07/11/12 — Eastpointe merger done, more changes still on the way

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Eastpointe merger done, more changes still on the way

By Matthew Whittle
Published in News on July 11, 2012 1:46 PM

More than 10 years after the original state mental health reform efforts, the local system is still undergoing change -- the latest on July 1 when Eastpointe tripled in size, growing from four to 12 counties.

The next major change to the local system is expected to occur on Jan. 1, 2013, when the newly expanded Eastpointe takes over the management of care and payment for clients receiving Medicaid.

"The reason we merged (with the other counties) was for efficiencies, and in order to manage Medicaid," Eastpointe Director Ken Jones said.

The growth, he explained, is stemming from the merger of Eastpointe, the N.C. Division of Mental Health's local management entity covering Wayne, Duplin, Sampson and Lenoir counties, with fellow LMEs Beacon Center, which covered Edgecombe, Nash, Wilson and Greene counties, and Southeastern Regional, which covered Robeson, Columbus, Bladen and Scotland counties.

And that growth, he said, is what is allowing Eastpointe to take over Medicaid management, which had previously been done by a private company contracted with the state. In order to manage Medicaid payments, Eastpointe was required to serve an overall population of 500,000 people and a Medicaid population of 75,000. Before the merger, Eastpointe was serving 300,000 and a Medicaid population of 50,000. Now Eastpointe serves a total population of 807,000 and a Medicaid population of 176,000.

The reason for the desire to take over Medicaid management, Jones said, is that in the past when claims were being processed by the private company, costs often overran the amounts that were budgeted.

"A lot of that was poor planning and no management of the Medicaid dollars," he said. "Now we will actually manage those Medicaid dollars, and we will have to stay within our ($180 million overall) budget."

That means, he said, reviewing and approving plans based on actual medical needs. It also means that Eastpointe will have more control over the provider network and the rates at which they are reimbursed, which is likely to eventually lead to a closed provider network with those in the fold meeting certain performance measurements.

"Right now, if they are an able and willing provider, they can get into the system and provide services, and we have no control over that," Jones said. "Once we become a Medicaid management site, we have complete oversight of the provider network for the Eastpointe cachement area."

However, he said, seeking to re-assure providers and consumers, he does not anticipate any major upheaval -- or any changes, really -- to the provider network for at least another year. And when those changes do occur, he said, they are likely to come naturally as companies providing enhanced services for patients in crisis begin to either partner with companies providing less intensive out-patient services or offer those themselves.

"We have a lot of good providers, and what you will see is a lot of providers, they will be able to expand and provide a continuum of care," Jones said. "That's added value to the system, I think."

But the biggest change, he said, will be Eastpointe taking over coordinating care for Medicaid patients -- the same as it does for indigent patients with no insurance -- taking the place of the case management services currently being offered by local providers.

"The function is pretty much the same. We will work with the family, the consumers and the providers to develop plans of care and implement those plans," Jones said. "We have to be more efficient in how we spend our money. We have to make sure consumers are receiving the services they need."

That change, though, won't take place until Jan. 1 when the Medicaid management goes into effect.

In the meantime, Jones said, Eastpointe will be working to educate its providers, consumers and supporters about the merger and its implications.

And, he added, while they were able to hire back about 90 percent of employees at the three agencies, they also have several positions left to fill, most notably in their finance and care coordinator positions. The goal, though, is to maintain a strong presence in all 12 counties with offices in Goldsboro, Beulaville, Rocky Mount and Lumberton, and two board members from each county, with three from the three largest counties, including Wayne, which is represented by Wayne County Manager Lee Smith, Wayne County Board of Commissioners Chairman John Bell and Eastpointe consumer and family advocate Nancy Moore for Wayne.

"Eastpointe's philosophy is 'local presence.' The reason we'll have the community care providers spread out is because we have the philosophy that local presence is necessary and we want to continue to maintain that," Jones said. "We've got three strong agencies that have come together. We've been planning this for two years and there's been a really good relationship between the three programs, so the merger has been pretty smooth."

Still, Jones acknowledged that any time there are changes, people, understandably, tend to get nervous. But, he said, as far as changes to the mental health system go, while this is a major one, he doesn't see it causing holes in the safety net like other efforts have done.

"This is a change that will affect the entire community. It's a time of unknown for a lot of people, and a lot of our consumers," he said. "It will be one of the biggest, if not the biggest changes since the divestiture of services (in 2001). But it's not going to be an abrupt change with the provider network at all.

"Our plan is to get out into the community in the next couple of months and do some intense education so when we take over the Medicaid waivers on Jan. 1, it's a not a surprise to any one."

Then, Jones said, looking forward to 2014 and beyond, he anticipates future changes to focus on the influx of Medicaid patients as the rest of the federal Affordable Health Care Act takes effect, and to focus on working more closely with primary care providers to create plans for patients dealing with both physical and mental health problems.

"A lot of times one affect the other," he said. "We want to be sure both those groups are talking to each other."