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Rep. Marilyn Avila

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Medicaid Pilot Will Help Some, But Not All, NC TBI Patients with Rehab

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Medicaid Pilot Will Help Some, But Not All, NC TBI Patients with Rehab - North Carolina Health News

Medicaid and the state of North Carolina recently announced they’ll spend a combined $6 million for a higher level of services for traumatic brain injury patients, in part to keep them out of long-term care.

By Thomas Goldsmith

Carol Ornitz wants to make sure that her only son, Mark, 45, continues to live at home instead of in a nursing home, despite the disabling traumatic brain injury he sustained in a bike race 13 years ago.

“He’s not confused enough not to know where he is put,” North Raleigh resident Ornitz, 73, said this week. “Just because he has these other moments, it doesn’t mean he wouldn’t know.

“He’s actually reading things. He responds to some news reports; he responds to football and baseball games.”

About the waiver

The state Department of Health and Human Services announced April 20 that a four-county pilot project will kick off May 1 designed to facilitate rehabilitation for people who suffered TBI injuries at age 22 or older.

Actual services will likely begin in August for people who take part in the program’s coverage area of Wake, Durham, Johnston and Cumberland counties.

Medicaid is the federal health insurance program for low-income people and those with disabilities. A waiver allows DHHS programs to provide designated clients with help beyond the level specified in state and federal Medicaid rules.

“This waiver is an important milestone in North Carolina’s commitment to improving the life and well-being of individuals who experience a traumatic brain injury,” said Dr. Mandy Cohen, DHHS secretary.

To have the waiver approved by the federal Medicaid authorities, DHHS had to show that the program would save money, include input from stakeholders, use patients and families to drive the planning process, supply a choice of providers, allow for appeals, and meet assessment and monitoring conditions, among other requirements.

The TBI waiver will make possible Medicaid reimbursement for “extended occupational therapy, physical therapy and speech therapy; supportive services such as respite, home and vehicle modifications; and assistive technology, equipment and supplies,” DHHS said. Medicaid will also pay for Medicaid beneficiary services including supported employment, life skills training, cognitive rehabilitation and day supports.

Advocates such as Ornitz and Jeannie Irby, of Burlington, place a high value on the long-term improvements possible for their family members. Irby has been focused for five years on care for her son Zack, 28, who has lived with a TBI since a horrific car wreck.

Like many caregivers, Irby has patched together public, private and nonprofit resources to augment the considerable out-of-pocket expenses needed for someone to receive care in settings that encourage his development.

“I’ve gotten him into a two-day-a-week day program at the Lamb’s Chapel,” Irby said. “He goes to be part of a group. Being with people that aren’t necessarily like him, I think it’s helping him come to terms with his disability. It took him a while to acclimate.”

Medicaid and the state of North Carolina recently announced they’ll spend a combined $6 million for a higher level of services for people such as Mark and Zack, to be delivered in the community and not in expensive long-term care settings. The program will include such life-advancing services as occupational, speech and physical therapy; cognitive rehabilitation; supported employment and assistive equipment.

But there’s a catch: The Medicaid pilot program applies, at first, only to residents of Wake, Durham, Johnston and Cumberland counties, the catchment area for Alliance Behavioral Healthcare. Lasting for three years, it will touch 47 people the first year, 99 the second and 107 the third.

That means that Mark Ornitz’s family can at least apply for additional services because they live in Wake County, but not Zack Irby’s family, at least for now.

“We need this work to be expanded”

Advocates want the wave of help to reach the much wider group of the state residents who also need it, as many as 200,000 by one estimate. Citing support from legislators such as Sens. Tommy Tucker and Louis Pate, Reps. Nelson Dollar and Verla Insko, and former Rep. Marilyn Avila, activists said this week they appreciate the new aid and hope that it will be scaled up statewide sooner than later.

“We at minimum would like for it to (expand) right after three years,” said Ken Jones, executive director of the Brain Injury Association of North Carolina. “There’s a process of getting the providers prepared; that will probably be something that is manageable the first year.”

Said Irby, “Even for those four counties, it’s not going to be a tremendous amount of help.

We need the money to be expanded and we need this work to be expanded into other counties because the need is so great.”

Shows a young man in a wheelchair with a bib around his neck, a woman sitting next to him helps him eat.
Zack Irby gets help eating dinner. Since his traumatic brain injury, Irby’s family members give him dozens of hours of care each week. Photo credit: Irby family

For families with a member affected by TBI, a number of ifs remain. Ornitiz can apply for more services for Mark, who already receives some care via Medicaid, but there’s no guarantee he’ll be accepted.

