Cardinal Innovations has returned to a familiar strategy — a public relations campaign — in an attempt to keep its behavioral health oversight network intact as six of its 20 counties are in various stages of departure.
That includes Forsyth County, whose board of commissioners unanimously authorized on Nov. 12 a resolution that began the process of disengaging from Cardinal, the state's largest behavioral health managed-care organization.
The resolution said Forsyth "has repeatedly addressed concerns directly with Cardinal over the years with little to no resolution."
"The county is actively evaluating options with other MCOs," commission vice chairman Don Martin said. "It is clear this is a lengthy process.
"In the meantime, we are working with Cardinal to provide the best services that we can for all those families and agencies served by Cardinal. It is too soon to measure real progress."
Five other Cardinal counties — Cabarrus, Mecklenburg, Orange, Stanly and Union — are on the same path.
Cardinal, based in Charlotte, oversees providers for mental health, substance abuse and developmental disabilities services for more than 800,000 North Carolinians utilizing federal and state Medicaid funds.
Its network includes Alamance, Davidson, Davie, Forsyth, Stokes and Rockingham counties in the Triad. Nearly 25% of its network population is in Mecklenburg.
The Cardinal campaign has included a full-page ad in the Winston-Salem Journal, a Dec. 22 statement placed on its website and also released through a public-relations outlet, and an updated "plan of action progress report" on its website.
Cardinal took a similar PR tactic in 2018 as it tried to recover from the ousting of controversial former chief executive Richard Topping and disbanding of its board of directors by state Health Secretary Dr. Mandy Cohen.
State law permits the health secretary to remove the chief executive and the board of a behavioral-health MCO if the secretary determines that the organization demonstrates serious financial mismanagement or serious regulatory noncompliance.
The largest component of the Cardinal action plan is a pledge to spend $30 million over two years "to help take care of children in foster care" in all 20 counties.
There have been concerns expressed in the six departing counties about Cardinal's lack of assistance in placing youth in foster care, particularly those released from juvenile detention centers, along with slow reimbursement rates when counties take the initiative to place the youths.
Cardinal is pitching progress made with the six counties that includes newly available resources that behavioral health advocates have been pining for years.
"We are making progress on the commitments outlined in our county action plan, and in our latest progress report, we share how we are doing on the measures that matter to our members and communities," Cardinal said.
The action plan touts "an entirely new child welfare program," more choice and quality of providers, improved access for care, and better communication with hospitals.
Perhaps most importantly, Cardinal touts "improving how we interact, engage and support our members with intellectual and/or developmental disabilities."
Cardinal sums up the campaign by saying "we have never been more determined to find solutions to bridge gaps in care, cut through red tape and overcome obstacles for our members."
"It is a new era for Cardinal Innovations as we work with counties and the state to enable better, longer, happier and healthier lives for those we care for."
Yet, Forsyth commissioners have not been persuaded by the latest action plan or the PR campaign.
"Forsyth County remains committed to ensuring the best service for our residents," deputy county manager Shontell Robinson said Dec. 23.
"We are continuing the process of disengaging from Cardinal Innovations, and I hope to provide a recommendation of a new MCO to the board next month."
Forsyth County attorney Gordon Watkins said there would be a 30-day public comment period on the disengagement process.
"The citizens of Forsyth County face numerous challenges in accessing behavioral health, substance abuse, and intellectual/developmental delay services through Cardinal," the Forsyth resolution said.
Those include: gaps and delays in service authorization; authorization of lower levels of care than what is clinically recommended; limited local providers, and a lack of seamless transition during hospital emergency-room discharge planning and transitions to higher levels of care.
Cardinal chief executive Trey Sutten said after the Forsyth resolution was authorized that "we presented a thoughtful and thorough plan to Forsyth County that addressed the concerns they shared with DHHS."
"Regardless of the resolution and ultimate decision by Secretary Cohen, we will continue to listen, respond and improve how we work with Forsyth County on behalf of the health and well being of its most vulnerable citizens."
Forsyth commissioner Chairman Dave Plyler said Nov. 12 that commissioners "owe it to the people we serve ... to make sure" that Cardinal secures quality, timely service from behavioral health providers.
"We've got to, somehow or another, to follow through on the resolution that's being proposed."
Letter of intent
The commissioners' resolution represents a letter of intent to Cohen. The other five counties have authorized similar letters of intent.
By state law, Cohen is required to approve any county move. The disengagement process would take up to nine months to complete if approved.
Cohen said Nov. 10 that “we take those concerns (expressed by the counties) very seriously.”
On Dec. 30, Cohen said DHHS "continues to work through on the process of folks who have asked us to disengage from Cardinal."
"Our teams are reviewing that information and I don't have any further update."
"There are a number of counties trying to do the same thing, so we would imagine that at some point there could be a global solution to this," Watkins said.
Sutten previously said the timing of the investment and improvements coincides with planning for Medicaid transformation that's slated to begin July 1. The MCOs will be serving four statewide prepaid health plans in providing physical and behavioral health services.
Cardinal said it will offer an agreement with each county's DSS that provides a monthly payment, referred to as sub-capitation, for every Medicaid-eligible foster child in its care.
Counties will be able to use these Medicaid funds to cover the cost of some preliminary or transitional care, or to address social determinants of health, such as housing, transportation and food insecurity.
"We believe that the improvements we are making are significant, particularly the $3.2 million investment for children entering DSS custody and our new child welfare program," Sutten said.
Cohen said that “our role as regulators is to make sure that plan turns into action, that it follows through with (the plan) and delivering services.”
“If it doesn’t, we will hold it accountable.” That includes potential fines and other financial penalties.
In February 2019, Cardinal released a self-assessment report titled “A Year in Recovery — What we’ve learned, how we’ve grown and what to expect going forward.”
Cardinal acknowledged that “a lot has happened, good and bad. This year’s report addresses both head on.”
Sutten said about the report that Cardinal’s “core missions has always been to serve our members and communities with compassion and expertise.”
“But things got cloudy at the top. Corporate spending was needlessly inflated and the focus was taken off our members, our providers and our communities,” Sutten said.
He said the organization’s self-assessment report was designed in part to show how it is now “all about responsible money management, preventive care and investment in our communities.”
Some critics of Cardinal said at that time the MCO’s report represents, at times, a glossing over of continuing service issues, particularly what they called a lack of urgency in how it supports individuals experiencing a behavioral-health crisis.
Rep. Verla Insko, D-Orange, has expressed concerns about Cardinal's performance in her county.
"One of the criticisms I have heard about Cardinal Innovations is that they and their providers are out of touch with the people they serve," Insko said. "This (campaign) may be an effort to be more visible."
Rep. Donny Lambeth, R-Forsyth, has been among a bipartisan group of legislators who have been critical of Cardinal's performance under both Topping and Sutten.
"Cardinal has taken some serious criticism in the last few months, and with a number of counties publicly noting their concerns with Cardinal long term, it would appear they have decided to be more aggressive," Lambeth said last week.
"These issues are complex and many in the public don't understand the seriousness.
"So, I believe Cardinal is trying to repair some of the negative publicity they have been getting in hopes of either not losing other counties, or retaining a few of those that have given notice that things must change and the best way to do that is to move to an alternative MCO," Lambeth said.
Lambeth said the PR campaign "may be too late for the counties who have given notice and are concerned with the lack of services being provided."
"But I am sure they hope to start 2021 off on a better foot and not lose any other county."