People trying to arrange mental-health and substance-abuse treatments for themselves or relatives likely will be scrambling when a state law takes effect July 1 that is expected to significantly reduce the number of providers.
The regulation requires that providers become a Critical Access Behavioral Health Agency, or CABHA, to offer services in five key categories.
A chief requirement to be recognized as a CABHA provider is adding or contracting for a medical director, clinical director and at least one more high-profile position, with a cost ranging from $100,000 for small providers to $450,000 for large providers. A small provider is defined as having fewer than 750 cases annually.
The costs are expected to have a larger effect on providers with limited resources.
The service categories that will require the CABHA designation are: case management, peer support for recovery initiatives, community support teams for adults, intensive in-home treatment for children, and day treatment for children and adults dealing with issues such as substance or sexual abuse.
Case management and peer support are new programs that are replacing services offered through a community-support program eliminated by the General Assembly and end June 30.
The N.C. Department of Health and Human Services said that the purpose behind the CABHA program is to ensure that critical services are delivered in the five categories by a clinically competent organization with appropriate medical oversight, and the ability of agencies to deliver a continuum of services.
Critics say that the CABHA program is another example of mental-health reform in the state being rushed without taking the time to assure that those in need of the services won't fall through the cracks, or that the expected end result of larger provider agencies will lead to better quality services.
Just 55 to 65 providers statewide are expected to qualify for accreditation out of more than hundreds now. The deadline is April 1 for submitting a letter of attestation -- essentially proof that a provider can meet service requirements. As of Thursday, 73 letters have been filed, with another wave expected by the deadline.
"Lots of providers may be impacted, but the majority of those serve very small caseloads, so the impact on consumers will be much less," said Leza Wainwright, the director of the N.C. Division of Mental-Health Services.
Providers that don't apply or that don't gain accreditation will be required to help their local management entity -- such as CenterPoint Human Services in Davie, Forsyth, Rockingham and Stokes counties -- to transfer their clients to a CABHA provider.
That means many current providers will have to either shift into other services with lower client demand, try to find merger partners, or go out of business. Some providers offer services to local school systems and medical facilities.
Worry about services
Local advocates say they are concerned that providers who can't -- or choose not to -- qualify for CABHA status will lose enough employees that their remaining services will suffer.
Umesh Jain, the official in charge of AIM Human Health Services LLC of Winston-Salem, said she is struggling to justify the additional medical-staffing cost. Without achieving CABHA status, she said, AIM could lose 14 of its 35 clients.
"We may be considering getting out of those fields because we don't have the funds," Jain said. "We have expressed our intent to CenterPoint that we may do other mental-health services.
"The way the state keeps redefining services, it keeps a level of uncertainty present and has providers struggling to keep up. Even if I hire the additional staff, there's no guarantee the state won't come back in six months and require further changes."
Altogether, there are 80 behavioral-service categories listed by the N.C. Department of Health and Human Services. There is some overlap of services covered by Medicaid and by state money.
However, community-support teams, intensive in-home and day-treatment services are among the highest categories in terms of use, Wainwright said.
Advocates said that the CABHA requirements could affect about 25 percent of providers statewide.
According to the N.C. Division of Mental Health Services, there are 462 providers of intensive in-home care, 298 community-support teams and 206 providers licensed for day treatment. Some providers offer two or more of the services.
There are at least 321 providers of those services within the networks of the seven local-management entities serving the Triad and Northwest North Carolina.
As of March 4 -- the last time the state updated its list -- only three providers based in CenterPoint's market have submitted their letter of attestation to meet CABHA requirements with the state -- Faith in Families Inc. of Reidsville, and People Helping People of N.C. LLC and Top Priority Care Services LLC, both of Winston-Salem.
Others that have submitted their letter in the region are New River Behavioral HealthCare of Boone, PQA Healthcare Inc. of Dobson and Youth Focus Inc. of Greensboro.
Betty Taylor, the director of CenterPoint, said she knows of at least 13 providers in CenterPoint's market that have submitted letters.
