Map of the state's mental health agencies or LMEs
Map of the proposed mental health agencies in North Carolina from late 2011. By that time, Cardinal Innovations' footprint had grown from five counties to 15. Eventually, the organization would manage mental health care for more than 20 counties before boards of commissioners started pulling their constituents out. Image courtesy NC DHHS

By Lydia Wilson

Reports obtained through a public records request show North Carolina’s new mental health management agencies are struggling to meet the state legislature’s ambitious mandates.

A state-contracted auditor, Mercer, found potential issues at all of the regionally-based agencies that were mandated last summer to adopt a new business model, operating like small insurance companies. The new structures are called Local Management Entity-Managed Care Organizations, or “LME-MCOs.”

The first of three separate reports showed that one of the LME-MCOs was providing insufficient care for some mental health consumers, substandard telephone call monitoring, and a lack of proper staffing. A second report expressed concern that another LME-MCO might not be able to handle call volume from consumers, and another report warned that a third LME-MCO may struggle to pay service providers on time.

Despite this, a formal plan of correction was not required from the agencies.

A review of minutes and presentations from the Department of Health and Human Services showed no evidence these problems were systematically corrected by the monitoring committee that meets monthly in Raleigh to review the LME-MCOs’ operations.

A DHHS spokesman did not respond to a request for comment.

Problems at the state’s ‘model’ agency

In an annual review of Piedmont Behavioral Health (PBH), the Concord-based agency that has piloted North Carolina’s mental health reforms for six years, Mercer reported issues with consumer care when it reviewed files at random.

  • In three cases concerning consumers who had both a mental health disorder, and an intellectual or developmental disability, the February report, found “little evidence of… addressing the collective developmental, mental health and biomedical needs of the individual.” The audit also found none of the cases “had evidence of appropriate assessment and reassessment of the medication regime.”
  • In other instances, where auditors found need for a doctor consult, only a third of the cases had the consult requested and conducted, despite Mercer’s opinion that PBH would be “well-positioned” to improve on these concerns because it had “strong clinical resources.”
  • Mercer said PBH did not meet industry standards for answering calls to its 24-hour phone access line, which acts a crisis and referral service. During business hours, PBH’s own staff answered 100 percent of calls within 30 seconds, with only a 3 percent abandonment rate.

 But after hours, the LME-MCO uses a contractor, Protocall, which had up to a 19.7 percent call abandonment rate.
  • PBH took over responsibility for managing the care of consumers in 10 additional counties in January, however, Mercer found that PBH had ‘insufficient’ staff to make the expansion. The report cited that agency representatives should have visited providers’ offices, but had not been doing so. “Staffing to support network development, credentialing, contracting, and ongoing monitoring appears insufficient in light of this expansion,” according to the report.

After several weeks of requesting a response from PBH, a spokeswoman replied in an email, “The Mercer Report is a valuable tool to PBH as we assess the services we’re delivering. We are reviewing and adjusting our programs as appropriate based on the evaluation in the Report.”

PBH is just one of 11 LME-MCOs that will be operating under the new mental health reforms as of next January, and is the model for the others.

Other new agencies struggle

The Mercer auditors also found issues at the other agencies they visited, in particular, when making a determination whether the agencies were prepared to transition to the new system.

Western Highlands Network (Asheville), started operating under the new system in January. Mercer auditors found  some of Western Highlands’ processes were “non-industry standard.” For example, staff were still hand-entering some data from forms, which increased the possibility of errors.

Concerns that Western Highlands Network needed a backup plan for paying providers were expressed last December. But as recently as mid-April, payments were being delayed by technical glitches, not for the first time.

One Western Highlands Network therapist, Pia K. Arrendell of Asheville, said four months of payment problems are taking a toll on local therapists.

“You think you get paid and then you get paid four days later,” she said. “It has happened to me that I couldn’t pay a bill until I get paid. And sometimes that causes  late fees.”

Arrendell acknowledged that Western Highlands Network’s staff is friendly when she calls with questions about late or missing payments.

Deputy Finance Officer Trisha M. Ramsey wrote in an email that Western Highlands Network did follow Mercer’s recommendation for a backup system, but said the backup is not efficient for use in every situation. “We are fully prepared to do this in the event of a major system issue,” she wrote.

East Carolina Behavioral Health is the third LME to adopt the model mandated by the mental health reform law passed last year in the General Assembly. The agency started operations on April 1, and provides services for people with disabilities in 19 eastern counties.

The Mercer report raised concerns that ECBH may not be ready to handle the increased call volume it would receive when the changes went into effect, and that consumers whose providers did not enroll with ECBH could struggle to find care. Mercer recommended that ECBH send weekly reports to the state.

The first report from ECBH shows that, by the third week of operation, the agency was answering its consumer access lines quickly and efficiently, in an average of 19 seconds, abandoning only 4.71 percent  of calls.

But as ECBH enters its second month of operation, consumers and providers will find out whether the auditors’ concerns about care being affected by the transition will materialize.

Two more agencies, affecting 22 western and central counties, are scheduled to convert to LME-MCOs on July 1.

Mental Health 3.0 is adapted from Lydia Wilson’s thesis for a Masters in Journalism from UNC Chapel Hill’s Medical Journalism Program.

The title image is adapted from a portrait of Dorothea Dix, a 19th century crusader for better mental health care, that hangs at the National Portrait Gallery.

Creative Commons License

Republish our articles for free, online or in print, under a Creative Commons license.

Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...