The NC Outpatient Mental Health Zeitgeist

-----Original Message-----
From: Geoffrey Zeger
To: ncadvocacy
Sent: Sat, Feb 2, 2013 4:34 pm
Subject: The NC Outpatient Mental Health Zeitgeist

NOTE: The following is somewhat long but is a reflection of the recent topsy-turvy, sinusoidal, and duplicitous events in the NC Outpatient Mental Health setting.......

During the summer of 2012, while I was standing outside of a clinic where I contract waiting for my next client, a car rapidly pulled up and out jumped 4 stony faced people with briefcases and a purpose in their steps as they entered the clinic.

It was an unannounced Medicaid audit.

Many clinicians and agencies knew these were occurring so it was not completely unexpected. At this particular free-standing private clinic which accepted Medicaid there was some anxiety (as any audit would produce) but we were pretty confident about our work - electronic medical records had fail safes for compliance, supervision occurred regularly, and the Clinical Coverage Policies for Medicaid were followed.

Over the next few months as the audit progressed a surrealistic Russian style bureaucratic nightmare occurred. Medical records were requested by the auditors and submitted by the clinic. CCME (Carolina Center for Medicaid Excellence) who was doing the audit would say 'we didn't get the records' and be elusive and dodgy. Medical records were re-submitted - hand delivered. Feedback from CCME was that the Treatment Plans did not meet standards. The Treatment Plans were being developed in line with the posted Clinical Coverage Policy and they were also in line with the recommendations of one of the LME/MCO's right over the county border but after much back and forth CCME continued to say they were not in compliance. CCME did not provide a clear indication of what compliance was nor did they provide a clear template for the Treatment Plans. (NOTE: The LME/MCO from the nearby county said the clinic's Medical Records per their site review were at a 92.5% accuracy!!!).

Staff at the clinic worked diligently to cooperate with CCME but every attempt at cooperation was met with a shift of the carrot on the stick. Conference calls were scheduled, emails were written, repetitive requests for clarification were pursued without any success or resolve.

The clinic was then put on a "pre-payment review" meaning claims for services rendered were not paid until the records were reviewed and approved. 'Pre-payment review' is an unguided process that could take 30 days - the approval of records is based on unclear standards so any clinical services rendered were like the lottery - maybe they'll get reimbursed if someone somewhere says documents meet some kind of unknown standards....or maybe they won't get reimbursed at all.

Eventually, so much unproductive hoop jumping occurred and time was wasted that a deadline for acceptance by the local LME/MCO came due. Because of the delays by the CCME, the LME/MCO which went live on 2/1/13 said to the clinic 'we can't enroll you' due to the 'pre-payment' status.

With only 3 days of lead time, over 100 clients - some of which were children in foster care or with PTSD or within the Juvenile Justice System - had to suddenly be terminated from treatment and referred to other agencies. Fortunately, the clinic will continue - contracted with the other county LME/MCO and accepting private insurance.

Was this top-down inefficient State bureaucracy? Was this effective Public Mental Health policy? Was there any consideration for how this would impact service provision and the clients? Was this purposeful - intended sabotaging of a clinic in order to reduce the number of providers within a community and save Medicaid dollars? Is this the CCME's way of insuring 'Excellence?'

I, and my colleagues who provide Public Mental Health services and who have weathered many pressures and changes, are not naive about accountability - we are ready to stand accountable and provide appropriate services with appropriate billing and documentation. I understand there are economic pressures at hand here but the current zeitgeist of audits, regulations and site reviews seems like a witch hunt and feels like a displacement for the past sins of others (http://www.inthepublicinterest.org/article/reform-wastes-millions-fails-mentally-ill). With the laser beam aimed at service providers - purposely geared to finding the smallest of errors in an effort to go 'GOTCHA' the zeitgeist is a culture of fear in order to insure accountability to DMA, CCME, DHHS, CMS, EDS, and the LME/MCO. Well what about accountability to our clients? Have policy makers forgotten about the clients in an effort to weed out the service provider playing field?

As a side note, it was rumored - and it may just be urban legend - that Medicaid auditors were paid based upon how much money they generated from the audit. If anyone has more information on this I would love to hear it - but at the community level it is understood that the contracted auditors were paid based upon how much money they were able to save Medicaid - how many claim denials they could find and how much money they were able to claw-back.

