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Compromise proposed on pending behavioral health care bill

By Taylor Sisk
Staff Writer
As the General Assembly discusses legislation that would once again overhaul the state’s mental health, developmental disability and substance abuse services system, a change has been proposed to that legislation that has won the approval of an influential statewide organization that advocates for people with developmental disabilities.
Dave Richard, executive director of The Arc of North Carolina, said that last week’s announcement by Rep. Jeff Barnhart and state Department of Health and Human Services Secretary Lanier Cansler that local management entities, or LMEs, could continue to contract with outside agencies to provide certain case management services for those with developmental disabilities means his organization will no longer oppose the House bill.
Barnhart, a Republican of Cabarrus County, is a primary sponsor of the bill that would grant to providers of mental health, developmental disability and substance abuse services a 1915(b)(c) waiver of the Social Security Act, freeing them from certain Medicaid provisions. The waiver allows states to move agencies that manage services (in North Carolina, LMEs) from a fee-for-service delivery system to one in which LMEs are given a fixed dollar amount.
Piedmont Behavioral Healthcare (PBH) – the LME that oversees publicly funded behavioral health care services for four counties immediately east of Charlotte – has been operating under the full 1915(b)(c) waiver model since 2005 as a pilot project.
The pending legislation would roll out the waiver statewide. LMEs would be given all Medicaid, state and local funds in a lump sum – thus producing a managed-care system. Proponents of the waiver say this provides for more accountability and improved efficiencies at the local level.
Last Friday, an action alert was sent to Arc members explaining that the proposed change would allow LMEs to contract with outside agencies to provide targeted case management services to the developmental disability population.
Consumers of behavioral health care services, as well as their families and other advocates, have been concerned that, under the waiver system, case management would no longer be offered as a stand-alone service, but by the LMEs as a component of managed care. Advocates argue that people with developmental disabilities will be hardest hit if case managers familiar with the particular needs of their clients, whose sole responsibility is to advocate for the individual, are eliminated.
For those with developmental disabilities, case management includes client assessment, writing a treatment plan, referral to a provider for service and monitoring the delivery of that service. Under the proposed change, those duties could be shared by the LME and an outside advocate.
“Though this does not replace independent case management as we know it today,” the Arc wrote to its members, “it will allow for people with developmental disabilities to have someone outside of the [LME] writing the plan and assisting with finding appropriate services.” 
As defined by the Centers for Medicare & Medicaid Services, said Rep. Verla Insko of Orange County, another primary sponsor of the bill, “case management is a management function and is appropriately placed within the LME. I agree with that.
“One of the battles I lost during reform was not leaving case management with the LMEs,” or, as they were known prior to reform measures launched in 2001, area programs.
But Insko acknowledges that case management for the developmental disability population is a bit different than for those with a mental illness or substance abuse issues, in that it includes some direct services.
“I would rather it all stay with the LMEs,” Insko said on Wednesday. “But this is a compromise I can live with.”
Jennifer Hancock, a case manager and advocate based in Wilson, said that many families and providers from across the state are disappointed in The Arc’s endorsement, saying the proposed change “does not meet the needs of the families across the state who rely on their case managers for much more than simply writing the annual [person-centered plan] and referring them for services.”

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