“I’m sure there are other people who have acute needs coming out of the hospital,” said Ornitz, who spends as much as 16 hours a day caring for her son. “They’re going to have to make some tough choices — I understand that.”

Putting the change into perspective, Ornitz said the first attempt at a waiver for adults with TBI came 25 years ago. Other attempts followed in 2009 and 2013. The General Assembly passed legislation allowing the waiver in 2015 and the Centers for Medicare and Medicaid Services recently approved it.

“I think this community has waited long enough,” Ornitz said.

The years of delay that have occurred could have had significant impacts on thousands of TBI patients, advocates say.

“The brain has something called neuroplasticity — it can create new pathways around the injury,” Ornitz said. “But it takes a lot of years to do that.”

Learn more:
Visit DHHS site
Or: Brain Injury Association of North Carolina
Call: Alliance Behavioral Healthcare at 800-510-9132
Email: TBIInfo@alliancebhc.org
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Lawmakers Agree on Need for Child Services

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Lawmakers Agree on Need for Child Services - North Carolina Health News

At the 39th annual mental health legislative breakfast, lawmakers found points of agreement.

By Rose Hoban

Legislators from both sides of the aisle found points of agreement on health care issues Saturday as they discussed Medicaid, child services and mental health care, and the need for better community psychiatric services in North Carolina.

A capacity crowd of 400 filled UNC-Chapel Hill’s Friday Center for the 39th annual Legislative Breakfast on Mental Health, which featured a panel of two Republicans and four Democrats who agreed that more uninsured people in North Carolina need health coverage.

Legislators on the panel also found common ground on the idea that 16- and 17-year-olds in the justice system should not be automatically charged as adults and that there’s a need for more community-based mental health services.

“Every year, when it comes time to register for this program, I hesitate,” said former Rep. Marilyn Avila, who will take a new position this year as the policy adviser to the House Speaker Pro Tempore’s Office after losing her Raleigh-based seat in November.

“I know when I come in here, I’m going to feel so ignorant… but I always learn from you guys when I come here.”

In the past, the breakfast has been focused on legislators and residents of the Triangle, but organizers said they opened the event to people statewide in an effort to be more inclusive.

“We hope to get more people to the table to talk about these issues,” said Jenny Gadd, one of the morning’s organizers. She also said it’s likely the breakfast will move to a larger venue next year.

Agreement around Medicaid

So much around North Carolina’s Medicaid program is uncertain right now: Gov. Roy Cooper and legislative leadership are locked in a legal battle over expanding the program; the new Congress in Washington is talking about changing the funding mechanism for the program; and North Carolina’s leaders are preparing to convert the state’s program from a fee-for-service system to one run by commercial managed care.

Photo shows four people smiling at the camera. Julie Bailey holds up a clock.
Organizers of Saturday’s event gave a lifetime achievement award to Steve and Julie Bailey (center) for their years of advocacy for people with mental illness. Pictured with them, Janny Gadd (l) and Karen Kincaid Dunn (R) The Bailey also have been parents of three adoptive sons, all of whom have special needs. Their teenaged son Josh was murdered in 2012. Photo credit: Rose Hoban

Even with all the question marks, Republicans and Democrats in a bipartisan panel discussion found common ground, even on the contentious issue of expansion.

“I have a son who was diagnosed many, many years ago as paranoid schizophrenic,” said Rep. Carla Cunningham (D-Charlotte), a nurse. “When ACA came along, Medicaid expansion was going to eliminate pre-existing conditions. That meant the world to a lot of parents who have children with mental illness.”

Cunningham said the state should expand to cover as many as 500,000 currently uninsured people.

Rep. Greg Murphy (R-Greenville), the legislature’s only physician, agreed. It’s a stance that’s been unusual for a Republican in the General Assembly.

“I’m a practicing physician. I see folks on Medicaid. This is a vulnerable population that we cannot abandon,” Murphy said to applause.

Murphy also inserted a dose of reality about the future of the ACA and what it would mean for expanding Medicaid.

“You can be on different sides of whether you expand Medicaid or not,” he said, noting that the Republican-controlled Congress is determined to repeal the law. “I’m a realist… I want everybody in this state to have accessible affordable health care, but we have to put a system together where it’s going to happen.“

Pushing for childhood services

In the past few years, more research and attention has been paid to issues of early childhood experiences and their effects on later life, psychologist Betty Rintoul told the gathering.

