ZEN KOAN 4 2008: What do a colonoscopy and mental health care have in common?: LACK OF COVERAGE

FROM: Marsha V. Hammond & Anthony V. Jones : Asheville, NC

TO: BCBSNC Appeals Process PO Box 30055 Durham, NC 27702-3055

RE: no office visit colonoscopy services available in Western NC under any BCBSNC plan

December 28. 2007

Dear BCBSNC:

Thank you for making available health insurance for our family. We have paid your company approximately $50,000 over the past 7-8 years.

We have needed no major surgeries and have therefore spent, inclusive of outpt visits, emergency care offices, and medication, less than $5000 as associated with that payment into your system.

I realize that this is not the way that things are ‘figured.’ Your representative with whom I spoke on December 28, 2007, whom was very helpful, stated: “No provider chooses to offer office based colonoscopies” in Western NC. She was not able to uncover ANY physician’s office that would offer an office based colonoscopy in one-fifth of the state of NC.

This is what I note to be taking place from my perspective: BCBSNC is not adhering to best practices and medical necessity regarding a critically important screening device. Providers are not offering office based colonoscopies as it is not best practices.

**Why is a screening colonoscopy important?

“Colorectal cancer is the third leading cause of cancer deaths in the United States, and the risk for it increases with age. Patients with colon cancer rarely display any symptoms, and the cancer can progress unnoticed and untreated until it becomes fatal. Fortunately, colorectal cancer can be prevented if diagnosed and treated early.” http://www.umd.nycpic.com/Colorectal.html

**Why is clinic based colonoscopy stated to be best practices by medical providers?

“Colonoscopy.Those patients who had effective analgesia during their procedures and reported less discomfort were much more likely to agree to come back on a 10-year basis, which is what is recommended. "If you hurt people too much, they just won't think it's worth it to come back," Romeo explains.” HealthCare Benchmarks and Quality Improvement, March, 2003 : http://findarticles.com/p/articles/mi_m0NUZ/is_3_10/ai_98469410

I have been trying to obtain this service for sometime. In speaking w/ one of your representatives in September, 2007, he advised me there was one provider in Henderson county, 50 miles from Asheville, who provided office based colonoscopies. I called that office several times. No one answered and no one returned my calls. I just cannot believe, in this litigious day, that your company does not want to make available such a critically important screener. Should I get into my car, drive 100 miles round trip to Hendersonville in order to simply make an appointment for an office based colonoscopy, wait for a number of months, undergo a painful critical procedure which is not best practices? This is not acceptable

Here is the problem in a nutshell: BCBSNC will only pay for an office visit colonoscopy. Office visit colonoscopies are not available. Why aren’t they available? Because they are not best practices any longer and have not been for probably 15 years. Why aren’t office based colonoscopies available any longer? Because GI physicians understand that people do not willingly submit to un-medicated, painful procedures. Clinic based colonoscopies is what is available---across the board. In a clinic, one gets an IV, medication, and a fiberoptic scope inserted into one’s rear. In office, one gets a fiberoptic scope inserted into one’s rear and no medication.

Why won’t BCBSNC therefore pay for clinic based colonoscopies which is associated with giving the patient something to ease the procedure? Are you trying to save this money in order to take BCBSNC taxpayers’ assets and turn it into corporate assets, making a power money grab off the backs of consumers like myself and my husband?

No BCBSNC plan (A,B, or C) makes accommodation at any level of deduction for any best practices, clinic-based colonoscopy procedure. You either pay the $1300 out of pocket for this (only availability) clinic-based, critical procedure----or you don’t get it. I cannot imagine that the cost of treating colon cancer is cheaper than the offering of this medically necessary, best practices, procedure.

This letter it therefore a request to make available to my husband and myself, as associated with our BCBSNC Plan A, both 53 years old, a screening colonoscopy that is clinic based for the year 2008.

Thank you for letting me know about your decision.

