Note: highlights, links and italicized quotes are entirely my own mark-up and not reflective of the author nor original posting, link below. Further, while, I usually avoid reading reader comments, I simply had to include the two articulate viewpoints posted at the time of this blog, following the article.
Changes to bill would give more power to groups overseeing mental health services
Published: June 18, 2012
By Richard Craver
[ Original Winston Salem Journal article posted here. ]
A late change to a bill giving more power to groups that oversee behavioral-health services in the state is raising concerns among advocates because the new language allows oversight groups to gain even more authority than the initial bill did.
The changes to the bill would create a new category of oversight group — a behavioral health authority. A BHA could borrow money and buy or sell property, would have no limits on executive salaries and would not be required to have any advocacy group members on its board.
The new language was inserted into N.C. House Bill 1075 on June 11 — five days after the bill had passed the House.
The substitute bill has been put on the Senate's agenda for Tuesday. If approved, the bill would return to the House for review and potential passage.
The changes would allow a local management entity (LME), such as CenterPoint Human Services, to become a behaviorial health authority after three years of serving as a managed-care organization (MCO) under the Medicaid waiver program being rolled out in the state.
The waiver program is intended to combine the management of Medicaid and state funds at the community level to reduce costs and add more accountability. MCOs would operate with fewer restrictions on how they manage the mental-health, developmental-disability and substance-abuse providers and services they oversee.
Becoming a behavioral health authority would take the oversight groups' level of independence to a higher level since public authorities can borrow money and buy or sell property. Authorities have limited or no local government oversight on their overall operations. They are allowed to file lawsuits and have a legal staff.
The initial bill already shifted much of the oversight of an MCO from county commissioners to the N.C. Department of Health and Human Services. The DHHS secretary would be required to approve a group's change to a behavioral health authority.
Local and statewide advocates expressed exasperation when informed of the new language. They worry that past mistakes in state mental-health reform will be repeated, hurting patient care and costing the state tens of millions of dollars in wasted spending.
David Cornwell, executive director of N.C. Mental Hope, said the proposals before the latest change already gave MCOs the best of being a private and a public entity.
"I don't see how it's conscionable for largely clueless legislators to consider such far-reaching changes to an already shattered system at a time the state faces multiple lawsuits over its (behavioral-health) services," Cornwell said.
Controversies over care
The bill is the latest development in the controversial recommendations submitted in September by Piedmont Behavioral Healthcare and the N.C. Council of Community Programs.
The bill's primary sponsors are state Reps. Nelson Dollar, R-Wake, and Justin Burr, R-Montgomery. The bill has bipartisan co-sponsor support.
Senate sponsors of the new language are not identified. Dollar and Burr could not be reached for comment about whether they approve of the new language.
Piedmont Behavioral Healthcare is the only local management entity operating as an MCO, but 11 MCOs, including CenterPoint, are supposed to be operating statewide by Jan. 1.
The council, led by CenterPoint executive director Betty Taylor, wants to eliminate limits on top executive salaries because MCOs compete with private-sector insurance companies for staff with specific expertise. Salary proposals would not require the approval of the DHHS secretary.
The bill removes the requirement that county commissioners approve the hiring of an MCO director, giving that responsibility to the MCO board. Advocates say many LME boards already operate as rubber stamps for their executive directors.
The benefit for county governments, particularly those with tight budgets, is that the changes could limit their liability for MCO overspending and put it on DHHS.
The new language represents substantial additions to those recommended by a 24-member General Assembly subcommittee before the legislative session began in May.
For example, advocates and analysts said they are concerned that although membership on a BHA board is expected to reflect expertise on local needs and priorities, including at least one family member or individual from an advocacy group is suggested only "when possible."
"There appear to be no absolute compositional requirements for the board of a behavioral health authority," said Mark Botts, an expert on mental health records and confidentiality at UNC Chapel Hill School of Government, in an email to advocates.
The initial bill required MCO board seats for a county commissioner, individuals or family members of those with behavioral-health issues, a member of the general public and professionals with expertise in health care.
Botts' email said a behavioral health authority would have even fewer requirements for board composition than in the current statutes or the previous version of the bill.
Laurie Coker, a local advocate who served on the General Assembly subcommittee, said a major concern is whether MCOs will be more responsive to customer demands.
"There have been troubling additions to the original bill on MCO governance," said Coker, who also serves director of the N.C. Consumer Advocacy, Networking and Support Organization.
"We could move toward much more privatized system management, in that public input and responsibility through counties could be cut out altogether from local management. Yet we supposedly are to have a public managed-care system, and not a private one."
Coker said the initial bill reflected agreements derived from "a level of critical discussion rarely had in committee meetings that involve such a variety of perspectives.
"North Carolina doesn't need further complication and confusion added to our already substantial system change. We need the inclusion of consumers, family members and county officials to ensure best outcomes locally."