Rintoul described what’s being learned about “adverse childhood experiences,” traumatic events such as emotional neglect, violence in the home or familial substance abuse that are often experienced by young children. She said new research is finding that children as young as infancy can suffer from “toxic stress” induced by such events.

photo shows two women talking.
Rep. Verla Insko (D-Chapel Hill) speaks to UNC-Chapel Hill psychiatrist Mary Kimmel after the legislative panel at Saturday’s Breakfast on Mental Health. Photo credit: Rose Hoban

“From birth to 3, the brain gains about 80 percent of its adult weight,” she told the audience “That weight is largely in connections that form to help the brain communicate and to lay the foundation for everything that comes in the future.”

In the wake of stress, though, those connections can be lost, research indicates.

A large and detailed database of tens of thousands of children studied over decades has yielded surprising information about what happens to children exposed to such childhood trauma. Not only do these children display more behavioral problems as they reach adulthood, they experience more physical health problems.

It turns out that experiencing childhood trauma can make a person more susceptible to cancer, obesity, HIV and stroke, decades later.

“Think for a minute about the cost to society. Think about our skyrocketing health-care costs,” Rintoul said. “There’s estimates about 80 percent of our health care costs are due to avoidable physical problems. These are right there with them.”

She said it was a “no-brainer” to put more resources to ensuring children get the best start possible, whether it be programs such as the Nurse-Family Partnership, enhanced foster care services or more Smart Start and pre-K programs.

Changing the status of teens in the justice system

North Carolina is one of only two states in the country (the other is New York) where 16- and 17-year-olds arrested for felonies and some misdemeanors are automatically treated as adults.

An attempt to raise the age where offenders are treated as adults made it through the state House of Representatives in 2013, but died in the Senate the following year.

photo shows the backs of three people talking to another woman as she takes notes in a calendar.
Former Rep. Marilyn Avila takes notes as Linda McDonough and Leslie Sharpe talk to her about mental health services. Photo credit: Rose Hoban

“I think 2017 will be the year it passes,” Avila said. She worked on the measure when she was elected and promised the audience she would continue to build coalitions around passage in her new position.

She told the group that last year’s Governor’s Task Force on Mental Health and Substance Use recommended raising the age. The task force was lead by state Chief Justice Mark Martin, who has been pushing the judicial branch to support the measure and this past year, the state sheriffs’ association finally dropped its opposition.

Only the state’s district attorneys are not on board, Avila said.

“And one of their biggest concerns was where the money was going to come from to shift that 16-year old,” Cunningham said. “There’s going to be an influx, so we handle that new change, where do we put them, how do we house them and who gets to see them, and do we have enough of the programs in place to assist them.”

Both women encouraged audience members to advocate to their local district attorneys to support the measure, and said they were confident they eventually would.

 

The NC House of Representatives met late into the evening last night, debating the budget bill.

No Big Surprises in House HHS Budget

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No Big Surprises in House HHS Budget - North Carolina Health News

With Medicaid reform completed, this year's House Health and Human Services budget lacked some of the drama of prior years.

By Rose Hoban

State House lawmakers provisionally passed a $22.2 billion budget Wednesday that includes more than $5 billion for health and human services needs, which represents a decrease of about $190 million from what was budgeted for the upcoming year.

“The first thing I’d like to say … there’s no harm in this budget,” said Rep. Josh Dobson (R-Nebo), a co-chair of the House Appropriations, Health and Human Services Committee. “There are increased rates where we could make those changes to make the investments we needed to make.”

Rep. Josh Dobson (R-Nebo) headshot
Rep. Josh Dobson (R-Nebo) Photo courtesy NCGA

And it seems like many in the chamber agreed with him. The bill passed 103-12, with many Democrats siding with the Republican majority.

“We didn’t have anything to do with setting the spending cap, which was 2.3 percent over last year’s budget, and I really agree that the appropriations subcommittee chairs did a really great job with the money they were allowed to spend,” said Cary Democrat Gale Adcock.

“It was a bipartisan budget. Why are people surprised when we act in a bipartisan way?”

Shortcomings

But Democratic leaders in the chamber said they were disappointed in the budget, such as Chapel Hill’s Verla Insko, who said budget writers set their sights too low, particularly on the health care budget.

