The Transylvania Times -

Mental Health Services Facing Financial Crunch – Transylvania County, NC


Last updated 3/10/2020 at 9:26am

Vaya Health, which oversees funding for services related to mental health, substance abuse and intellectual/developmental disabilities in 22 counties, including Transylvania, is under “severe financial stress,” according to County Commissioner Page Lemel.

During the recent Transylvania County Board of Commissioners meeting, Lemel referenced Vaya’s financial situation.

Vaya manages Medicaid, federal, state and local funding, working with various agencies, such as the nonprofit Meridian in Transylvania County, to provide the necessary services to more than 1 million people in the region eligible for prevention, treatment and crisis services.

Lemel serves on Vaya’s Board of Directors and is the chair of the Health & Human Services Steering Committee for the N.C. Association of County Commissioners.

Lemel suggested some have the misconception that Vaya has plenty of funds, noting there is $47.8 million in its Medicaid Risk Reserve fund.

That money, however, cannot be accessed by Vaya, as explained by Larry Hill, Vaya’s chief finance officer, in a letter to county representatives.

“The most blatantly misleading aspect of the misrepresentation of the LME/MCO’s (local management entity-managed care organization) cash position has to do with including the Medicaid Risk Reserve in the cash available for LME/MCOs to spend,” Hill said. “The Medicaid Risk Reserve funds may be spent only in the case of insolvency to pay claims of providers and must receive the prior written approval of the N.C. Department of Health and Human Services.”

The restricted and unavailable Medicaid Risk Reserve is approximately more than 50 percent of Vaya’s total cash and investments of almost $93.2 million as of Dec. 31, 2019.

There is a “big disconnect,” Lemel said, at the state level over “understanding how LME/MCOs operate.”

She said there are only a few General Assembly members who understand the LME/MCOs’ structure. Lemel was also critical of State Auditor Beth Wood, who, Lemel said, characterized the LME/MCOs as being “loaded” and needed to spend down their fund balances.

“Well, they have spent their fund balances now, and the organizations are coming to a crisis point,” Lemel said.

Lemel said it was difficult to get the “word out” and “educate the right people” on the importance of single-stream funding. The current funding model, she said, particularly impacts those who don’t qualify for Medicaid services and don’t have insurance. Lemel said an additional problem is not having an approved state budget.

Commissioner David Guide agreed that there are not enough people in the General Assembly who understand the LME/MCO structure and the lack of a state budget.

“It’s a huge, huge problem – if talking about shutting down behavioral health services,” he said. “It would create major issues for this community.”

Lemel also mentioned a related concern.

The county’s Department of Social Services’ Adult Protective Services, for example, made 400 calls trying to find a space for one individual.

Commission Chairman Mike Hawkins said the county would continue to work on the issue, including reaching out to the county’s two state lawmakers, N.C. Sen. Chuck Edwards and N.C. Rep. Jake Johnson.

Meridian Behavioral Health Services is the only provider in Transylvania County that offers Assertive Community Treatment (ACT) services for individuals who do not qualify for Medicaid. ACT and Community Support Team (CST) services for uninsured and underinsured individuals will be restricted to targeted populations beginning June 1, according to Allison Inman, a Vaya spokesperson.

“Based on our records, this change will impact five individuals in Transylvania County,” she said. “Over the next 60 days, Meridian staff will work with those individuals to transition them to other services and supports. Transylvania County residents will continue to have access to an array of other state-funded services: outpatient therapy, medication management, peer support, psychosocial rehabilitation and supports through Meridian’s recovery education center. Residents will also continue to have access to crisis services.”

Vaya’s CEO Brian Ingraham also said his organization would “scale back assorted services to individuals without Medicaid coverage as a result of ongoing funding reductions.”

This will occur, he said, “most notably” with behavioral health urgent care programs at The Balsam Center in Jackson County and at C3356 in Buncombe County.

“There are other assorted reductions to services to this same non-Medicaid populations throughout our 22 county catchment area,” he said. “Again, (this is) related to multiple years of cuts made in state budget appropriations that have come down to us.”

More than $41 million (net) in single stream funding has been cut from Vaya’s budget over the last five years, according to Inman.

Along with county and block grant funds, these are the only funds available to pay for mental health, substance use disorder, and intellectual and developmental disabilities services for individuals who do not qualify for Medicaid (individuals without insurance or too little insurance).

Until now, Inman said, Vaya absorbed single-stream funding reductions internally by using savings to pay for services, reducing non-essential functions, eliminating positions and reducing administrative overhead. This approach means that Vaya’s counties and providers have not yet experienced the full impact of the statewide reductions, she said, and Vaya continues to lead the state in providing non-Medicaid services to eligible members who are uninsured or underinsured. Unfortunately, Inman said, Vaya can no longer continue to absorb the impact of ongoing single-stream funding reductions.

