(How) can NC Community Colleges bar ‘dangerous’ students?

On Friday, the NC Board of Community Colleges approved a rule that would allow individual colleges to bar students who pose an “articulable, imminent and significant threat.” This isn’t a done deal yet… the rule still has to go before a  rules committee in March for final approval. But already, advocates for people with disabilities are raising questions.

Story here:

My first call was to Vicky Smith at Disability Rights.  She says they’ve been expressing their doubts and concerns about the rule since it was proposed last fall (the post-Tuscon timing is coincidental – actually the CCBoard started work on this last year in response to the Virginia Tech massacre).  She says the rule quite possibly runs afoul of the ADA (link on the right) and the Rehabilitation Act, in particular Section 504.  In that part of the law, it says

(a) No otherwise qualified individual with a disability in the United States, as defined in section 7(20), shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance…

What that means is that if during a screening, someone is flagged as being an “articulable, imminent and significant threat” due, perhaps to mental illness, then they can be denied admission to the school.  But it’s something of a Catch-22… the community college system is an all-comers system.  There’s no screening process other than confirming residency and that you have a high school diploma or GED.   So, Smith had a question… how would this ‘threat’ be screened for if there’s no screening process done?  She feared the criteria would be arbitrary, and ultimately discriminatory. They detail their concerns in this letter (PDF).

That’s the fear being expressed by advocates for people with mental illness.

I asked that question of board spokeswoman Megan Hoenk several times…  what she did say is that the rule is not a blanket requirement… each of the system’s 58 colleges can choose whether or not to implement it.  However, Hoenk didn’t really answer the question about how the determination of an imminent threat would be made – either how the screening would be done, or what criteria would be used.

Each school has a code of conduct for current students… why aren’t the current codes adequate to deal with potentially violent students?

Legislative Breakfast for Mental Health

I was at the annual event, held Saturday morning, Jan. 22 at the Friday Center.  This was the biggest yet!

If there was a zeitgeist to the room, it was, “What’s gonna happen?”  There were a lot of questions directed to the lawmakers present, in particular, the few Republicans there.  I sat at a “speed meeting” next to Pat Hurley (District 70), who’ll chair the mental health subcommittee of the new Health and Human Services Committee.  She was somewhat vague in her reassurances… she started out by saying that Medicaid money would be cut.  Hurley said she understood the need to provide services to people who need them, but also said there’s a big deficit and it needs to get addressed.

Hurley, from Asheboro, has been Clerk of Court in Randolph County.  She also described herself as having worked in banking, and in auto auctioning.  So, Hurley doesn’t have a lot of health care experience – and she admits it. But she also says she’s been going to a lot of meetings to get herself up to speed. She also mentioned she’d visited some mental health facilities, notably Central Regional Hospital.

If there was an overarching theme, to the day, it was, “advocate your butts off.” Several of the speakers talked about inviting lawmakers to visit their facilities and programs so they can get familiar with what they do.

Folks listening glumly to Beth Melcher as she talks about budget cuts

The morning ended on an up note (irony here) with Assistant Secretary (for mental health) Beth Melcher laying out in stark detail what will happen with budget cuts.  Right now, the DHHS budget for FY ’11 is at $17.3 billion, of that, $13.4 B comes from the fed in the form of Medicaid matching funds to what the state spends.  The state appropriates $3.9B for health, and for each dollar the state cuts, we lose several dollars in federal matching funds.  In other words, if legislators cut, say, $1 B from DHHS in the state budget, that means it translates to a cut that’s more like 3 or 4 billion dollars.

Melcher didn’t mince words about warning about what happens when you cut those state dollars.

She did say, though, that so far, DHHS has ‘protected’ mental health from cuts. But she didn’t know how much further they could do that.

The mathematical figure of the day also came from Melcher, who talked about the rhetoric from Raleigh to cut ‘wasteful administration expenses.’  Melcher reported that even if lawmakers cut all, yes ALL, state facilities, all DHHS personnel and all administration, that would only reduce the budget by 8.5%. The current budget deficit stands at about 15 percent.

Paul Luebke got the last legislative word… he suggested that the gathered advocate to their lawmakers that the state retain all of the temporary taxes and fees due to sunset in the upcoming year.  That would account for about $1.3 B, leaving a gap of $2.4 B.

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…