“If you have the capacity to be an astronaut and you fly model airplanes, you’ve missed the mark,” Insko said during the debate. “And this budget missed the mark.”

She went on to critique appropriations chairs’ choices to pour an extra $300 million to the state’s so-called rainy day fund, bringing the total to $1.4 billion. Instead, Insko argued, the state should have put more money into the fund used for providing services for uninsured people with mental health issues.

“Historically, that pot of money has been about $350 million. When the downturn came, we pulled that money back,” Insko said. “Currently in the budget bill, you’ll find it says that fund now stands at $247 million.”

She cited increased population, long wait times in emergency departments for psychiatric care and more uninsured people with mental health issues.

“And they end up in our jails, they end up in our prisons, they end up back in our state institutions,” Insko said.

She also criticized the decision not to expand Medicaid to cover as many as a half-million uninsured working poor.

This year, budgeted health and human services expenditures will be $5.07 billion, reduced almost $200 million from what lawmakers planned to spend in the upcoming year when they first created the state’s biennial budget last fall.

No innovation

Another disappointment for disability advocates was budget writers’ failure to include additional “slots” for so-called “Innovation waivers,” which allow people with developmental disabilities to receive enhanced services that allow them to stay in their homes and do things like work and go to school.

But there’s a backlog of between 9,000 and 12,000 people waiting for one of these slots, a wait that can be up to a decade, said John Nash, head of The Arc of North Carolina.

Gov. Pat McCrory’s budget allowed for 250 slots; House lawmakers didn’t make allowance for any.

Rep. Marilyn Avila (R-Raleigh)
Rep. Marilyn Avila (R-Raleigh)

“We’re concerned that the House budget does not have those slots,” Nash said. “We’re hoping that the Senate will address that themselves.”

He said he “gets” that money is tight and that everyone is in competition for dollars. But Nash also argued that the average $50,000 per person, per year for the slot could actually save money.

There’s an expense, he said, “related to not adding those slots when people go into crisis.”

That exclusion from the budget disturbed Raleigh Republican Marilyn Avila as well. As lawmakers amended and debated the bill, Avila offered an amendment that would create a study committee to examine the cost benefit of providing more slots.

“It seems to be so much of a benefit that we actually save money on it, because people are getting the services when they need services; we’re keeping them out of crisis,” Avila said. “We’ll prove to people that people are getting what they need and if we can get more bang for the buck and show that the cost-benefit analysis is on the plus side, then it becomes easier for us to say we’re getting our money’s worth.”

Highlights

Many Republicans and Democrats, however, said there were a lot of good things in the budget within the financial confines of the budget target.

Some of those highlights include:

  • $350,000 in funding for helping corner stores provide fruits and vegetables survived a challenge during appropriations meetings on Tuesday to stay in the budget.
  • $7.7 million in funding for students from Campbell University’s new medical school to a residency program at Cape Fear Valley Medical System, serving the rural Southeastern part of the state.
  • Restoring $60 million in cuts to fund balances held by the state’s mental health local management entities, funding almost all of McCrory’s $30 million funding request for mental health services.
  • Providing funding to resolve problems in the state’s child welfare system.
  • Providing $750,000 to fund efforts to combat Zika virus and the mosquitoes that carry it.

Legislators, Advocates Discuss Stemming the Flow of Mentally Ill to Prison

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Legislators, Advocates Discuss Stemming the Flow of Mentally Ill to Prison - North Carolina Health News


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This year’s annual legislative mental health breakfast addressed why there are so many people with mental illness in prison and what North Carolina can do to change that.

By Rose Hoban

North Carolina has about 36,900 people incarcerated in state prisons and, according to numbers from the state Department of Public Safety, at least 14 percent, or about 5,100, of those people have a severe mental illness.

Compared to the number of psychiatric beds available in the state, about 2,700, it’s clear that North Carolina’s prison system houses more patients with mental health problems than the health care system, said David Guice, who manages adult corrections and juvenile justice for DPS.

Commissioner David Guice, head of both adult and juvenile services for the Department of Public Safety, told those gathered at Saturday's breakfast that the prison system needs to focus more on incentivizing good behavior and treating mental health issues than simply locking people up.
David Guice, head of both adult and juvenile services for the Department of Public Safety, told those gathered at Saturday’s breakfast that the prison system needs to focus more on incentivizing good behavior and treating mental health issues than simply locking people up. Photo credit: Rose Hoban

“Our jails and our prisons have become de facto mental health hospitals,” Guice told about 350 legislators, mental health consumers and people who work with and for them at Saturday’s 38th annual Mental Health Legislative Breakfast, held at the Friday Center for Continuing Education in Chapel Hill.

