Aug. 19--Finding a cost-effective way to care for those who can't care for themselves has proved to be a heartstrings-pulling challenge for four Triad county governments.

CenterPoint Human Services, a Winston-Salem based agency that oversees behavioral-health services, says it needs to borrow a combined $2 million from Forsyth ($1.53 million), Davie($89,270), Stokes($148,127) and Rockingham($228,579) counties.

The agency said the loans are critical to helping it pay $3.7 million in transition costs toward becoming a managed care organization (MCO) by Jan. 1. The agency has pledged to pay back the loans over five years.

The primary goal of the MCO initiative is to move to the community level the Medicaid and state dollars that go to help the mentally disabled and those with mental-illness and substance-abuse issues. Why? To reduce costs and add more accountability and consistency to behavioral-health reform.

It also allows MCOs to operate with fewer restrictions.

On one hand, the four county managers say commissioners recognize CenterPoint's financial and time crunch. They realize many providers would have to eliminate jobs to adjust to their funding shortfall.

On the other hand, they are aware of why CenterPoint needs the money, as the agency's financial liquidity was questioned in a 2011 report by consultant firm Mercer. CenterPoint also has been hamstrung by three recent state and federal funding cuts.

That's why the counties are insisting on written contracts and quality-performance stipulations in an attempt to ensure accountability with whatever money they provide.

CenterPoint warns that without the borrowed funds, it will continue to shift discretionary money it would spend on services toward startup costs -- affecting thousands of patients.

"If a county does not make its MCO startup contribution, CenterPoint must reserve its own funds for that purpose," said Kevin Beauchamp, the agency's chief financial officer. "This means that the contribution amount is no longer available for services.

"If the discretionary funds (the loans from the counties) are received ... we will return like amounts back to services in those regions."

Adding to the tension is CenterPoint's pattern of lacking transparency with its finances, resulting in complaints from county officials, and its resistance to freezing salaries and rescinding recent salary and merit-pay increases despite its requests for more taxpayer money.

That has the four counties trying to find the right balance between prudent stewardship of taxpayer money and assuring residents that loved ones won't fall through the funding cracks.

"My heart goes out to the children, parents and family members caught in this dilemma," Forsyth Commissioner Gloria Whisenhunt said.

Whisenhunt said she is opposed to CenterPoint's request because $1.53 million is a lot of taxpayer money to tie up in a sour economy.

She also said she's put off by CenterPoint's unwillingness to search deeper for internal solutions. CenterPoint's budget for fiscal 2012-13 is $93.2 million, according to its website.

"$1.5 million is a small percentage of its overall budget," Whisenhunt said. "Surely to goodness they could come up with that amount through cutting their expenses rather than cutting consumer services.

"The county has had to make due with what we have for years now. Why can't CenterPoint?"

CenterPoint officials have been putting pressure on Forsyth commissioners, telling them that without their action, local residents will lose services. At last week's Forsyth commissioners meeting, about 75 people lobbied the board to provide the allocation. Several speakers shared poignant stories of dealing with behavioral-health issues, whether their own or those of family members.

Whisenhunt stressed that those stories did not fall on deaf ears.

"It's a difficult position to be put in, being portrayed as an insensitive person," she said. "Nobody likes to be perceived that way.

"But I want assurances that the county will be protected with the loan, and that services will improve if it provides the funding. I haven't gotten either yet from CenterPoint.

"I hear more complaints about CenterPoint than all other complaints combined."

Commissioners in Forsyth split on issue

Advocates worry about the threatened service cuts at a time when more people with behavioral-health issues lack insurance and more people are winding up in emergency departments seeking or requiring services.

Although the counties combined provide about $5.3 million annually, they do not, by state statute, have a say in how the money is spent.

In a recent report to the Forsyth commissioners, CenterPoint said discretionary spending for care coordination would be cut by $573,259, mental health by $562,197, developmental disabilities by $211,948, substance abuse by $161,620 and community outreach by $25,000.

The Forsyth commissioners have not said when they plan to formally discuss or vote on CenterPoint's request. When CenterPoint made its request last week, three commissioners appeared to be in favor, three opposed and Chairman Richard Linville undecided.

Commissioners Dave Plyler and Whisenhunt said the board has had little collective discussion about the CenterPoint request.

"Until the board places it on the agenda, neither Dudley Watts or Ed Jones will present figures," Plyler said. Watts is county manager, and Jones is deputy county manager.

Watts said he still is evaluating CenterPoint's request from a financial perspective.

The state expects the MCOs to pay upfront for their Medicaid waiver expenses before they begin to receive the reimbursement funding necessary to sustain the expenses.

The state did something similar in 2011 to providers who sought status as a critical access behavioral-health agency, with many not qualifying for lack of resources.

Counties still evaluating

CenterPoint may not be as far along the approval route as the agency has led the community to believe.

Only Davie is in the process of providing its allocation of $89,270.

The Rockingham and Stokes county managers said that although funding has been set aside, extensive negotiations are necessary before their commissioners will feel comfortable with releasing the money.

CenterPoint officials, led by executive director Betty Taylor, said in a news release that two counties have made pledges that are done deals.

A press release from CenterPoint, dated Aug. 8, states "CenterPoint requested one-time, refundable contributions from each county to be used toward MCO startup costs. Two of the counties have agreed to provide discretionary funding to support the MCO."

The press release was sent to the commissioners in all four counties.

Davie County Manager Beth Dirks said the reasons her county has moved quicker than the other counties is because it had the smallest funding request to wrestle with and because CenterPoint agreed to a written loan contract.

Davie will reduce its annual allocation to CenterPoint by $17,854, one-fifth of the loan amount, each year during the five-year period, as well as receive a 1 percent interest rate.

Dirks, who serves on CenterPoint's board of directors, said she provided "a full and accurate" briefing of the request to the Davie commissioners.

"We don't want to hurt the delivery of services to vulnerable residents in our community," Dirks said. "We believe this transition by CenterPoint to MCO status will provide better services.

"The commissioners felt a written loan contract was the prudent choice to make. No matter what CenterPoint's future financial status is, we will enforce the contract. If CenterPoint were to become defunct, we would have a claim on its assets."

Stokes has agreed to the one-fifth rule as well, meaning it will reduce its annual allocation by $29,625 for each of the five years.

A matter of guarantees

Rockingham County Manager Lance Metzler said that before the commissioners agree to disburse funding, CenterPoint would have to agree to measurable service standards that require it to at least sustain current quality outcomes, if not exceed them.

"There's a lot to work out in terms of dates, times, specifics," Metzler said.

For example, he said that to raise CenterPoint's accountability, Rockingham may choose to provide the money over time based on performance rather than in the lump sum the agency wants.

"If they can't guarantee the services will be better, then we may not guarantee the money," Metzler said.

He said commissioners want assurances that the loan can be recouped if CenterPoint fails and its oversight duties are taken over by another MCO.

Stokes County Manager Rick Morris said the commissioners have only agreed to put the funding in its 2012-13 budget. They want details on how CenterPoint would use the money and how the county would be repaid.

"We want to help CenterPoint because we want to protect the critical services they oversee in our county," Morris said. "But our commissioners also want to be able to reach a comfort level about minimizing the risk to the county as much as possible."

Morris also said the Stokes commissioners will seek the advice of the Local Government Commission about the CenterPoint request. The commission operates under the state treasurer's office, and it approves the issuance of debt for all units of local government and assists those units with fiscal management.

"CenterPoint may have actually thought the request was approved when we put the money in the budget," Morris said.

"Until the commissioners actually approve the request, we will not disperse the money."

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