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Community Assistance program falls under fire

In the wake of the recent revelations of the last few months that North Carolina is in serious need of mental health reform, three counties in the Roanoke-Chowan region are at the top of a list no one wants to be on.

Millions of taxpayer dollars have allegedly been wasted on seemingly unnecessary &uot;community support&uot; services since the state first launched its reform plan.

According to statistics initially uncovered by investigative reporters from the News & Observer, the state has wasted upwards of $400 million in the last two years by paying up to $61 an hour for community support workers to perform simple tasks such as taking clients to the movies or to the mall.

The vast majority of these workers only had a high school education.

Local trouble

Here in the Roanoke-Chowan region, each of the four counties are in the top ranks of the state’s &uot;most-wasteful&uot; list.

Private mental health providers in Bertie County, with a population of 19,355 as of the latest available data, billed Medicaid an average of $812.32 per capita for community support services during a 17-month period from April 2006 until January 2008, or a total of $15.8 million.

That puts Bertie as the fourth highest-spending county in the state for per capita community support expenditures and also as one of the highest percentages of services labeled community support, at an astounding 98.24 percent.

Only 0.46 percent of services originating from Bertie County went toward critical care services, an extremely low percentage given that the state’s mental health reform system was initially designed for the majority of funds to go to those more serious types of services.

Hertford County’s situation is just as bad, with just 0.12 percent of the Medicaid money going toward critical care services, as opposed to 98.39 percent ($18.2 million) being billed as community support.

The slightly higher population of Hertford County (23,878) puts them below Bertie for per capita community support expenditures, but they are still ranked fifth highest in the state at $762.29.

Bertie and Hertford are two of only 11 counties in North Carolina to have above a $500 per capita community services expenditure rate.

All four Roanoke-Chowan area counties (Bertie, Hertford, Northampton and Gates) are in the group of just 29 counties that have a less-than $5 per capita rate of spending for the more medically necessary critical care services, with all furthermore conducting less than one percent of their business in that vein.

Mental health facilities in Northampton County (pop. 21,524) are listed as having billed Medicaid a total of just over $9 million during the same time frame, with 97.68 percent of that ($411.21 per capita) going to community support services.

Gates County, with a population of 11,602, saw $2.7 million in community support bills and had a high percentage rate at 97.17 percent but a lower per capita spending ($231.38) than the other Roanoke-Chowan area counties.

Still, compared with most other North Carolina counties, which averaged less than $100 per capita spending for community support services, $231 is still a high figure.

Recent developments

On April 17, the situation worsened for the state when federal Medicaid officials announced they would be deferring payment for community support services in North Carolina.

The funds cutoff is supposed to last for one calendar quarter or until the federal Centers for Medicare and Medicaid Services (CMS) are satisfied with North Carolina Department of Health and Human Services’ (NCDHHS) plan of reforming the community support aspect of mental health treatment.

Meanwhile, that imposes a shortage of roughly $138 million in funds for the NCDHHS… yet the NCDHHS is still responsible for paying individual providers across the state, whether or not they are receiving federal funds as normal.

One local official offered some insight into that problem.

&uot;They’re (the state) calling it a cash flow issue… they will make the payments until they are reimbursed, but suppose the federal government holds the next quarter as well, which may be a possibility… then where is the money going to come from?

Is the state going to absorb that?

It may become a more serious problem if it’s determined that these are not eligible expenses.

It’s a very, very serious thing,&uot; stated Hertford County Manager Loria Williams.

She added, &uot;This is truly a state issue and that is why the state has asked those provider networks to pay this money back, but I don’t know if that’s going to be possible with some of these places starting to close down and everything else.&uot;

According to figures that were published on the N&O website earlier this year, hundreds of mental health providers all across the state were found to owe the state money for services which were billed to Medicaid, but later determined to not be medically necessary.

The total amount owed by all providers was roughly $59 million originally, but a portion of that money is said to have already been paid back.

It is unknown at this time exactly how much was repaid or which providers have been doing so.

Locally, several providers in Bertie, Hertford and Northampton counties were on that list.

In Bertie County, Solid Foundation Facilities Inc. of Windsor is listed as having originally owed the state

$578,236.08, while their sister company in Ahoskie (Hertford County) owed an additional $617,021.88.

Also in Windsor, Uprising Homes Inc. owed the state a total of $231,830.88, the second highest amount in the Roanoke-Chowan region.

We Are All Connected, Inc., of Ahoskie, was listed as owing $213,603.84.

The Roanoke-Chowan News-Herald learned that as of April 8, that organization is officially closed and is no longer providing any form of mental health services.

In Northampton County, Family and Youth Services Inc. in Conway owed a total of $193,867.80.

In Hertford, Life Inc. in Ahoskie was listed as having owed $135,696.96.

Rooted and Grounded Inc., also in Ahoskie, was noted to have owed $94,141.44 and Middle Track United Family Services in Windsor was listed as originally owing $37,612.32.

Uplift Comprehensive Services of Windsor owed a total of $22,936.20 and Health Services Personnel in Ahoskie and Jackson together owed $21,549.36.

The Roanoke-Chowan News-Herald attempted multiple times to contact each of these organizations for further information, but either phone calls were not returned or the party declined to comment.

What can be done?

The Roanoke-Chowan News-Herald spoke with the county managers of Hertford, Bertie and Northampton counties to get their takes on the staggering local statistics and what could possibly be done on a state level to fix the problem.

