all sources in a way that created efficiencies that would have otherwise been unavailable with public management. In the process, the two for-profit BHO s were expecting to create profit opportunities for themselves.

The primary business points of the agreement that affect the first half-year of the rollout are as follows:

Services - the BHO s  were  expected to serve everyone who presented at any contracted facility, without waiting. Generally,  the largest providers of services within Dallas County have not changed in the early months of the program, although the largest provider-Dallas Metrocare Services is vigorously contesting certain procedures followed by one of the BHO s and has served notice that it intends to remove itself from the provider network in the near future. Problems have also been identified (see below) with apparent loss of certain residential detox capabilities,a possible loss of housing services  and with the relocation of  the stabilization function out of County.

Patient Split - an enrollment broker was hired to help consumers choose  one or the other plan. Consumers without a preference were randomly assigned to one of the BHO s. Enrollment packets were mailed to all then-identified MHMR patients. Other qualified individuals continue to be enrolled as they seek services.

BHO Profit - the agreement with the state required the pay out of a given percentage of funds to services, thus limiting the profit to an amount agreed-to during the bidding process. The profit was thus capped on the upside, but not guaranteed. The BHO s understood from experience in other jurisdictions that certain start-up adjustments would most likely not make the engagements profitable in the first year, and that acceptance of the engagement might require that less-than-efficient techniques be utilized for a temporary period.

Partial Roll-out - the system began to operate on schedule on July 1, 1999 despite the federal government's delay in approving a waiver that would allow the use of Medicaid funds in the pool of local money. Accordingly, certain unanticipated losses were created from July until December and duplicative structures were in place. The estimate of these unexpected losses has been estimated to be $1.2 million for the two  BHO s.

Community Agency - the design of the program called for the appointment of a local board to channel community input on policy matters relating to mental health services, and to act in an advisory capacity for the respective Commissioners Courts. The Dallas Area North STAR Authority (DANSA) was created at the beginning of the rollout and became fully operational is September, 1999 under the leadership of Rik Lindahl, board chair, and Dr. Tom Turnage, CEO. The board has met regularly since that time and has conducted several  community forums, a provider survey and has participated in the key discussions related to enrollment, service mix, financial viability, and performance of the BHO s. DANSA is currently reevaluating its own role and creating a set of objectives to guide its operation during the second year of operation. A later section of this memo will discuss possible options for the future of DANSA.

Summary - the North STAR program has rolled out more-or-less as planned, with the most troublesome aspects being (a.) state and local resources that were smaller than anticipated, ( b.) failure to  complete the networks with respect to a psychiatric emergency room,( c.) the delay of the waiver which created temporary unanticipated financial losses for the BHO s , ( d.) authorization and billing problems which involve large sums and the threat of disruption to the system of services provided in the community,  (e) poorly planned and executed data flow which has badly undermined confidence in the management of the program, and (f) the potential of unexpected shifts in costs associated with housing. Notwithstanding these problems, enrollment has occurred, virtually all services are being provided, providers are being paid despite start-up problems, and community input is being solicited as expected.  The program is given a reasonable chance of success by most observers and the BHO s and the state are finalizing their agreements for one additional year, assuming certain modifications to the plan can be made.

IV -  Cost Experience of BHOs

The BHO s responded to a state solicitation which estimated the amount of state and local funding that would be available to manage the MH and CD care of the community.  The "pool" of funds was to be distributed to the BHO s based on a formula which apportioned the funds based on the number of enrollees in each plan, providing an incentive for the BHO s to insure good service to entice enrollees to their plan. The BHO s were expected to arrange networks of service providers which would instill another level of competition into the system-the most efficient service providers could, in principle, provide quality services at lower costs, while less efficient providers would be unable to compete.

The total size of the pool was estimated to be $93.3 million, of which $74.7 million was to be cash while $18.6 was to have been "free" or pre-paid beds at Terrell State Hospital. Table I compares the current annual pool size to the original estimate, and the following paragraphs describe the most important departures from the original estimate.

