North Carolina's behavioral health system is in the middle of far-reaching reforms. In response to a 2015 legislative directive from the North Carolina General Assembly, the system is in the process of transitioning from a FFS structure to a managed care structure. The state is also working to expand Medicaid coverage and to integrate behavioral health and physical health services. A 2017 amendment to the state's pending 1115 waiver demonstration application also includes a proposal to cover the entire ASAM continuum of care for SUD and to provide residential treatment for SUDs in institutions of mental diseases (IMDs); at the time of writing, CMS approval for the amended waiver application and state legislation approving the proposed Medicaid expansion were still pending.
Currently, the behavioral health and intellectual/developmental disability services in the state are administered by local management entities (LMEs)/MCOs through a "closed network" system. Providers are required to contract with the local LME/MCO in order to be reimbursed; LMEs/MCOs may impose contracting criteria above and beyond the state's credentialing and licensing regulations. Out-of-network services can only be reimbursed under limited conditions and through regulated agreements.
Current Barriers Facing Substance Use Disorder Professionals
Like much of the rest of the nation, North Carolina has long experienced an SUD workforce shortage, especially in rural counties; however, the shortage has become an increasingly urgent issue in light of the opioid crisis. Recent system reforms that were designed to increase access to high-quality SUD care for the entire population have created some short-term challenges for providers during the transition.
The biggest of these barriers are the revisions to licensing rules and SOPs necessitated by the waiver demonstration requirements. To establish full alignment with ASAM criteria, the state's entire array of SUD services is currently under revision. Until the revisions are fully institutionalized, providers aiming to enter the profession are forced to navigate a system in flux.
North Carolina's closed network system poses an additional barrier: Currently, there is no centralized source of information about the varying contracting criteria of the state's seven LMEs/MCOs. As a result, providers are forced to consult the LMEs/MCOs one by one to find the network that best fits their credentials and practice goals. (The relative recency of the closed network system is one reason for the difficulty of obtaining this information.)
Both of these barriers are associated with the uncertainty that accompanies any system transformation. What is most relevant to the present study are the measures under way to address these transition-related challenges by providing effective workforce supports. North Carolina's Behavioral Health Strategic Plan (2018) incorporates several measures, some of them already in progress, to alleviate the challenges that SUD providers are encountering as a result of the changing practice and reimbursement environment. Before describing these measures, it is useful to consider several points of strength the state already possesses and can build on.
Current Facilitators Supporting the Substance Use Disorder Profession
Centralized Credentialing System
All credentialing functions for SUD professionals are housed under a single roof, the North Carolina Substance Abuse Professional Practice Board (NCSAPPB), with the sole exception of peer support specialists, whose credentialing is provided by the University of North Carolina. NCSAPPB was established in the mid-1980s, when the certification body for alcohol counselors merged with its counterpart for drug counselors. The merger process was not an easy one, as would be expected when two professional disciplines work to establish a new profession that encompasses the practice standards and ethical codes of both. Once established, however, the consolidated Board streamlined the credentialing process and became an important asset for professionals interested in an SUD practice. NCSAPPB is not administratively linked to the DHHS but reports directly to the legislature, the state auditor, and the governor's office. Although it works closely with the DHHS, its administrative autonomy provides it with a degree of flexibility in its day-to-day operations.
Move from a Title Act to a Practice Act
Until 2005, NCSAPPB operated under a title act only. This type of legislation mandates that only individuals qualifying for an SUD counseling license can legally use the associated title. However, any professional with a counseling license (e.g., a mental health counselor) can provide SUD counseling services so long as they do not use the SUD counselor title. Starting in 2005, SUD licenses have been regulated by a practice act which prohibits the provision of SUD services without an SUD license. According to the executive director of NCSAPPB, this legislative move was a game-changer that "transformed the SUD landscape" and contributed to the growth of the SUD workforce. It constituted legal acknowledgement of the need for specialized training to provide SUD services, thus contributing to the professionalization of the field. It is important to note that the addition of a credential requirement to practice could easily have become a workforce barrier if the state had multiple credentialing entities with varying criteria, as is the case in many states.
Peer Support Specialists
North Carolina is one of the first states to introduce a peer support specialist credential. The certificate program is offered by the University of North Carolina's social work program and consists of 30 hours of dedicated training. Peer support specialists can count their practice hours toward credential requirements for more advanced positions. This gives them an incentive to advance within the SUD career ladder. On the other hand, peer support services are currently not reimbursable except as part of a bundled service. They are funded through other resources such as CURES Act funds. As part of the system reforms, the legislature is considering expanding service definitions to include peer support services as a reimbursable clinical category.
Centralized Credential Information, Academic Programs, and Active Recruitment
Ten universities and multiple community colleges in the state offer SUD-specific undergraduate and/or graduate degree programs, in addition to accredited training programs such as summer schools or online training courses. The NCSAPPB is responsible for the accreditation of all SUD-specific training programs in the state, facilitating the alignment of available training opportunities with credentialing criteria. One out-of-state degree program (East Tennessee State University's Master of Social Work, including SUD Certificate) is also accredited by the Board.