"The goal of CABHA has always been to have a range of clinically appropriate service for consumers," Taylor said. "The CABHA service continuum will in some cases allow consumers to choose to stay with one provider as their individual needs change."
Cost savings for state
However, Danny Freeman, the executive director of N.C. Quality Care Provider Association, said he believes that CABHA will not result in significant cost savings for the state.
"Many mental-health consumers no longer served by small providers will end up being served by emergency rooms, hospitals and the penal system," Freeman said.
Meanwhile, he said, the program will have "virtually no impact on large providers because they already have the staffing in place."
"In our current economic environment and in the face of reduced reimbursement rates, CABHA allows large providers to add new mental-health consumers without increasing their cost structure, which allows them to maintain or increase profit margins," Freeman said.
Bob Hedrick, the executive director of the N.C. Providers Council, said that there are concerns about whether rural agencies that want CABHA accreditation will be able to secure the services of a medical or clinical director. Those positions are in limited supply statewide.
"Every mental-health provider is asking the same questions," Hedrick said. "Can they get enough case-management business to support the infrastructure?
"There is support for what they are trying to accomplish, but will 55 to 65 providers statewide be enough? We don't know yet."
Wainwright said that the list of providers that have submitted letters offers a good geographic balance. "We want to ensure that consumers have access to high-quality services, not just access to a service of questionable quality," she said.
Advocates for people with behavioral-health issues say they are concerned that because of CABHA requirements, patients will have to start new relationships with psychiatrists and other officials.
"If small providers are eliminated, it is highly unlikely that large providers will step in and fill the void," Freeman said. "It is also unlikely that persons in need of mental-health services will travel outside of their primary locality to receive help."
Non-CABHA providers can offer all other services related to behavioral health. But those services tend to not have the same level of demand and caseloads.
CABHA agencies can offer those services, too, and may not have incentive to make referrals to non-CABHA providers.
"At that point, it becomes a principle of marketing, with the small providers becoming less competitive," said David Cornwell, the founder of N.C. Mental Hope, an advocacy group.
The level of influence by a local management entity will expand after July 1, when a provider must be referred by that group as part of the accreditation process. Critics say that allowing local management entities to have that kind of say-so will further politicize mental-health reform.
Wainwright said that her agency will be working with local management entities and consumers "to develop monitoring standards for CABHAs."
Taylor said that her agency is trying to assist providers wanting to merge to achieve CABHA status.
"Many providers agree that CABHAs will positively impact the quality of care, but want to make sure CABHA providers will continue to refer consumers to specialty services outside of CABHA," she said.
Robert Beasley, the president of Youth Opportunities Inc. of Winston-Salem, said his group is preparing its letter for CABHA designation even as it figures out how to pay for the additional $150,000 to $200,000 in expenses.
"Our goal is to have the psychiatrist who is already providing 10 hours of service to expand to 20 hours," Beasley said. "It just seems like the state is hellbent to reduce the number of providers in the state, although there appears to be more providers trying than the state probably expected."
Wainwright said that people who criticize the cost involved in becoming CABHA accredited miss a key point when it comes to clinical issues.
"These are services for adults with severe mental illness with a physical component," Wainwright said.
"For every other illness, treatment delivered by a physician or supervised by a physician is considered essential.
"We do not believe that treatment for individuals with mental illness and substance-use disorders should be different."
rcraver@wsjournal.com
727-7376
Potential CABHA providers
There are seven local-management entities that serve the Triad and Northwest North Carolina for behavioral health. Within those networks, there are at least 321 providers that offer programs falling under the Critical Access Behavioral Health Agency umbrella. Here are the number of current providers for each service:
Local-management Community- Day Intensive entity support team treatment in-home
Alamance-Caswell (1) 4 6 14
CenterPoint (2) 14 19 13
Crossroads (3) 5 8 6
Guilford (4) 21 15 28
Piedmont (5) N/A 22 N/A
Sandhills (6) 15 48 33
Smoky Mountain (7) 10 18 22
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