Table I



  Original Current  
  Estimate Estimate Difference
Local Funds 7,184 5,060 (2,124)
TCADA Funds 9,166 8,644 (522)
TX MHMR Funds 32,923 34,684 1,761
Medicaid Funds 24,381 25,766 1,385
MH/SA Project 1,000 1,000 0
Total Cash 74,654 75,154 500
Prepaid Beds 18,652 18,533 (119)
Grand Total 93,306 93,687 381

The following paragraphs discuss the largest departures from the original estimates.

Parkland/Mental Health Connections - Parkland elected not to contribute $1.1 million in local match to the pool , rather provided it directly to Metrocare for the support of a redesigned Mental Health Connections. MHC also bills North STAR for its services.

Misinterpretation of County Contribution - the state miscalculated Dallas  County's contribution by including some CPS costs (approximately $109,000) in its estimates.

Smaller Counties - small counties have not contributed to the pool as expected. Collin County has contributed $255,000 of its expected $382,346.The other five counties in North STAR owe an annualized contribution of $292,210. The state reports continuing negotiations to resolve this issue.

TCADA budget cut - budget shortfalls at TCADA have caused a reduction in the amount of the state's contribution to the NorthSTAR pool of  $522,000 per year.

Summary - The North STAR pool is essentially equal to the planned amount, although the expected pay-out has been somewhat higher than expected, primarily as a result of greater demand for services than was expected and  higher pharmaceutical costs. The partial rollout effected the pool resources for a temporary period. The size of the pool is absolutely limited(unless additional local or grant sources are identified) until at least the state's next biennium. Thus, any departures from plan (higher costs, higher enrollment) must be met with more restrictive procedures or temporary BHO losses rather than with new dollars.

Corrective Strategies - The BHO s have identified and pursued several strategies with the state for balancing the costs and revenues of the program. These include (a) pharmacy cost reduction, (b) diversion of patients to pre-paid of Terrell State Hospital beds, (c) reduction of services to individuals with higher income, and (d) reduction of services for chemically dependent consumers.

Pharmacy Costs - the state allotment for new generation medicine did not find its way into the pool on a net basis, due largely to budget overruns at TDMHMR, although the BHO s began dispensing these medications when the rollout began. The pharmacy costs experienced by the BHO s were roughly $175,000 per month higher than had been expected. Magellan and Value Options have adopted a new medication protocol, after extensive interaction with the advocate community, which places restrictions on non-generic drugs (which can cost up to 3 times their generic counterpart) until the attending physician has specifically determined that the generic is unsatisfactory. A grandfathering of existing consumers has been implemented, so that the changes will occur slowly for new patients requiring medication. The administrative changes involve instituting "preferred" medications for which there is no co-pay. The state contract monitors have approved this change.

Utilization of Terrell State Hospital Beds - the BHO s are required to pay for unused beds at Terrell State Hospital even though Parkland's emergency room physicians are reluctant to send patients there directly without an evaluative period at DPICU (Timberlawn or Green Oaks). The BHO s contend that some patients can be clearly identified as needing long-term hospitalization immediately on arrival at Parkland, and therefore do not need a temporary and expensive stop at a local hospital while a prepaid empty bed is available at Terrell.

Beginning April 1st, new criteria for determining the destination of patients began being used. These criteria provide that patients who have had a previous hospital stay or who could not be reasonable expected to be released within four days of hospitalization should be sent to Terrell directly. Census at Green Oaks and Timberlawn have immediately begun to drop although there appears to be a danger of overusing Terrell beds as a result of this new cost-saving methodology. A critical point related to this abrupt shift to Terrell usage is the question of whether or not bad clinical decisions are being made purely for of cost savings. The Commissioners Court should be particularly sensitive to this question because crisis stabilization in local environment is the single most significant mental health function that has historically been acknowledged as a County government responsibility. The funding of DPICU is the largest single part of the $5 million County contribution. Transferring a large segment of the population out-of-County for treatment, purely for cost reasons, could be seen as violating one of the key understandings associated with the County agreeing to contribute to the NorthSTAR pool.(See Section VII "Comparison of  Performance with Agreement.")

