Lake Lure Dam forms Lake Lure on which the town of the same name is nestled, on the Rocky Broad River in western Rutherford County. Colby Rabon / Carolina Public Press

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If Rutherford County goes through with a plan to stop receiving behavioral health services through Vaya Health, the agency has claimed that residents will face unnecessary instability and reduction in some services.

County commissioners and representatives of Partners Behavioral Health Management, the regional agency to which commissioners are seeking to switch, have strongly rejected that claim and accused Vaya of fearmongering over a letter that Vaya CEO Brian Ingraham sent to service providers and care recipients.

In interviews with Carolina Public Press this week following an initial report on the situation earlier this month, representatives of all sides doubled down on the claims and counterclaims, as well as their expression of outrage over the actions of the other parties.

But Asheville-based Vaya and Gastonia-based Partners aren’t private companies in competition with each other. They are two of the seven Limited Management Entity-Managed Care Organizations, commonly called LME/MCOs, which are taxpayer-funded regional governmental entities through which the state distributes funding for behavioral health and related services.

As Rutherford County attempts to switch LME/MCOs, key questions have emerged, not just about whether residents will see a change in services, but also whether they experienced problems with existing services, why and how the county decided to do this, and how the process has worked and will work.

Vaya Health’s headquarters is located in Asheville in Buncombe County, which is just west of Rutherford County across the high easternmost ridge of the Blue Ridge Mountains. Photo courtesy of Vaya Health

Loss of services?

“We offer some unique services like Long Term Community Supports and Intercept that are not currently available through Partners,” Vaya CEO Ingraham wrote to Rutherford County residents in a May 4 letter. “We have already heard from members and providers who share our concerns. We want to be sure all of our members are aware of the Commissioners’ decision. You have the right to be heard if you disagree with the decision and want to continue to have your services managed by Vaya Health.”

Brian Ingraham is chief executive officer of Vaya Health. Photo courtesy of Vaya Health

Neither side disagrees that this letter sparked concern among those who received it.

“Those comments were intentional,” Ingraham told CPP this week. “People were not aware of what might happen.” He also described getting calls from care providers who were concerned, leading him to write the letter.

Brian King, chairman of the Rutherford County Board of Commissioners, sees the situation differently. He sharply criticized Ingraham for spending Vaya resources on a direct mail campaign to disseminate what King found to be a misleading letter.

Regarding the mailing costs, a Vaya spokesperson has said it came from the agency’s administrative budget and did not take any funds away from services.

Partners has pushed back against Ingraham’s claims on multiple fronts. Appearing alongside Ingraham on June 15 at a Vaya meeting with its providers at Isothermal Community College in Spindale, Partners Chief Operating Officer Will Callison told attendees that Partners intended to continue offering all services currently offered in the county under Vaya.

“We’re not not offering certain services that have been offered in the past,” he said.

Talking with CPP this week, however, Ingraham rejected the idea that Partners is already offering or will soon offer the services in question.

“It isn’t even close to being that simple,” he said.

Jesse Smathers, special populations clinical director for Vaya, talked with CPP on Thursday about specific programs the LME/MCO offers that differ from those available elsewhere.

“Many adults with intellectual and/or developmental disabilities (IDD) have Medicaid,” Smathers said. “Historically, the only Medicaid IDD-specific services available to people with IDD have been NC Innovations, a home- and community-based services program that is only allowed to serve a set number of people each year, and intermediate care facilities for individuals with intellectual disabilities (ICF-IID), residential and day services limited by the number of licensed placements available in the state.

“All other services that may be accessed by people with IDD are funded by allocations from the state legislature and are limited by available funding.”

Smathers and Ingraham described an innovative approach that Vaya took to getting around this funding issue.

“We sought and received approval from the N.C. Division of Medical Assistance (DMA) to offer a service called Long-Term Community Supports (LTCS),” Smathers said.

“This service is offered ‘in lieu of” ICF-IID. It allows adults with IDD to receive comprehensive community-based services while they either wait for an NC Innovations funding slot or an ICF-IID residential placement.

“This service supports adults with IDD (and who) have Medicaid to live with family and attend day activities, live in their own apartments and participate in day activities, or live in roommate situations with other disabled adults and attend day activities. We implemented this service in partnership with our IDD providers in November of 2016.

“This service has not been implemented by Partners,” Smathers said.

“Because of our implementation of the ‘in lieu of’ LTCS service for people with Medicaid, we have been able to continue state-funded services to adults with IDD that do not have Medicaid. These services include Adult Day Vocational Services and Individual Habilitation. These services have been either frozen or discontinued by other managed care organizations in the state. For example, Partners has not allowed new admissions to Adult Day Vocational Placement since July 2017.”

Smathers conceded, however, that in theory it was possible for Partners to add comparable services over time, essentially by copying what Vaya has been doing.

Asked about the services Smathers described, Partners spokesperson Rachel Porter said Partners is already transitioning in that direction.

