Rutherford County commissioners want to switch from one regional state agency managing behavioral health services to another similar agency, but the effort could bring turmoil to clients as well as disrupt procedures for making such a change.

Commissioners are asking to disengage from their current local management entity and managed care organization, Asheville-based Vaya Health, and switch to Partners Behavioral Health, an LME/MCO based in Gastonia.

Following a multistep process, the switch would become final only if N.C. Department of Health and Human Services Secretary Mandy Cohen signs off on it. A spokesperson for DHHS told Carolina Public Press that this could be a high hurdle because of the instability it could promote at a sensitive time.

The commissioners’ stated reasons for switching include no specific objections to Vaya, the absence of which could make this a precedent-setting move in North Carolina. While it’s not clear whether anyone tied to Partners solicited the move, such competitive behavior between state agencies would also be unprecedented.

When Carolina Public Press asked a spokesperson for Partners whether the agency or its lobbyist played a role in soliciting the move, she did not deny it. Instead of saying yes or no, she wrote, “I’d direct you to Rutherford County for more information about their process for seeking the best alignment (for services) in their county.”

Rutherford County officials did not respond to any inquiries from CPP prior to publication.

Regional agencies

LME/MCOs like Vaya and Partners are government agencies assigned to regional districts for the purpose of using Medicaid and state money to administer mental health, substance abuse, and intellectual and developmental disability services.

According to the UNC School of Government, these agencies take the resources allocated to them to provide these services through their own network of private providers. Currently, there are seven of these agencies.

Mark Botts, a specialist on the state’s mental health system at the School of Government, told Carolina Public Press that any such changes would result in movement of Medicaid dollars for that county from one LME/MCO to the other.

North Carolina statutes and administrative code describe a clear process for a county to switch from one LME/MCO to another. In practice, only two counties have ever used it.

Nash County left Eastpointe after a former executive of the LME/MCO received an embezzlement conviction. Columbus County commissioners also expressed dissatisfaction with the services of Eastpointe, based in Beulaville in Duplin County. Cohen later approved their request to switch to Greenville-based Trillium, which will be effective July 1.

In their request to disengage from Vaya, Rutherford commissioners described no such criticism of their current LME/MCO. Instead, they talked about the many excellent services they associate with Partners without stating directly how those compared with Vaya’s programs.

They did allege that dealing with Vaya is inconvenient for Rutherford residents due to geographic issues. The eastern slopes of the Blue Ridge Mountains run through western Rutherford County, near communities like Chimney Rock and Lake Lure. But the bulk of the county’s population resides in its southeastern corner in towns that include Rutherfordton, Forest City, Spindale and Ellenboro.

Many county residents are accustomed to traveling east into larger towns in Cleveland County, such as Shelby and Kings Mountain, for goods and services, including health care.

“From a commuting pattern and ‘citizen flow’ perspective, Rutherford County aligns well with Cleveland County and shares much in the way of normal flow of residents,” Rutherford County’s disengagement letter states.

“There is a greater sense of connection to Cleveland County for most local citizens than traversing the mountain to reach Asheville for goods and services, including health care.”

However, these geographic and demographic features aren’t new. Vaya and its predecessor agencies have been navigating the terrain in Rutherford County since 2004.

Some 20 Vaya staff members work in Rutherford County and would be affected by a change. This includes a care coordinator who works out of Rutherford Regional Health System.

Vaya currently provides services to nearly 3,000 Rutherford County residents. Many more may seek such services over time. All of them would potentially be affected by the proposed change.

Commissioners unanimously passed a resolution to disengage at their April 9 meeting.

In theory, the process would take nine months before Secretary Cohen’s final decision. Included in this is a 60-day public comment period along with an additional 30 days for reviewing the comments.

However, the county’s disengagement request doesn’t designate a target date for the switch to become effective, instead indicating plans to ask for a waiver of that period. Botts suggested that could pose a problem: Without a known starting date, as required by statute in the disengagement letter, the clock won’t have started ticking on the nine-month wait in case commissioners’ request for a waiver is unsuccessful.

Although Rutherford County has voted, notified some of the necessary parties and posted notice of the planned change to its website, a spokesman for DHHS said Tuesday that the county has not yet formally submitted its request to DHHS.

The county may face an additional hurdle that discourages, not just a waiver of the nine-month waiting period, but approval of the change itself.

“During this period of transition to Medicaid managed care, if (DHHS) were asked to evaluate any disengagement … requests, it would be required to consider the impact on the stability of the health care system and would likely find granting such a request to have a negative impact,” the DHHS spokesman said.

Botts additionally noted concerns about the lack of specificity in the county’s rationale for switching, which would be one of the items Cohen will evaluate when making a decision. The statute also requires her to weigh the content of the public comments the county receives about its proposal.

