Betty Taylor: Waiver changes will impact consumers and providers

On Oct. 31, 2011, CenterPoint Human Services received approval to be a 1915(b)/(c) waiver site. As CEO of CenterPoint, the Managed Care Organization or "MCO" that will implement the waiver for Forsyth, Stokes, Davie and Rockingham counties, I want to share with you what this means for our community.

Your first question may be what is a "waiver"? The Social Security Act sets out requirements that must be satisfied before Medicaid will pay for services unless the state has federal approval to "waive" them. North Carolina received federal approval to "waive" two sections of the act in its provision of Medicaid-funded mental-health, substance-abuse and intellectual/developmental-disability services. Waiving §1915(b) allows North Carolina to implement managed-care delivery systems for these services while waiving §1915(c) allows long-term care services to be delivered in community settings instead of institutional settings.

Most of us agree that receiving care near home instead of in distant state facilities is a good thing. Unlike concerns with commercial, for-profit managed care, implementing a publicly managed care-delivery system also has benefits. Access to services is increased, quality is continually assessed and stakeholder input and education is key. It is up to the MCO in our community, CenterPoint, to assure these results. With wise management of funds, any remaining funds will be reinvested in the community to create additional services.

There are changes under the waiver that impact consumers and providers. Without a waiver, the Social Security Act requires that any "willing and able provider" be allowed to deliver and bill for Medicaid-funded services. This is called an "open network." Under waiver the MCO is not required to contract with all providers and a "closed network" can be created. The MCO is charged with analyzing local needs and designing its provider network to address those needs. In the closed network, consumers still have choice, although it is not unlimited. CenterPoint will maintain an open network in the first year of waiver operation allowing providers the opportunity to demonstrate their value in being included in the closed network in the second year.

North Carolina has toyed with expansion of waiver for several years as a way to contain Medicaid costs and to raise the bar on service quality. PBH, a MCO serving Cabarrus, Davidson, Rowan, Stanly and Union counties, launched its publicly managed waiver in 2005. The state watched closely and asked questions about outcomes, efficiencies, access to services and consumer responses. During this period, North Carolina experienced multi-million dollar Medicaid cost overruns for a service called Community Support. At the same time, PBH had no such economic issues and legislators noticed.

With state deficits deepening and Medicaid costs skyrocketing, the support for waiver intensified. To implement such change requires incredible political will and unity between the executive and legislative branches. Competing, legitimate agendas are expressed, addressed, re-framed and re-addressed. What is North Carolina's role in policy and funding? What voice does a county receive for its monetary contribution? How do stakeholders establish a powerful voice? The list goes on and debate continues, as it should. But the tipping point was reached, and tough political decisions were made.

In early 2011, Lanier Cansler, secretary of the North Carolina Department of Health and Human Services, announced the plan for statewide expansion of the waiver. The public management system under 23 Local Management Entities was no longer economically sustainable. Escalating costs, the current budget environment, cost overruns, lack of positive service impact and duplicative administrative costs demanded change. The legislature put statutory teeth in the plan; the current 23 Local Management Entitites will become 11 MCOs.

Forsyth, Stokes, Davie and Rockingham counties got on board with waiver in 2010 when they endorsed CenterPoint's pursuing MCO status. Now waiver will be in operation locally on Jan. 1, 2013. County, state and Medicaid funding will be publicly managed by CenterPoint under a cohesive administrative structure capped at 9.5 percent overhead with a focus on maximizing quality services and positive improvements in individuals' lives.

Waiver is not the total answer. Waiver does not eliminate concerns over the historically low level of funding for services, but it is a positive step in establishing a comprehensive system that is outcome focused, fiscally responsible and clinically sound. That is what consumers, families and communities expect and deserve.