The Office of Budget and Evaluation reviewed data from the last 18 months of the "old" DPICU, to determine if more individuals were now going to Terrell than under the old arrangement. An appropriated defense of the new policy is that "these are people who would have ended up at Terrell anyway." If that were true, pre-NorthSTAR Terrell commitments would equal post-NorthSTAR commitments. The data appears to show otherwise. Prior to NorthSTAR, only 25% of all individuals stabilized at DPICU were committed to Terrell, while the remaining 75% received less intensive care within the community.

By contrast, beginning with the April 1st policy shift, 52 of the next 80 OPCs(65%) have gone to Terrell with most of the rest going to Timberlawn. Clearly, overuse of Terrell seems to be occurring. However, due to the budgeting technique built in to NorthSTAR, this overuse is probably creating resources that are being made available for other local services.           

A related problem involves the mental illness court's ability to provide signed OPC s on a daily schedule that matches the transportation constraints of the state hospital. Judge Loving has been consulted on this matter and has been working with the plans to improve this coordination.  

Eligibility Tightening - it seems generally agreed that much of the financial strain on the program is resulting from the improved access to care which has been granted without sufficient management of the presenting population's ability to pay. As a result, some care is being given to individuals who are above the level of income that was being cared for by the prior system administered by the community mental health centers. A strategy to limit North STAR enrollment to individuals below 200 % of the Federal Poverty Level is in the process of being implemented by the BHO s, with state approval. The BHO's estimate that 357 individuals will be removed from the rolls by this strategy, and therefore the cost savings will be minimal. Metrocare has disagreed with this conclusion and asserts that as many as 600 individuals who previously were MHMR clients will suffer a loss of service if this occurs.  However, reserving the funds for the poorest of the County's citizens is obviously consistent with the intent of the program and this step should be completed and monitored.

Chemical Dependency Treatment Limitation-in response to the TCADA funding cuts described above, the BHO s have adopted a strategy  for limiting  CD care to one treatment of each type per year. The impact of these strategies will require additional discussion before they are fully understood.

Summary-overall, the managed care pool for the seven-county region is $ 93 3 million, which is approximately equal to the planning number used by the state . The BHO s have each experienced losses exacerbated by the partial rollout and the state agencies budget problems. These losses are difficult to accurately ascertain because data is unavailable and several large-dollar billing challenges will ultimately effect the profit/loss statement of the BHO s.  Furthermore, the ongoing nature of the program suggests that the most recent profit picture is more favorable to the BHO s, helping to mitigate earlier losses.  Evidence exists that the plans are reaching a plateau of financial stability. Several financial changes are in process which will also improve the viability of the plans. Both BHO s have indicated their intention to remain in the program for one additional year, indicating their belief in a positive outlook for profitability.

V - Services Provided

Gathering  data on the level of services being provided has proven to be problematical, and especially making a before-and-after comparison of the effects of North STAR. The generalization that waiting lists have been eliminated and that access to care has been broadened is generally accepted, although actual demonstration of this fact is difficult. The following discussion summarizes known information regarding services being provided.

Enrollment - The state's data shows that there are slightly less than 200,000 enrollees in North STAR. Because the concept of "enrollment" has not been consistent during the advent of North STAR, it is difficult to draw conclusions based on this number. Individuals continue to go through an "enrollment" process at Medicaid, after which they become North STAR members. The tightening of federal regulations has reduced the number of individuals who qualify for North STAR through Medicaid eligibility, resulting in a shift from Medicaid to indigent category. However, only a small percentage of the individuals "eligible" actually require behavioral health services, so enrollment data is not helpful in predicting cost, especially if it is relatively flat. Said another way, the cost of service is independent of the method of enrollment (Medicaid or indigent).

