State moves ahead on Medicaid changes for more home services

Department of Health and Human Services Deputy Secretary Dave Richard told the Joint Legislative Oversight Committee on Health and Human Services that the two 1915-c waivers, as they're known, would allow the state Medicaid program to expand home- and community-based services to both groups.

Currently, federal Medicaid rules cover treatment for traumatic brain injury, or TBI, and for children's severe emotional disturbance only in the context of an inpatient treatment facility. The waivers would allow Medicaid in North Carolina to cover the same services for patients and families for whom institutionalization is not the best choice.

Richard said both programs have the potential to lower treatment costs.

"It’s one of those rare instances when doing the right thing actually saves money for the state," he said.

The waiver for TBI treatment is ready to submit to federal administrators at the end of February after its 30-day public comment period, set to begin Jan. 26.

Once it's approved, a process that averages 12 to 18 months, the pilot program would get underway in Wake, Durham, Johnston and Cumberland counties. Richard said those counties were chosen because their local behavior health management entity, Alliance, is already working on a TBI program, and UNC Hospitals, Duke University Medical Center and WakeMed are all available as resources for the pilot.

The pilot would serve 49 patients in the first year who couldn't otherwise access TBI services, 99 in the second year and 107 in the third year, It's expected to cost around $2 million in state dollars for the first year, which would be matched two-to-one with federal money.

After an evaluation period, Richard said, the goal is to expand the pilot statewide. He said similar programs in other states have offered "strong evidence" that helping TBI patients remain at home during rehabilitative therapy produces better outcomes than institutionalization in many cases and is often less expensive.

"We think that’s the best way we can go. For most families, they want to provide services for their loved ones there," he said. "If they don’t have this support, then they run through their resources, the ability to do it – this allows us to put it in the home."

"We hear from people every day about the need for TBI [services]," he added. "We haven’t had the resources to do it."

More than 10,000 people are currently on the state's waiting list for services for intellectual and developmental disability, but Julia Adams-Scheurich, a lobbyist for disability rights group The Arc of North Carolina, said it's difficult to know how many are dealing with TBI. But with so many military veterans in North Carolina, the incidence is likely to be higher than in some other states.

"The VA can't do it all," Adams-Scheurich said. "We know for a fact that a lot of these families have been struggling. They’ve been dealing with respite services. They’ve been dealing with wraparound services. They’ve been trying to deal with just state services that were never designed for people with TBI."

The waiver for children with severe emotional disturbances, or SED, would be a statewide program, Richard said. The option was only recently offered to states after successful pilots in nine other states from 2007 to 2012.

The data from the pilot states show markedly better outcomes for SED children kept at home with intensive wrap-around support services, supervision and peer support for the family, Richard told lawmakers. School performance was better, suicide attempts and contacts with law enforcement were fewer and the environment for the child and family was more stable. Also, the cost savings are substantial, he said, running 35 to 60 percent less than institutionalization of the child in a hospital or residential psychiatric treatment facility.

"If we get the kids early, we provide the right services to them upfront, there is a potential cost savings for the state," Richard said, stressing the need to train and supervise local teams to ensure that all necessary behavioral and other support is provided appropriately.

If the waiver is approved by federal Medicaid officials, the new program would serve 180 children for $1.5 million state dollars in its first year, 228 children for $1.9 million state dollars in year 2 and 324 children for about $2.7 million state dollars in year 3.

Richard cautioned that change won't happen quickly, telling lawmakers that institutionalization has been the "default setting" for these children for a long time, but the tide is turning toward more community-based solutions.

"Anything you can do to support these families who have these difficult-to-support children at home is a good thing for our communities," he said.

Adams-Scheurich agreed, saying, "Any time the state can move forward on a Medicaid waiver that allows an individual and a family to be served in home or in limited settings that really specialize in that population, serving those very specific needs, that is a great thing."