Wouldn't this contractual arrangement be considered a kickback?....'the more money you save or make us the more you will get from us?' Aren't kickbacks considered illegal within the Medicaid and Medicare system?

Clinicians, Clinics and Agencies believe that there has been an INTENDED consequence with the tightening of regulations (such as CABHA and Medicaid Waiver) - the intention is the eventual reduction of the number of private agencies that provide outpatient Mental Healthcare. Both, agencies that do enhanced services as well as core services, are being purposely circuitously and indirectly liquidated. When looking at lists of agencies that accept Medicaid over time, there was a 50% reduction of agencies after CABHA. With the implementation of the Medicaid Waiver the list has dwindled even further. Initially LME/MCO's have been accepting virtually all agencies that apply but it is anticipated that over the next year the bonsai tree will be trimmed even further with reviews of 'outcome measures.' More and more agencies will not be able to sustain. It is presumed that the final goal is to have a few large agencies contracted across the state.

Now, be advised that I have seen with my own eyes heinous service and billing improprieties in 2005 and 2006 and received backlash from profiteers when I called out inappropriate activities....so, I agree that it is necessary to set clear standards and hold providers accountable... HOWEVER, the zeitgeist is an over-rotation.

Let's see how the pendulum swing, tightening of the noose and reduction of reimbursements is working....

One of the larger agencies that has satellite offices in 15 counties in the central NC area just closed two of it's offices in 2 counties. In a different county where this large agency still has an office the pay for clinicians was cut, then cut again, then cut again, and a colleague of mine who works at this agency said that there were sweeping layoffis in her office. What is interesting is that many community clinicians believed this big multi county agency was one of the golden children that would sustain and still be standing while all the other 'mom and pop' or 'pop up' agencies were dissolved. Well, it seems like no one is immune anymore.

Another colleague of mine described how his multi county agency had radical re-structuring recently, specific Medicaid services were cut and the providers of those services were laid off, and there were across the board pay cuts.

Clinicians have no recourse either - 'if you don't like the pay cut then you can always try to find another job...wait...there are no other jobs since everyone else is closing so I guess you are stuck.'

On another side note, I recently head about a survey of private Psychologists who had been accepting Medicaid. The survey showed that over 40% of them intended to stop taking Medicaid clients due to the increase of regulations and requirements and reduction of reimbursements (all of which makes service provision cost and time prohibitive). Many of these surveyed Psychologists had over 8 years of experience - the intended consequence of reducing providers ALSO reduces your qualified and experienced professional base - these are the providers who know the clients and know the community and know the collateral resources.

I am aware of several private multi-county/multi-provider agencies that used to accept Medicaid clients but have stopped due to the cuts in rates and arduous regulations. What is interesting is that these private non-CABHA agencies provide excellent care, are preferred by clients, and ironically they bill a FRACTION of what CABHA agencies bill.

On February 1st a therapist from NC had an 'opinion' published in the Washington Post called:
"The risk of skimping on mental health funding"
Below is the link to this article which describes his frustrations with the Medicaid cuts in Southern Pines:

http://www.washingtonpost.com/opinions/the-risk-of-skimping-on-mental-health-funding/2013/02/01/5cdf8ad4-6ba6-11e2-ada0-5ca5fa7ebe79_story.html

Since you may have to do a free 'Register' with the Washington Post online to see the article, here is an excerpt:

For mental health providers in North Carolina, 2013 marks another year of cuts to Medicaid reimbursement rates, which have declined steadily since 2008. States are responsible for a larger portion of mental health services than they are for physical services, which means mental health is hit hard by state budget negotiations. More than $4.3 billionhas been slashed from state mental health budgets nationwide since 2009, according to the National Association of State Mental Health Program Directors. South Carolina, Alabama, Alaska, Illinois and Nevada are among the states that have had the deepest cuts.

The director of our clinic in Southern Pines, N.C., in the center of the state, has told me that this year’s cuts are likely to force us to close. Our facility offers mental-health and substance-abuse counseling to 75 to 100 clients a week, half of whom are 18 years old or younger. Typically, they are referred to us from child protective services, doctor’s offices or the local domestic violence/sexual assault agency.