Provider Networks - The two BHO s were responsible for developing broad provider networks to accomplish the delivery of services. They accomplished this through automatically enlisting Significant Traditional Providers from among the former Medicaid providers and aggressively marketing to others. In general, it seems likely that there are more individual practitioners on the networks now than there were prior to North STAR.  One facility provider for intensive outpatient substance abuse treatment (New Place) has ceased operations. The current threat by Metrocare to remove itself from one plan's network has been mentioned. However, the claim that North STAR provides wider access appears to be true. Another indicator of this conclusion is the lack of complaint data that can be attributed to consumers whose treatment plan was interrupted by network shifts.

Services Offered-All types of services that were offered pre-North STAR are still being provided with one exception: residential detox  treatment is no longer available even though it was provided last year at DPICU at County/MHMR expense.

According to Dr. Gilfillen, approximately 20 individuals per month, who would have received publicly-funded treatment for substance abuse, are no longer eligible for treatment and are allowed to leave the ER. These individuals cannot by OPC 'd to Timberlawn or Green Oaks because neither plans will  pay for their care. They cannot be OPC 'd to Terrell because the facilities are inadequate to deal with a chemical detox. The plans WILL pay for non-secure chemical dependency facilities (e.g. Homeward Bound) although the patient must agree to go. The OPC process implies and requires that a facility be secure since the individual being legally restrained  has been deemed to be a danger to themselves or others.  Last year, an individual requiring chemical detox could be place in DPICU under the diagnosis "chemically-induced mood or psychotic disorder."  This diagnosis is no longer accepted by the BHO s.    

Complaints/ombudsman-providers have given information that the payment process is cumbersome and that the approval process has not worked smoothly. In addition to the Parkland dispute, discussed elsewhere in this memo, one large ($500,000) case between Green Oaks and Magellan is awaiting arbitration under the terms of the agreement. This case involves a refusal by Magellan to pay the contracted rate ($475 per day) for a dually-diagnosed patient if the patient is physically located in a CD bed. In addition, Green Oaks reports a problem with both BHO s related to being retroactively denied payments for out-of-county residents who receive emergency care under an order of protective custody.  Historically, local dollars would have paid for such care.

VI -  Program Data Flow

The level of information provided to the local government representatives, including DANSA has been insufficient to clearly establish patterns of utilization. The state contract monitors have provided assurances that this situation will be remedied, although data flow has been irregular. This section lists the data that appears to be routinely available, and makes a recommendation on second-year data requirements.

Currently-Available Data - While certain ad hoc reports have been provided by the state and the BHOs, the following is the only data that can be described as a routine deliverable to the local officials:

  1. Complaints by type and by disposition
  2. Telephone system calls, wait times and abandoned calls
  3. Provider network changes

The availability of data is universally believed to be unacceptable by everyone at the local level, and is probably a major contributor to the feeling of poor planning and management that accompanies local opinions of the program.

Requested Data- The following management/financial data should be provided beginning in July, 2000, retroactive to the beginning of the program:

  1. Managed Care Pool Sources and Uses of Funds by Month- to include state and local funds paid into the pool, and payments to the BHO s
  2. BHO Sources and Uses of Funds by Month for Each BHO
  3. Claims Flow by BHO by Month-providing summaries of claims received, claims rejected, claims paid, and claims carried over;
  4. Services Flow by BHO by Month-providing number of enrollees, number of service units provided, category of services provided, with breakdown of the above data by gender, age category, and county of residence       

Certain important clinical data (length of stay, for example) is also important ultimately to judge the quality of the services being provided, although is of secondary importance in the early months of understanding the impact of managed care.

Until this data is flowing regularly, without need for a request, to local officials, it will be hard to ascertain the progress and long-term viability of the program and local officials will always be subject to various interpretations of the success of the program.

Ideally, the data provided should be accompanied by planning assumptions used by the state in the design of the program, in order that these planning assumptions can be continually tested and refined as needed.

