Questions remain unanswered
By Taylor Sisk, Staff Writer
It’s pretty much a given that when the federal government approves a new designation of mental health care provider proposed by the state’s Department of Health and Human Services (DHHS) there will be fewer agencies providing services in North Carolina. The question raised by mental health care consumer advocates is whether fewer agencies providing a more comprehensive suite of services will better serve those with mental illness. And smaller agencies, a great many of which are minority owned, are concerned that they’re going to be driven out of business in this move to consolidate.
DHHS says that providing more comprehensive services is precisely the intent behind the model for these new agencies – to be called critical access behavioral agencies, or CABHAs – which is being presented for approval to the federal Centers for Medicare and Medicaid Services. That approval is required in order for the state to receive federal dollars.
A DHHS memorandum introducing the concept of CABHAs last November stated that the objectives were to ensure that “critical services are delivered by a clinically competent organization with appropriate medical oversight and the ability to deliver a robust array of services,†to begin the move to a “more coherent service delivery model†and to ensure that mental health care is “based upon a comprehensive clinical assessment and an appropriate array of services.
No one disputes the fact that these are laudable goals. Since mental health care reform was introduced in 2001, the delivery of services in North Carolina has been in disarray. With legislation passed that year, state government began privatizing mental health care services. Area programs, such as Orange-Person-Chatham (OPC), were ordered to divest services and contract them out to private providers, then oversee those providers. The idea was that more services would be made available within communities and that state institutions would be less crowded and better positioned to treat the more critically ill.
But adequate services were not provided within communities. Many private providers entered the industry to offer only those services that were easiest to provide, then overbilled the state for them.
CABHAs, says DHHS Sec. Lanier Cansler, are the remedy, and many mental health care advocates across the state are open to the concept.
“A renewed focus on the clinical integrity of services, with an emphasis on key issues such as staff credentials, national accreditation, agency-wide quality management and oversight can only help to restore confidence in the public system,†OPC Area Program director Judy Truitt wrote in an email to The Citizen.
Debra Dihoff, executive director of the National Alliance on Mental Illness North Carolina, an organization that advocates for families affected by mental illness, said that she recognizes the potential upside of CABHAs.
“We do recognize some of the positive aims that would be achieved with CABHAs,†she said, particularly, “quality of care and one-stop shopping.â€
“It’s good of the department to back up and take a fresh look to figure a way out of this mess,†Dihoff said.
But, she added, there are always unintended consequences. A primary concern for her and others is that qualified providers will be put out of business. Clubhouses, such as Club Nova in Carrboro, are going to find it difficult to meet the criteria for CABHA designation.
CABHAs must provide four core services: case management for those with mental illness or a substance-abuse problem, comprehensive clinical assessment, medication management and outpatient therapy. They also must provide two additional services from a list that includes intensive in-home care, therapeutic family services, day treatment, psychosocial rehabilitation, a mobile crisis team and six others.
Club Nova provides psychosocial rehabilitation that allows those with mental illness to better integrate into their communities, and could still provide that service without becoming a CABHA. But Dihoff points out that because psychosocial rehabilitation services are reimbursed at such a low rate, clubhouses have offered other services to make ends meet. Under the newly proposed model, the bulk of such services can only be provided by CABHAs.
Three weeks ago, Cansler introduced four changes to the CABHA criteria to be presented for the Centers for Medicare and Medicaid Services’ consideration: to provide greater flexibility for smaller providers to subcontract with CABHAs to provide services; to provide an additional transition period of up to six months to establish or join a CABHA; to provide an option for an eight-hour per week medical director for CABHAs that serve 375 or fewer clients; and to evaluate opportunities for additional flexibility for local management entities to contract with small providers to enhance access to services.
Subcontracting with a CABHA could be the solution for Club Nova. But the particulars of how the model ultimately will be defined remain in doubt.
Danny Freeman, executive director of the N.C. Quality Care Provider Association, believes that the changes Cansler introduced are a step in the direction of better accommodating smaller providers – particularly, reducing the number of required weekly medical director hours. But he remains concerned about the requirement for full-time clinical and quality management/training directors, which, he said, are beyond what smaller providers require and “a financial barrier that you’re not going to be able to overcome.â€
Rep. Verla Insko, who represents Orange County and is co-chair of the Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse, said that many of the smaller providers are run by minority entrepreneurs and, “My concern is to make sure they’re treated fairly.†She said that many of these providers’ clients are also minorities, and that she wants to see to it that they are not shut out of the system.
Asked if he felt the DHHS was hearing his concerns, Freeman said, “They are now.†He has argued that the department’s implementation of the CABHA model has failed to follow proper legal channels, and he’s meeting with Cansler next week to share his concerns.
The new model is scheduled to go into effect July 1. Dihoff said she believes DHHS is open to accommodations on an ongoing basis. “They’re beginning to make exceptions where exceptions are appropriate.†Where there are service gaps, “they need to be out there recruiting CABHAs.†If a provider is the only one in a geographical area offering a particular service, she said, “they can’t be shutting down facilities.â€
“I’m ever hopeful,†Dihoff said, “and frequently disappointed.â€
Hi Mr. Sisk,
I appreciate your article. I think you did a good job of getting accurate information. I operate a small provider agency in Chapel Hill. I was wondering if you might like to talk at some point in the future. If so, please email me.
Thank you,
Angela Annas