Why mental health providers don't want to work with state funded mental health clients: the poorest of the poor

RE: Raleigh News & Observer article; Privatizing treatment left gaps in the system, an expert says, and people without Medicaid can end up with no place to go by Lynn Bonner, Staff Writer
http://www.newsobserver.com/politics/story/686861.html

August 29, 2007

Hello:

Ms. Bonner's welcome article stated the following, which is referring to state funded clients: "...Local mental health offices say it is harder now to find treatment for poor people without Medicaid because companies don't want patients whose bills are paid with limited state money...."

Here is a comment from a provider who directly services state funded clients. State funded clients are people who cannot access Medicaid because: 1. they are not under 21 or over 65 and, 2. they have no children. Given such a democraphics, one can speculate that these are indeed the poorest clients for Medicaid does give one a leg-up in terms of services which advantage one e.g., medical care, etc. Thus, such clients commonly have no transportation and commonly are jobless.

These are the problems re: the state funded clients from the perspective of a provider who has worked with them for several years through all the well-meaning mental health reform changes-----which have been vast:

1. the authorizations are more numerous for state funded clients (every 3 mos instead of once/ year for Medicaid clients)

2. in association with authorization for state funded clients, the overviewing of the paperwork in terms of Diagnostic Assessments, the initially submitted Person Centered Plan (short form), the demanded longer (as in 15 pages plus) Person Centered Plan, which has to be updated with every authorization, is a prohibitive amount of work for a provider. This filling out of paperwork pays no money.

3. if a client merits community Support Services, which entails working with the client in order to make a liveable life and learn skills, the state only allows 2 hours/ week/ client which is not enough to pay for the Community Support worker's gas associated with working with the client. Medicaid clients can receive 12 or more hours/ week/ client of Community Support services. Hooker Odom cut the hours by gigging providers with post payment reviews beginning in April, 200. Now no provider is willing to be endlessly scrutinized by the quality control taskmasters at LME's who, directed by DHHS, go over every document associated with a client should they receive 'medically necessary' Community Support Services of more than 12 hours/ week/ client.

Please don't paint a picture of providers as refusing to work with these clients because 'they don't pay enough money'; contrarily, the problem is that DHHS and the LME's have created barriers to providers working with these state funded clients. The money is the same as for Medicaid; however the barrier of the authorizations, associated, assumably, with the LME's wanting to keep a close eye on the money, has created a situation wherein the providers are not willing to spend many unpaid hours creating paperwork so that the LME can then deny or pass them through the portal----every three months----to work with the state funded clients on a very limited basis.

While your story may be grossly accurate, Ms. Bonner, and while I appreciate it, you do not understand WHY providers do not want to work with state funded clients.

Thank you and I am looking forward to more coverage on these important issues.

Sincerely,
Marsha V. Hammond, PhD

So NOW the LME realizes there's a problem as providers stop providing Community Support Services

Marsha V. Hammond,PhD, Clinical Licensed Psychologist

'urgent' CSS problems

August 21, 2007

Dear Bill and colleagues at SMC and SMC afffiliated providers:

For the past 6 mos I have sent Bill Hambrick (Smoky Mountain Center LME key administrator) e mail which is part of my documentation of the defunding of CSS at my blogsite, Madame Defarge,which concerns itself with NC mental health reform. I like Bill and I have admired many people part of SMC LME administration. But let me say, my friends, that there is no use in you alerting us NOW at this late point in time to the problem with CSS. You've been given information about the affect on providers and you chose to look the other way or at the very least you never responded to this vexed provider pertaining to what is now becoming 'urgent.'

I would have hoped that you would have leaned on DHHS to let them know just how concerned providers have been. Now you appear to be leaning on providers as you have not listened to them.

You stated that you are concerned about CSS and that you want to: "listen to not only what barriers you are finding, but hear your creative ideas and recommendations as to how such barriers might be resolved. "

I have been telling you since April, 2007 what the barriers are. To put it in a nutshell,these are the barriers:

1. post payment review threats issuing from DHHS and then at the behest of the LME's who carry out DHHS's whims

2. Charles Berry's (your quality control person) gigging of the providers in terms of post payment reviews. Specifically, Mr. Berry's punitive demeanor as associated with post payment review pertaining ONLY to clients receiving 12 hrs/ week/ CSS(contrarily, Tara Larson of DHHS last week stated in Asheville 'there is no magic number of hours' when in fact we know that there is). CSS services were provided in good faith prior to Hooker Odom's vindictive and destructive defunding of CSS in April, 2007. Mr. Berry has applied standards to the post payment review which were not in place prior to the utilization of the CSS which were given in 2006 and early 2007. Yes, quite probably DHHS has 'trained' Mr. Berry and yourselves to do this.

