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Lawmakers have been promoting management consolidation in the state’s mental health system for several years, but no movement has taken place. Until this week.
By Rose Hoban
In a move that’s been anticipated by many actors in North Carolina’s mental health system, Secretary of Health and Human Services Rick Brajer announced that it’s time for the state-funded mental health management organizations to consolidate.
In an announcement late Thursday afternoon, Brajer unveiled the bones of a plan that would boil down the state’s eight local management entities – known as LME/MCOs – into four larger organizations divided along roughly geographic lines (see map).
“The legislature has been pushing for quite some time to get down to four LME/MCOs,” said Julia Adams, governmental relations director for The Arc of North Carolina. “It seemed to be that the intent was for them to do this on their own. At least the secretary has gone out and presented a plan as to what the mergers will look like.”
Adams noted that the maps create organizations that oversee areas with contiguous counties, replacing the current system wherein some LME/MCOs have service areas separated by counties or mountains.
“It supports what their Medicaid reform maps look like,” she said.
Reform a driver
Indeed, aligning the organizations with the six delivery regions outlined in the Medicaid reform plan that was unveiled earlier this month was part of the strategy, Brajer confirmed in an interview.
“Now we have the Medicaid reform vision in front of us. It really more clearly lays out the requirements to successfully build towards a future where we integrate behavioral health and primary care,” he said.
Brajer said that once the Medicaid reform plan is implemented, three or four years down the road, mental health service delivery will need to be more consistent across the state.
“Getting started earlier is going to give them the best chance of success after we go live,” Brajer said of the LME/MCOs.
Brajer had the support of Sen. Tommy Tucker (R-Waxhaw), who’s been active on the Joint Legislative Oversight Committee on Health and Human Services.
“The department and the secretary have kept us abreast of their thought process,” Tucker said. “It was not our decision wholly, but we had input and the secretary has our support in the final decisions that were made.”
Leza Wainwright, head of Trillium Health Resources, which provides mental health services to 24 coastal and eastern counties, said she got a call this week to meet with the other LME/MCO heads and Brajer.
Wainwright said that at that meeting, Brajer expressed his “strong support for the LME/MCO system and the understanding of … how important that is to the vulnerable populations that we serve.”
She said the secretary did not set out any timeline for the mergers to be complete, but that her gut sense was that the process would take no more than two years.
Wainwright said she looked forward to economies of scale but worried about losing connections with local entities such as sheriffs, school systems, departments of social services and hospitals.
“We want them to feel like we still have enough of a local presence that we’re fully engaged yet partnering with them,” she said.
Brajer said some LME/MCOs are already prepared to consolidate.
“CenterPoint [Human Services] and Cardinal Innovations are anxious to go,” he said, referring to a merger that he put on hold in the middle of 2015. “They’re ready to sign paperwork between May 1 and the end of June. They’re ready to go. And then it’s off to the races.”
Jenny Gadd directs quality management for Alberta Professional Services, which runs group homes and day programs for people with developmental disabilities and severe mental illnesses. She was overjoyed.
“You just made my day,” Gadd said when told about the impending mergers.
For her, eight LME/MCOs has meant eight sets of contracts to manage, eight service audits to complete, eight networks to interface with and multiple information technology systems.
Her workload will be reduced once the consolidation is implemented.
“The other part of that is that they’ll have a provider council at each LME/MCO, and for an agency that works statewide it’s really challenging,” Gadd said. “So if I only have to go to four meetings rather than eight, that could be so great.”
“I really don’t see anywhere what will be problematic from a provider standpoint; I only see positives,” she said.
Tucker said that was part of the thinking, including having standard IT systems and “standard forms, so that if someone transfers from Asheville to Greenville they will be in a system that everybody can identify with.”
“Consolidation and lesser numbers should bring continuity to the process,” he said.
But advocate Laurie Coker was not as pleased. The head of the North Carolina Consumer Advocacy, Networking, and Support Organization, Coker was on the board of CenterPoint, but she resigned because of her frequent disagreements with management over direction and tone.
“The priority has been productivity and infrastructure development over outcomes,” Coker said. “When any of us on the board would try to talk about outcomes and quality, we’d be accused of advocating.”
She said she believed that it’s not possible to properly manage a human services business without advocating for good outcomes.
“You can’t do it to the exclusion of considering quality,” Coker said. “It can’t just be business based.”
Legislators, in particular Tucker, have criticized Cardinal Innovations executives for amassing a large balance of unspent funds rather than spending it on patient care.
“I feel like the mental health community is not even a factor in what goes on anymore,” Coker said.
“If consolidation helps us get to better care, and access is better, I’m all for it,” said a “cautiously optimistic” Jack Register, executive director of the North Carolina chapter of the National Alliance on Mental Illness.
But he too expressed concern about large “mega-providers” losing that local flavor.
Register also noted legislators’ concerns about the large fund balances being held by LME/MCOs.
“My sense is that the consistency between LME/MCOs of what they’re doing with their fund balances is part of what the problem is,” he said.
Tucker said he sat in on a presentation by the LME/MCO heads early Thursday in which they presented their plans for spending their amassed money.
“They have cash on hand to be able to provide more services to folks,” he said. “We all understand what we need to do.”
Tucker’s support has been reassuring to Register, who said that in much of the state availability of services has been spotty at best.
“From Murphy to Manteo, it should not depend on your zip code whether or not you get services,” Register said.
And Tucker said he’d be watching to see that roadblocks to care get cleared.
“I take it personal when children can’t get served due to contracts and bureaucracy and form requirements and peer review, etc.,” he said. “I’ve been involved in moving the LME/MCOS to make it easier for people to have services and to get funded.
“I just think that consolidation will make it easier for things to happen.”
Correction: An earlier version of the story attributed a statement about legislative displeasure at large fund balances amassed by LME/MCOs to Laurie Coker.