Archived Opinion

If you reform a reform, is it still reform?

Michael Watson, assistant secretary at the Department of Health and Human Services, contends the state’s overhaul of its behavioral health system doesn’t amount to an abandonment of its past reform effort of 2003.

“I wouldn’t call it a rollback of reform, I would call it a response to some of the issues that came out of reform,” Watson said. “I think if you look at reform where we really made mistakes is when we preferred access over quality.”

Under a set of changes called the Critical Access Behavioral Health Agencies (CABHA) program, the state is forcing mental health providers that use Medicaid funding to comply with a new set of requirements by July 31.

According to Watson the changes will improve quality by demanding accountability from private providers.

The most significant new requirement is that any agency that wants CABHA certification needs a full-time psychiatrist on staff to function as a medical administrator two months prior to July 31.

The changes were prompted in part by the state’s budget crisis and in part by criticism of a Medicaid-funded mental health program called “community support”.

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Under direction from the General Assembly, DHHS will dismantle “community support” services, a major component of a system-wide reform initiated in 2003. The goal of the reform was to improve access to the public by decentralizing and expanding the netwokk of providers in the private sector.

Community support was a service in which mental health professionals, often without advanced degrees, offered clients mentorship and skill-building in real-world settings. The intent of community support was to deepen the contact between mental health providers and their clients. But at least in some systems around the state, the practice was abused, leading legislators to cry foul that the program was akin to expensive state-sponsored babysitting.

Between 2006 and 2009, the state spent over $800 million on enhanced services and a report by the General Assembly claimed that 97 percent of the money went to community support.

That decision set off a domino effect for services billed through Medicaid and led to a total overhaul of the system.

DHHS Assistant Secretary Michael Watson claims the CABHA program will improve quality and save money at the same time.

“The issue with quality really has to do with the problems with community support and the fact that we were beginning to see similar abuses in the services that would replace them,” said Watson.

Duncan Sumpter –– CEO of Appalachian Community Services, a mid-size provider that serves rural Graham, Swain, and Cherokee counties –– thinks the failure of community support had to do with the way the state administered the program.

“The state is saying lesson learned from community support,” Sumpter said. “But the lesson learned by the providers is the rules were never clear and some people took advantage of it.”

CABHA affects businesses that provide “enhanced services,” a catch-phrase for a menu of Medicaid-funded behavioral health services for people with mental health and substance abuse issues.

In 2003, the state moved away from a consolidated area program model in which large regional agencies were responsible for providing services and paying out Medicaid claims.

The reform effort was designed to eliminate the potential for abuse of the Medicaid billing system by ensuring that the same companies –– in the case of the seven western counties the regional entity was the Smoky Mountain Center –– did not both pay out claims and provide services.

The reform effort resulted in a privatized model where multiple service providers answered to a singe local management entity (LME) for paying claims.

The Smoky Mountain Center became the LME for the seven westernmost counties in the state and many of the center’s staff left to start their own companies to provide services.

With the implementation of CABHA, the private provider network will re-consolidate.

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