The fact or assumption that you did not attempt to vigorously admonish DHHS about the ramifications of this as associated with this now 'crisis' could have been anticipated months ago.

Mr. Berry is: hard to get in touch with; does not respond in a timely manner; has attended to details that were not his business (e.g., my contract with ------------ went back and forth to him, trying to please him with the right wording, until he finally dropped the ball and I got tired of trying to find him); uses his position to lay into providers who have worked hard to provide services in good faith.

In summary, providers cannot work in this kind of vindictive environment wherein standards that were created by DHHS in 2006 no longer apply in 2007 and indeed standards have been 'value added' subsequent to the services which were rendered in good faith.

Your problem, to my mind, is with DHHS and if you cannot argue with DHHS the affect that their instability in terms of procedures, then really there is nothing to tell or ask providers. If you are in control of monies untethered to DHHS then you better tell us now.

Creative recommendations?

No 1: Give us a quality control person that is amenable to working with the providers that the LME has endorsed. You could benefit from a spokesperson who treats providers as if they are colleagues rather than entities to be disciplined. We do not respond well to threats which would destabilize our companies. We simply will not provide the services.

No2: it would be useful if DHHS heard from YOU as to the above matters. Tara Larson, a key person in DHHS, simply submits that 'I don't know what you're talking about.' If you can't convince them, then no one can.

No 3: make EVIDENCE rather than hearsay that you will support providers who have moved through your endorsement process that you want to work with them as you realize that DHHS shifts criteria and demands. All the SMC LME meetings I have been too hint at the difficulties of working with DHHS but I suppose you are unwilling to speak pointedly to the matter as you are beholden to DHHS. This leaves providers with the feeling that you are simply unwilling to go to bat for us. Moreover, we have to figure out which of what you are saying is true and dependable by endlessly cross-referencing with DHHS/ SMC/ Value Options.

No 4: it was useful to have had the rather recent table from SMC comparing what USED to be acceptable for PCP's , etc., and what is now required. Clear, concise, thoughtful information to providers is always appreciated. This is in contrast to what is stated by DHHS. That information is: backtracking; untethered; confusing; non-overlapping; and hieroglyphic in terms of 'wonder what they mean by that.'

No 5: any well managed ways of creating online (that means we don't go 2 hours round trip to Cullowhee) training such as the refreshingly launch of BUI, is to be commended and recommended. Rick, the BUI guy, was: easy to reach; knew what he was talking about; stayed on the task until it was figured out when the provider called him up.

Please Let me know if someone takes notes from the meeting. I'd be interested in coming to meetings if there is evidence that something is actually being attended to in terms of what concerns the providers. Please do circulate these comments to any pertinent person, including Mr. Berry.

We have all moved to 'no more than 12 hours/ week/ CS' for ANY CLIENT as no one can afford all the time that Mr. Berry demands re: post payment review. Rather than endure that travail, we simply will not go there. So, if your intention was to create that, then you've succeeded.

Additionally, companies find it harder to keep workers as associated with the complete instability of the mental health reform that DHHS has enacted. Thus, you have hold-ups in terms of services. We cannot give workers CSS hours and then pull the rug out from under them several months later. That lends itself to an unfocused, untrained, unappreciated and unappreciative CSS workforce. And they simply quit rather than starve.

To my mind, DHHS has destabilized mental health reform significantly and the LME's have colluded with that.

Sincerely, Marsha V. Hammond, PhD

This is the e mail letter sent to SMC providers alerting them to the problems with Community Support Services (CSS):

To: Community Support Providers Southern Region (Cherokee, Clay, Graham, Haywood, Jackson, Macon, and Swain counties) Date: August 21, 2007

We have an urgent need that necessitates a meeting with Community Support providers from the Southern Region. In recent weeks a number of providers have decided to cease provision of Community Support Services or have limited capacity to receive further referrals, while others wish to select the type of consumer they will serve. This puts consumers in our community at risk. It is our responsibility to ensure consistent availability of services within established standards. We plan to meet that obligation. However, before we take steps to resolve these concerns, we want to meet with you and listen to not only what barriers you are finding, but hear your creative ideas and recommendations as to how such barriers might be resolved. This must be done quickly as the need is urgent and has significant impact on consumers. We plan to host this important problem-solving meeting next Thursday, August 30thth at 4:30 p.m. at the Area Office (following the DVIP training for those providers involved with this). This is your opportunity to have input and be a part of the solution. We appreciate your constructive and resourceful thinking as we move forward with a plan.

