Posts tagged ‘Mental Health Reform’

May 12, 2011

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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January 7, 2011

Mental Health Reform is dead. Long live Mental Health Reform!

by Richard Edwards

Today, at a press conference, NC DHHS Secretary Lanier Cansler stated that the era of mental health reform was over. You can read about it here, here and here.  That’s a bold statement, to say the least, bordering on hyperbole, but I suppose it depends upon how you define reform and set the boundaries for the era itself.

Strictly speaking, mental health reform ended when Local Management Entities, previously community mental health centers, divested their mental health, intellectual and developmental disability and substance abuse services in an effort to increase efficiencies by privatizing the system. The vast majority of this transition occurred years ago, from 2004 to 2006 or so. So, yes, that era of mental health reform is over.

Another focus of mental health reform was to bring people living in institutions back into the community–a move that would be supported by the development of community services. This part of reform never happened–there are still many people living in institutions, and there doesn’t seem to be any inclination to support the community-based service capacity necessary to assure a safe transition. So, also, that era of mental health reform is over–in fact, it ended before it ever began.

So, I suppose, the processes that were supposed to bring about system transformation are over, if they ever really began. But the era of mental health reform is emphatically not over.

The establishment of Critical Access Behavioral Health Agencies (Kah-bas), described in the articles and press releases, is a response to the failures of mh reform, but it’s not the end of it. Far from it.

CABHAs are, in many respects, private mental health service providers who provide an array of services to a given population (adults and/or children) in at least one area of the state. Certain services can only be provided by a CABHA-certified agency, including case management and peer support, but also intensive mental health and substance abuse services. Ostensibly, the goal is to create a more professional, more competent provider network. See, when the state ordered the LMEs to divest their services, they didn’t order them (or pay for them) to divest their clinical and medical oversight. Consequently, some providers had it, and some didn’t. There was no requirement to have it, and there was no funding to support it. The CABHA certification requires that level of clinical and medical oversight to be held within the provider agency, and there is a lot of hope–as evidenced by today’s press conference–that oversight will address many of the problems in the system.

And I would agree, it might, but here’s the rub–there is no guarantee as to how many of the some 175 certified CABHA entities will survive the next 6 months. Consider the following:

Each CABHA must have a Medical Director, for which there is no additional funding.

Each CABHA must have a Clinical Director, for which there is no additional funding.

Each CABHA must have a Quality Improvement/Training Director, for which there is no additional funding.

Each CABHA must provide Outpatient Therapy and Psychiatric services, both of which are loss-leaders in the field and are inadequately supported by state rates.

The cost of the three unfunded positions could easily top $300k annually, and even if you take into account that many agencies may have had a Clinical Director or a QI Director, most small agencies were doomed from the start. Out of some 600+ provider agencies, only 175 or so made it through the certification process. Of that 175, it is almost certain that a third to a half will not survive the next year.

You could argue that the 11-12 budget will actually be to blame for that, and that’s not unfounded, but my angle is this…

In trying to assure mental health reform went over smoothly, the state made it too easy for a business to get into the mental health industry, and for the last four years, has been trying to clamp down on this proliferation.  So, call it what you will, but we are still dealing with the effects of mental health reform.

The era of mental health reform may be over, but the vision is still a long way off.