Community Support fiasco redux? The weekly rate for case management

After the problems created by the North Carolina Department of Health and Human Services through the Community Support service definition and billing structure, resulting in over $400 million in waste and a sharp decline in service quality, Department leadership needed to take a close look at how financial incentives influence the delivery of services.  It had been apparent from the time the draft service definition for Community Support was released that the new scheme was going to encourage providers to use less qualified staff to provide services in order to increase the bottom line.

 One need not be an economist to understand that if you set up a system which pays the same rate ($64/hr.)  for a service performed by someone with a high school diploma as someone with a master’s degree, and authorize each to perform essentially the same services, businesspeople will tend to utilize staff that are cheaper to employ in order to maximize profits.  The Department failed to grasp basic capitalist principles that the new system was founded on.

One of the driving forces behind mental health reform was the notion that the invisible hand of the market would insure that the system would be transformed into a more effective and efficient one, because public providers are inherently lazy and wasteful, and those in the private sector are high-performing.  You will not find this belief articulated in the Blueprint for Change, but it was key to shaping reform.  This idea was pushed by lobbyists for large provider companies, and only continues to gain currency in today's political environment.  Privatization, some would have you believe, is the answer to all of societies problems, from fighting wars to supervising parolees. 


Through reform, responsibility for the care of the state’s most vulnerable citizens was transferred from people who saw themselves as public servants, doing what needed to be done because they were responsible, to people who see themselves as purveyors competing for revenue in the private marketplace. It seems that administrators in the Department, many of whom have been public servants for decades, have not made the necessary shift to a more capitalist mentality.    

By introducing a weekly case rate for case management services, the Department has again developed a service and reimbursement schedule that invites both fiscal abuse and reduced service quality.  Case managers will bill $81.25 for the first 15 minutes of service per week.  It’s a different scheme, founded on the same faulty assumption that sealed the fate of Community Support.  The assumption is that providers will adhere to an ethical code and do the right thing for consumers, without regard to financial incentives.  What is the incentive in this case?  Provide 15 minutes of service per consumer, per week and no more, regardless of clinical necessity.  The provider agency will be paid $81.25 if they provide 15 minutes or 15 hours of service to a consumer. 

Mental health providers are not an inherently greedy lot, but they live in the same capitalist society as everyone else.  The incentive to exploit this easily exploitable payment structure will only be exacerbated by the fact that providers have been treated badly by the state, with reduced reimbursement rates (some retroactively imposed), expensive mandatory trainings, and constantly shifting regulations. 

I am not an economist or a railroad engineer, but the light at the end of the tunnel is looking a lot like a train.

Welcome!

Welcome to the new blog for Mental Health America of the Triangle!

MHA of the Triangle was formerly  the Mental Health Association in Orange County.  We are now affiliated directly with Mental Health America, the nations oldest mental health advocacy organization.  With our new name, we promise to continue to provide the same kind of innovative solutions, advocacy, and education that we have been providing since 1966 to the wider Triangle community.

We will be bringing information and discussion about mental health and agency related topics here.  Please share your thoughts and ideas with us!