Communications on switching

Rutherford County initiated the discussion about the proposed change, according to Rachel Porter, Partners senior director of marketing and communications.

“Partners was pleased to respond to Rutherford County’s invitation to join county commissioners, providers and community stakeholders to discuss the future path for intellectual/developmental disabilities and behavioral health care services in their county,” she said in an email.

Allison Inman, Vaya senior marketing and communications director, said her organization found out about the commissioners’ vote the day after.

“It’s a little bit concerning considering all the things we’ve been doing in the county,” she said. “It’s concerning to us. We’ve not been able to have any contact with them beyond our public comments.”

During a May 7 Rutherford commissioners meeting, Vaya board Chairman Rick French asked for a meeting with Rutherford County commissioners. Inman said there has been no response to that request or the other multiple requests the organization has made.

“We just wanted to make sure we are available to answer questions from our members to the best of our ability,” she said.

Vaya CEO Brian Ingraham sent a letter to Rutherford County residents on May 4 that stated no county official involved the Asheville-based MCO in the proposed decision to switch from Vaya to Partners.

“We were not asked to provide information about how the decision will impact members and services in Rutherford County,” Ingraham stated. It stated further that it appeared residents who currently receive Vaya services were not consulted.

After the public comment portion at the May 7 meeting, Rutherford County Commission Chairman Bryan King publicly expressed his frustration about Ingraham’s letter.

“By taking this action, Mr. Ingraham demonstrates his clear disregard and disrespect to Rutherford County and our legislative protected right to realign with a different LME/CMO,” he said.

“It’s concerning that the tone of this letter is intended to create fear and anxiety for the county’s most vulnerable families rather than highlight what you believe would be Vaya’s strengths.”

Relying on services

Tom Elkins is a father of a son who needs 24-hour care and was against making the change. He has been using Vaya and said he likes its services, he told commissioners during public comments on May 7.

“Every time you change, there are challenges that come with that change that not only impact the individual (who) needs the care, but … everyone throughout the community,” Elkins said.

He wanted to know the motivation for the proposed change.

“In 20 years, trying to find good caregivers in this county and retaining them is very difficult,” he said.  “It was a huge blessing for us when Vaya came on the scene.”

Vaya board member Nancy Baker was one of three representatives who also spoke at the May 7 meeting.

“As a board member, I’m deeply concerned about the impact of the proposed disengagement from Vaya would have on members,” she said.

“Any changes, whether if it’s a different provider or different service is disruptive, and it could cause a setback in a person’s recovery or treatment.”

She said 2,779 Rutherford County residents are currently receiving Medicaid or state-funded mental health, substance abuse or intellectual developmental disability services. Baker said there are 634 county residents that have complex needs and work with a care coordinator from Vaya. Care coordinators make sure patients receive the correct amount of care at the right time.

“Being reassigned to a different care coordinator or losing services altogether could be traumatizing for a member,” Baker said.

Ingraham said he was concerned because some of the providers with Vaya are not in the Partners network.

“We also offer some unique services like Long Term Community Supports and Intercept that are not currently available through Partners,” Ingraham said.

However, two officials with the Gastonia-based LME/MCO said that service levels would remain the same.

Partners CEO Rhett Melton said at the May 7 meeting that all providers that currently serve county residents could join Partners. He also said his organization seeks to grow its services.

“Change is hard,” he said. “Change is difficult, but oftentimes change can be an improvement. The worst thing that could happen is for something in this transition to fall through the cracks.”

Jean Harris, another Partners official, said at the June 4 commissioners meeting the agency is committed to keeping all services in place, if the change occurs.

“Unfortunately, that cannot be stated with absolute certainty for a variety of reasons,” said Vaya board member Pat McGinnis at the June 4 county commissioners meeting. Providers in the Partners network would have to go through a credentialing process, she said. Also, Vaya currently has services Partners doesn’t offer.

N.C. Department of Health and Human Services policy states that providers impacted by the decision to disengage must be sent a notice.

One of those services is the work with Youth Villages, which helps youths transitioning out of foster care. The other is long-term support for those waiting on a state-funded innovations slot, which offers intellectual and developmental disability services.

Vaya was also the first LME/MCO to purchase Narcan, a prescription medicine used for treating opioid overdoses. Inman said most of the Narcan in the state was purchased by Vaya and that there have been six overdose reversals in Rutherford County.

“We’re kind of scratching our heads about it,” Inman said about Rutherford’s proposed switch. “We feel like over the past couple of years, we’ve worked together in the community to help those that need it most.”

To learn more:

Rutherford County Commissioners May 7 meeting video

Rutherford County disengagement letter

How to provide comments on plan

LME/MCOs in North Carolina, previous reporting from CPP

Editor’s note: CPP Managing Editor Frank Taylor also contributed to this report.

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