Sincerely,

Marsha V. Hammond, PhD Anthony V. Jones, MA

cc: BCBSNC CEO Bob Greczyn, president and CEO, BCBSNC
Dr. Don Bradley, chief medical officer, BCBSNC
Blue Cross and Blue Shield of North Carolina P.O. Box 2291Durham, NC 27702

Health and Insurance NC State Legislature: Tomw@ncleg.net,Beverlye@ncleg.net,Bobe@ncleg.net,Carolynj@ncleg.net,
Raymondr@ncleg.net,Bruceg@ncleg.net,Hughh@ncleg.net,Angelab@ncleg.net,
Margaretd@ncleg.net,Jerryd@ncleg.net,Mitchells@ncleg.net

Connect-the-dots: lack of emergency mental health services leads to mentally ill woman shooting sheriff in neck

Assaulted sheriff can thank Governor Easley and DHHS for being attacked by mentally ill woman

The Burke County sheriff who was shot in the neck by a woman who was to be involuntarily committed is part of the ‘connect-the-dots’ picture associated with mental health defunding by the Easley administration.

Last week, Governor Easley alluded to his desire to ‘re-centralize’ mental health, blaming the problems mostly on the LME’s. DHHS sets the guidelines for the LME’s and so if there are problems w/ the LME’s (the old community mental health centers who morphed into merely administrative centers for services), then DHHS has created the problems.

In April, 2007, Carmen Hooker Odom, DHHS Secretary, appointed by Easley, blamed private providers, the Endorsed Provider companies providing Community Support Services (CSS), for spending too much money and initiated post-payment reviews of providers commonly associated with missing paperwork.

CSS are services associated with everything from emergency mental health services (such as would have been needed by the woman who shot the deputy in the neck) to skill building.
Endorsed Provider (private) companies struggle to maintain a business in the face of first, throwing money at the problem (in 2006), without training or pointers about what is expected from DHHS and/ or the LME’s, and it is simply no surprise that not only is Broughton Hospital closed for new Medicare and Medicaid patients but that emergency rooms are full of sheriffs standing around mentally ill patients tied down on gurneys for dozens of hours at a time while no psychiatric beds are available.

The BLAME needs to be laid right at the door of the governor as he is the person who appoints the secretary of DHHS. While Hooker Odom resigned in August, 2007, Dempsey Benton, the new secretary, has been the recipient of a nightmarishly run business.

CIGNA GOV'T SERV of CIGNA CORPORATION: MEDICARE PART B: illusory single-digit administrative overhead (OR JUST PLAIN INCOMPETENT) ??

FROM: Marsha V. Hammond, PhD: Clinical Licensed Psychologist, NC
E mail: hammondmv@netzero.com cell: 404 964 5338
Billing address: -----------------Asheville, NC 28806
Medicare Provider Number: 2492758 / v653

TO: Michael D. Woeller, Executive Vice President and CIO
H.Hanward Hanway, Chairman & CEO, CIGNA Corporation
CIGNA CorporationDirector Access AddressOffice of the Corporate SecretaryTwo Liberty Place, TL17A1601 Chestnut StreetPhiladelphia, PA 19192

December 20, 2007

RE: inability to speak to any human at the Part B (outpatient and mental health) CIGNA Government Services, NC, provider tel #: 866 520 4007, CIGNA Government Services, even when utilizing ‘repeat dialer’ software for a busy signal

Dear CEO of CIGNA:

I have been a Medicare provider, Part B, in NC, for several years now. Recently, I have needed to change my address. I have sent in the paperwork four times over the past 4 months.

I have received 2 calls back from CIGNA Government Services employees in Nashville. The first call I received a couple a weeks ago, as associated with the 3rd filing to change my address; that employee indicated that I had not written on a line, ‘CIGNA.’ The second call back after the 4th submission of change of address, indicated that I had not filled in ‘CIGNA Government Services.’ I had no idea that your organization was composed of both ‘CIGNA’ and ‘CIGNA Government Services’ until I noticed the news article about the 17 yr old woman who was denied a liver transplant authorization by CIGNA---and so she died.

I cannot be paid until the address matter is settled. While it would appear to be a simple matter, it apparently is not. And there is no one to talk to. Only endlessly submitted paperwork is permitted.

I would like to know why I cannot get a human on the phone to answer my questions. I have called a.m.’s and p.m.’s, bearing in mind that I only have any possible chance of speaking to someone from 11-1 CST or 2-4, CST. This is what is declared to be acceptable business hours at the Medicare Provider number. I have asked many ancillary services if there is another way to get through: they state there is not.

Though there be 8 hour workdays for most people and other agencies, for CIGNA Government Services there are only 4 hours which providers who render Medicare services, can utilize.

