By Hyun Namkoong
In a Wednesday morning session of the Joint Appropriations Committee on Health and Human Services, legislators questioned the state’s role in providing substance abuse treatment in state-run facilities.
But the hour-and-a-half session wasn’t long enough to discuss all the implications of a report on the funding and management of North Carolina’s three state-operated alcohol and drug abuse treatment centers. In the report, legislative staff researchers made two main recommendations: to better integrate patients receiving treatment at ADATCs into community-based substance abuse programs and to better track how well the ADATCs do at helping people get clean and sober.
Even after that long discussion, lawmakers left the room with many unresolved questions and concerns.
“Now the detail of [the recommendation] still needs to be discussed more fully,” said Sen. Louis Pate (R-Mount Olive). “This was a full hour and a half. I think some more direct questions could be asked.
“I don’t think this bill is quite ready to go yet,” he said, referring to proposed legislation that would create a three-year period to transform the programs and end direct state funding for the ADATCs.
No data
Jeff Grimes, an evaluator with the legislative Program Evaluation Division, told lawmakers that the state doesn’t have a way to track how well people who use the ADATCs are doing over time.
The road to recovery can be a long one. Research from the National Institute on Drug Abuse shows that substance abuse treatment can last anywhere from 90 days to multiple years.
ADATCs rely heavily on state appropriations. They received more than $41 million to fund 90 percent of operations in fiscal year 2013-14 to treat a total of 3,875 individuals, many of whom have mental health issues as well as substance abuse problems.
“We’re spending a lot of money with nothing to back it up from a data standpoint,” said Rep. Marilyn Avila (R-Raleigh).
And lawmakers don’t have a lot to go on when deciding how well the money is being spent. One of the findings Grimes and his staff reached was that ADATCs don’t keep data on long-term outcomes such as improvements in personal health, social functioning or even if people are successful in abstaining from drugs and alcohol.
That lack of data was a big concern for legislators who are wary of making uninformed decisions.
“I have to have data to make decisions. I can’t just go out and say that’s too much money, cut it in half. I might be killing people doing that,” Avila said.
Dave Richard, the Department of Health and Human Services’ deputy secretary of behavioral health and developmental disabilities services, acknowledged that the absence of a data system was “absolutely a flaw in the system.”
He said federal privacy laws around substance abuse treatment make it difficult to track long-term outcomes among patients
“But we have to have long-term data to see what’s actually happening to those individuals,” Richard said.
Misaligned incentives
The state’s three ADATCs have a total of 196 beds at locations in Greenville, Butner and Black Mountain.
Those beds are paid for by state funds, at an average cost of $12,336 per 16-day admission for services. Some ADATC patients stay for “an exceptionally long length of stay” at a cost of more than $1.5 million per year. All told, ADATCs cost state coffers $46 million to provide treatment to 3,875 people in fiscal year 2013-14.
Lawmakers were alarmed at the high price tag.
“Forty-six million dollars can be spent effectively to help a lot of people, and it doesn’t look like we’re spending it as effectively as we should,” Avila said.
Local mental health managed care organizations don’t pick up the tab when they send a patient to an ADATC. Grimes said there are few financial incentives for MCOs to restrict or manage the use of these inpatient treatment services.
And the state is on the hook, no matter how long the patient stays at the ADATC.
“The longest case we identified was an individual who stayed at an ADTC for 335 days straight,” Grimes said.
He recommended that the three locations eventually be privatized and that more services be integrated into local community-based programs run by the state’s mental health MCOs. That changes the MCOs financial incentives.
Grimes pointed to Salisbury-based MCO Cardinal Innovations (formerly known as Piedmont Behavioral Health), which made an agreement with ADATCs to cover the costs for patients. That reduced Cardinal’s use of the facilities: The MCO’s average admissions to ADATCs was three per 100,000 in 2013 compared to the statewide average of 42 per 100,000.
“It’s had a dramatic impact on utilization of the ADATCs,” Grimes said.
And because Cardinal is responsible for picking up the tab when one of its patients is at an ADATC, it’s come up with cheaper alternatives, such as facility-based crisis centers that provide evaluations, treatment interventions and behavioral management to detox patients.
Grimes presented a three-year plan to gradually wean ADATCs off state funds, to be fully receipt supported by the final year.
Sen. Ralph Hise (R-Spruce Pine) asked why ADATCs couldn’t become receipt supported immediately, rather than waiting three years.
Grimes said ADATCs and MCOs needed time to adjust to the different business model.
“[MCOs] felt they needed time to build up that capacity in the community,” he said.
“Having gaps in the community can lead to individuals going to an ADATC who wouldn’t otherwise require that level of care,” Grimes said.
But he was unable to answer Rep. Floyd McKissick (D-Durham), who asked how many people would be served by LME/MCOs if lawmakers made these changes.
Loss of specialized care
“The General Assembly, since 1974, has wreaked havoc upon our mental health programs and citizens,” said Rep. Gary Pendleton (R-Raleigh). “What I’m talking about is the closing of so many inpatient psych beds. Look at the growth of our population.… Hope to god that you don’t close any of these 196 beds.”
Other legislators also expressed concern that integration of ADATCs would result in the loss of beds or in the loss of specialized care for substance abuse. ADATCs throughout the state have dedicated programs targeting specific populations such as veterans or pregnant women, something Avila said she supports.
Mark Ezzell, executive director of Addiction Professionals of North Carolina, said it’s important to maintain the expertise found at ADATCs to ensure specialized care for those populations.
He, along with some lawmakers, raised questions about whether the MCOs had the capacity to provide adequate services if ADATCs are phased out.
Ezzell said a significant study needs to be done to measure community capacity, especially in rural areas.
“One thing we don’t want to get into is a repeat of mental health [reform in 2001], where we deinstitutionalize and hope against hope that the community capacity is there, and it’s not,” he said.
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