Editor’s Note: This is part two of a two-part series on changes to mental health services throughout the state. Read Part One.
Once again, North Carolina is overhauling the mental health system. Mental health consumers in Wake County will start seeing some of those changes in the county’s mental health system in the upcoming year. The problem is, no one can say how things will look during and after this latest round of upheaval.
County mental health officials are quick to offer reassurance that clients will get the services they need, while advocates and mental health clients are skeptical the changes will be benign. What they all have in common is a lingering desire for more time to make the changes — time state legislators denied when passing the new law this summer.
Some are calling the changes a “second mental health reform” — one implemented with a lot less fanfare than the reform effort that began in 2001.
“Even if you thought it was a good change, I question the speed,” said Gerry Akland, president of the Wake County chapter of the National Alliance on Mental Illness (NAMI). “The speed is bothersome. Legislators should have learned from history; if you do major changes there will be big problems and the state has a poor history of facing that.”
The new law requires all of the mental health local management entities (LMEs) in the state to make plans to become HMO-like managed care organizations. They must do so by January 2013, or become part of an LME that has already transformed.
To that end, Wake County Human Services officials spent most of the last six months working on a proposal to become like an HMO. State mental health officials notified county officials Nov. 1 that their application was denied.
Now Wake County mental health will be absorbed by Durham County’s local management entity. The Durham Center will also absorb the LMEs encompassing Johnston and Cumberland counties. The new organization will continue to be housed in Durham, and will have a board with a majority of seats representing Durham.
Wake Human Services Manager Ramon Rojano said the merger with Durham represents a “great possibility.”
“Merging with Durham was always a Plan B for us,” he said. “We started talking with them last December.”
Rojano said Wake County has some advantages as it merges with the Durham Center. The Wake County Board of Commissioners allocates millions annually for mental health services. Wake County has one of the few freestanding mental health crisis centers in the state and there are a lot of providers for mental health clients to choose from.
And, part of the state’s plan compels LMEs to create a risk pool in case they run short of money. Rojano says that’s a situation where being bigger — and having more money — is better.
Rojano admitted making the changes will be a challenge and hopes mental health clients won’t be adversely affected. He also bemoaned the speed with which changes were required to occur.
“We were running about a year behind,” Rojano said about Wake County’s attempt to make the transition.
Flying with Only One Pilot
Under the new law, mental health management entities will essentially become HMOs, receiving a set amount of money per year for each patient. The agencies then have to manage the allocation of services so patients get care, but not too much that it bankrupts the agency.
The model for care is based on a pilot program begun in 2005 by Salisbury-based Piedmont Behavioral Health, which currently provides services for five counties in the central part of the state.
Early results showed the PBH model reduced costs. In the 2009-10 legislative session, lawmakers gave a green light for two other LMEs to adopt the model and study it further before scaling up to the entire state. But the newly-installed Republican-led legislature decided to skip the additional pilots and scale up quickly.
“The original plan was to have a phased in approach, but that had to be changed,” Akland said. “The whole idea was to save money. It’s not about providing care; it’s about providing cost savings.”
State officials readily admit they want to control costs in a system that has steadily gotten more expensive. But they’re also quick to provide reassurance that mental health consumers won’t see much difference — at least at first.
“For that first year, expectation is that we’re trying to create as much stability as possible,” said Beth Melcher, assistant secretary of Health and Human Services for Mental Health, Developmental Disabilities and Substance Abuse Services. “For the most part, the provider system should stay the same as the same contracts are offered to present providers.”
She said mental health clients might start seeing more changes in year two, as some providers are dropped from the system.
“When you have these kinds of transitions, the folks you hear from are those who feel like they’re not getting the same services, but as you transition, there are people who get more,” Melcher said.
“The train has already left the station”
Even though the mental health reform process has been turbulent during the past decade, Wake County has done some things right, said Akland, who monitors how county policies affect people with mental health disabilities.
“We’ve got new facilities that we long needed,” Akland said, referring to the new crisis facility and the substance abuse detox and treatments center at the WakeBrook Recovery Center.
“The Board of Commissioners have really stepped up to understand there was a serious problem,” he said.
Akland also believes Durham is a good LME with which to merge. The Durham Center has a good reputation, and has been the recipient of several federal grants to innovate.
But when asked what he thinks overall of the coming changes, Akland sighed and said he is worried the merger would give the Board of Commissioners an excuse to reduce the county money being allocated to mental health.
He lamented the fact that changes are being driven by cost, not by quality of care.
“The train has already left the station,” he said. “You can continue to fight the train that’s left, without impact, or make the best of what you’ve got. There will be quotas; it’ll be a numbers game, not based on performance … not based on whether people are getting better.”