In the free-for-all that erupted when the private market came to dominate mental-health care in North Carolina, only one region had direct control over how its public system would look.

Piedmont Behavioral Healthcare, the office covering Cabarrus, Davidson, Rowan, Stanly and Union counties, sets its own rates and decides which companies will be paid with government money.

Piedmont, a local government agency, has federal permission to pay for services in a different way. The region receives a set Medicaid payment each year, and local officials decide how to spend it.

The arrangement keeps a grip on spending and builds strong companies, said Pam Shipman, Piedmont's deputy area director.

Piedmont relies on only four companies to provide most of its community support. Some other regions have 10 times as many community support companies.

"We set our own rules," said Craig Hummel, Piedmont's medical director. "That allows us to shape our own network."

No other region has asked for the same powers.

From March 2006 until the end of last year, Piedmont spent a significantly larger share of its money than other areas for intensive services versus basic community support. Its overall spending on intensive outpatient services is lower than that of some regions because it spends more on clinical care.

With savings from its Medicaid budget, Piedmont pays for programs for people with mental illnesses and addictions that it wouldn't have otherwise. The region is starting a program for mentally ill children who need to leave their homes for a short time but do not need hospital care.

A report done for the state last year said the quality of care has stayed the same or improved since the region set its own rules.

Piedmont can use Medicaid money to help people with mental illnesses find and keep jobs. The office decided to increase its payments for psychiatric services.

"You can't have a mental-health system if you don't have psychiatry," Shipman said.