Worries about unknowns
Al Delia, acting DHHS secretary, acknowledges that patients and caregivers are worried about the unknown. He said LMEs must clear several hurdles with state regulators before managed care is instituted, and mistakes are being fixed.
"DHHS believes this amendment represents a substantive change and that it deserves more thorough discussion," said Julie Henry, DHHS' acting director of public affairs.
"We are concerned about the limits the measure places on DHHS' authority and oversight. The amendment would exempt BHAs from provisions of the state mental health statute."
In an exchange reported by the Associated Press, Sen. Jim Davis, R-Macon, said "this whole thing scares me to death" during a discussion of the House bill before it was referred to the committee on mental health and youth services. The discussion, which lasted several hours, appears to have taken place before new language was inserted.
If lawmakers struggle with this bill, Davis asked, "How are we going to take care of the folks that this governance is supposed to be protecting?"
Dollar told Davis turning back now is a mistake.
Otherwise, Dollar added, "You're almost going to doom this iteration of reform to failure, and I would just submit that we cannot afford to do that for the citizens of this state."
Several legislators serving the Triad said the complex nature of creating a BHA will require more time to understand than the current short legislative session will allow.
Dave Plyler, a Forsyth County commissioner who has paid close attention to local behavioral-health issues, said, "Legislators appear badly divided with no sense of what needs to be accomplished. One size does not fit all."
The changes to the bill come as CenterPoint is requesting $1.53 million from Forsyth County to help with its estimated $3.7 million cost of transitioning to a Medicaid waiver program.
CenterPoint receives taxpayer funding as a local management entity in Davie, Forsyth, Rockingham and Stokes counties.
Without the allocation — to be paid back over five years — the agency warned it would cut its discretionary funding for services in Forsyth by about 42 percent. The agency also wants one-time funding of $228,579 from Rockingham, $148,127 from Stokes and $89,270 from Davie.
CenterPoint's first MCO application was rejected in July, primarily because a health-care consultant, Mercer, questioned the agency's financial liquidity, information technology and clinical operations. Mercer recommended CenterPoint pursue extra funding from the counties it serves and alternative sources. CenterPoint's second application was approved in October.
Advocates worried about the threatened service cuts at a time when more people with behavioral-health issues lack insurance.
Although the counties provide about $5.3 million annually, they do not, by state statute, have a say in how the money is spent.
"In an already underfunded system, a further reduction compounds the unmet needs," Taylor said in a statement.
However, at a May board meeting, Forsyth commissioners had too many questions about CenterPoint finances and legislative changes to decide on the funding request. Forsyth County Manager Dudley Watts said the board is working on finding a time for a briefing session on the issue in June.
Reader Comments
Marsha Hammond · University of North Texas------
HOW IS IT THAT FEDERAL AND STATE MONIES ARE BEING USED TO CREATE EVER MORE PRIVATIZED PUBLIC ENTERPRISES SUCH AS THE LME-MCO'S, THE OLD COMMUNITY MENTAL HEALTH CENTERS?
What an important piece of news coverage and its coming right at the time when most providers are being denied or have refused to be recredentialed by the LME-MCO's, the old community health centers, as the Medicaid Waiver moves across the state in order that they continue to see Medicaid patients who have serious mental illnesses. For the population at large, this means people who could be dangerous or at least suicidal, roaming the streets due to no mental health treatment.
Can you say: Virginia Tech? Can you say: going postal? This is a public health dilemma, make no mistake about it. This is not an exaggeration. Yet, there will be no one clearly to sue when that happens and the real culprits will be the LME-MCO's who have further mismanaged Medicaid-----FEDERAL AND STATE ------monies.
For God's sake, Smoky Mountain Center (SMC) LME-MCO has a lobbyist. Where do they hide that in their accounting data? How is it that an entity funded by tax dollars has a lobbyist to protect its own interest? Here he is and he is registered with the state: Name: Joseph H. Lanier Address: PO Box 30519 Raleigh, NC 27622-0519 Phone: (919) 329-3871 http://www.secretary.state.nc.us/lobbyists/Lobbyist.aspx?PId=9039109.
And all this is taking place w/ the state legislature looking on, scratching their heads, being fed a wagonload of 'if you don't' stories by Piedmont Behavioral Health's LME-MCO (pbh) CEO Betty Taylor who wants a big fat raise for herself---an undisputable raise. And that LME-MCO is the one that started all this Medicaid Waiver stuff 5 years ago. And now it has spread like the bubonic plague across the state with officials at DHHS looking on the matter as a way to further distance themselves from the mess they created when the NC State Legislature passed a NC Mental Health Reform law in 2000.
