{"id":9571,"date":"2011-11-16T09:33:18","date_gmt":"2011-11-16T14:33:18","guid":{"rendered":"http:\/\/www.raleighpublicrecord.org\/?p=9571"},"modified":"2011-11-16T09:33:18","modified_gmt":"2011-11-16T14:33:18","slug":"new-hmos-for-state-mental-health","status":"publish","type":"post","link":"https:\/\/theraleighcommons.org\/raleighpublicrecord\/news\/2011\/11\/16\/new-hmos-for-state-mental-health\/","title":{"rendered":"New HMOs for State Mental Health"},"content":{"rendered":"

Editor’s Note: This is part one of a two-part series on changes to how mental health services will be changing throughout the state.<\/em><\/p>\n

North Carolina is changing the way the state Medicaid<\/a> program will pay for mental health services in a move some are calling a second round of major mental health reform. But no one can give a clear answer of how that will affect mental health consumers statewide and their ability to get needed services.<\/p>\n

In June, state lawmakers enacted a new law requiring all mental health management agencies in the state to apply for Medicaid waivers in order to reorganize the way they get paid for care. \u00a0The changes also mean Wake County Mental Health Services will be dramatically <\/a>re<\/a>organized<\/a> and merged into an organization based in Durham County.<\/p>\n

Lawmakers say the new system will contain the rising costs of mental health care while continuing to provide services for people who really need them. Opponents say the changes are all about cost containment, and don\u2019t guarantee high-quality care to the hundreds of thousands of North Carolinians who need mental health services annually.<\/p>\n

\u201cIt’s a complete transformation in the mindset and developing more skill sets and being able to live below the means… so that we’re living with a tight budget,\u201d said Ramon Rojano, head of Wake County Mental Health Services<\/a>.<\/p>\n

By the new law<\/a>, the state requires mental health agencies to adhere to a model piloted by Piedmont Behavioral Health<\/a>, a Salisbury-based agency that provides care for mental health consumers in Cabarrus, Davidson, Rowan, Stanly and Union counties. In 2005, PBH received a Medicaid waiver to reorganize itself to act more like an HMO in the way it allocated and paid for mental health care in those five counties.<\/p>\n

Instead of simply referring patients to a doctor or a therapist who then bills Medicaid (a system called fee-for-service), PBH gets a lump sum for each patient approved for care. The agency then pools all the money it receives for all the clients and agency officials. Then they determine just the right amount of social services, doctor visits and therapy sessions for each client, all while not exceeding their total monthly income \u2014 a system called prospective payment.<\/p>\n

Some months, some patients need less care, while others need more. Under a prospective payment system, the idea is to find the right balance of services delivered so everyone gets what they need.<\/p>\n

Basically HMOs<\/strong>
\nEssentially, the state\u2019s mental health agencies will become more like HMOs.<\/p>\n

In passing the new law, legislators cited PBH’s pilot model, calling it \u201ca proven system for the operation of all public resources for mental health, developmental disabilities, and substance abuse services.\u201d<\/p>\n

Now, all mental health management agencies in the state must apply for a waiver to convert to the PBH model by January 2013, or be taken over by an agency that has.<\/p>\n

\u201cThe state is telling LMEs (mental health local management entities) to become insurance companies,\u201d said Dave Richard, head of the ARC<\/a>, a statewide organization that cares and advocates for people with developmental disabilities.<\/p>\n

Richard said his organization has heard from families in the PBH area who have had services cut, and haven\u2019t been happy with the results when they appealed.<\/p>\n

\u201cThe people who are dissatisfied say it’s cut and dry and harsh, and looks more like an insurance company, complete with the denials of service,\u201d Richard said.<\/p>\n

Richard said his organization, and others, watched the PBH pilot unfold during the past five years. \u00a0In the last legislative session, lawmakers made room for two more LMEs \u2014 Mecklenberg and Western Highlands \u2014 to adopt the PBH model and get more data on how well it works before scaling up to the entire state.<\/p>\n

But when the new, Republican-led legislature came into power, legislators pushed through the new law, requiring all of the state\u2019s LMEs to switch by early 2013.<\/p>\n

\u201cThe logic of expanding statewide without doing this study and reviewing it doesn’t seem to make sense. When the previous legislature was talking about this, the Secretary [of Health and Human Services] said, \u2018let’s go slow.\u2019 \u00a0And now, going slow is thrown out the window,\u201d Richard said.<\/p>\n

Richard said his read of the data doesn\u2019t show the PBH approach actually saved money for people with developmental disabilities, who often need extensive care for their entire lives.<\/p>\n

\u201cThe outcomes in PBH for people with intellectual disabilities are the same as the average for the rest of the state,\u201d Richard said. \u201cAnd the cost? They claim it\u2019s less, but the cost in the developmental disability part of the waiver was higher in PBH, was higher than in the rest of the state. \u00a0So the idea that it was less costly and provided better services, we don’t see the evidence. \u00a0They’re not bad, but they\u2019re no better than the rest of the state.\u201d<\/p>\n

