Restructuring of services to developmentally disabled causes anxiety

by Keith Barber

Local mental health care professionals expressed concern about potential impacts in the next phase of mental health reform after a presentation by Betty Taylor, CEO of CenterPoint Human Services, at Senior Services in Winston-Salem last week. Taylor assured local mental health professionals that if CenterPoint is selected as one of the eight to 10 local management entities, or LMEs to run the state’s new proposed Medicaid waiver program, the agency’s decisions will not be based on the bottom line.

Despite the fact less money will be invested in the Medicaid waiver program, Taylor maintained that CenterPoint will make decisions for its clients based on the needs of the consumer and the medical necessity of the services provided.

“When you hear about savings, that is not because people are going to be deprived of [services],” Taylor said. “That is not the goal of the waiver and it’s certainly not the goal of CenterPoint.”

If CenterPoint is one of the managed care providers selected by the NC Department of Health and Human Services, it will mean an additional $140 million in annual funding for the agency and an increase of 75 to 80 new positions. As the number of LMEs is decreased from 23 to between 8 and 10 under the new reforms, the surviving agencies could potentially take on thousands of new clients.

Andy Hagler, executive director of Mental Health Association in Forsyth County, questioned whether the additional funding to CenterPoint would be sufficient to cover the needs of all the new clients in its service area while simultaneously maintaining the clients’ current level of service.

“What I would like to see is [mental health clients] get the services based on their needs and not based on the [billing] rates for services or what [CenterPoint] thinks they might need,” Hagler said.

Taylor identified one of the immediate impacts of CenterPoint being selected as one of the LMEs under the new Medicaid waiver program as the agency being able to provide services to 750 developmentally disabled individuals on its waiting list.

“We have 750 people on the waiting list for [developmental disabilities] service that get absolutely zero, absolutely zero,” Taylor said. “For this four-county area, it means we can serve those people. There will be changes as the [waiver] transitions. People will be maintained at the level of support they need, but instead of millions of dollars reverting back to the state every single year, 750 people who get nothing will be served.”

However, Jeff Payne, manager of waiver implementation for CenterPoint, stated that even if the NC General Assembly passes House Bill 916 and 15 percent of the funds saved under the new system are reinvested in services, CenterPoint could not fulfill the needs of those on its waiting list.

Payne said there are a number of reasons why the state mental health system is “exploding” with respect to the number of people served.

“Our diagnostic assessment tools are improving to identify disabilities earlier so our assessment and identification of people is heightened,” Payne said. “Our awareness is heightened, the growth of our system is exploding and to keep up with the need in the community based on the long-term care costs anticipated to support people, and those two things are not equal.”

To meet increasing demand for services, the new Medicaid waiver system restructures how money is disbursed to individual clients, which provides a solution to CenterPoint’s waiting list dilemma, Payne said.

Under the current Medicaid system, the state issues two kinds of slots for new clients. One has a maximum of $17,500 per member per year while the other has a ceiling of $135,000.

“Most families on the smaller waiver use up to the ceiling,” Payne said. “Those who are on the $135,000 waiver, typically only spend between $50,000 and $60,000. The difference between what they are spending and the ceiling that is returned to the state at this point is not redistributed back to the community.”

“We don’t have that flexibility now and we hope under the new model we will,” Payne continued.

Under Section 1915(c) of the Social Security Act, Medicaid law authorizes the secretary of the US Department of Health and Human Services to waive certain Medicaid statutory requirements. The waivers enable individual states to cover a broad array of home and community-based services for targeted populations as an alternative to institutionalization. Waiver services can be optional state plan services, which either are not covered by a particular state or enhance the state’s coverage.

A 2006 survey of the state’s mental health system revealed there were 24,013 participants in the five Medicaid waiver programs in North Carolina with expenditures totaling $564.4 million — an average expenditure of more than $23,500 per participant—according to the Center for Personal Assistant Services website.

Hagler said the proposed reforms would alter the current model of the Medicaid waiver for mental health clients with intellectual and developmental disabilities by returning individual case management responsibilities to the LME. Under the current model, targeted case management is the responsibility of service providers. The current model keeps people in the community, which saves the system a significant amount of money, Hagler said. One of the advantages of the new proposal is the possibility for a greater number of developmentally disabled individuals who need lifelong services to be kept in the community as opposed to institutionalization.

“It may cost X amount of dollars to keep someone in the community, but it’s far less than institutionalization,” Hagler said.