Other Mental Health Issues

After last week’s Board of Commissioners’ meeting, County Manager Jaime Laughter noted that mental heath was the focus of the recent Family Dinner Series, a part of the Get Set project.

She said the event attracted 87 participants, indicating to her “the relevance and concern that is growing in the community on mental health.”

A panel at the event included Dr. Will Dalton, a local pediatric psychologist.

Dalton indicated he has a waiting list of four months, with a demand and need for services, Laughter said.

“The growing needs in our community for mental health services and the increasing severity of needs at younger ages is increasingly taxing on an anemic system of mental health services,” Laughter said. “The issues that we are seeing are those that could have impacts throughout the community on a general basis that will take generations to recover from – much like the intricately related opioid crisis. Solutions will take evaluating adequate funding and systemic response in a collaborative way throughout all levels of governance, including our nonprofit and business communities. However, this complicated and coordinated approach will not take place without consistent and salient advocacy.”

Laughter also passed on comments made by Dalton, who has been operating a private practice out of Hendersonville Pediatrics since 2015 and currently is contracted a few hours per week at Hillview Head Start.

“This past year I have seen the biggest increase in needs across all age groups,” he said. “As Jaime mentioned, my wait list to get in patients for a first visit has grown longer and longer. In the fall I had to place a freeze on taking any new referrals at all because I had several families return who I had seen in the past and there were beginning to be no openings for follow-up visits. I typically see around 150 new families per year and that is with me there just two full days per week.

“In addition to Meridian, I frequently refer to two other child therapists, or license professional counselors, in Brevard that accept Medicaid. One typically has a four-month wait and the other is now up to about a six-month wait. Many families will accept a referral to Meridian and some will not. We are thrilled to have a new counselor, Abbey Bruce, LPC, at the Child Advocacy Center who takes Medicaid and sees ages 3-18 and does only trauma work.

“She has only been here a couple of months, and we plan to have her caseload full in another week or so as I and others have been sending lots of referrals. We hope they will be able to hire another counselor who is trained in evidence-based trauma therapy, specifically parent-child interaction therapy, to serve our younger children and parents.

“We are observing more significant behavior problems younger and younger in the preschool setting that require one-to-one attention that takes teachers away from the rest of the class and prevents them from doing what they do best – teaching. These same children continue to struggle in elementary school, and as they move forward, we see increased rates of trauma beginning at infancy, increased rates of severe behavior problems at school and home, and increased rates of teen anxiety and depression.

“There is a desperate need for more intensive services than can assist families in the home, in the classroom, services that can assist families that have children with autism (we currently don’t have any in the county) and services that can reach teenagers, including those who miss significant amounts of school.”

Dalton said families with insurance also face challenges.

“Whereas families with private insurance and the ability to self-pay have a few additional options for child counselors/therapists, they typically do not have access to more intensive services,” he said. “For example, intensive in home services and day treatment services are not available to families unless they have Medicaid.

“Similarly, whereas Medicaid will often pay for diagnostic evaluations (typically $500-$2,000), for complex concerns private insurance may only cover a small portion, if any, of this fee. This is a significant problem as behavioral health concerns are not restricted to a specific (socioeconomic status) SES group.”

As previously reported, local school officials have also complained that current mental health services are inadequate to meet the school system’s needs.

It was noted the school system has had five different private mental health services providers since the 2006-07 school year, with Meridian as the current provider.

School officials, however, did not blame Meridian for the current situation.

“To be fair, Meridian’s in a tough place,” Superintendent Jeff McDaris said during a Board of Education meeting.

“Mental health funding in the state is not where it needs to be,” said McDaris. Don Buckner, Meridian’s CEO and medical director, said that as a nonprofit agency, Meridian has the “mission to provide behavioral health and substance-use services to anyone who is in need, whether they have an ability to pay or not.”

“We have partnered with the schools to find ways to provide services, such as day treatment for children even if they do not have Medicaid or another payer source and do not turn down children for services,” he said. “In cooperation with the district, we made the decision to close the day treatment program at Brevard Middle School in order to expand the program at Pisgah Forest Elementary.

“Children at Brevard Middle School continue to receive support through school-based outpatient services and intensive in-home services.

“As noted, Vaya has reduced state-funding for ACT services, which currently affects five consumers in Transylvania County. We are committed to providing the level of service those consumers need, and if other services are not adequate or available, we will continue to provide ACT services.”

Lemel said she will work with school staff to address mental health services and that she and Laughter are planning on a “larger meeting with a deep dive into the issues with actual services within the county and the challenges citizens are facing.”

“We will be including the community stake-holders, the overarching management entities and our legislators to look at opportunities for solutions,” she said.


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