
{"id":19371,"date":"2011-06-30T08:44:44","date_gmt":"2011-06-30T12:44:44","guid":{"rendered":"http:\/\/www.carrborocitizen.com\/main\/?p=19371"},"modified":"2011-12-15T13:16:18","modified_gmt":"2011-12-15T18:16:18","slug":"dhhs-overhaul-to-hit-home","status":"publish","type":"post","link":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/2011\/06\/30\/dhhs-overhaul-to-hit-home\/","title":{"rendered":"DHHS overhaul to hit home"},"content":{"rendered":"<p><strong>By Taylor Sisk<br \/>\n<\/strong><em>Staff Writer<\/em><\/p>\n<p>Jim Wells is back in private practice now in Chapel Hill, but until just recently he served as attending psychiatrist for Female Continuing Care at Dorothea Dix Hospital.<br \/>\n<figure id=\"attachment_19374\" aria-describedby=\"caption-attachment-19374\" style=\"width: 300px\" class=\"wp-caption alignleft\"><a href=\"http:\/\/www.carrborocitizen.com\/main\/2011\/06\/30\/dhhs-overhaul-to-hit-home\/medicaid1\/\" rel=\"attachment wp-att-19374\"><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/www.carrborocitizen.com\/main\/wp-content\/uploads\/2011\/06\/Medicaid1.jpg\" alt=\"\" title=\"Medicaid1\" width=\"300\" height=\"201\" class=\"size-full wp-image-19374\" srcset=\"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-content\/uploads\/2011\/06\/Medicaid1.jpg 300w, https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-content\/uploads\/2011\/06\/Medicaid1-113x75.jpg 113w, https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-content\/uploads\/2011\/06\/Medicaid1-150x100.jpg 150w, https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-content\/uploads\/2011\/06\/Medicaid1-120x80.jpg 120w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-19374\" class=\"wp-caption-text\">PHOTO BY AVA BARLOW. Michael and Toni Wilson in front of their Chapel Hill home.<\/figcaption><\/figure><br \/>\nIn the couple of years he was there, he became familiar with the culture of the state\u00e2\u20ac\u2122s behavioral health care system, and he has it on good authority that a popular handbook called <em>High-Velocity Culture Change<\/em> has made an impression on some of the individuals driving the latest overhaul of that system.<\/p>\n<p>\u00e2\u20ac\u0153I know some of them have been influenced by this book,\u00e2\u20ac\u009d Wells says.<\/p>\n<p>Among the book\u00e2\u20ac\u2122s aphorisms are, \u00e2\u20ac\u0153Analyzing your present culture is like going to history class, when you could learn more valuable stuff from studying the future.\u00e2\u20ac\u009d And: \u00e2\u20ac\u0153Start out fast and keep trying to pick up speed. Leave skid marks.\u00e2\u20ac\u009d <\/p>\n<p>Wells certainly isn\u00e2\u20ac\u2122t opposed to the principles behind the overhaul \u00e2\u20ac\u201c to serve more people living with mental health, developmental disability and substance abuse issues and to more efficiently and cost-effectively manage services. He hopes though that something has been learned from a history of rushing to the next solution without doing due diligence. <\/p>\n<p>Meanwhile, another Chapel Hill resident, Toni Wilson, is praying that her developmentally disabled son, Michael, who\u00e2\u20ac\u2122s in his 30s, and also suffers from lifelong mental health issues, won\u00e2\u20ac\u2122t be a skid mark on the road to further ill-fated reform.<\/p>\n<p><strong>Uncertain days<br \/>\n<\/strong>Toni Wilson has witnessed the state\u00e2\u20ac\u2122s mental health care reform peregrinations and seen her son\u00e2\u20ac\u2122s services curtailed.<\/p>\n<p>Thava Mahadevan, executive director of XDS Inc., a Pittsboro-based agency that\u00e2\u20ac\u2122s worked with Michael in recent years, understands his mother\u00e2\u20ac\u2122s concerns: \u00e2\u20ac\u0153Mom\u00e2\u20ac\u2122s terrified about what\u00e2\u20ac\u2122s going to happen to Michael.\u00e2\u20ac\u009d<\/p>\n<p>Uncertainty isn\u00e2\u20ac\u2122t good for Michael Wilson. His father was murdered when he was 2. XDS has provided him with a number of support services \u00e2\u20ac\u201c sometimes, simply, much-needed companionship \u00e2\u20ac\u201c but those services have been incrementally defunded by Medicaid.<\/p>\n<p>\u00e2\u20ac\u0153If they take the services away,\u00e2\u20ac\u009d his mother says, \u00e2\u20ac\u0153he\u00e2\u20ac\u2122s got to go to the doctor much more than he did; he\u00e2\u20ac\u2122s got to take much more medication than he did. That\u00e2\u20ac\u2122s going to cost the state.