The NCSAPPB website provides all the information that an SUD professional would need to practice in North Carolina, including certification and licensing requirements, SOPs, accredited academic programs, online and in-person training courses, and downloadable application forms. Centralized and easy access to these resources is, in and of itself, a facilitator for entering or advancing within the SUD workforce.
In addition to the outreach efforts of colleges and universities to attract students into these certification programs, members of the NCSAPPB engage in active workforce recruitment by visiting campuses to provide information about available professional opportunities in the SUD field.
Supervision and "Telesupervision"
The NCSAPPB offers a separate credential for clinical supervisors (Certified Clinical Supervisor, or CCS). This is not a standalone credential; Licensed Clinical Addiction Specialists interested in pursuing the supervision of persons providing can apply for the certificate which clearly defines supervision requirements and standardizes supervisor qualifications. This facilitates the credentialing process for positions requiring a certain number of supervised practice hours.
CCSs are allowed to provide supervision through telepractice. This enhances access to supervision services for professionals seeking an SUD credentials with supervised practice prerequisites.
The state has a simplified licensing process for out-of-state professionals who are International Certification and Reciprocity Consortium (IC&RC) members. These individuals are required to complete a special application form and undergo a background check, but they can generally obtain their state license within 15-30 days. Out-of-state practitioners who are not members are expected to go through the full credentialing process; their existing credentials are reviewed on a case-by-case basis to assess equivalence and to determine further action required for endorsement, if any
Remaining Challenges and Future Directions
While the behavioral health system transition is still under way, the uncertainty about SUD service definition revisions, the changing benefit and reimbursement models, and the difficulty of joining insurance networks in the relatively new closed network system continue to pose challenges for the SUD workforce and for new practitioners. The DHHS's Behavioral Health Strategic Plan and the North Carolina Opioid Action Plan (2017-2021) include measures to attract new behavioral health practitioners and to help the existing workforce navigate this changing landscape. In addition, the Department has recently issued a policy paper entitled Supporting Provider Transition to Medicaid Managed Care with further details on the state's policies regarding workforce development and retention.
Credentialing and Reimbursement Supports
Although North Carolina's consolidated and centralized credentialing system has streamlined the credentialing process for SUD practitioners in past years, the managed care system has introduced some new complexities. To be reimbursed, providers are now required to join a network, and many providers need to contract with multiple networks to retain their existing patients. To meet their accreditation requirements, MCOs impose some prerequisites above and beyond the state's credentialing criteria, and these can vary by network. Thus, providers are forced to apply separately to multiple networks with different but overlapping contract requirements.
As part of the transition to managed care, the DHHS will develop an integrated Provider Data Management system and Credentials Verification Organization to centralize the credentialing and enrollment process. Until this system is fully operational, the current Medicaid enrollment process will remain in place and will be enhanced with additional features. Specifically, all prepaid health plans in the state will be given access to a centralized clearinghouse that combines verified provider enrollment data with managed care credentialing data. They will be prohibited from requesting additional information from providers for their contracting process, and providers will no longer be expected to give credentialing information separately to every plan with which they contract.
In a further effort to facilitate the network enrollment process for providers, DHHS will provide SUD practitioners with training and education on contracting strategies under managed care, changes to administrative and operational processes, changes to state systems, continuous quality improvement strategies, and evidence-based practice models.
Regional Provider Support Centers
As part of the system transition, DHHS is developing Regional Provider Support Centers. These will be organizations under contract with the department (through a competitive bid process) to support the workforce in their clinical transformation and care improvement efforts as well as electronic health record and health information exchange connectivity.
As part of the North Carolina Opioid Action Plan, the state will convene a Payers' Council. The Council is currently being assembled with cooperation from the major health payers in the state. Although the main goal of the Council is to collaborate in regulating opioid prescription and dispensing practices across the state, the members will also partner in designing clinical benefits policies, treatment plans, and recovery supports. This collaboration will help reduce variability across plans in these policies and practices and reduce administrative burdens and reimbursement barriers experienced by providers.
The behavioral health system reforms include a plan to enhance the infrastructure for telepractice and to encourage health plans to make use of this option. For example, health plans will be able to leverage their telemedicine capability to meet their network adequacy requirements. These measures will allow providers to expand their client base.
North Carolina's centralized credentialing system, educational opportunities, and active recruitment of new professionals into the SUD field have been important factors facilitating the development and retention of the state's SUD workforce. The far-reaching system reforms currently in progress will, in the long run, benefit the SUD workforce in the form of improved reimbursement opportunities and streamlined enrollment processes. The transition period, however, has presented some challenges as providers try to adapt to the new system and to continue their practice within an environment in flux. These barriers are also common in other states implementing similar system reforms. The provider support measures that North Carolina has included in its strategic plans will provide useful examples for other states.