The Julian F Keith ADATC in Black Mountain has had 199 admissions and 190 discharges since the new year.
The Julian F Keith ADATC in Black Mountain has had 199 admissions and 190 discharges since the new year. Photo courtesy NC DHHS.

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Advocates worry that the changes facing ADATCs could lead to a loss of specialized care and beds for substance abuse treatment.

By Hyun Namkoong

A move to place state-run substance abuse centers under the control of local mental health agencies is one step closer, as members of the House Health Committee gave House Bill 119 a favorable report on Wednesday morning. The bill now goes to the appropriations committee.

If passed, HB 119 would significantly change the funding and management of the three state-run alcohol and drug abuse treatment centers and create a data system to track long-term outcomes of patients, such as employment or if people are abstaining from drugs and alcohol.

The state pays for the 196 beds at the three ADATCs in Greenville, Black Mountain and Butner. In fiscal year 2013-14, ADATCs cost the state’s coffers $46 million to treat 3,875 individuals, mostly referred by local mental health managed care organizations that aren’t responsible for picking up the tab for treatment.

Since MCOs don’t have to pay for services used at the ADATCs, they have little reason to restrict the use of these inpatient beds, an expensive form of treatment. This misalignment in financial incentives is one of the drivers for “integration,” according to a study from the legislative Program Evaluation Division.

The study also found that there’s a gap in services between local treatment centers and ADATCs, resulting in some patients getting treated in settings that are more intensive and more expensive than they need. The report also found that MCOs had “little incentive to invest in expanded community-based treatment options that would serve as a substitute for ADATC services.”

Dale Armstrong, head of the state Division of State-Operated Facilities, said he believes the bill would incentivize MCOs to use the ADATCs when it’s appropriate.

However, the study showed utilization of ADATCs plummeted after one of the state’s MCOs, Piedmont Behavioral Health (now called Cardinal Innovations), started receiving money in 2003 to replace ADATC services with locally based services and was also required to pay the full tab for any patients sent to ADATCs.

Piedmont’s utilization of ADATCs is now only one-tenth the rate of other MCOs in the state. Some advocates worry the incentive has shifted from overuse of ADATCs to not getting complicated patients into the more intense treatment they require. But they also acknowledge there’s limited data to back up their fears.

Crowded EDs

The overuse of emergency departments for people who experience mental health or substance abuse crises is a major problem across the nation and in North Carolina.

Armstrong said ADATCs play an important role in continuity of care, especially for providing inpatient treatment for people who need more time to get off of drugs or alcohol. He said those beds help the state avoid a situation where limited beds could result in more patients backlogged in community emergency departments.

Mark Ezzell, executive director of Addiction Professionals of North Carolina, said HB 119 doesn’t pull the rug out from under ADATCs, but worried the bill could potentially create problems for people with multiple concurrent diagnoses of mental illness, developmental disability and substance abuse.

“Folks served in ADATCs are those with the most significant problems … with no insurance, with no place to go,” Ezzell said. “Closer is better, and so if those community capacities are there let’s use them.

He said he hoped ADATCs stayed in place because there needs to be a place for those complicated patients who get turned away from private providers.

“The ADATCs are an important safety net,” Ezzell said.

HB 119 would gradually wean ADATCs off state funds to be fully receipt supported in three years. State dollars formerly appropriated for ADATCs would be diverted to MCOs to invest in creating cheaper alternatives to ADATCs, such as facility-based crisis centers.

Advocates also worry that the capacity of the community centers to provide specialized care for complicated patients won’t match that of ADATCs.

“It’s not that ADATCs shouldn’t be privatized,” said Tad Clodfelter, CEO of SouthLight Healthcare, a substance abuse provider in the Triangle. “Simply that the level of care needs to be ensured. My concern is that it wouldn’t be.”

Armstrong raised concerns about the time needed for transition and the plan for making the switch.

He said the proposed implementation plan will not allow MCOs and communities to have a smooth transition of services and that he hopes for more flexibility in the way funding will be distributed during the transition.

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Hyun Namkoong

Hyun graduated from the UNC-Chapel Hill Gillings Global School of Public Health in the health behavior department and she worked as the NC Health News intern from Jan-Aug 2014.