\u00e2\u20ac\u009d<\/p>\n<p>Zoloft has been good for her son, Wilson says. <\/p>\n<p>\u00e2\u20ac\u0153But it\u00e2\u20ac\u2122s not enough. We need the people. Everybody needs somebody to talk to and somebody to help them out through life. <\/p>\n<p>\u00e2\u20ac\u0153We all sometimes get upset or depressed. But when people like Michael, who have severe problems, get upset, they don\u00e2\u20ac\u2122t know how to deal with it; they don\u00e2\u20ac\u2122t know what to do. The only thing they know \u00e2\u20ac\u201c I mean, his body will get to jumping and going every which way \u00e2\u20ac\u201c is to act out. \u00e2\u20ac\u00a6 That\u00e2\u20ac\u2122s the only way he knows to let it out.<\/p>\n<p>\u00e2\u20ac\u0153When you take him out, you\u00e2\u20ac\u2122ve got to watch him,\u00e2\u20ac\u009d his mother says. \u00e2\u20ac\u0153Some women think that he\u00e2\u20ac\u2122s mean and that he\u00e2\u20ac\u2122s going to hurt them and they\u00e2\u20ac\u2122re a little afraid of him. But he\u00e2\u20ac\u2122s not really going to hurt them.\u00e2\u20ac\u009d<\/p>\n<p>But she worries that a situation could get out of control. Michael struggles with boundaries, and sometimes crosses them. He once tried to pull a pizza delivery driver into the house. <\/p>\n<p>Mahadevan worries about what would happen if Michael were to cross too far beyond those boundaries.<\/p>\n<p>\u00e2\u20ac\u0153I\u00e2\u20ac\u2122m afraid his mother would have a huge breakdown if he were to be sent to prison,\u00e2\u20ac\u009d he says. \u00e2\u20ac\u0153It would be devastating. And he wouldn\u00e2\u20ac\u2122t survive.\u00e2\u20ac\u009d <\/p>\n<p><strong>Consolidation<br \/>\n<\/strong>The proposed new system is designed, proponents say, to better serve people like the Wilsons. Under the plan, agencies that oversee mental health, developmental disability and substance abuse services will be granted a 1915(b)(c) waiver of the Social Security Act, moving them from a fee-for-service delivery system to a managed-care system.<\/p>\n<p>The state\u00e2\u20ac\u2122s 23 local management entities (LMEs), which oversee publicly funded behavioral health care services, will be consolidated in an attempt to create administrative savings and efficiencies. Legislation passed this session stipulates that the consolidated LMEs will be given Medicaid, state and local funds in a lump sum, resulting in a managed-care system under the 1915(b)(c) waiver. The plan must now be approved by the federal government.<\/p>\n<p>OPC Area Program, the LME that serves Orange, Person and Chatham counties, is preparing to merge with Piedmont Behavioral Healthcare (PBH), which serves Cabarrus, Davidson, Rowan, Stanly and Union counties. In a pilot project begun in 2005, PBH has been the only LME to operate under the full 1915(b)(c) waiver, and will serve as the model for the statewide system. <\/p>\n<p>It\u00e2\u20ac\u2122s all new ground. One high-level state official who asked not to be identified said of the shift to a statewide waiver system, \u00e2\u20ac\u0153It\u00e2\u20ac\u2122s like moving from a slingshot to a rocket launcher.\u00e2\u20ac\u009d It\u00e2\u20ac\u2122s \u00e2\u20ac\u0153the biggest thing to happen\u00e2\u20ac\u009d to mental health, developmental disability and substance abuse services in \u00e2\u20ac\u0153a long, long time\u00e2\u20ac\u009d and, the official says, will put North Carolina on the cutting edge in the delivery of these services.<\/p>\n<p>The objective is to provide more and better services to more individuals. The fee-for-service system had the potential to create incentives to provide patients with services they may not have needed, and proponents of managed care say that when LMEs are given lump sums with which to provide services to all who require them, equity will prevail. Clients, they say, will receive what they need \u00e2\u20ac\u201c no more, and no less. <\/p>\n<p>\u00e2\u20ac\u0153We can\u00e2\u20ac\u2122t keep doing what we\u00e2\u20ac\u2122re doing,\u00e2\u20ac\u009d says Rep. Verla Insko of Orange County, a primary sponsor of the legislation. \u00e2\u20ac\u0153There will be managed care. That\u00e2\u20ac\u2122s for certain.