Behavioral Health Plan Still Needs Refining

February 28, 2018 | By Rose Hoban

Sometime in the coming two years, North Carolina’s Medicaid program will go from being the fee-for-service plan that it’s been for more than 50 years to being run by large managed care companies. And when that happens, the current mental health system is likely to see big changes.

That’s part of the reason the legislature ordered the state Department of Health and Human Services in 2016 to prepare a strategic plan for how the state’s mental health system will evolve and improve services.

This week, state health officials presented their draft plan to lawmakers.

“This is kind of a first step,” said Assistant Secretary for Health Policy Walker Wilson, who admitted the strategic plan is nowhere near done.

“You have to pick a point in time and go with where the system is and the feedback you received is.”

Unmet needs

State health officials estimate about 227,000 people in the state have a substance use problem. Another half million adults and a quarter of a million children have a serious mental health need.

Many of those people are on Medicaid, which helps cover many people with a low income. But many people with behavioral health needs lack insurance altogether and they receive services through state-only dollars that are directed to North Carolina’s seven local managed care organizations (known as LME-MCOs).

DHHS assistant secretary Mark Benton acknowledged that the LME-MCO system doesn’t fill all the needs that are there. He estimated that about 475,000 people received mental health, substance abuse or intellectual/ developmental disorder (I/DD) services last year from the state.

But another 600,000 needed those services and didn’t get them.

“Our takeaways are that there are significant unmet needs across the state,” Benton said, “and it’s perhaps more pronounced among the uninsured and in our rural areas in our state. We know that unmet need varied significantly by county, also by payor and certainly by disability type. We also know that there is an uneven or inconsistent access for services.”

The report notes a majority of the funding in the mental health system, 62 percent, is spent on inpatient, institutional, residential or facility-based care. For I/DD recipients, 63 percent of dollars go to funding facilities.

“What we are hoping to achieve by laying out this vision is… the need to move to providing more community-based services in the future,” Benton said.

Recurring problem

Rep. Verla Insko (D-Chapel Hill) was in the legislature when it decided to overhaul the mental health system close to 20 years ago in response to a scathing assessment by former state auditor Ralph Campbell. She said the problems looked all too familiar.

“We had too many people staying in institutions for too long, they could have been served in the community and kept well, and we didn’t have enough money to do that,” Insko said, noting that when the state closed hospitals such as Raleigh’s Dorothea Dix, the money did not subsequently flow to the community.

And she noted that the money allocated now for state-funded services for the uninsured is “almost the exact same amount of money we had in 2001.”

Big goals for broad access

In the document DHHS officials state their vision for the state’s behavioral health system: to have timely access to high-quality services and to integrate services for the brain and the body so that people with behavioral health problems get help with conditions such as diabetes and heart disease that are often overlooked.

To get people access to coverage the document refers to “broadening the pool of people with access to health insurance,” which committee chair Sen. Tommy Tucker (R-Waxhaw) took as a reference to expanding the state’s Medicaid program.

“I just want to make clear for the record there’s no hidden agenda for expansion of Medicaid in this, right?” Tucker asked Medicaid head Dave Richard. “Yes or no?”

Richard appeared a bit flustered and laughed uneasily.

“Sen. Tucker, that’s a really unfair question for me,” he responded. “I don’t think there’s any question, and I think you know this, that the Department believes that expanding, or increasing the, or lessening the coverage gap for people without insurance is an important thing that we should be having a conversation with you on.”

“But there is nothing that we can do as a department to do so without the General Assembly approval, obviously,” Richard concluded.

Too few providers

The committee also discussed the lack of mental health specialists throughout the state. According to data from the Sheps Center for Health Services Research in 2016, a third of North Carolina counties lacked a psychiatrist and two-thirds of counties had no child psychiatrist.

Those numbers are likely to get worse as fewer physicians nationwide have chosen to specialize in mental health specialties.

Spruce Pine Senator Ralph Hise (R) asked Richard whether requirements for Medicaid managed care companies to provide “adequate networks” of providers in counties they serve would resolve some of the issues with access to mental health services.

“Our health plans will have to meet those needs,” Richard responded.

“At the same token, you can’t create something that doesn’t exist, no matter how strong our standards are, if there is a provider type that there just aren’t enough of in North Carolina, we’ll have to work closely with them.”

Hise suggested that expanding scope of practice for so-called mid-level providers, such as nurse practitioner and physician assistants, might alleviate some of the shortages in rural areas.

Richard said he anticipated that more use of telemedicine, telepsychiatry and “other ways of using the opportunities that technology brings to us” could address some of the staffing lacks in the system.

Other strategies for meeting behavioral health needs in the strategic plan include:

  • providing patient “navigators” to help people connect to services
  • development of intermediate “step-down” clinics for people being discharged from psychiatric hospitals
  • creation of a psychiatry residency program at both Broughton and Cherry Hospitals to increase the number of psychiatrists in the state

More input, please

After hours of discussion, advocates for people with mental health issues had an opportunity to weigh in on the plan.

“I see all of this terminology in the plan and it’s all about Medicaid beneficiaries,” said long-time advocate Martha Brock. “I want to emphasize that there’s a lot of other needs.”

She argued that folks with mental health issues need things that go beyond what doctors and nurses can provide, including the support from people who have recovered from or learned to live effectively even with mental health issues.

Laurie Coker, head of the North Carolina Consumer Advocacy, Networking and Support Organization, said she was “frustrated” while reading the plan, because of the lack of voices of people like her in it.

“There is no emphasis on the cultural shift that needs to happen whereby this system starts being informed by system users, family members and other caring and loving stakeholders,” Coker said, as Richard and Benton nodded. “We’ve not truly been welcomed or valued in informing our public system.”

She said she was thankful that the plan was still a draft.

“It looks like from this report there’s an assumption that we’re going to … ensure that there’s ‘access to quality services,’ but where are the indicators showing that the services are of sufficient quality for the dollars we’re using on them?” she said. “There’s no quality measurements specifically addressed in a meaningful way in the plan.”

“We need to have people who use the system help identify what are the outcomes we’re measuring,” she said. “If we’re not buying outcomes, it’s a low-value system.”

Tucker agreed.

“We can never have enough public input from people who use the system,” he said. “You learn a lot when you’re on the ground with the folks who are the beneficiaries of this system.”