Implementing CABHAs

(Note: I’ll update this by the end of the weekend, with links to news stories about Community Support)

Secretary of Health and Human Services Lanier Cansler called reporters to Raleigh to talk about CABHA (Critical Access Behavioral Health Agency), the new structure for delivering mental health care.

The most striking feature of the day’s events was Sec’y Cansler’s assertion that mental health reform is ‘over’.  Now, we have…

My story here:

CABHAs have been in the works for more than a year.  When the structure was first proposed in late 2009, it was supposed to go into effect in July, 2010. But providers, advocates and consumers all protested the timetable would be an example of yet another change to the mental health system hastily introduced – some would say ‘foisted – onto the system, forcing everyone to scramble to comply.  The Division of Mental Health, Developmental Disabilities and Substance Abuse Services backed off, pushing implementation to the recent new year.

So, why CABHA? Some history…

Back before mental health reform, services were coordinated and delivered by area agencies, usually county-based agencies that delivered everything from therapy to helping people with housing.  The area agencies were largely funded by state and county funds, and they were the only agencies in a county.  So, if a ‘difficult’ patient had exhausted the patience of all the providers… or when a patient felt they couldn’t find a provider they liked, they were stuck with the area agency.  This lack of choice was a prime driver of reform in 2001.

When reform started, area agencies were dismantled and services would be coordinated by LMEs – Local Management Entities – that did assessments, billing, and utilization review.  Service delivery would be via private providers, paid via the LME.

Early in reform, some private providers entered the market, but it was tough to get the ‘right’ case mix of insured patients who were paid for, Medicaid funded patients who were not-so-well paid for, state funded patients who were even less-well-paid-for and uninsured patients who were not paid for at all.

Then came Community Support, as service definition rolled out in March 2006.

Ah… Community Support.  It was done with good intentions: the idea was to create a market space where ‘any willing provider’ could provide services and get decent reimbursement.  And providers came out of  the woodwork – thousands of them, all billing for services which were sometimes provided by people with high school diplomas and little training

It was that ‘any willing provider’ concept, combined with loose regs around who those providers were, and the services actually provided, that lead to lots and lots of money getting spent.  The state backpedaled and cut reimbursement rates, but the damage was already done.  By early 2007  estimates of the waste (fraud) generated ranged from $400-700 million.

News and Observer broke the story, the state audited, the General Assembly acted.  DHHS, thoroughly embarrassed, tightened up on Community Support, changing the definition of what could be reimbursed for by Medicaid.  Actually, what came after the debacle was a pretty good service, by many accounts, but the damage was done. Community Support had been such a PR disaster, it had to go. The General Assembly eliminated it as of mid-2008.

Hence… CABHA.

The idea behind CABHA is that there will be oversight of the services delivered and the people delivering them.  But the Division may have swung too far in the opposite direction.  To become a certified service-deliverer, i.e., a CABHA, an agency needs: a medical director (~ $250K), a clinical director (~$200K), a training supervisor (let’s say a cheap $100K). Just to deliver services, an agency needs a half million dollars of overhead before they can post the first bill – and for the most part, those folks don’t generate revenue. This is a tall order in a cash-strapped system.

As of January 2011, close to 180 CABHAs have been certified and according to Assistant Secretary Beth Melcher, there are CABHA services available in ‘every county.’

In the meantime, some smaller good quality niche providers, like clubhouses, say CABHA could potentially put them out of business. But more on that another time…

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