VII -  County-Specific Services

The county contracted for, or received free the following services prior to North STAR. The agreement with the state was expected to maintain these services intact:

Jail Liaison - the NorthSTAR-funded position in the jail has been maintained as planned

Forensic Jail Diversion Unit - In January 1999, the Forensic Jail Diversion Unit was established to target 40 mentally ill inmates who frequented the jail system and who were resistant to traditional psychiatric treatments. It is based on the "Assertive Community Treatment" model (a.k.a. "ACT") but with one major difference: the Program is designed to help consumers understand and anticipate the consequences of their actions The three primary goals are:

  1. Reducing the number / duration of arrests
  2. Reducing hospital bed day utilization
  3. Reducing the use/dependence on crisis services for treatment

The FDU's treatments/services cover all aspects of the consumers' psychosocial functioning.  The caseworkers service the participants' needs of housing, health care, and employment, as well as rehabilitation classes that focus on areas such as anger control. The follow up treatments, visits etc. are performed to create an environment from which the consumer will less likely be rearrested.   An activity center located at its Dallas MetroCare offices (formerly Dallas County MHMR) provides a place to socialize with other consumers through such activities as card games and shooting pool.  This center sees, on average, 30 consumers a day.

In January 1999, 50 "frequent flyer" names were originally submitted by the jail and courts systems as well as 3 transfers from SNOP; however, not all could be contacted and 13 were originally reached. This prompted the "pool" to grow through additional referral sources such as Parkland Psychiatric Emergency Room, Terrell State Hospital, and Vernon State Hospital to reach its desired 40-member level

All new mental illness patients that circulate through the jail system are identified with an assessment. They, as well as current FDU members, are referred to the in-house employee designated with FDU who coordinates the next step to receiving care.  These two groups, the jail mental health team and FDU, work closely and meet to resolve issues.

As of July 1st, the agreement between the then DCMHMR and Dallas County rolled into the NorthSTAR project at which time the funding for the program was provided by the BHOs.

By February 2000, half of the original members maintained an open case with the FDU. Participants' cases have been closed either due to a move outside of the area, or the member simply left the system and could not be located.  Overall from February 1999 to February 2000, 63 consumers received services from the FDU. Currently, the level is fluctuating around its 40-member limit. Currently, the 3 case managers individually handle between a 12 and 15 member caseload, with the maximum capability of 15. (If the FDU should reach the point when each manager maintains a sustaining15-member caseload, an additional case manager would be warranted.) Of the 44 currently active cases in the focus group, 32 members have been in the program for a minimum of 6 months.  Only two members (6.25%) have been re-arrested with a Class B misdemeanor or Felony charge. Since its rollover into NorthSTAR, the jail mental health has seen no influx of mental health inmates that could have been a potential effect from the managed care contracts.

Juvenile Treatment Beds-the agreement between the State and the County called for the first ten beds for substance-abusing youth to be without cost to the County, based on the loss of TCADA money that funded these beds prior to NorthSTAR. Initially, it has proven to be difficult to maintain sufficient youth in these unpaid beds and since the County always has more than ten youth in this sort of placement, the lack of uncompensated beds resulted in a substantial cost shift to the taxpayer from NorthSTAR.

As the start-up problems diminished, the Juvenile Department began to maintain the appropriate census in the free beds. However, the closing of  Daytop Pine Mountain and a reported slowness and selectivity of the providers in accepting youth for uncompensated treatment has caused the financial benefit of this arrangement to decrease to almost nothing.  As of May 30th, the overall usage of uncompensated beds 1,691 bed-days with the promise being 3,360, a difference of 1,669 bed. The cost shift to the County at $75 per day is approximately $125,000. For each additional month with an average uncompensated census of two juveniles(the current census), an additional $18,000 will be shifted to the County.   