'Medical Necessity': will no one free us from this troublesome term?

FROM: Marsha V. Hammond, PhD: Clinical Licensed Psychologist e mail: hammondmv@netzero.com

TO: Deana Dolan, RN, BS Email: deana.dolan@ncmail.net
Jane Plaskie, RN, MS Email: jane.plaskie@ncmail.net
Nurse Analysts
Division of Medical Assistance
Telephone #: 919-855-4260
FAX #: 919-715-7679

and

Tara R. Larson, Assistant Director, Clinical Policy and Programs 919 855 4260
tara.larson@ncmail.net

August 13, 2007

Hello Ms. Larson, Ms. Plaskie, and Ms. Dolan:

I have a question pertaining to recent trainings on EPSDT as associated with the term 'medical necessity' which, of course, is the lynchpin piece pertaining to the obtaining of mental health services.

In the online power point presentation by Ms. Plaskie and Ms. Dolan, they indicated, as associated with 'medical necessity':

"....Must be listed in the federal law at 42 U.S.C. § 1396d(a) [1905(a) of the Social Security Act]. Must be medically necessary "to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified by screening...'ameliorate' means to improve or maintain the recipient's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.....must be determined to be medical in nature....."

I do not understand how 'medical necessity' is associated with mental health challenges---IF mental health challenges are (assumed to be) 'medical in nature.' Therefore I do not understand how 'medical necessity' is deemed by DHHS to be the background lynchpin piece associated with mental health services.

'Medical Necessity' is associated with medical problems e.g., lab work; x-rays; CAT scans; medications.

This may seem to be a silly point but when Ms. Larson indicated in her EPSDT presentation in Asheville, NC, last week, and she was queried as to where on the DHHS website was the 'definition' of 'medical necessity' she indicated it was not present. And so, we have a free-floating power point presentation presented by some people associated with DHHS which is untethered to the DHHS web page. If its on the web page as pertaining to mental health services, could I please have the URL?

I am not trusting of an agency that puts forward this notion of 'medical necessity' but is willing to run through the mill the Endorsed Provider agencies when the doctoral level psychologist, or psychiatrist, has been asked to sign off re: 'medical necessity' but then is told that it is not medically necessary as associated with a set of criteria that for all purposes is INVISIBLE.

As a provider, I sign off on the PCP forms in order to indicate that Community Support, for instance, is 'medically necessary'. However, my signature and opinion matters not. I am not allowed as the doctoral level psychologist to seek out more than 12 hrs/ week/ client of Community Support services unless I want to be flogged with a post-payment review and associated with that---it is entirelly possible my company would have to pay back any monies earned for hours greater than 12 hrs/ week/ client. It does not matter that I may deem it to be 'medically necessary' utilizing your criteria, namely: "'ameliorate' means to improve or maintain the recipient's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems."
.
To my mind,something has to give: either you get another term; or you redefine 'medical necessity' so that it includes mental health treatment; or you allow the demanded doctoral level signatory to do their work; or, you just let anyone sign the 'medical necessity' Person Centered Plan.

DHHS continues to create massive confusion with these various sets of information which confuses providers and certainly will obtain the (assumably) desired results: No Community Support of greater than 12 hrs/ week/ client is acceptable. And no Endorsed Provider agency is going to continue to provide services while the matter is appealed because no one can afford to pay back such massive amounts of money come post payment review. And no Medicaid Appeal is in place. And no attorneys are there to challenge this entire matter.

I am looking forward to you providing me some clarification re: this matter of just how does 'medical necessity' overlap with mental health services.

Sincerely,

Marsha V. Hammond, PhD: Licensed Psychologist, NC

Medical necessity as UNDEFINED by DHHS: "why, its anything you like for it to be" (AS LONG AS WE GET THE LAST SAY)

As associated with the continuing downsizing of mental health services, the Catch-22 that DHHS/ DMA/ Value Options delivers non-stop, will not change because the background term, medical necessity, is not uniformly applicable to mental health services.

