The Senate used the budget bill it approved this week to rein in community support, a basic mental health service that in its first year cost about twice as much as expected.
The budget sets out minimum standards for monitoring companies, changes how they would be paid and opens a way for county mental health offices to revive their role in deciding what types of mental health treatment Medicaid patients should receive.
"It's an effort to try to put some controls on this mess," said Sen. Bill Purcell, a Laurinburg Democrat who helped write the mental health sections of the budget.
Considered the foundation of community mental health, the service is for people recovering from drug and alcohol addiction and people with mental illness.
The state Department of Health and Human Services audited 167 companies this year and found some were misusing the service. Companies are supposed to have workers with a mix of experience and educational backgrounds working with clients, but the audit found that workers with high school diplomas were doing most of the work. As a result, the state cut the rate it pays companies from about $61 an hour to $51 an hour. In late April, the department announced it was tightening controls on community support and having local mental health offices check some patient records to see if they are getting the needed treatment.
Senators would go further.
Some local school leaders have complained that, under community support, mental health workers are sitting in classrooms with students whom the district didn't know needed special therapy. In response, the Senate is proposing to give school districts the power to approve the companies that can work in schools. The requirement would make sure the schools knew background checks were performed and give the districts some control over who was going into classrooms, Purcell said.
The Senate would have companies' pay based on the qualifications of workers serving clients, rather than at a flat rate. And the state Department of Health and Human Services would have to take the first steps toward returning decisions about Medicaid patients' treatment to county and regional offices. A Virginia company, ValueOptions, has a contract with the state to authorize treatment for Medicaid patients that runs through June 2008, with two yearly options for renewal. The Senate would put restrictions on renewing the contract or signing a new one with a different company.
Both ideas are controversial. Representatives from the state Department of Health and Human Services would not comment on the Senate's proposed rules, but administrators told legislators that changing company pay would be risky. The department does not want to ask the federal government's approval to change the payment plan, saying it would open the door to more restrictions on community mental health services, said legislators and others familiar with the administration's argument.
But legislators strongly support changing the payment plan.
"As long as we have a single rate, we're going to have problems," said Sen. Martin Nesbitt, an Asheville Democrat who worked on the budget's mental health provisions.
Rep. Verla Insko, chairwoman of a House committee on mental health reform, said she wants to change the payment system and isn't convinced that the state needs federal approval to do it.
But she wouldn't want to give the federal government another crack at rewriting the entire mental health program.
"It's hard to predict what's going to happen," she said."Our system is in enough chaos right now."
Some regional and county mental health offices balked when the state took their power to authorize Medicaid patient treatment, though they may still authorize treatment for patients who pay with state money. Legislators blame the limits on local control for high costs and for problems state-paid patients have getting treatment.
Abuses in community support flourished because local offices could not monitor it, Nesbitt said. And because they no longer had to justify their operations to local administrators, companies were freer to reject state-paid patients who generally receive less treatment because of financial constraints.
"When you don't have the ability to manage the whole system and you're only given the weak parts, it's hard to keep the providers network and all that going," Nesbitt said.