He said this means the most vulnerable individuals with mental illness who receive support are frequently placed in correctional facilities. And he admitted that a disproportionate number of inmates in the prison system are people of color.

Two years ago this month, Michael Anthony Kerr, a man with a persistent mental illness incarcerated in a Taylorsville prison, died of dehydration after being held in solitary confinement and denied water.

Now, Guice told the gathering, he’s making changes to improve care and services for people with mental health problems in prison. And he said he’s committed to breaking the cycle of people with mental health issues ending up behind bars.

Secretary of Health and Human Services Rick Brajer makes a point at the Mental Health Legislative Breakfast Saturday, while Rep. Verla Insko (r) looks on.
Secretary of Health and Human Services Rick Brajer makes a point at the Mental Health Legislative Breakfast Saturday, while Rep. Verla Insko (r) looks on. Photo credit: Megan Griffin

Treatment slowly coming

Guice, a former Republican member of the state House of Representatives who was first appointed by Democratic Gov. Bev Perdue, worked in the prison system before becoming a Transylvania County commissioner. He said that when he first worked in the prisons, he saw the failings of a strictly punitive system.

“We built … prisons to be able to control people, not to address any programmed need, not to address changing behavior,” he said. “We assume just because we placed them in that controlled setting, that somehow things would improve and then they would be released back into the community.”

But Guice said that has not worked. He said it’s time for incentivizing and rewarding positive behavior, and also time to get help for all those with mental health diagnoses.

Troy Manns, who works with Orange County-based Freedom House Recovery Center, told his story of leaving behind a life of substance abuse at the Mental Health Legislative Breakfast Saturday morning. Photo credit: Rose Hoban
Troy Manns, who works with Orange County-based Freedom House Recovery Center, told his story of leaving behind a life of substance abuse at the Mental Health Legislative Breakfast Saturday morning. Photo credit: Rose Hoban

He got some assistance from the General Assembly in last year’s state budget, when legislators appropriated funds to open eight mental health units in the prison system. Four of those units will come online this year and four in 2017.

Guice also said that by moving those with misdemeanors out of prisons, placing more people on parole and lowering caseloads for parole officers, they were able to reduce readmissions to jails, close facilities and save more than $192 million since passage of the Justice Reinvestment Act in 2011.

But, he said, “We’ve only reinvested $32 million into the system. That’s not enough.”

And while Guice thanked the legislators who were in attendance at the event for last year’s funds, he also told them, ”If we do not provide the level of funding as we move forward to address re-entry issues, and programming issues within our prison system and within our communities, if we do not provide the level of funding to address the mental health needs that we face in our system, in a short period of time justice reinvestment will also fail.”

Raise the age

In an unscheduled appearance at the breakfast, North Carolina Supreme Court Chief Justice Mark Martin told the crowd that he was looking to initiate training for all justice system officials in Mental Health First Aid in order to identify people with mental health needs earlier in their court process.

“We want to make sure we can put ourselves into a position where we can divert individuals for treatment rather than imprisonment in the system,” he said to applause. “By doing so, we also hope to decrease the stigma.”

Martin, who has been co-chairing the Governor’s Task Force on Mental Health and Substance Use, said he’s also recommending that the justice system create “crisis navigators” to help families and consumers make their way through the system.

But the strongest statement Martin made was about young people in the corrections system. North Carolina remains one of only two states that routinely charge 16- and 17-year-olds as adults. New York is the other.

Panelists at Saturday's Mental Health Legislative Breakfast included (l to r): Commissioner David Guice, Rep. Verla Insko (D-Chapel Hill), Rep. Graig Meyer (D-Hillsborough), Rep. Marilyn Avila (R-Raleigh), Gary Junker, head of mental health services for the Dept. of Public Safety and Rep. Pat Hurley (R-Asheboro).
Panelists at Saturday’s Mental Health Legislative Breakfast included (l to r): Commissioner David Guice, Rep. Verla Insko (D-Chapel Hill), Rep. Graig Meyer (D-Hillsborough), Rep. Marilyn Avila (R-Raleigh), Gary Junker, head of mental health services for the Dept. of Public Safety and Rep. Pat Hurley (R-Asheboro). Photo credit: Megan Gifford

“We need to raise the age in North Carolina,” Martin said. “I recently saw the chief judge in New York state, and we looked at each other and said, ‘Who is going to get rid of this archaic practice first?’”