Indeed, the topic of medical necessity as associated with the creation of the Person Centered Plan (stated on page 3 of the revised 7.11.07 document from DHHS) is sadly ludicrous: "The Person Centered Plan as a Unified Life Plan." There will be no 'Unified Life Plan' as long as DHHS utilizes medical necessity as the guiding tool because it is simply a game of GOTCHA vis a vis the LME's and DHHS.

No, your client should not have had these services which you rendered in good faith (as associated with this post-payment review for any Community Support hours over 12/ week/ client) because (so far: keep trying with that paperwork) you have not outlined well enough for us, the authority, the matter of medical necessity as it pertains to mental health services.

If someone is run over by a bus, all the medical procedures which are applied can easily be deemed to be medically necessary. As key point person, Tara Larson of DHHS (Tara R. Larson, Assistant Director, Clinical Policy and Programs 919 855 4260 tara.larson@ncmail.net) put forward as an example this past week at a mandated meeting for Endorsed Provider companies: orthodontic care is medically necessary if the teeth are separated by such and such a space, thus causing problems with mastication and digestion.

And so is mental health care a necessity if one provides the research indicating that if mental health care, outpatient, is associated with diminished incarceration, or suicidal behavior, or homicidal behavior? I think not. The research is an attempt to 'look into the future' and how it can be augmented as associated with measures applied to the problem. However, behavioral health is not the same as sewing up your gaping wound in order to stop you from bleeding to death. Drugging people, however, is a pretty reliable way to shut down obnoxious behaviors. Yes, indeed: you can get a clear change in behavior by over-medicating someone.

However, there is no real application of medical necessity which can clearly be applied to mental health care other than the prevention of suicide or homicide. Yet, DMA and DHHS persist in using this medical term to authorize (or not) mental health services.

Simply put, this is nothing but a demand put to Endorsed Provider companies to create more and more clouds of paperwork and endless discussions about research that may or may not be acceptable to DHHS/ DMA. Heck: you might even get a question into the 'round table discussion' alluded to by Ms. Larson which takes place with some kind of regularity at DHHS/ DMA. Indeed, the question that was proposed by an Endorsed Provider company employee was the following and it reportedly, per Ms. Larson, upon further submission of the matter to DMA/ DHHS:

"Smoky Mountain Center LME, as associated with a post-payment review of Community Support services for a client, recently stated that a diagnostic assessment---though it was not required by the LME, created by a PhD psychologist, with many years of training in assessment, was not supportive enough for Community Support services. So, the Community Support services rendered in good faith by the Endorsed Provider----in excess of 12 hours/ week (no Endorsed Provider DARES give more than 12 hrs/ week, contrary to what Ms. Larson stated at this past week's meeting "12 is not a magic number") are to be skewered on the basis of an assessment which was not required because it was 'contradictory' and did not wrap clearly enough around the matter of Community Support items.

And what kind of assessment is now acceptable to DHHS and the LME's?: why anything you like...there's a smorgasbord of assessments as per an outline of such a couple of months ago. For, we don't want to limit you, the Endorsed Provider with the professional training. (However, we will surely gig you if you do not write it the way we want it which we do not explain but instead indicate that all of these kinds of assessments are OK). Ms. Larson indicated to the attendees at this past week's meeting: 'Well, that's something to be put to our round-table discussions.'

Yes, indeed.

Maybe the psychological assessments/ diagnostic assessments should simply be a compendium of research: heavy on the footnotes and references and xerox copies of references. It does not matter that your training was to have overviewed this and that you are considered something of an expert and that is why your signature is required as associated with 'this is a medical necessity' as per the Person Centered Plan forms. It simply matters what you can bring forward in order to convince DHHS/ DMA who responds to the money/ legislative end of things rather than the consumer/ client/ family/ provider ends of things. I say let anyone sign the person centered plans, for it does not matter WHO signs them.

Neither would an approach 'heavy on the references' work, however, as research associated with behavioral health is not associated with a continuous, seamless stream as would be present with 'great' discoveries like washing your hands before assisting a woman w/ childbirth as dimiishing the rate of post-partem deaths (physicians gleefully discovered at the turn of the last century that washing your hands would save lives).

