Hey, Remember CABHAs? Nah, Me Neither…

by Richard Edwards

It was just January of this year, 2011, that DHHS Secretary Cansler made the announcement that “the era of mental health reform is over”. A new service model–Critical Access Behavioral Healthcare Agencies (CABHAs)–would put mental health and substance abuse services on a firm foundation, finally, after years of turmoil and substandard services for people in need.

CABHAs would, through the substantial investments they make through the addition of key personnel–a Medical Director and a Clinical Director, as well as a Quality Improvement/Training Director–provide a clinically sound provider community to NC’s citizens. Of course, this would cost money, so CABHAs would be the only providers allowed to bill the new Targeted Case Management service.  TCM would offset the costs encumbered by the CABHAs and provide stability to a fragile provider community that has been hit by repeated service rate reductions in the past two years. As of this writing, there are just over 200 CABHAs operating in NC, and while that’s a much larger number than was anticipated, it also represents a significant winnowing of the provider field. Becoming a CABHA clearly had raised the bar beyond what many were able to achieve.

CABHAs were the future. Until they weren’t.

In April of 2011, the state announced the rollout of statewide 1915b/c Medicaid waivers similar to the Cardinal Innovations plan being operated by Piedmont Behavioral Healthcare since 2005. A 1915b/c waiver, in Medicaid language, means essentially that the managed care organization has much greater control over the services in its array and the providers in its array. Waiver operations, unlike the current NC state plan for Medicaid services, are closed networks–they do not have to admit any willing provider, and they manage the network more closely.

The state has been moving towards a waiver-based system for a while. PBH began its pilot operation in 2005, and two additional Local Management Entities–Mecklenburg County and Western Highlands Network–have also been approved. There are several others that are in the cue, but according to the release by the DHHS, all services will be overseen by Managed Care Organizations (nee LMEs; nee Area Programs) by July, 2013.

Why is this relevant? Remember all those CABHAs who hired their medical directors and clinical directors and QI/training directors and provide outpatient therapy and psychiatric services…remember how we thought they were the future? Under the waivers, there is no guarantee that any of them, anywhere, will be part of the contracted provider community. Of course, many of them will, because one of the primary responsibilities of the MCO is to provide access to services, but many of them won’t–perhaps as many as half–and if you’re a CABHA, there’s simply not a thing you can do about it.

A bill on the statewide rollout of the waivers has been introduced–you can read about it here.

My angle is that public systems should not be set up to protect anyone but the people receiving services and the public at large. CABHAs, any more than LMEs, or DHHS staff, or state operated services, or the Adult Care Home industry, do not have guarantees they’ll be here tomorrow.  But my great concern in all of this is that it seriously calls into question the long-term vision for the mental health and substance abuse system in North Carolina–what is the ultimate plan? Is there an ultimate plan? And does it really include undermining what was until recently the underpinning of the whole system?

Further underscoring this concern is the announcement–made in a flyer (warning: pdf) posted on the Division of MH/DD/SAS website for people with intellectual and/or developmental disabilities–that Targeted Case Management (remember that service?) would not exist as it does today under the waivers. (There have been subsequent communications, but this was the first official statement.) So, if you’re a CABHA…and if you survive the next two years…and if you make it into the provider network of the MCOs for the communities you serve…you will lose the ability to provide the one service that it supposed to help you cover the costs of being a CABHA in the first place.

What a difference a year makes.

Oh, wait, it hasn’t been a year, yet. It hasn’t even been six months.

But that’s just my angle–what are your thoughts?

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One Comment to “Hey, Remember CABHAs? Nah, Me Neither…”

  1. I remember a number of folks asking why we would have CABHA’s if the state was moving toward a 1915b/c waiver, since they would become irrelevant. The answer is that it would “prepare” providers for the waiver environment.
    Meanwhile, people continue to need services they can’t access, because they can’t figure out where to find them. That is what I see everyday-or their provider went out of business or changed services…very sad situation.

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