Sunday, August 12, 2007

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 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.

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. ...."


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