“Partners has received approval to provide Long-term Community Supports,” Porter said Thursday. “It will be launched throughout our network well before a transition into Rutherford County. Partners is dedicated to ensuring that Rutherford County consumers receiving this service will experience no lapse in care.

“Further, Partners is committed to ensuring continuity of care for all Rutherford County consumers. Any Medicaid services being offered by Vaya in Rutherford County that are not currently in the Partners service array will be added to Partners prior to the date of engagement with Partners by the county.”

Despite the back and forth over whether residents will lose services through a county switch to Partners, these type of service questions did not drive the Rutherford commissioners to seek a switch in the first place.

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A vehicle crosses the roadway across the Lake Lure dam in western Rutherford County. Some county leaders have said difficulty navigating across the mountains to Buncombe County is a key reason for their effort to switch the county’s behavioral services to an LME/MCO based to the east in Gastonia. Colby Rabon / Carolina Public Press

Mountains as obstacles

Brian King

County Commissioner King told CPP that a key concern with Vaya has been geographical. Vaya’s Asheville headquarters are located on the opposite side of the high easternmost ridge of the Blue Ridge Mountains, the Eastern Continental Divide, which passes through the western portion of Rutherford County.

While the beauty of the mountains at sites like Chimney Rock and Lake Lure creates opportunities for recreation and a tourist economy in western Rutherford County, the mountains create a substantial barrier to travel and commerce to the west and north.

However, the county is easily accessible from Cleveland County to the east. And unlike most of the counties on other sides, which are served by Vaya, Cleveland uses Partners’ services.

Rutherford County is mostly rural, though peppered with many small towns including Forest City, Rutherfordton, Spindale, Ellenboro, Mooresboro, Ruth, Bostic, Lake Lure and Chimney Rock Village, in addition to many unincorporated communities like Cliffside, Sunshine and Golden Valley, among others.

As a result, many Rutherford residents do their shopping primarily in Cleveland County’s cities, including Shelby and Kings Mountain. They also travel there for many medical services that may not be available in their own county.

King said he doesn’t want Rutherford residents to have to travel across the mountains for services because the county is under Vaya. He believed Partners offered a more logical choice.

Although he said he doesn’t have any such feedback in writing, he said he heard from Rutherford residents who faced problems with this issue and were unhappy with Vaya.

Debbie Clary, who a former legislator representing Rutherford County in both the state House and Senate, told CPP on Thursday that she also heard from residents who faced difficult travel situations due to the need to cross the mountains. She described one family who struggled to gas up their vehicles so they could travel to get care.

She said providers had expressed similar concerns to her. But in neither case could she offer any names or samples of their communications. She said they were concerned about retaliation from Vaya if they spoke out and identified themselves.

Since leaving the legislature, Clary has worked as a registered lobbyist. One of her customers is Partners.

According to Vaya, the geographical argument doesn’t hold up because Rutherford residents have been able to travel to Cleveland all along.

During last week’s meeting at Isothermal Community College, Ingraham pointed to the many providers that Vaya has contracted with in Cleveland County in order to serve Rutherford County’s population.

According to a provider directory from 2017, Vaya had contracts with 25 providers in Cleveland County, despite not serving that county’s residents. A search using its online tool to find providers in Cleveland County also yielded multiple listings.

Regardless, King is clearly not a fan of Vaya’s.

In 2015, the county designated him its representative on Vaya’s advisory board. Although the parties disagree about the exact number of meetings he has attended since then, he said it has not been many. King blames other commitments and Vaya’s unwillingness to adjust its schedule or meeting locations.

He also complained that this advisory board is basically powerless and said Vaya has had insufficient representation from Rutherford County on its governing board.

King generally expressed concern that Vaya has not been responsive to Rutherford County’s needs. “Vaya is too big,” he said.

Asked to respond to this claim, Ingraham observed that the LME/MCO regions were set up by the state.

During the most recent round of consolidation, in which the number of regional agencies was reduced to seven, Vaya evolved from its predecessor organizations to have 23 constituent counties, while Partners has just seven.

The size of the LME/MCOs in the future is likely to grow. Some projections have indicated that the state is headed toward just four regions, though eventually the regional concept may be abandoned entirely.

Rutherford County’s Board of Commissioners, which meets at the county administration building in Rutherfordton, voted to disengage from Vaya Health and switch LME/MCOs to Partners. Ben Ledbetter / Carolina Public Press

Who proposed switching?

King told CPP that the idea of switching LME/MCOs arose at a meeting that Partners conducted with county officials, though by that time they were already investigating the concept.

Earlier, he had met with Clary, with whom he has worked on other political issues, and the issue of their concerns about Vaya as well as her work for Partners arose in conversation.

Regarding that meeting, Clary confirmed that it took place but said the idea that the county should switch really first came from the feedback she received from residents and providers who were unhappy with Vaya.

Asked whether Partners paid Clary to initiate a conversation with King about switching, she strongly denied that this had taken place, though saying it would not have been inappropriate, if she had.

CPP has asked Partners for records of any correspondence with Clary about the Rutherford County situation but had not received a response prior to publication.