Legislation to raise the age passed the House in 2014, but the bill died in the Senate.

During a panel discussion later in the morning, Rep. Marilyn Avila (R-Raleigh) expressed belief that it would happen during the 2017 long session.

“I feel like this time, with the forces that are behind it, we may even get the Senate to see the light,” she said.

New staff, more training

One question raised during the 90-minute panel discussion was about the role of training prison staff to better handle people with mental health issues.

Guice and his director of behavioral health, Gary Junker, said they’ve been expanding Crisis Intervention Training and Mental Health First Aid for all staff.

“This issue is at the forefront,” said Junker, who told the crowd he meets regularly with leaders from professional mental health organizations, advocates and providers to talk about issues in the prison system and elicit their input.

Rep Graig Meyer (D-Hillsborough), who works as a social worker outside of the legislature, shared his frustration with navigating the state's mental health system to get help for his teen-aged daughter.
Rep Graig Meyer (D-Hillsborough), a social worker when not at the legislature, shared his frustration with navigating the state’s mental health system to get help for his teenaged daughter. Photo credit: Rose Hoban

Junker and Guice have also received permission to more quickly hire people. Guice told of an event in early March at which they were able to make offers to 29 new nurses by the end of one day.

“We have been able to hire more of our medical staff in the last year with the new processes than we have in the past,” Guice said.

Rep. Graig Meyer (D-Hillsborough), who has worked as a social worker with the Chapel Hill Police Department, said that in his experience cops find the Crisis Intervention Training to be a huge benefit.

“Those police officers hated to show up at mental health calls because they felt so unprepared and knew that the badge and the gun and the handcuffs were sometimes going to be the least helpful things they could do in the situation,” he said.

CIT remains voluntary, however, and as yet many police and sheriffs’ departments have not yet embraced the training.

“It’s another piece I wish we wouldn’t have to put into statute, to mandate the training,” Meyer said. “There may be a role for the legislature to play in terms of expanding the funding.”

Advocates also complained that it can often take days for people with mental health issues to get their medications once they’re placed in local jails.

Avila expressed surprise and frustration that this was the case, pondering what would happen to her after several days without medication for diabetes.

“I guess my question is, ‘Do we have to legislate that kind of common sense?’” Avila asked to applause.

Health Care Plays Supporting Role in Budget Plan

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Health Care Plays Supporting Role in Budget Plan - North Carolina Health News


The real debate over health care issues comes next week, when Medicaid reform will be debated.

By Rose Hoban

A state $21.73 billion budget is on its way to Gov. Pat McCrory’s desk Friday after two bipartisan votes in the House of Representatives on Thursday evening.

In a bill that was close to three months overdue, lawmakers finally found common ground on a spending plan that differed greatly between the two chambers of the legislature.

Lawmakers debated into the evening, passing the final $21.73 billion after midnight Thursday evening. Photo credit: Rose Hoban
Lawmakers debated into the evening, passing the final $21.73 billion after midnight Thursday evening. Photo credit: Rose Hoban

“I’ve never seen two budgets further apart,” said lead budget negotiator Rep. Nelson Dollar (R-Cary) in his introduction to the plan on the House floor. “This was a challenge, but … i can report to you of the principles of this House that are in this conference report.”

Many members of both parties spoke of how they were pleased budget negotiators had wrestled as long as they had in order to wring concessions from the Senate on key pieces of legislation, including child care subsidies, medical examiners and improvements to the foster care system.

While most of the debate centered around the new tax plan, teacher salaries and transportation, health care took a back seat this year. That differs from previous years when lawmakers wrestled with growing costs of Medicaid, mental health and the state employees health plan.

Health care issues did get some attention during the debate, in particular when Rep. Carla Cunningham (D-Charlotte) drew attention to the mental health budget.

Cunningham took issue with cuts to mental health local management entities, several of whom have amassed large cash balances. The budget claws back some of that money in the form of cuts to funding totaling $260 million over the biennium.

“Some years ago, we told the LMEs of their allocation that if they had funds left over, they could keep these funds and use them for new programs or other related issues,” Cunningham said. “So these LMEs moved forward with that understanding from the state.”

“I don’t think that sets a good tone for our state. After we’ve led these LMEs to believe that you could keep this money, now we’re going to come back and say, ‘Oh, no, no, no; we’re going to punish you for doing that.’”

