Mental health management should stay local

Jun. 21, 2013 @ 12:31 PM

As a medical director of a local mental health nonprofit, I have been following closely the recent proposals to contract the management of North Carolina Medicaid mental health benefits to out-of-state corporations.
As we seemingly race toward another round of mental health reform, I am reminded of my first experience with mental health reform. About 10 years ago, while I was a resident in psychiatry, I attended a presentation to community providers about the changes that were being made during our last round of reform. I remember being struck by the anger and outrage of the audience of mental health professionals at that time.
Now, I hear few protests from my colleagues about the latest proposed changes. Our field has been traumatized by the last round of reform and the personal and professional fallout. Many of our most experienced providers left the field or retired after the last round of reform, and those hired in their place may be much more inexperienced in the field and working in much more temporary positions than their predecessors. Lastly, many professionals are simply exhausted after spending 10 years working to improve the system from the last round of reform.
There are two basic reasons why the privatizing management of mental health and substance abuse benefits to out-of-state corporations is bad for North Carolina citizens. First, I think this privatization will harm the work that has been done in North Carolina over the past 10 years to improve the system, and also because a top-down, one-size-fits-all, whole-state approach to managing mental healthcare is not the right solution for very local mental health and substance abuse problems.
Because of we have so few state hospital beds, mental health and substance abuse crises occur in the community. The fallout from mental health and substance abuse problems involves family members, law enforcement, schools, crisis centers and hospitals. Many people may not understand that developing good, cost-effective mental health solutions for a community requires tremendous coordination from many different parts of a community, including the police departments, county sheriffs, corrections, public health departments, universities, hospitals, schools, non-profits, and county and city governments.
While our current system has flaws, the Managed Care Organizations (MCOs), based out of our state regions, have made and are making an important contribution towards improving case coordination and integration of our different systems. Local is better. Having regional, North Carolina-based non-profits as MCOs ensures local communities have a local agency that understands the needs of the community and have accountability for improving the system, improving outcomes for patients, as well as ensuring that care is cost effective.
I believe the current size of the MCOs is about right -- large enough to address system problems but still accountable to local governments. The MCOs are helping local communities to work together to find solutions that work in that community. What may require a crisis center in one community, may be able to be done from an emergency room in another. We should let local communities find their own solutions rather than mandating from Raleigh or a call center in another state (or country!).
Fundamentally, we must maintain a stable business environment where MCOs can effectively partner with local non-profits. This can allow MCOs, over time, to leverage resources strategically from mental health resource-rich areas into some of our more mental health resource-poor areas. The stability of our mental health non-profits is crucial for continuity of patient care and providing a stable workplace for our mental health professionals.
Effective, coordinated mental health systems in our local communities are not created by the free market, but instead require the kind of local, coordinated effort that the MCOs are already performing. We need to look no further than the experience of our neighboring state, Tennessee, which has tried privatizing Medicaid mental health care to see that this experiment would neither save money nor result in better care mental health care for citizens of North Carolina.    
Dr. Logan Graddy is medical director of Freedom House Recovery Center Inc.