Public response

Norlina Cochran has a 14-year-old daughter with autism. She previously worked with a care-providing company that dissolved. Vaya suggested she legally become an “employee of record” for care purposes. Cochran has control over the whole budget and is responsible for hiring staff to help her daughter. Since her daughter has access to her full budget, her staff was able to receive a raise.

“I’m most afraid of losing my staff,” she said. “Vaya has been nothing but excellent to us.” When looking for staff, she likes for them to be state-certified, CPR-certified, have first aid training and experience with autism.

Tom Elkins is a parent whose son receives intellectual and developmental disability services from Vaya. He also serves as an employee of record. He’s still looking for answers that Rutherford County or Partners has yet to provide.

“It doesn’t make any sense to me,” he said. “What is the motivation for making the change?”

Youth Villages provides several services in Rutherford County; one of those is for children aging out of the foster care system. The Tennessee-based organization is also partnered with Vaya for a new program for children in the foster care system that helps them find a permanent home.

For George Edmonds, Youth Villages assistant director, keeping services intact is a main concern.

George Edmonds

“The most important thing is that care for families is not interrupted,” he said. Youth Villages is contracted with Partners, however, not for all services.

Edmonds said he has been in North Carolina for 11 years and has witnessed numerous LME/MCO consolidations.

While Rutherford County has a population of 66,551, according to a 2017 estimate from the U.S. Census Bureau, it is just as challenging to find providers as other peer counties.

“I think Rutherford is similar to some other rural counties in that you’re always looking for providers that can handle the need,” Edmonds said. The organization has a partnership with the state departments of social services and juvenile justice, which has helped it obtain the service providers it needs.

“One of the things I’m most proud in Rutherford County is the continuum of services,” Edmonds said.

He cited a program where juveniles receive a mental health screening when they are brought to the court system because of a complaint.

“It’s a neat way to see if kids are getting screened for their mental health needs,” Edmonds said.

Youth Villages and Vaya partnered in 2013 to begin the Intercept program, which has an objective of diverting children from out-of-home placements like group homes and reuniting them with their families. Components of the treatment program include community-based treatment and 24-hour crisis support. In 2017, the program was featured in the Institute for Medicaid Innovation’s best practices compendium.

The North Carolina Department of Health and Human Services is headquartered at this building on the former campus of Dorthea Dix state mental hospital in Raleigh. The final decision on whether Rutherford County can switch LME/MCOs will come from DHHS Secretary Mandy Cohen. Frank Taylor / Carolina Public Press

Where the process stands

Rutherford County sent a letter to the state Department of Health and Human Services on April 19, informing the agency of its plans to disengage, a spokesperson for DHHS confirmed Thursday. (This contradicts information from DHHS that CPP reported previously.)

However, DHHS is apparently still waiting on a formal request for DHHS Secretary Mandy Cohen to approve Rutherford’s disengagement from Vaya and switch to Partners.

State law does provide for such a switch, but in the past a switch has only been allowed twice, both times to counties leaving Duplin County-based Eastpointe, which was troubled by allegations of mismanagement, something that Rutherford County does not directly allege in its disengagement letter.

Cohen’s decision normally would come after a nine-month waiting period, however Rutherford County has indicated that it would like this period to be waived.

A spokesperson with DHHS has previously told CPP that Rutherford’s request to switch may face an uphill battle because it comes at a sensitive time for Medicaid policy and could be viewed as too disruptive, even if Cohen agreed with county commissioners’ reasons for wanting to switch, which she may not.

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As part of the process, the county is required to gather public comments and post them to its website. The public comment period closed earlier this week, and the comments have been posted.

The statutes provide for Secretary Cohen to weigh these comments when deciding whether to approve Rutherford’s request.

CPP has asked DHHS about whether some issues with these comments may raise concerns. They include posts from employees of both Vaya and Partners, some individuals who have a vested financial or political interest in a certain outcome, several nonresidents of Rutherford County and some anonymous individuals who make unverifiable claims. DHHS did not respond prior to publication.

A Rutherford County spokesperson has told CPP that the anonymous comments are not anonymous to the county, but the names of those providing comment have been withheld at the request of the individuals.

Downtown in Rutherfordton, which is the county seat of Rutherford County. File photo. Katie Bailey/Carolina Public Press

For more information

Rutherford proposal and public comments: https://www.rutherfordcountync.gov/news_detail_T6_R27.php

State directory of LME/MCOs and which counties they serve: https://www.ncdhhs.gov/providers/lme-mco-directory

Partners statement on Rutherford County: https://www.partnersbhm.org/transparency/#Rutherford

Vaya on Rutherford County: http://caring4rutherford.org/

Vaya provider locator tool: https://www.vayahealth.com/members-caregivers/provider-search/#/home?_k=52sxzz

Editor’s note: This story has been updated to reflect new information that came to light about the public comments received by Rutherford County.


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Ben Ledbetter and Frank Taylor

Ben Ledbetter is a freelance contributor to Carolina Public Press. Frank Taylor is managing editor of Carolina Public Press

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