Mental health in the Cape Fear: Part two, alternatives and access
Lack of access to behavioral healthcare isn’t a recent problem to pop up in North Carolina. The state has a history of lagging behind in healthcare, in general. But there are some potential solutions.
Historically, North Carolina has lagged behind in mental health. The state was next to last among the original 13 colonies (the last was Delaware) to enact legislation for the establishment of a state asylum.
Recently, a report was released showing that North Carolina ranks as one of the worst states for healthcare. Released on Oct. 13, Forbes' rankings placed North Carolina last among the 50 states in healthcare costs and third to worst for healthcare overall.
The ranking comes months after North Carolina became the 40th state to implement federal Medicaid expansion, expected to bring insurance coverage to over 60,000 North Carolinians.
An expensive alternative to run
These days, the main psychiatric facility in the Cape Fear region is New Hanover Regional Medical Center and its behavioral health facility.
NHRMC has a longstanding commitment to providing charity care for the uninsured, but it's not an ideal solution for everyone dealing with a mental health issue. A main issue is wait times, which means people are held in the Emergency Department without the same level of support you might find at a dedicated psychiatric facility. NHRMC also covers a vast area of nine counties — meaning it's not nearby for a lot of potential patients. But, the nearest of the state's three psychiatric facilities. Cherry Hospital in Goldsboro, is also an hour and a half away from the Wilmington area.
There is an alternative — facilities known as Behavioral Health Urgent Care (BHUC) centers. They're designed to provide local, fast, specialized care with little to no wait. So, why doesn’t the Cape Fear region have a BHUC?
We did — they didn’t work out due to a lack of financial stability. BHUCs are very expensive to run, according to both COOs of Alliance and Trillium — those are LME-MCOs, quasi-governmental agencies that manage state and federal funding for mental and behavioral health (Trillium covers New Hanover County and over two dozen other counties in the eastern part of the state, Alliance covers Charlotte-Mecklenburg and the Raleigh-Durham-Chapel Hill area).
Kelly Crosbie, Director of the NC Division of Mental Health, said that BHUCs don’t turn people away, which means they’re providing a high amount of charity care.
Sean Schreiber with Alliance agreed, noting that the BHUCs they oversee in Wake County are also expensive because of the demographics they primarily serve.
“[Patients] tend to be a higher rate of people who are currently uninsured, hoping that changes soon with Medicaid expansion. We see a fair number of individuals with Medicaid as well. … That's the primary group. And that's what [BHUCs] were kind of established for," he said.
With Alliance’s BHUCs, they’re able to receive help from Wake County to help cover the difference that can’t be made up in insurance claims.
But that's not likely to happen in the Cape Fear region. Even with New Hanover County's considerable resources, Trillium COO Cindy Ehlers said they don't intend to ask the local government to help support a BHUC due to the financial risk.
There is some hope though: the General Assembly gave NCDHHS about $80 million in crisis funding, and part of that money they asked for was to build and sustain more BHUCs, Crosbie said.
How does insurance work with BHUCs and long-term care?
It’s important to understand how Medicaid works, since most people being served by BHUCs have Medicaid — if they have insurance at all.
Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.
Insurance in general, works like this: You go to the doctor for an issue and receive care. The doctor, hospital, or other facility generates an itemized list of the services you received, each item getting its own insurance code. Based on what type of plan you have, insurance will cover varying portions of each item — sometimes it's covered entirely, sometimes there's a copay, and sometimes you're on the hook for the whole cost.
Some people that go to BHUCs have commercial insurance, Schreiber with Alliance said, “You do have occasionally though, someone with commercial private insurance… but more are people with Medicaid and the uninsured, underinsured.”
The problem, though, as Cindy Ehlers, COO of Trillium says, is that no insurance covers BHUC services: “There's not a BHUC service, right? There's not something called BHUC. It’s not like an emergency room. There is a service called ‘emergency room.’ And there's also inpatient. And [BHUC] is somewhere in between those levels of care.”
In a 44-page list of insurance codes on Trillium’s website, BHUC services are not mentioned once. There's no code to bill insurance for the visit — so it can't be covered.
Crosbie confirmed that while individual services — for example, a prescription — at a BHUC might be covered a general visit to a BHUC isn't covered the way a trip to the ER is. So someone who just needs to visit a BHUC to de-escalate a crisis probably won't be covered.
“Your insurance might cover your going to the emergency department, with your big copay, but they won't recognize something like a behavioral health urgent care," she said.
Insurance is an issue with long-term care, as well, according to Ehlers at Trillium.
Typically, someone has two main options for acute or long-term care that is closely supervised by medical professionals: residential and inpatient.
In Trillium's long list of billing codes, there’s no entry for residential treatment for mental illness, meaning it can be out of reach for low-income people on Medicaid.
“There's not a service called long-term residential treatment for mental illness,” Ehlers said.
Medicaid/Medicare insurance does cover inpatient care, however.
Inpatient vs. Residential care
For inpatient care, patients may be hospitalized and receive 24-hour care and medical attention. Inpatient care will often follow a trip to the emergency department for a crisis situation; it's usually in a hospital setting where patients stay a couple of weeks to a month. Inpatient care is generally more intense — and restrictive — than residential care as the goal is usually getting someone through the acute (that is, more severe) phase of a mental health issue.
Residential care is voluntary, live-in treatment at a rehab facility where patients can attend therapy sessions and have medication or withdrawal symptoms closely monitored — although not as intensely as with inpatient care. Patients will often stay for several months or longer, and they have more privacy and freedom, since the goal is no longer averting immediate risks of harm to themselves or others, but long-term mental health management.
But long-term care comes with a cost. Residential care facilities are almost always covered out-of-pocket for people under Medicaid, Ehlers said.