When the events at the service delivery level are brought to policy makers' attention, I deeply resent their disregarding platitude of "oh well....we know change is hard." Well, it has been change (2001 divestiture and privatization), and change (2005 slashing community support), and change (2006 ValueOptions authorization policy changes) and change (2010 CABHA), and change (2012 Medicaid Waiver) and change (2013 Medicaid rates rates slashed 40% effective 1/1/13 then returned to prior rate on 1/23/13 with delays of payment for 1/13) and change (2013 CPT code changes and Medicaid rate and service time reductions). You don't know how many times I have had to say to clients "....I am sorry but there are NEW Medicaid regulations which will effect you in the following way..." You don't know how many of my colleagues have said to me "....the agency where I was working closed....do you know who is hiring...."). 

Furthermore, I resent the proverbial 'pot calling the kettle black' when Community Agencies, Individual Clinicians, and Private Practices accepting Medicaid are being scrutinized and audited to the point of being inoperable ALL THE WHILE there is waste and mismanagement at the top - DMA mismanagement (http://pulse.ncpolicywatch.org/2013/02/01/problems-identified-by-medicaid-audit-largely-result-of-nc-republicans-own-budget/), cost over runs with Computer Sciences Corporation (http://www.newsobserver.com/2012/06/17/2142627/state-contract-for-updating-computer.html), "structural flaws," and more (http://www.wral.com/audit-mismanagement-costs-nc-medicaid-system-millions/12048026/).

I hope McCrory means what he says ( “We want to make sure that the money that’s supposed to help people is going to them, not to the administrative cost.”) and that 'Medicaid Reform' will have a positive result. I hate to be a 'Negative Nick,' but my fear (based on experience) is that if you squeeze on one side of the tube of toothpaste it gets smooshed (yes...a real word) to the other side....in other words, the ATTEMPT to reduce administrative waste may actually make its way down to the community level in the form of service and provider cuts. We shall see.....

I continue to provide services to Medicaid clients and IPRS clients through contracts with agencies, but it is unclear how much longer I will be able to provide Medicaid services through my own private practice. More to be revealed.

Please forgive the long ramble. I haven't written for a while and a lot has happened. Feel free to write back with your experiences, thoughts, and or comments.

Geoffrey Zeger, ACSW, LCSW
(919) 286-[ redacted ]
[ email address redacted ]

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Provider Stonewalling via Paperwork Nitpicking?

Insult to Injury: Expungement?

Re: Talk about insult to injury?!! Fwd: [lme_providers] Expunction of Criminal Records in North Carolina
From: Crystal J. De la Cruz
Thu, Feb 21, 2013 at 1:35 PM


Dear Families, People of Conscience, Senators and House Members, and Federal Representatives,

Pardon my French, but seriously, WHAT THE HELL?

Please see below an listserv I received today in which Eastpointe MCO's CEO, Karen Salaki, offers up to her colleagues and underlings a helpful reference guide to Expunction of Criminal Records in North Carolina presumably for MHDDSA professionals and staff... which, in my humble opinion, is not only completely inappropriate for this field, but begs to question:

1. Is criminal activity really such a problem for employees in North Carolina's field of Health and Human Services that it warrants dissemination of this information to the entire NC Local Management Providers listserv?
2. And this problem, is it a global epidemic throughout the entire I/DD field or is it isolated to say, direct care staff who work with clients who can neither defend themselves and, in most cases, communicate their needs or fears?
3. Is there such a shortage of decent, trustworthy, qualified applicants that we gotta break the levy in order to widen the pool because it's near impossible to find direct care staff willing and able to work for what pitiful portion of funds are left after the hierarchy trickle-down?
4. Would you knowingly allow a convicted felon (even a non-violent one?) access to your home and more importantly, to babysit your children? How about a someone with just a little ole Class 2 Misdemeanor charge (in NC, charges of Simple Assault and Shoplifting are both Class 2 Misdemeanors, while Speeding is a Class 1) And would you allow this same individual to care for your elderly mother with dementia?
5. When are we as a society, as a state, as a community - going to STOP subscribing to this unwritten American caste system of human value?

I really hope this is a misunderstanding, however, given the trends of this entire Medicaid process, it feels more par for the course.

We, the parents and family members, are still waiting to be heard and taken seriously regarding our experiences, knowledge, expertise, fears, concerns, and stuff like this that we're simply shocked and appalled about. Gosh, there's really no end to all we could accomplish if we all chose to work together... Just sayin'.