Liz Boltz, assistant director of support brokerage services for the Arc of North Carolina, expressed concern that the new proposed waiver system would place too much control in the hands of the LMEs and take away the advocacy role of service providers. Under the proposed health management organization model of waiver implementation, care management will be provided by the managed care entity and targeted case management will go away.

“That service will not be offered or provided in North Carolina,” Boltz said. With so much power in the hands of the

LMEs, it could diminish community-based services for the mentally ill, Hagler said, and all evidence indicates that the current system needs to invest even more in com munity-based services. Hagler said he’s hopeful that the new Medicaid waiver system could expand community-based services for mentally ill clients.

The most recent reform of the state’s mental During a presentation to the Forsyth County “On the mental health end of it, if we health system came in 2001 when the NC Commission on April 28, Taylor submitted can provide more community-based ser-

vices, then hopefully we can start seeing less people going into the emergency rooms because we have folks right now with mental illness who are waiting, 8,10, 12, 15 days in the emergency room before getting a bed,” Hagler said. “But if we start seeing more com- munity services on the mental health and sub- stance abuse end, hopefully we’ll begin to see a decrease in the crisis services.” The most recent reform of the state’s mental During a presentation to the Forsyth County health system came in 2001 when the NC Commission on April 28, Taylor submitted General Assembly passed the Mental Health System Reform Act, which required local jurisdictions to separate the management of mental health services from the delivery of those services, according to the website Public Interest. Previously, local entities such as counties and regional agencies delivered men- tal health services by directly employing the care providers. The 2001 law mandated that LMEs contract with private providers to serve the state’s mental health clients. Taylor acknowledged that some of the moti- vation for the current set of reforms is cost savings to the state on Medicaid spending. During a presentation to the Forsyth County Commission on April 28, Taylor submitted a PowerPoint presentation composed by NC Health and Human Services Secretary Lanier Cansler that projected that in the first year of a publicly managed Medicaid waiver system, the state would save $10.5 million in Medicaid costs. By the fifth year of new waiver imple mentation, the state would save an estimated $250 million annually.

The state will create substantial savings in its Medicaid program by paring down the cur- rent number of LMEs from 23 to between 8 and 10 by Jan. 1, 2013. Taylor said she could not verify Cansler’s projections but confirmed that most of the sav- ings on Medicaid spending under the new plan would be returned to the state. “With our deficit spending on Medicaid, you bet [it’s a good deal for the state],” she said.

CenterPoint is the LME that serves Forsyth, Davie, Stokes and Rockingham counties.

Taylor touted the fact that under the new mental health waiver system, savings on healthcare costs would be reinvested in ser- vices to mental health clients. Yet under the provisions of House Bill 916, which was referred to the House Committee on Health and Human Services earlier this month, only 15 percent of savings in Medicaid spending would be reinvested in the state’s mental 1915(b) and Medicaid 1915(c) waivers will the state as a funnel and distributor of funds health system. Taylor said the hundreds of be blended and follow the model created and looks at our population and local com- people on CenterPoint’s waiting list, including those with intellectual and developmental disabilities, would receive services under the new plan. CenterPoint began preparing for the next phase of mental health reform two years ago and will file its application to be one of the LMEs in the new system by May 20, Taylor said. Payne said under the new system, Medicaid 1915(b) and Medicaid 1915(c) waivers will the state as a funnel and distributor of funds be blended and follow the model created and looks at our population and local com- by Piedmont Behavioral Health, a man- aged health care company that serves more than 20,000 clients in Cabarrus, Davidson, Rowan, Stanly and Union counties.

Piedmont Behavioral Health has been operating under the blended system for the past six years. “In the 1915(b)(c) blend, it will be changed to the PBH version, which is the innovations waiver,” Payne said. “Right now, we are a tra- ditional local management entity that gets our funding from the federal government funneled through the state to us in terms of allocated dollars based on population and disability group. The PBH model as it exists removes the state as a funnel and distributor of funds and looks at our population and local com- munity and issues that payment directly to the community and expects to manage it accord- ing to local needs.” The Piedmont Behavioral Health model offers “more local control, more local deci- sion-making opportunity and more accountability to meet the needs of its citizens,” Payne said.

Boltz disagreed, saying that under the new system individual case management will be eliminated, which she believes could be dif- ficult for those with intellectual and develop- mental disabilities. “My concern of the [intellectual and devel- opmental disabilities] component and the managed care waiver is that [services for] indi- viduals will be lost,” Boltz said. “The funding will go toward people with mental health and substance abuse.”