Juvenile Staff Positions-One assessment officer and two substance abuse counselors were added to the County's General Fund at an annual cost of $90,000 to  replace  TCADA-funded positions doing the same work. The individuals were expected to bill for their services and were projected to pay for themselves from this source. As of December 30th, the Juvenile Department ceased billing NorthSTAR with total collections approximating $25,000, due to the overwhelming complexity of the managed care system. At least two meetings were held with both BHO Managing Directors and the State program manager, with a goal of understanding and resuming the billing process although this was never done. The net effect has been to transfer costs of approximately $65,000 to the General Fund from NorthSTAR.

Public Defender-it was expected that the workload of the Public Defender would increase as the Probate Court began to convert prior-medicaid patients. The Chief Public Defender has not had the need to hire the additional position, for which approximately $58,000 on an annual basis  was deducted from the County's contribution. However, Judge Loving began appointing a contract public defender on April 1st to represent the new increased caseload of patients sent to Terrell. The County's Chief Public Defender has provided the opinion that she would need the additional staff resources if she were to represent these individuals. However, the caseload was handled without additional resources during the months of January, February, and March, and therefore $15,000 should be restored to the pool.

The Chief Public Defender originally received an indication from  Judge Loving that he would utilize a second public defender in place of the court-appointed attorney. This original indication is now in question, according to Ms. Roden. The current annualized rate of pay for the court-appointed attorney is $146,000. An additional public defender can be hired at approximately half this amount.

Court costs-no extraordinary transfers of court costs have been identified.

Welfare Costs- The County's emergency Welfare program-operated by the Health and Human Services Department- has experienced an explosive growth since the beginning of the North STAR program, after several years of no growth. Approximately $800,000 of an annualized increase of $1.2 million can be attributed to a higher number of clients, with the remaining $400,000 attributed to a rate increase. Although the increase in clients began at approximately the same time as North STAR began, direct evidence the causality is under investigation. Neither BHO nor Metrocare indicates that any procedural change has occurred that  can explain a shift of housing clients from MHMR(pre North STAR) to the County. However, it is undeniable that growth has occurred and that the onset of this growth occurred concurrent with the start-up of North STAR. Additional evidence is being accumulated by HHS to document the source of the new clients.

Retainage calculation.-the contract with the state for the County's contribution calls for a retainage of $200,000 to be evaluated  and paid to the BHOs if no identified cost shifting has occurred. The following table summarizes the cost shifts discussed above:

Original Retainage $200,000
Bed deduction (125,000)
Staff deduction (65,000)
PD addition 15,000
Grand total $25,000

However, major uncertainties remain in the area of Public Defender(if the judge continues to utilize a court-appointed attorney for Terrell patients), housing/welfare costs, and the remaining month of uncompensated beds for substance abusing juveniles. It is likely that these additional shifts will not fully account for the $25,000 "positive balance" shown above.

Comparison of Performance with Agreement-The County entered into an agreement (Memorandum of Understanding) with the BHOs, the state, and DANSA which described the County's expectations relative to the delivery of services in the local area. The County's responsibilities under this agreement were to provide a monthly payment to the program. The County has made its payments on a timely basis.

The services to be provided under the agreement have been met with the following exceptions:  

  • "Persons placed under an Order of Protective Custody in Dallas County.will be stabilized and diagnosed at a location or location within Dallas County. Priority should be given to locations that are easily accessible to the Parkland Psychiatric Emergency Room and where court proceedings are held". As of April 1st, this section of the agreement is being largely ignored.
  • Performance Reporting - "DANSA will provide quarterly performance  reports to the Dallas County Commissioners Court related to each of the items in Section 3.0(Stabilization beds, Forensic Diversion Unit, Residential Substance Abuse Treatment for Juveniles, Juvenile Programs) and its training responsibility" This section has not been complied with, although DANSA has routinely copied the Commissioners Court with all reports it has received form the BHO s. satisfactorily
  • Future Planning-"TDMHMR will prepare a plan for fully integrating the jail and juvenile mental health and substance abuse effort into the overall NorthSTAR program. This plan will be available approximately nine months after the start date for the managed care system and will be presented to the Dallas County Commissioners Court". This mandate of this section has not been met although it is often discussed.
Click the link to access the file. Format*
Memorandum of Understanding PDF

VIII - Role of DANSA

The DANSA budget of approximately $500,000 is used to fund staff and office space, including an Executive Director, Administrative Assistant, five ombudsmen and a part-time accountant.

