Uncertainty Hangs Over Providers As They Work to Improve Care

By Rose Hoban

More than a hundred physicians, nurse practitioners, social workers and other health care providers crowded into the cafeteria space at the City of Medicine Academy magnet school in North Durham Monday night to hear about how they could do a better job integrating mental health services into their primary care practices.

The providers – who are part of the Northern Piedmont Community Care network that serves Medicaid patients in Durham, Vance, Warren, Person, Franklin and Granville counties – sat at picnic and cafeteria tables eating a dinner of cheap burritos. As they ate, they were barraged by presentations on programs they could take advantage of to help patients with mental health problems do better both psychologically and physically.

And even as medical providers shared and connected with mental health professionals, the room also buzzed with talk of the recently passed North Carolina Senate budget. That budget would dismantle Community Care of North Carolina, the organization that manages the care for more than a million of North Carolina’s 1.8 million Medicaid beneficiaries.

CCNC is also the parent organization for Northern Piedmont, and provides the logistical and data backup for the state’s 14 such networks.

Community Care Network Map, courtesy CCNC

Integrating mental and physical

At the meeting Monday, Larry Greenblatt, Northern Piedmont’s medical director, cited research showing that between 20 and 40 percent of all patients in the offices of family doctors and OB/GYNs also have mental health issues.

“Those of us in the room who are primary care physicians, I’m one of them, we do a lot of mental health care,” Greenblatt said. “In the world of Medicaid, it’s more than half.”

Those patients end up costing the health care system more, lots more, in part because they’re repeat visitors to doctors’ offices and emergency departments and are being admitted to hospitals more.

“A patient might wake up with a headache or fatigue or dizziness [and] might have to decide, ‘Should I see my medical provider for this, or do I go to my behavioral health provider,’” Greenblatt said. “What we’d like is for them to call one number, and they go one place, and they get an integrated approach to managing their problem.”

Greenblatt cited federal data showing that annual medical expenses for patients with both chronic medical and behavioral health conditions cost 46 percent more than for patients with only a chronic medical condition.

“Mental health diagnoses are associated with higher rates of ED utilization, higher rates of hospital admission and higher rates of 30-day readmissions” to the hospital, explained Natasha Cunningham, who works in the Duke Outpatient Clinic that’s run by Greenblatt.

Driving down ED use

Targeting small groups of patients can bring significant reductions in ED utilization, Cunningham said.

In the Duke Outpatient Clinic, Greenblatt and Cunningham targeted the highest users of ED care, providing enhanced access to their services and phone access to a care coordinator. Patients also had access to transportation, and the team gets notified if patients show up at the emergency department.

four people sit at a table in an almost empty room long after the meeting is over. — The last stragglers at Monday evening’s meeting stayed about an hour after the presentations ended. LIsa Stacey (back to camera), head of Family Legacy, a mental health provider, said she thought the evening was helpful. “Just to emphasize the importance of collaborative care…. I think it’s very important to get the word out,” Stacey said.

Their goal for the first year of their project was a 10 percent reduction in ED use and a 20 precent reduction of admission rates. For 37 targeted patients, they saw a 53 percent reduction in ED use and a 36 percent reduction in admission rates in the first year.

“Which translates into a savings of $170,000 for our first 37 patients,” said Cunningham, who said they’ve now expanded to 80 patients.

Amelia Davis from B&D Behavioral Health Services, a large, private mental health provider in South Durham that serves complicated Medicaid patients, said her approach is to have primary care services available in the places where her clients go for mental health care.

“Their psychiatrists are there; their peer-support specialists are there; their family, so to speak, are there. So they’re comfortable asking us for [blood pressure medication],” she said. “However, it’s not something they do in their primary care home, because they don’t know their provider.”

Davis also has peer supporters take patients to the lab or to the medical doctor to form “mini-integrated health care teams.”

“They’re there with the people they know, they’re there with the people that they’ve shared very intimate details with, intimate parts of their lives,” she said.

“We can treat the whole person, not just one aspect of them,” she said.

Lingering concerns

As the presentations and the small group discussions ended, dozens stood around talking for as long as 45 minutes, swapping ideas and business cards.

But conversations kept coming back to the proposed Senate budget, which would eliminate the state’s contract with CCNC, disband networks such as Northern Piedmont Community Care and instead tap managed care companies to run the state’s Medicaid program.

[pullquote_right]Did you know NC Health News is a non-profit? Last year, a third of our funding came from readers. Please consider a donation today![/pullquote_right]When asked what would happen if CCNC went away, Fred Johnson, who directs Northern Piedmont, pointed at a whiteboard on the wall.

“Erase it. You’ll start all over … after 20 years,” he said.

Johnson said Northern Piedmont has been working for years to integrate mental health care with both private mental health providers and a progression of state-sanctioned mental health agencies. Alliance Behavioral Health Care is the current mental health local management entity in Durham County. Johnson said Duke and Alliance co-employ several social workers so as to better integrate care.

For example, he said, when one of Alliance’s patients used to show up at Duke’s ED in mental health crisis, he might get admitted to the hospital.

“Now we can prevent that admission,” Johnson said, because the ED staff alerts Alliance staff. “It saves the LME money, it saves the health system money and it saves Medicaid money because we immediately utilize the appropriate resource at the right time.”

But Johnson worried that if the community care network went away, all of the collaborations created over the years would vanish.

“The managed care companies, they’ve already got a template,” he said.

“They know how they’ll make their money, they’ve already demonstrated that in other states, even though a year later they’re going to come back and say, ‘Give me a raise,’ the way they did in Florida,” he said, referring to managed care companies that have asked Florida for hundreds of millions of dollars extra to cover pharmacy cost overruns only a year after that state’s managed care conversion.

Even though CCNC has been credited with holding down costs and is being replicated in several states, Sen. Ralph Hise (R-Spruce Pine), one of the architects of the Senate plan to replace the state’s Medicaid system with managed care, said there would be no need for CCNC.

“There’s no point to having a separate entity that we contract with to do services that will fall under the capitated entities, whether that’s managed care entities or provider-led entities,” Hise said Tuesday. “Their job will be management of care, not just case coordination.”

He argued managed care companies would have to coordinate care to avoid having patients in higher-cost care.

“It is central to how they’re profitable,” Hise said.

But Mark Benton, who heads CCNC, pointed out that right now when a community care network saves money, the savings accrue back to the state, and taxpayers, not to a managed care company and its shareholders.

Read all of our joint coverage with The Charlotte Ledger here.