Thank you in advance for you time and attention. As always, please do not hesitate to contact me at any time.


Kind regards,
--
Crystal J. De la Cruz - Hopper
Mother, Advocate & Concerned Citizen

When we allow the value of human life to be determined by capital gain, when we sacrifice the well-being of the most innocent among us to compensate our own shortcomings, and when we judge the worth of our most fragile, not by their character nor intention, but rather their abilities – We Are in Crisis.

http://no2nchb916.blogspot.com/

"The moral test of government is how it treats those who are in the dawn of life . . . the children; those who are in the twilight of life . . . the elderly; and those who are in the shadow of life . . . the sick . . . the needy . . . and the disabled."
--Hubert H. Humphrey


----- Forwarded Message
From: Listserve Administration
Reply-To: Listserve Administration
Date: Tue, 19 Feb 2013 16:53:33 -0500
To: NC Local Management Providers
Subject: [lme_providers] Expunction of Criminal Records in North Carolina

To: Provider Network
From: Karen Salacki, Chief of External Operations
Re: Expunction of Criminal Records in North Carolina

Attached is a very helpful guide on how to have eligible offenses removed from criminal records. Please share with applicable staff within your agencies.


This e-mail is for informative purposes ONLY.

Please do not reply to this e-mail.

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EXPUNCTION OF CRIMINAL RECORDS IN NORTH CAROLINA.PDF [460K]

Ongoing problems with NC's managed care transition, and how to address them

From The Arc of North Carolina

Ongoing problems with NC's managed care transition, and how to address them

In mid-2011, the NC legislature passed a bill that would dramatically change the way the state of North Carolina provides services for people with developmental disabilities, mental illness, and substance abuse (MH/DD/SA) issues. The state would shift from a fee-for-service system to a managed care system.

The Arc originally opposed the move to a managed care system and still has significant reservations about the design. However, the political reality is that managed care is here to stay, and The Arc is committed to ensuring that NC's managed care system effectively meets the needs of people with disabilities.

A year and a half after the initial move towards managed care, we are feeling the impact of the plan’s short-sighted design and hasty implementation. Across the state, many of the entities responsible for implementing the shift to managed care (generally referred to as LME/MCOs) are struggling to make the managed care transition and are behind schedule. The effects of these transition problems can be felt throughout North Carolina.

In Mecklenburg County, the state first found that MeckLINK, the LME/MCO responsible for MH/DD/SA services in the area, had not achieved the necessary milestones to switch to a managed care model by its February 1st deadline. The state then re-assigned the responsibility to implement the new managed care system in Mecklenburg to a LME/MCO already operating under the managed care system, Cardinal Innovations Behavioral Healthcare. This decision meant that millions of dollars of public money MeckLINK spent preparing for the new managed care system would be wasted, and Mecklenburg County would adopt the new managed care system several months later than planned.

On January 23, DHHS, now under the leadership of Governor McCrory’s administration, gave MeckLINK a new target date of March 1st, providing it meets its “readiness benchmarks.” This change occurred just eight days before Cardinal Innovations was to take over.

In the southeast corner of the state, Coastal Care, the LME/MCO responsible for MH/DD/SA services for 5 counties including New Hanover, will miss its deadline to convert to the new managed care system by February 1st. While this came to light recently and details are scarce, for whatever reason the LME/MCO is not prepared to switch to the managed care system on schedule, which will result in a significant loss in savings.

Large overruns and implementation controversies are nothing new to NC’s managed care transition. Starting in January 2011, Western Highlands Network, the LME/MCO that manages MH/DD/SA services in 8 counties in the western part of the state, ran a monthly deficit of over $500,000.

Not every LME/MCO has made headlines with its transition to managed care. Many have made the transition largely out of the limelight, but questions remain about their readiness and the effectiveness of current operations.

Obviously, there have been significant problems with North Carolina’s transition to a managed care system for MH/DD/SA services. Now is the time for state leaders to learn from these controversies and make reasoned decisions about the future of our system, and the people it serves.

The Arc believes problems with the state’s transition to managed care stem from an overzealous rush to find savings, rather than a thoughtful and deliberate approach to system design. The operationally arbitrary deadlines for management entities to convert to the managed care waiver are a key example. Converting to a managed care system is not easy- it is expensive and disruptive. We must be sure that LME/MCO’s are truly ready to begin before they turn the switch.

