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Big Changes For Developmentally Disabled In NC

This shows that Piedmont Behavioral Health costs have increased very slowly when compared to the fee for service system. Image

This shows that Piedmont Behavioral Health costs have increased very slowly when compared to the fee for service system. Image provided by PBH. Big changes are underway in how North Carolina determines services for people with developmental disabilities. In an effort to control costs, the state is adopting a new model that takes a fresh look at how much support developmentally disabled people on Medicaid need. The new model is specifically for people who receive services in a home setting. Some of the roughly 11,000 affected may get additional services, but others are losing support they depend on. It's a controversial change that disability advocates say emphasizes cost over care. Why is the state switching models? The biggest reason is to control costs. In about the last decade, the number of people on Medicaid receiving developmental disability services in a home setting has more than doubled to roughly 11,000. But North Carolina isn't very good at handling the cost of those services. It spends about $12,000 more per person than the national average, according to the Human Services Research Institute. On top of that, there are still about 7,000 people on a waiting list. State lawmakers want to serve more of those people. They look at the new system as a way to control costs and use the savings created to get people off the waiting list. Khalil Collins' back is really hurting. Life in a wheelchair can do that to you. So Mom steps in. "So now I'm getting him up under his arms," Africa Heath said, " and lifting him up. Stand up - so he'll stand for me." For a rare moment, Heath and her 14-year-old son stand eye to eye. Khalil has cerebral palsy. "And I just turn him, and transition him to the couch," Heath said, straining under the weight of her 100-pound son. It's one of many things - really, almost everything - Khalil needs help with. He said Mom is always there. "Taking me a bath, and getting me ready for school and stuff," Khalil said. "She cut my food up for me, and I just eat it when she cut it up." Heath is a single mom. She works full time and has two other kids at home. And lately, Khalil depends on her even more. He's been hit with an $11,000-cut in developmental disability services. That means a loss of about 400 hours each year in at-home services paid for by Medicaid. Under a new formula, it was determined that Khalil doesn't need as much help, in part because his mom can take care of him and he goes to school. But before we get into that, you need to understand how the old system worked, and you need to know what a "local management entity" is. We'll call it an LME - that's what the experts do. Years ago, North Carolina created LMEs to monitor the services on a local level. LMEs are something between a non-profit and a government agency, kind of like an airport authority. Care providers billed Medicaid directly, and the state had people decide case-by-case if an individual was getting enough support. Dave Richard of advocacy group The Arc of North Carolina said there were lots of checks and balances. But now? "In the PBH managed care model that goes away," Richard said. PBH is Piedmont Behavioral Healthcare. It's the LME for five counties, including where Khalil lives in Union County. Things started to change about five years ago. PBH convinced the state to let it try something new - let the Medicaid money go directly to PBH. The theory was it could do a better job managing the services than the state. But Richard said it gives PBH too much power over people's lives. "The agency who now controls all of the funding now writes the plan for the individual, determines how much money they'll get, does the assessment that sort of links them to that determination, and is the agency that you appeal to if you don't believe what you're getting in the level of services is appropriate," Richard said. But PBH said it's not that simple. For one, there are federal requirements it has to meet. And by state law, 91 percent of the Medicaid money it gets must go to services. But this year, PBH took its new system a step further, and this is where Khalil comes in. It started using a new method to determine exactly how much support someone needs. Pam Shipman, Piedmont Behavioral Healthcare's CEO. Pam Shipman is Piedmont Behavioral Healthcare's CEO. "You have to assure Medicaid that people are not over-served and they're not under-served," Shipman said. Here's how PBH figures that out: "This is actually the Supports Intensity Scale," Andrea Misenheimer said as she pulled out the eight-page written assessment. She's PBH's director of Medicaid programs. "What we actually measure is what kind of support and how much support do you need to do all of these things," Misenheimer said. Examples are using the bathroom, communicating with others, and getting to school or work. PBH also factors in age. "Children can attend public school, so you don't have a cost for a day program or a job program for those individuals," Misenheimer said. And PBH considers where someone lives. "People who live with their private families clearly have supports that are not paid," Misenheimer said. "So Medicaid doesn't have to fund that." Remember Khalil? Even though he needs help with almost everything, he's losing funding because he's in public school and lives with his mom. He's one of about 170 people PBH determined were over-served. But Shipman, the CEO, said PBH found more people were under-served, although she couldn't say how many. They will likely get additional services in the new system. "You're getting people to the right care, making sure they get enough care, and people cost less if they get what they need," Shipman said. That's the idea: to save money by paying for exactly the care developmentally disabled people need - no more, no less. But Vicki Smith of Disability Rights North Carolina said that model puts too much emphasis on costs. "We're very worried that people who have been stable and not going into crisis will be looked at as someone driving a Cadillac," Smith said. That's kind of what happened to Khalil. Smith said taking away services from him and others like him could put their health in jeopardy. But Shipman, the PBH CEO, said there's another group of people to think about in all this: the roughly 7,000 throughout North Carolina who are on a waiting list for developmental disability services. "This will help the state be able to plan for these people that don't have anything," Shipman said. First the state needs to see how much money it does save from the new model. The transition for the roughly 20 other LMEs will take place over the next two years.