State Officials Defend PBH\u2019s Results <\/strong>
\n\u201cI think when you have these kinds of transitions, the folks you hear from are those who feel like they’re \u00a0not getting the same services,\u201d said Beth Melcher, DHHS<\/a> assistant secretary for Health and Human Services for Mental Health, Developmental Disabilities and Substance Abuse Services. \u201cBut as you transition, there are people who get more services… that doesn’t often get into the paper.\u201d<\/p>\n

Melcher admits many LMEs will have a period of trial and error, trying to find the best mix of service providers, economic incentives and network size.<\/p>\n

\u201cThis model is a model that has met the outcomes that it was set out to meet,\u201d she said. \u201cTo manage more effectively, to have more predictable costs, especially Medicaid, to meet expectations about access and quality. So, with respect to that and the outcomes they’ve gotten, it has been successful.\u201d<\/p>\n

Melcher says mental health consumers should not see many changes, especially during the first year, when all of the people providing care will have their contracts extended. But during the second year, provider networks will become smaller, and some people will find their providers are out of the network. She said it\u2019s a concept familiar to people who are privately insured.<\/p>\n

\u201cI think the balance you have to find is that people are required to have a choice of providers and they need to have an adequate choice. But the flip side doesn’t mean unlimited kinds of choices of any kind of provider, anywhere that you want it to be,\u201d Melcher said. \u201cIt’s a limited choice option. There will be balances in monitoring and review to make sure that those choices are adequate and of quality that people are happy with the choices they have. \u00a0But it does not mean limitless choices.\u201d<\/p>\n

In the Courts<\/strong>
\nAdvocates for people with mental health disabilities say mental health clients will be adversely affected and that clients served by Piedmont Behavioral Health already are suffering. Disability Rights North Carolina<\/a> head Vicki Smith said her organization has filed two federal class-action lawsuits against PBH.<\/p>\n

\u201cThe lawsuits are specific to PBH’s operations on the Medicaid waiver,\u201d Smith said.<\/p>\n

Smith said one suit alleges PBH’s way of allocating care denies people what they are entitled to under the Americans with Disabilities Act<\/a>. The other suit alleges PBH denies mental health patients and their families due process to appeal when they are denied services. Both cases are making their way through the court system.<\/p>\n

Smith said an HMO-like model can work for patients with physical health problems who get better and need fewer services as time goes on. But it can be a problem for mental health consumers, who often have chronic conditions that require a lot of care over a long time, if not a lifetime. Those patients can be expensive, Smith said, but providing that intensive care is cheaper than having them end up in a state psychiatric hospital.<\/p>\n

\u201cOur concern is that [PBH] has reduced support to consumers to the point that the individuals are destabilized,\u201d Smith said. \u201cThe reduction of services has caused people to become unstable when they were doing fine before. Two or three of our clients have had to go to psychiatric hospitals as a result.<\/p>\n

Advocates also say that creating smaller provider networks contradicts one of the primary goals of the reform effort started a decade ago, which was to give mental health clients choice in who provided them with care.<\/p>\n","protected":false},"excerpt":{"rendered":"

A new state law requires counties to either create a new HMO-like agency or join an existing one to spend Medicaid money on mental health. The move has been called \u201cmental health reform round two.\u201d Wake County tried, but failed, to create a new program, so its Medicaid mental health service will be taken over by an outside organization.<\/p>\n","protected":false},"author":24033,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[34,15,23],"tags":[],"_links":{"self":[{"href":"https:\/\/theraleighcommons.org\/raleighpublicrecord\/wp-json\/wp\/v2\/posts\/9571"}],"collection":[{"href":"https:\/\/theraleighcommons.org\/raleighpublicrecord\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/theraleighcommons.org\/raleighpublicrecord\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/theraleighcommons.org\/raleighpublicrecord\/wp-json\/wp\/v2\/users\/24033"}],"replies":[{"embeddable":true,"href":"https:\/\/theraleighcommons.org\/raleighpublicrecord\/wp-json\/wp\/v2\/comments?post=9571"}],"version-history":[{"count":0,"href":"https:\/\/theraleighcommons.org\/raleighpublicrecord\/wp-json\/wp\/v2\/posts\/9571\/revisions"}],"wp:attachment":[{"href":"https:\/\/theraleighcommons.org\/raleighpublicrecord\/wp-json\/wp\/v2\/media?parent=9571"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/theraleighcommons.org\/raleighpublicrecord\/wp-json\/wp\/v2\/categories?post=9571"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/theraleighcommons.org\/raleighpublicrecord\/wp-json\/wp\/v2\/tags?post=9571"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}