The struggles of LME/MCOs the state deemed ready to move forward to the new system, including Western Highlands Network, prove that the prior notion of what ‘ready’ means is insufficient and needs to be re-examined. Clearly, LME/MCOs must prepare business systems capable of dealing with the large volume of claims, payments, and calls they will receive. It is also important that they are prepared to implement any new services available under the managed care system, respond to people with disabilities and their families about their concerns, and have a well-trained provider network that understands the intricacies of the new system.

Our system’s focus should be on the needs of individuals it is meant to support and the providers working within the system, rather than dreams of short term savings. Getting it right the first time with a well-measured, steady approach will lead to efficiency, cost containment, and higher satisfaction among consumers, providers, and LME/MCOs.

The Arc believes we must adhere the following basic principles if we are to make this transition to Managed Care successful. 

Stability for individuals served and those who provide the services must be the highest transition priority. No LME/MCO should be allowed to shift to managed care if they are not ready. It should be clear that readiness means the ability to successfully support people with disabilities. 

Decisions about LME/MCO mergers and “assignments” need to be about competency and not about politics. 

Where competing goals exist, the state needs to be clear about which it values more. For example, ‘local public management and ‘administrative efficiencies’ are not always mutually exclusive, but in certain areas they may be. 

All interested parties, including The Arc, must be open to new ideas and approaches surrounding managed care. There is no dishonor in adjusting a plan to meet current circumstances. The needs of people with disabilities should dictate policy, not the established position or ego of any state agency, MCO/LME, private organization, or individual. A real partnership with stakeholders must be achieved if we are going to succeed.

Finding savings within state systems for people with disabilities is certainly laudable, but if the savings mean sacrificing the ability of the system to perform its mission, then they are counter-productive. As the saying goes, buy it right or buy it twice.

Comments

MCO's

We who are involved in all the changes sit back and watch and read all that is occuring. We hear that different MCO's get different PMPM amounts and do not understand why. We hear that LME's can not get it together in the outlined time frame. We watch and read about Western Highlands being half a million dollars in the red for months while the board did not realize it. We hear and wonder how MCO's like Western Highlands have the monies to hire agencies like the private group they hired at the cost of hundreds of thousands of dollars to tell them what they are doing wrong after this State hired Mercer to tell them that and still the Mercer organization is at Western Highlands looking at what they are or are not doing right over a year after they began operating while the private agency is there. Now we hear of Mercer going into other LME's to see if they are ready. Why? We watch Western Highlands fire their CEO and pay an agency thousands of dollars to locate a new CEO. We hear agencies not getting reimbursed in a timely manner over never ending changing requirements. We have watched as agency, therapists and psychiatrist have left Western Highlands and I am sure this is the same for other MCO's and wonder where this State is in thinking of the Best Interest of the individuals that they are to serve while spending monies on things that should have already been in place. What is wrong with this picture? Does anyone wonder why all these monies are being spent on requirements that were supposed to be in place instead of on the individuals that they are to serve. I have not heard of any direct care staff which are the back bone of all this getting anything extra for all their efforts. We are forgetting the reason all these MCO's were started, the individuals that they are Supposed to Serve.

Special Medicaid Bulletin on b/c Waivers

Good Afternoon,

Please see the Special Medicaid Bulletin on the 1915 b/c waivers posted today. Please share with your stakeholders.

http://www.ncdhhs.gov/dma/bulletin/pdfbulletin/0113_1915bc_waiver_expansion.pdf

Thanks.

Kelly Crosbie, LCSW
Chief, Behavioral Health Section
Clinical Policy & Programs
Division of Medical Assistance
1985 Umstead Drive
2501 Mail Service Center
Raleigh, NC 27699-2501
(919) 855-4293
kelly.crosbie@dhhs.nc.gov

Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed to third parties by an authorized State official. Unauthorized disclosure of juvenile, health, legally privileged, or otherwise confidential information, including confidential information relating to an ongoing State procurement effort, is prohibited by law. If you have received this e-mail in error, please notify the sender immediately and delete all records of this e-mail.

WSJ article: HB1075 & MCO/LME quest for power

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/.

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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.