&uot;I would hope that they (the state) are putting stronger checks and balances in the legislation as it relates to community support services; I think that’s the biggest failing,&uot; Williams noted.

She added, &uot;There weren’t specifics as to what community support services truly are, and for any given community that may be two to three different things… so that’s what made it easy for things to go awry, especially since they left that up to the providers to determine.&uot;

&uot;Of course, here you’d think community support services as it relates to mental health wouldn’t be certain things like driving a child to school or taking him to the movies, you’d think that was common sense, but as legislators and administrators we can’t bank on that.

You have to set strict rules as to what is allowed and what isn’t,&uot; Williams further stated.

When asked, she verified that Hertford County’s budget for fiscal year 2007-2008 was $22.9 million.

For Williams, it was a shocking thought to realize that in a similar time frame (17 months), Hertford County mental health providers billed Medicaid nearly that much ($18.2 million) for community support services.

Similarly, providers in Bertie County, which operated on a $19.5 million budget for the last fiscal year, billed the state an amount close to that as well ($15.8 million) for community support over the same 17-month time frame.

Bertie County Manager Zee Lamb explained the history that likely brought the whole scenario about.

&uot;They tried to go from a state-based delivery of service to private providers.

It sounds like they just inadvertently created a loophole that allowed this to happen,&uot; he noted.

Lamb added, &uot;There’s plenty of blame to go around.

Obviously the law and the interpretation of the law was flawed.&uot;

When the state’s mental health reform plan was first announced, it was intended to save money by keeping people out of institutions and provide better services to those who need it most.

&uot;It was costing the state money and the state thought reform would provide an avenue to save money by eliminating jobs and shifting the focus from state to private,&uot; Lamb explained.

Instead, the reform plan did the opposite of that.

Since reform, the cost of mental health care has more than doubled and the lack of availability of necessary services has become much more widespread.

In many poor, rural areas such as the Roanoke-Chowan region, dozens of providers offering only community support services opened their doors in the months following the reform plan’s implementation.

The NCDHHS has since issued a moratorium on any new providers and attempted to impose more stringent administrative policies on existing ones, but community support services continue to dominate the mental health system.

What’s so bad about that is state audits determined that up to 89 percent of these community support services are medically unnecessary.

Lamb noted, &uot;Clearly, the state did not set proper criteria to ensure that abuse did not occur and so these providers sprung up all over the state… they saw an opportunity to profit from the decentralization of mental health and they took it.&uot;

He finished, &uot;Mental health reform brings to mind the old saying, be careful what you wish for because you just might get it.

While trying to improve the system they created a flawed system that many would argue is worse than the one before.&uot;

Williams and Lamb both predicted that as the reform plan is reformed itself, many of these community support providers would begin to either follow the new guidelines or close down.

&uot;There are so many of them (mental health providers) now that it’s hard to police them.

I think they need the Local Management Entity’s (LME) help.

For those LME’s who have gotten it right, they really need to rely on those folks who know the system,&uot; Williams noted.

Lamb commented, &uot;They’re going to begin streamlining… the legitimate agencies will start straightening up and the others will fold.&uot;

Williams added, &uot;For those who really want to provide community-based services, they can do that and there’s a legitimate way to do that, and it’s very needed.&uot;

Northampton County Manager Wayne Jenkins also had much to say on the issue.

&uot;I think that the intent of the program has a tremendous benefit to Northampton.

Anytime that there is a citizen that needs mental health services, I think we as a society should do what we can to make sure that citizen’s needs get met… however I think certainly if there are uses and abuses in the system that circumvent the intent for which that program was made, then those issues should be cleaned up and the program parameters tightened,&uot; he began.

Jenkins continued, &uot;There have been issues that have come as a result of regionalizing this effort, and from a manager’s perspective, bigger is not always better. The programs that I find are most effective at the county level are those in which the counties have some oversight in the decision-making process.

I realize there’s a governing board but I see it that the programs that are most effective are the ones the county has direct oversight over.&uot;

He further acknowledged that the state’s reform effort had missed the point and that some local organizations which had sprung up to provide community support services had apparently taken advantage of the system.

&uot;A federal program that is earmarked for the needy (Medicaid), such as this with mental health, is not an economic boost to create a business.

I’m sure most of these organizations are competent, but it’s the ones that are not who are creating the problem,&uot; Jenkins stated.

He continued, &uot;We need to clean up the abuse here as we do in Medicaid. These programs are not intended to be abused; they are intended to help the needy. The government is to serve its citizens; that’s why politicians are elected.

That’s not the purpose of a program to create new businesses.&uot;

Jenkins concluded by saying, &uot;I hope that those decision-makers who have made these allegations would follow through and clean this up.

If it’s being abused, then it’s wrong.

There is no right in this process, none whatsoever.

If that is not cleaned up then the integrity of the program has failed.&uot;

Efforts have been underway since August to change the way the system is set up, but apparently those efforts haven’t been enough for federal officials who are now withholding payment.

Where things will go from here is anyone’s guess, but only one thing is certain – drastic change is needed, and needed fast.

That goes for the NCDHHS who is now stuck with the bill, for the counties who were forced to fork over extra money for rising Medicaid costs over the last two years and for individual citizens in need of real mental health care who currently aren’t getting it.

Until such time when that change can happen, nobody is winning except for the mental health providers still apparently making money from mostly unnecessary community support services.