State lawmakers want private companies treating the mentally ill to offer more professional services, which they view as central to correcting substantial weaknesses in North Carolina's system of care.

Their wishes are reflected in the state budget, which requires licensed counselors or people with college degrees to perform more of the treatment in a basic and widely used mental health service program. The law requires licensed professionals to see patients before they diagnose an illness, addressing worries that medical orders are being signed indiscriminately.

Legislators are trying to correct problems that have plagued the mental health service called community support, in which companies charged the government as much as $61 an hour for work done by people with high school diplomas or GEDs. Earlier this year, The News & Observer reported that the state wasted at least $400 million on the program.

The law orders the state to develop a system to pay companies according to the qualifications and experience of the people doing the work. Once that system is in place, half of community support services must be provided by top-tier workers.

"I've been very distressed by the number of unlicensed professionals in the system," said Rep. Verla Insko, a Chapel Hill Democrat who helps write mental health laws. "This is a very ill population. We need highly trained professionals to deliver this service."

Stories about doctors approving services for patients they never saw and being forced, on the threat of losing their jobs, to sign diagnosis forms led legislators to require that trained and licensed workers determine what patients need. Professionals who don't see patients before signing diagnosis forms might be reported to their licensing boards.

"Assessment is the most important step," Insko said. "You have to get the diagnosis right before you get the treatment right."

The providers agree community support services should be more professional, said Jennifer Mahan, a lobbyist with the Mental Health Association in North Carolina. But in rural areas, finding middle- and top-tier workers is a challenge, she said.

Providers hope to have the law changed in the next week to allow for a gradual move to the 50 percent standard.

Greater local duties

Providers and representatives of local mental health offices were busy Thursday sorting out what the new mental health laws would mean for themselves and for patients. Major moves prescribed in the law would give local mental health offices more responsibility for providing emergency services and paying for patient treatment. Local offices are going to be responsible for starting new crisis services and buying space for mentally ill patients in local hospitals.

At the same time, legislators rebuffed calls from Gov. Mike Easley to merge local offices and give the head of the state Department of Health and Human Services a say in the hiring and firing of local government's mental health directors.

Sen. Martin Nesbitt, an Asheville Democrat who helps write mental health laws, said legislators did not want local offices working on mergers when they have to handle so many new responsibilities.

"We've done so many things piecemeal," he said. "Let's have a plan and have everybody knowing what the plan is and going in the same direction."

Franklin Freeman, a senior adviser to Easley, said Thursday that the legislature's refusal to accede to Easley's request leaves a blank in the list of cures for the mental health system. The administration will look to pass a law giving the DHHS secretary more powers before the legislators end their session, Freeman said.

DHHS secretaries are accountable for problems they have no power to correct, Freeman said, "which is a difficult position for a secretary to be in."

Insko, pointing to an existing law that lets DHHS secretaries take over local programs and appoint caretakers, said the administration is asking for powers it already has.

In another move that increases local control, the law begins returning oversight of Medicaid patients' treatment to local mental health offices. Two years ago, the state gave responsibility for reviewing and paying for Medicaid patients' treatment to a private company, ValueOptions. Legislators are giving it back gradually, saying the ValueOptions contract must end by Sept. 30, 2009.

Legislators and local authorities blamed overspending and lack of oversight of community support on the decision to remove responsibility for Medicaid payments from local hands. Providers liked working with one company rather than with local offices, most with different requirements for authorizing treatments and payments. They want more time before decisions are back in local hands.

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