Rep. Marilyn Avila (R-Raleigh) pointed out that the budget does spend money on the mental health system, in particular on funding for community programs.

“We’ve been struggling for a number of years to make up for the shortcoming of community services that were not there when we sent mental health patients back into our community,” she said.

Avila talked about a Wake County pilot program for training paramedics to identify patients in mental health crisis and redirect them to mental health crisis centers instead of to emergency rooms. The budget extends this pilot program to three more counties over the biennium.

“It cuts down on the expense regarding emergency rooms, but it also guarantees that people get quickly the right care that they need,” she said, also noting that the budget provides funding for a real-time registry of psychiatric beds for people in mental health crisis.

Other mental health initiatives in the budget:

  • additional psychiatric beds in rural and community hospitals;
  • the establishment of a traumatic brain injury program paid for by Medicaid;
  • and the creation of a crisis support team for children and adolescents with intellectual and developmental disabilities.

Rep. Jean Farmer-Butterfield (D-Wilson) praised dollars being earmarked for psychiatric services in the state’s prisons, but she pointed out that there still need to be better community-based resources for people with mental health problems.

“How do we avoid jails and prisons serving these individual versus providing treatment and services in the community,” she said, pointing out that 12 percent of the jail and prison population in the state has a mental illness. “So we’re saying that people with chronic mental illness need to go to prison to receive services.

“Why not do prevention and jail-diversion programs more in North Carolina. They work.”

Other expenditures in the budget include:

  • providing support for the Office of the Chief Medical Examiner, computerizing the death records system and providing revenue in the form of increased fees for autopsies;
  • provides money for increasing the age of foster care to 21 and extra supports for kids aging out of the foster care system;
  • and restores the tax deduction for medical expenses.

But among the things missing from the state budget are funding for tobacco-cessation programs, the corner store initiative and the ABLE Act, which allows families of children with disabilities to save for their future.

The final budget passed on a bipartisan vote of 81-33 and will be go to the governor just in time. The General Assembly’s temporary resolution allowing for the continued operations of state government runs out at midnight Friday.

You can get more details on the Health and Human Services budget on N.C. Health News’ final budget comparison table, available here.

Belhaven Mayor Paul O'Neal was at the legislature Wednesday morning. Sen. Ralph Hise (R-Spruce Pine) stands to his right.

Belhaven Mayor Looks for Answers to His Town’s Hospital Problem

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Belhaven Mayor Looks for Answers to His Town’s Hospital Problem - North Carolina Health News


A rural mayor wades into the ongoing argument over the state’s certificate of need program.

By Rose Hoban

In a press conference at the General Assembly Wednesday, Belhaven Mayor Paul O’Neal thumped the podium in frustration that Pungo Hospital, located in his town, remains closed after a year.

“This community needs a hospital,” he said. “I’ve walked to D.C. twice about it.”

O’Neal was in Raleigh speaking in support of lawmakers who would like to eliminate the state’s certificate of need laws, a complex suite of rules that help state regulators determine the distribution of hospital beds around North Carolina.

For months, Republican lawmakers in both chambers of the legislature have been calling for changes to the laws: Senate leader Phil Berger (R-Eden) has indicated his support for doing away with CON altogether.

Meanwhile, in the House, Rep. Marilyn Avila (R-Raleigh) has introduced a bill that would allow for the establishment of more freestanding ambulatory surgical centers separate from the state’s hospitals.

Now O’Neal, who has made two highly publicized walks to Washington, D.C. to raise awareness about the closure of Pungo Hospital, has jumped into the fray.

O’Neal’s complaint about CON was not as much about the existence of the regulations as about the fact that the state has asked for more information in granting a new certificate for a facility to replace Pungo.

“The head of the certificate of need people sat in a room with me, looked down his nose at me, and basically told me that we didn’t need a hospital,” O’Neal said. “Then he sent us a letter to ask us questions he already knew the answers to and sent it to the old hospital address, where he knew nobody was at.”

‘Antiquated system’

When certificate of need laws were established in the 1970s, they gave state oversight of the creation and distribution of health care facilities and services. The idea was to prevent the establishment of too many hospitals and hospital beds, which would create an incentive to keep those beds filled, thus driving up costs.

