Mecklenburg County’s mental health patients are being denied care they have grown accustomed to, after a statewide reorganization cut money available for Medicaid mental health. Mecklenburg County set up the agency, MeckLINK, to manage the remaining funds. The agency's officials blame the state for cutbacks, but providers say denials to patients for service exceed the amount cut by the state.
17-year-old Taylor Christie was coming home to Matthews, after a year in a locked treatment facility and then in a therapeutic foster home. Her mother Barbara was worried.
“She has all this anger pent up and when it erupts, it erupts toward me,” Christie says.
Taylor’s been diagnosed with a variety of mental health conditions, including a mood disorder and oppositional defiance disorder. Taylor’s therapist had recommended Intensive In-Home treatment, where counselors visit the family a few times a week. MeckLINK denied the request.
“That would be the next step when she came home from therapeutic foster care,” says Christie. “If we had had it, I think we’d be in a different place.”
Soon, Taylor began having violent episodes again. She will hit and bite her brother and mother. During one episode about three weeks ago, Christie had to call the police. They arrested Taylor, but Christie blames the lack of care, and not her daughter.
“She’s not a bad person, she doesn’t need to be in jail, she just needs the services she needs,” says Christie.
Taylor’s back home with her mother, although with charges against her. But county health providers say Taylor’s story has become alarmingly common since MeckLINK began overseeing Medicaid funds in March. Mark Brown, the owner of Mélange Health Solutions—Christie’s mental health provider for about a decade—says since MeckLINK took over, more than half of his client’s requests have been rejected, and crisis calls have increased 50 percent.
“We thought it was just you had new staff who hadn’t done this before, but when this continues now for three or four months, you understand that this is not a learning curve, it’s a strategy,” Brown says. “The strategy seems to be that there is a certain amount of approvals that just won’t happen, regardless of whether or not the clients meet the criteria for services or not.”
Other providers tell a similar story, putting their denial rate at 30 or 40 percent. MeckLINK itself issued a report in June that showed the number of people receiving In-Home Intensive Treatment—which Taylor Christie was denied—has been reduced from about 1,500 people to 600. While providers blame MeckLINK, MeckLINK’s chief financial officer Ken O’Neil blames the state for the cuts.
“The rules changed, and MeckLINK didn’t change the rules, the state changed the rules,” O’Neil says.
Providers used to bill Medicaid directly. There were very few denials and costs were high. To control those costs, lawmakers put regional organizations, like MeckLINK, in charge of managing care. The state estimates what it thinks the county should be spending, and then gives the money up front—over $200 million in MeckLINK’s case. That amount is still a 10 percent cut from last year’s costs, so agencies have to cut expenses to live within those means. O’Neill says the providers who are complaining have to adjust to the new system.
“If there’s an expectation on the part of the provider that it’s business as usual, that they can have everything they want—not necessarily everything they need—in the same fashion as they’ve had in the past, it’s a false expectation,” he says.
O’Neil says expensive programs like Intensive In-Home Treatment are overused, and there are cheaper alternatives that patients need to try first. This clash between providers and managed care organizations (MCOs) is happening all over North Carolina, according to Knicole Emanuel, a partner at the law firm Williams Mullen in Raleigh, because the system makes it profitable to deny patients care.
“Their incentive as an MCO is to not authorize services, especially very expensive services,” says Emanuel. “Because if they don’t authorize services, then they have extra profit.”
When it comes to MeckLINK, the stakes are high. Mecklenburg is the only county to start its own MCO. The county’s poured over $7 million into the agency and waged high-profile fights with the state to keep it in service.
But at a July meeting of the county commission, O’Neil revealed that MeckLINK is on tenuous financial footing. It ran a deficit in May and June at a rate that would put it out of business in less than a year. O’Neil says the agency had a better July. He also argues those deficits are proof that MeckLINK isn’t sacrificing care for profit.
“If we were withholding services, if we were paying a disproportionately lower amount, then we would be reporting to the Board of County Commissioners that our disbursements were way lower than what we were actually being paid,” O’Neil says. “I can assure you that what we’re paying presently is very close to what we’re actually being paid.”
But providers say that MeckLINK has denied requests at a higher rate than any of the other regional organizations they work with.
It is difficult to tell definitively who is right, because of another state change. Once MCOs took over, North Carolina stopped tracking what care patients are receiving. A health official said the database goes blank. That means the state does not know how many North Carolinians received services, what those services were, or what was denied. It can compare MCOs financials, but not their care.