The line in the sand is only drawn by DHHS/ DMA and never by the Endorsed Provider who is only in the position of expending time and energy to argue for the notion of medical necessity which cannot be applied to mental health care in any clear manner.

This is a no-win situation. Clients are losers and so are associated families and providers. Its time for the Endorsed Providers to simply say: we won't play this never-ending game of spot the line in the sand. I don't know how you dissassociate yourself from this wicked playground, however.

The only arguable way to utilize the notion of medical necessity as associated with mental health care, involves only 2 scenarios: suicidal or homicidal ideations. If carried out, the person is either dead or in jail. If someone attempts to commit suicide, they injure the body----thus creating medical necessity. If someone tries to kill someone, they injure someone else's physical body, thus creating a scenario clearlyl associated with medical necessity.

These require hospitalization or jail time. This is not mental health reform and this is not even the application of mental health services: this is a constant battle with DHHS/ DMA/ Value Options.

When Tara Larson was asked by Endorsed Provider representatives at the meeting the 1st week of August, 2007, where, on the DHHS/ DMA webpage, was the definition of medical necessity, she stated: IT'S NOT THERE.

right. The Catch 22 continues.

http://en.wikipedia.org/wiki/Catch-22

Joseph Heller & Catch-22

"........There was only one catch and that was Catch-22, which specified that a concern for one's safety in the face of dangers that were real and immediate was the process of a rational mind. Orr was crazy and could be grounded. All he had to do was ask; and as soon as he did, he would no longer be crazy and would have to fly more missions. Orr would be crazy to fly more missions and sane if he didn't, but if he was sane he had to fly them. If he flew them he was crazy and didn't have to; but if he didn't want to he was sane and had to. Yossarian was moved very deeply by the absolute simplicity of this clause of Catch-22 and let out a respectful whistle.
"That's some catch, that Catch-22," he [Yossarian] observed.
"It's the best there is," Doc Daneeka agreed. ...."

PROVIDERS MISGUIDED AND THEN GIGGED: Back Channel deals cut by Western Highlands LME?

When I called Smoky Mountain Center LME about a week ago in order to obtain some information about what I needed, or not, to submit to the LME pertaining to a new client receiving Community Support services----Mo-----(I don't want to embarrass people; I just want accurate information) told me I didn't need to submit anything to the LME. So, I began providing services to the client. Then, when I called back to the manager of the ACCESS Center a few days later (as I have learned who seems to know what they are talking about who does not), the supervisor of the ACCESS center was startled to find out what the other person had told me. Indeed: she indicated to me that I needed to submit some information and that the client's mother had to call in for a screening. Is the agency I am affiliated with going to be paid for the work that occurred after the 1st person's information---an employee of the ACCESS Center? Or are we going to be gigged? Is it any surprise that providers are collapsing?

Then I tried to utilize the Smoky Mountain Center BUI system, an 'extranet' system associated with obtaining authorization and billing for state funded consumers. The password works (after 2 conversations back and forth w/ IT). When you pull up the BUI page (the deadline is a few days from now in terms of putting through paperwork for these clients), it indicates that 'this might take a few minutes.' Both my computers are 'compatible' with the BUI system and so what in the world is going on? I let both computers sit for over 15 minutes in order to 'take a few minutes.'
ARGH.
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I would like to know what kind of 'assistance' Appalachian Counseling and Alpha-Omega are to receive courtesy of Western Highlands. Moreover, I would like to know if other agencies who serve this population can be advantaged 'assistance.' Interesting back channel 'deals' taking place, it appears. Marsha V. Hammond, PhD, hammondmv@netzero.com
associated article on Western Highlands 'assistance' to 2 Provider Agencies in Western NC

Mental health provider to close
by Leslie Boyd, LBOYD@CITIZEN-TIMES.COM
published July 23, 2007 12:15 am
ASHEVILLE — The fragile mental health services network in the region is showing signs of unraveling as providers struggle to stay afloat.
One of the smaller providers that stepped up to take on new clients last year when New Vistas/Mountain Laurel closed also will close next month.
Horizon Recovery on Patton Avenue will close Aug. 9, when its contract with Western Highlands expires......
Two other providers, Appalachian Counseling and Alpha-Omega Health, will receive money from Western Highlands......
Appalachian and Alpha-Omega are not in danger of closing, Carder said, but the agency will provide some financial help to them...."
http://www.citizen-times.com/apps/pbcs.dll/article?AID=200770722026