\u00e2\u20ac\u009d<\/p>\n<p>In a May email to advocates, Patricia Porter, a consultant to the General Assembly on health and human services, echoed that sentiment: \u00e2\u20ac\u0153The cost overruns, long waiting lists, duplication of administrative operations, lack of assurance that people are receiving the services they need and prefer \u00e2\u20ac\u00a6 cannot continue.\u00e2\u20ac\u009d<\/p>\n<p>Insko acknowledges that, \u00e2\u20ac\u0153Some things aren\u00e2\u20ac\u2122t going to work, and we\u00e2\u20ac\u2122ll have to back up.\u00e2\u20ac\u009d <\/p>\n<p>She also acknowledges that she initially warned state Department of Health and Human Services Secretary Lanier Cansler that the move to a statewide waiver system was proceeding too quickly, that the target should be 2014. <\/p>\n<p>Cansler himself said in 2009 that, \u00e2\u20ac\u0153Using a Medicaid waiver to shift to managed behavioral healthcare represents a significant shift in thinking for all stakeholders in North Carolina. Such a change takes multiple years to research, implement and refine.\u00e2\u20ac\u009d<\/p>\n<p>But Insko and Cansler are now on the fast track to a statewide waiver system.<\/p>\n<p>According to Insko, Cansler has said, \u00e2\u20ac\u0153\u00e2\u20ac\u2122If we\u00e2\u20ac\u2122re going too fast, we\u00e2\u20ac\u2122ll know by next year, and I\u00e2\u20ac\u2122ll slow it down.\u00e2\u20ac\u2122\u00e2\u20ac\u009d<\/p>\n<p><strong>Why the rush?<\/strong><br \/>\nThe transition has come fast.<\/p>\n<p>A report commissioned by the DHHS and released last August by Mercer Government Human Services Consultants said the department was not fully prepared to move forward with the administration of the proposed system. It cited \u00e2\u20ac\u0153an absence of senior licensed clinicians to help guide policies and procedures\u00e2\u20ac\u009d and a \u00e2\u20ac\u0153significant lack of IT tools and a limited number of technical staff to support efficient business operations and reporting requirements.\u00e2\u20ac\u009d<\/p>\n<p>Steve Jordan, director of the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, acknowledges Mercer\u00e2\u20ac\u2122s assessments.<\/p>\n<p>\u00e2\u20ac\u0153Mercer did point to some infrastructure challenges,\u00e2\u20ac\u009d he says, \u00e2\u20ac\u0153and these are being addressed independently and as a part of the individual and executive-level oversight groups.\u00e2\u20ac\u009d<\/p>\n<p>As for the LMEs, Jordan says that the pace of implementation won\u00e2\u20ac\u2122t \u00e2\u20ac\u0153outstrip the readiness of the sites to do the work. <\/p>\n<p>\u00e2\u20ac\u0153Each will have to pass rigorous readiness reviews, both desk reviews and onsite reviews, and correct any shortcomings, before that site will be allowed to function as a 1915(b)(c) waiver site.\u00e2\u20ac\u009d<\/p>\n<p><strong>Concern<br \/>\n<\/strong>Of the three constituencies, the developmental disability community is most concerned. Advocates contend that managed care is a recovery model, but people don\u00e2\u20ac\u2122t recover from developmental disabilities.<\/p>\n<p>\u00e2\u20ac\u0153This waiver was set up for mental health,\u00e2\u20ac\u009d Carrboro self-advocate Ellen Perry says; \u00e2\u20ac\u0153it\u00e2\u20ac\u2122s not set up for the DD population.\u00e2\u20ac\u009d She\u00e2\u20ac\u2122s concerned about losing hours of assistance with getting around that \u00e2\u20ac\u0153keeps me safe and lets me be out in the community.\u00e2\u20ac\u009d<\/p>\n<p>Mary K. Short, a Taylorsville advocate and mother of a 31-year-old daughter with a severe developmental disability, questions whether PBH\u00e2\u20ac\u2122s pilot project, the model for the statewide plan, has really saved money.<\/p>\n<p>\u00e2\u20ac\u0153It does not seem logical to me that any savings exist if there is a waiting list of people eligible for services,\u00e2\u20ac\u009d Short says.<\/p>\n<p>PBH CEO Pam Shipman says that the managed care system has allowed her agency to introduce what are called B-3 services.<\/p>\n<p>\u00e2\u20ac\u0153The B-3 services that we have added include respite and supported employment,\u00e2\u20ac\u009d Shipman says. \u00e2\u20ac\u0153We have experienced significant reductions in our waiting list for people with intellectual and developmental disabilities because of these services. This was accomplished by moving people with Medicaid coverage to the B-3 services, thus reserving the state-funded services for people that do not have Medicaid.