So, how does all of this relate to the Medicaid Waiver, which has been hoisted onto the LME-MCO's, the old community mental health centers, and is now moving step-wise across the state. Bear in mind that the purpose of the Medicaid Waiver, which was FEDERALLY allowed (we are talking about FEDERAL TAX DOLLARS HERE----not private insurance all the while the proposal is about a hostile take-over of FEDERALLY MANAGED ENTITIES) is to allow the LME-MCO''s to more efficiently manage their capped Medicaid $$.
Anything BUT efficiency iis what has taken place over the past year. Please refer to my multiple interactions with Smoky Mountain Center LME-MCO and Western Highlands Network LME-MCO over the past six months at my blog, http://madame-defarge.blogspot.com/, the purpose of which is to document the profound difficulties of working with these organizations. They have little accountability, are poorly organized.
The independent Mercer Reports have re-emphasized this time again and they are not even looking at any comments or feedback from providers or impacted citizens with mental health challenges. The Mercer Report is simply going into the LME-MCO and saying, 'show us what you've got.' What kind of report is that? Do they not understand that the LME-MCO will be putting its very best foot forward under such perusal?
Providers, you know, the ones who actually do the work of helping people who are suicidal and homicidal, have absolutely no representation anywhere at any table regarding even basic matters like the re-credentialinng process of providers who are already credentialed and licensed and have been seeing Medicaid clients FOR DECADES. And so, providers have done what any underrepresented group would do: OPT OUT. GONE. Refusing to take Medicaid. Sat down at the front of the bus, if you're like me: refusing to give up your seat.
We're not talking about a few citizens w/o mental health coverage. We are talking about 80,000 Medicaid recipients under WHN LME; 130,000 Medicaid recipients are SMC.
For January, 2012, WHN LME-MCO presented data at its monthly board meeting that only FIVE PERCENT of those 80,000 people had received mental health services.
Assuming that this trend will continue, this means that most of the FEDERAL AND STATE MONIES is being used to pay the fat salaries of the likes of Betty Taylor and the employees at the LME-MCO's who push paper around and standardly have salaries of 50 grand/ year w/ benefits.
Is THIS how the citizens of NC wish to have their tax dollars used? Isn't it supposed to be used to provide mental health services to people in need? Don't citizens deserve providers who are well credentialed with doctoral degrees who studied years in order to become experts on human behavior?
We may not be on Wall Street, but this is very much a Wall Street fat-cat CEO demanding---and getting it-----unlimited amounts of money in order to create a world and domain that has nothing to do with what it is supposed to be doing. There's not just one elephant in this room: there's an elephant at every LME-MCO in this state now: monkey see no evil, monkey do no evil.
Will NO ONE in the NC State Legislature rebutt this bill whose intention is simply to increase the inefficiency of the LME-MCO. For inefficiency is directly related to non-accountability and the very fact that things have been allowed to get this far----WHEN WE'RE TALKING ABOUT THE USE OF FEDERAL AND STATE TAX DOLLARS-----is indeed, 'scaring me to death', just like the NC State Legislator stated.
Marsha V. Hammond, PhD, Licensed Psychologist, Asheville, NC.
NC Mental Health Reform blogspot since 2007: http://madame-defarge.blogspot.com/.
Pamela Jarrett · Appalachian State University
Letter to the Editor:
The article by Richard Craven in Monday's Journal does not do justice to the depths that the mental health bottom feeders can sink to regarding the care for mentally ill and mentally disadvantaged people in this state. It chills me to think of LMEs gaining yet even more power locally and regionally to charge up huge amounts in Medicaid and Medicare funds, but they are following the hospitals of the state who charge enormous fees for emergency or patient care, yet are not accountable to patients or families.
The person seeking help at the street level is still facing stigma, often poverty, lack of mental health education, and 19th and early 20th century treatment. I have personally been treated in a rural hospital with isolation as a salve for my depression, and have seen people put in four-point restraints for being psychotic while waiting for a hospital bed. It is impossible to find a psychiatrist or psychologist in my county (Swain) or in the neighboring counties (Jackson, Macon and Graham).
There are no longer any civil rights attorneys in the state to keep a check on whether patients are granted even their basic Constitutional rights, as the state created a state agency for them under DHHS some years ago. All the good civil rights attorneys now protect the state against lawsuits, and humbly do not answer questions the public may have about some terrible medical abuse, citing a 'conflict of interest.' One cannot even get a referral to an outside attorney who might consideryour case.
So, now the LMEs get to magically transform into entities that are impervious to local government, and who will act without oversight by the state, as the local hospitals do now. They will even have their own lawyers, who I am sure will be well paid, but out of what funds--Medicaid or Medicare?
I see only doom and gloom ahead for the mentally ill in NC. I guess it will take a few people dying before this autocracy will start being responsible to the government. It will take a few more dying before we begin to see government oversight and a responsive legal system.
Pamela Jarrett, M.A., J.D.