Dr. Turnage has reported that the role of DANSA has evolved during the first year of the roll-out (View Report) and can be expected to continue to change. In particular, the ombudsmen will take on a variety of monitoring activities not currently assigned , for example specialization in nursing home placements, SPA activities, and provider complaints, allowing more in-depth problem-solving activities to occur. In addition, it is possible that DANSA staff will assume certain responsibilities currently performed under contract by the Mental Health Association although if this happens, funding will accompany this shift in responsibility.

While the role of DANSA ombudsmen is important, it should be evaluated as an alternative to direct services in a cash-limited pool. The question is : if funding could be released back to the pool, would it be used more productively than is planned under the current arrangement. DANSA staff and board should be challenged to defend their budget as a preferred alternative to direct services in the same amount.

Click the link to access the file. Format*

IX- Conclusions/Recommendations

Three key items emerge as the most fundamental problems that must be corrected  prior  to Dallas County continuing its participation at the current level: (a) resolution of the future participation, and perhaps the future direction of Metrocare Services of Dallas, (b) routine and useful program and financial data must be provided to local officials, and  (c) confidence must be restored in the decision process that resulted in expanded use of Terrell State Hospital for crisis stabilization. The amount of the County's FY2001 contribution could also be effected by the resolution of the origin of the increased Welfare housing assistance caseload.

It is recommended that TDMHMR provide written testimony on the following key points (a) reasons why only two counties are contributing to NorthSTAR; (b)definitive plans for full data flow to DANSA and to the County, and (c) response to the question of agreement violations discussed in this memo.

The difficulties encountered by the Juvenile Department in adjusting to the managed care environment are not offset in any meaningful way by an improvement in the care provided to children in county custody. Accordingly, it is recommended that beginning July 1st, the County return to an independent status relative to NorthSTAR, neither contributing County resources nor expecting NorthSTAR to pay for services for juveniles in custody. The most important distinguishing factor of  these youth is that they are lawbreakers, rather than that they are substance abusers. It is suggested that the "continuity" that matters most is that provided by the Juvenile Department, and this continuity is broken if they are occasionally considered North STAR "managed Care" consumers. The administrative difficulty encountered can be minimized by paying for all care and adjusting the County's contribution to the pool to reflect the full loss of TCADA funds that is now flowing to the BHO s.

In the event that the state can make a credible argument that the entire juvenile behavioral health care effort should be brought under the North STAR umbrella, the County should consider this proposal. However, the "piecemeal" participation in North STAR has not produced meaningful advantage for the youth in question. 

It is further recommended that the County's contribution for the second plan year be equal to the current year, adjusted to account for the removal of the Juvenile Department from the managed care system and perhaps for a shift of housing costs to the County. Beginning with the September payment, it is recommended that payment be contingent on receipt of all program data suggested in Section VI of this memo.

It is further recommended that the Court schedule a discussion on the question of the appropriate size of the  DANSA staff, with a possible objective of  downsizing it to limit its mission to staff support/consulting/data analysis for  the board, and public opinion focus and interpretation. This would involve returning  significant funding to  the pool and the  majority of the other functions to the BHO s. 

It is further recommended that the state be challenged to release the entire accreditation report for Terrell State Hospital, and that these reports from other participants be released and compared. Local officials need to be especially attuned to the diagnostic/stabilization process, which has occurred locally for decades and now has been shifted to a hospital that has traditionally rendered long-term care and may or may not be currently equipped to handle the stabilization function efficiently. 

It is further recommended that the County not return the $200,000 retainage, due to the documented cost shifts that have occurred during the first year of North STAR operation.