\u00e2\u20ac\u009d<\/p>\n<p>More must be done with less, says Jordan.<\/p>\n<p>\u00e2\u20ac\u0153The likelihood of there being no new [federal] funding makes the waivers even more important,\u00e2\u20ac\u009d he says, \u00e2\u20ac\u0153because waivers allow the current resources to be reallocated in ways that create savings and allow for those savings to be reinvested in services in the system.\u00e2\u20ac\u009d<\/p>\n<p>\u00e2\u20ac\u0153Because the waivers are operated as a captitated system, the LMEs must predict how many individuals are in need of service in order to determine the amount of money they will receive to provide these services,\u00e2\u20ac\u009d says Rep. Jeff Barnhart of Cabarrus County, another primary sponsor of the legislation. \u00e2\u20ac\u0153There are a number of strategies to determine this information, and this data is closely monitored by the Division of Medical Assistance.\u00e2\u20ac\u009d<\/p>\n<p>Jordan says that though each system is unique, his office is learning from other states\u00e2\u20ac\u2122 experiences. Managed care has worked elsewhere. <\/p>\n<p>In a 2009 report for the National Leadership Consortium on Developmental Disabilities, Robert Gettings, former head of the National Association of State Directors of Developmental Disabilities Services, wrote that in his research on states that have implemented managed care, no one, not even those who were initially its sharpest critics, suggested that \u00e2\u20ac\u0153people with developmental disabilities would be better off were [developmental disability] services to be carved out of the managed care program.\u00e2\u20ac\u009d<\/p>\n<p>Mahadevan is guardedly optimistic. He likens the change to replacing a credit card with a debit card. \u00e2\u20ac\u0153You know your limit.\u00e2\u20ac\u009d <\/p>\n<p><strong>Hoping<br \/>\n<\/strong>Gettings warned in his report that, \u00e2\u20ac\u0153A managed care system is complex, with many moving parts; and, to function effectively, these systems require the active engagement of skilled management staff at the state level.\u00e2\u20ac\u009d<\/p>\n<p>Is the state ready?<\/p>\n<p>Toni Wilson certainly hopes so.<\/p>\n<p>\u00e2\u20ac\u0153Thava says he never knows what\u00e2\u20ac\u2122s going to happen with services. And Michael don\u00e2\u20ac\u2122t need to go through that, because it worries him, puts pressure on him and makes him act out. He came to me and said, \u00e2\u20ac\u02dcThey\u00e2\u20ac\u2122re cutting out all my stuff.\u00e2\u20ac\u2122 And then he can tell I\u00e2\u20ac\u2122m upset about it. It\u00e2\u20ac\u2122s a mess. I don\u00e2\u20ac\u2122t know what to expect.\u00e2\u20ac\u009d<\/p>\n<p>The uncertainty frightens Perry as well. <\/p>\n<p>\u00e2\u20ac\u0153I\u00e2\u20ac\u2122m scared for everybody,\u00e2\u20ac\u009d she says.<\/p>\n<p>Insko can understand why. But, she says, \u00e2\u20ac\u0153There\u00e2\u20ac\u2122s good reason to be fearful if we don\u00e2\u20ac\u2122t make changes.\u00e2\u20ac\u009d<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Jim Wells is back in private practice now in Chapel Hill, but until just recently he served as attending psychiatrist for Female Continuing Care at Dorothea Dix Hospital. <\/p>\n","protected":false},"author":9,"featured_media":19374,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4,30],"tags":[],"class_list":["post-19371","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-news","category-top-story"],"_links":{"self":[{"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts\/19371","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/comments?post=19371"}],"version-history":[{"count":15,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts\/19371\/revisions"}],"predecessor-version":[{"id":22469,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts\/19371\/revisions\/22469"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/media\/19374"}],"wp:attachment":[{"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/media?parent=19371"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/categories?post=19371"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/tags?post=19371"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}