Belhaven Mayor Paul O'Neal was at the legislature Wednesday morning. Sen. Ralph Hise (R-Spruce Pine) stands to his right.
Belhaven Mayor Paul O’Neal was at the legislature Wednesday morning. Sen. Ralph Hise (R-Spruce Pine) stands to his right and Rep. Marilyn Avila (R-Raleigh) behind him. Photo credit: Rose Hoban

But in recent years, lawmakers have sought to do away with the certificate of need program, saying the application process is cumbersome and too expensive, and that having the system stifles competition.

Doctors in lucrative specialties, such as orthopedic or eye surgery, have pushed for elimination of CON. They’ve argued that they could provide the services for less in freestanding centers where there are no added hospital “facility fees.”

On the opposite side of the argument, hospital leaders worry that allowing those services to be offered by competitors would eliminate well-reimbursed programs that subsidize hospital loss leaders such as maternity and emergency care.

“We have an antiquated system,” said Sen. Tom Apodaca (R-Hendersonville), following O’Neal at the podium Wednesday morning.

“It’s not going to get any better if we just kick the can down the road. Every time we turn around, someone says, ‘Maybe in five years we can do this.’ Well, folks, it’s time to do it now.”

In search of a new certificate

“I would imagine what happened is when the most recent state medical facilities plan was approved by the governor, it was determined that there is already a saturation of beds in that area,” said Cody Hand of the North Carolina Hospital Association. “Not in that city or county, but in that area.”

He may well have a point. In the 1970s, when Pungo Hospital received its original certificate of need, Beaufort County, where Belhaven is located, and the two surrounding counties of Hyde and Washington had about 56,000 people. Now the state’s population has doubled, but the population of those three counties combined has only grown to about 66,000.

On top of that, the way doctors use hospitals has changed from the 1970s. Instead of filling beds overnight, most care is done on an outpatient basis, with few people staying in the dozens of beds that Pungo had a certificate of need for.

When Vidant Health came to Belhaven and took over Pungo in 2011, the place was running in the red. After managing the hospital for several years, Vidant, formerly University Health Systems of Eastern Carolina, decided to close it, arguing the hospital was hemorrhaging money.

“We tried to turn the hospital over to the town, but they wouldn’t accept it,” said Christine Mackie, a Vidant spokeswoman.

She also said Vidant pledged to build an urgent care center. And Vidant officials have pointed out that there’s a hospital in Washington County, about a half hour from Belhaven.

An artist's rendering of the new facility Vidant intends to build in Belhaven.
An artist’s rendering of the new facility Vidant intends to build in Belhaven. Image courtesy Vidant Health

But O’Neal said Wednesday that’s not good enough.

“Do you realize the winding, curving roads that are in rural North Carolina?” he asked. He also said at least one person has died waiting to be picked up by a helicopter.

Since Vidant announced the intention to close Pungo, the two sides have been at odds. They agreed to a federally mediated a consent decree in spring 2014, but the closure eventually proceeded last year. A lawsuit, fingerpointing and recriminations have followed.

“We’re building a $4.2 million multi-specialty clinic we’ll locate our physician practices to,” said Mackie. “It’ll be open 24/7 and will have a helicopter pad. That facility will open next summer.”

Charles Boyette, a local doctor and former mayor who accompanied O’Neal to Raleigh, was skeptical.

“Our Pungo District Hospital was one of the finest small community hospitals in the state,” he said mournfully.

The answer to Belhaven’s problems?

The Hospital Association’s Hand said his organization would like to see the CON process reformed to streamline applications and make it easier to transfer unused certificates from one hospital to another.

But he said eliminating the CON regimen wouldn’t necessarily solve Belhaven’s problems.

“We don’t have independent hospitals, or physicians clambering to open up practices or hospitals in rural areas,” he said. “If we want to avoid what the mayor of Belhaven talked about, which is the lack of access to care for those residents, we have to ensure that rural hospitals are viable and stable, which means they have to keep some of the services that they make a profit on.”

Belhaven officials say they want to reopen Pungo. O’Neal said they’ve gotten a loan from the U.S. Department of Agriculture and formed a not-for-profit holding company that’s raised about $800,000.

But first they need that certificate.

When contacted about O’Neal’s encounter with the head of the state’s CON office, Olivia James, a state Department of Health and Human Services press assistant, wrote that “more information than provided was required to determine if Pungo Hospital is an existing hospital and qualifies for the Certificate of Need exemption allowable under state law.”

“A list of requested information was provided to the Mayor of Belhaven. At this time, the information has not been received. When the information is received, we will expedite the review, consult with the Attorney General’s office and issue a decision.”

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