As a further testament to my inability to interact w/ Medicare, Part B, CIGNA Government Services, I sent an e mail request to your online services associated w/ Part B on October 29, 2007. I received an answer back on December 18, 2007. That is almost 1.5 mos between my online submitted query and any answer. The answer was of no help as I had already moved through at least 2 or my paperwork submissions.

Many of my clients receive Medicare. I am dependent on being able to interface w/ Medicare.

And, as perhaps you know, NC has been engaged in a brutal mental health reform effort for the past 7 years. Providers are experiencing a very difficult time interfacing w/ the companies that pay for our services. Thus, difficulties w/ Medicare, Part B, which is perceived as being an efficient, single digit overhead entity, in terms of administrative costs, is not helpful-----if the single digit administrative costs are obtained by simply ignoring any interfacing w/ Medicare providers.

Instead of humans to talk to as per the provider number as above, there are:

1. chronic busy tones
2. messages stating that ‘no one is available’
3. messages indicating there to be an ‘exceptionally large call volume’
4. being permanently on hold during the business hours allocated for providers to call, w/ no one ever picking up.

I am not speaking about an occasional problem. I am speaking about a chronic inability to provide services to clients in an efficient manner as there is no one at your agency to answer questions and take care of business.

In that CIGNA is one of the largest and oldest insurance companies in the US, and in that recently it has received some quite shocking press re: the 17 yr old girl who died w/o her liver transplant, I am suggesting that perhaps your venerable organization make available services for which US citizens whom pay quite a lot of money.

I would like to hear from you about a functional telephone number. I would like to have my change of address attended to. My current billing address is as above: 168 Virginia Avenue, Asheville, NC 28806. And I would like to be paid.

All this makes me believe that John Edwards is entirely correct: we can no longer work with the insurance companies in this country. They are not to be included in any negotiations re: national health insurance. Please show me that I am incorrect in this perception.

Thank you for your help.

Sincerely,

Marsha V. Hammond, PhD, Clinical Licensed Psychologist

cc: Mental Health Advocates, NC; NC State Legislature, Co-chairs, Legislative Oversight Committee as associated w/ mental health reform; NCPA; NCPolicy
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Items of interest:
CIGNA Government Services' Role in Medicare
http://www.cignagovernmentservices.com/overview.html
CIGNA Government Services, LLC is a wholly owned subsidiary of CIGNA Corporation – one of the nation's premiere health insurance companies. For more than 125 years, CIGNA has been helping people lead healthier, more secure lives.
Since 1966, CIGNA and its predecessor companies have administered the federal Medicare program. Today, CIGNA Government Services provides a variety of services for Medicare providers, suppliers and beneficiaries in 18 states and the U.S. Virgin Islands. Millions of Medicare beneficiaries and health care providers/suppliers rely on our quality services every day.

As a Part B and DME contracted carrier for the Centers for Medicare & Medicaid Services (CMS), we process and pay Medicare claims according to the Congressional laws and CMS rules and regulations. We do not determine who is eligible for Medicare.
CIGNA Government Services currently provides Medicare claims processing and support services for Medicare Part B and the states of Tennessee, North Carolina, and Idaho. On June 1, 2007, we assumed full operations for DME MAC Jurisdiction C (formerly DMERC Region C) for the states of: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia, and West Virginia.
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Item 2: Source: ABC NewsWESTWOOD -- A Northridge teenager awaiting a liver transplant died Thursday after she was pulled off of life support. CIGNA Insurance Company initially refused to cover the cost of the transplant for Natalee Sarkisian, saying the surgery was too experimental. On Thursday, friends, family and members of a nurses association held a protest outside CIGNA headquarters in Glendale, urging the insurance company to reconsider. But the decision came too late for Natalee. Just after six o'clock tonight, her condition worsened. Natalee's family took her off life support and she passed away. Read more: http://abclocal.go.com/kabc/story?section=news/local&id...

What are the differences between Basic Level Services & Community Support Services for state funded client?

Thank you for your TV coverage as associated with the myriad problems re: NC mental health reform.

As a provider, I would like to direct your attention to some matters which might create some detail re: your reporting. Some background material can be found at my NC Mental Health Reform blogspot where you will find a great deal of detail information as well as letters to pertinent people within DHHS, as well as their responses.

Here is a map of all the LME's: http://www.ncdhhs.gov/mhddsas/lme7-2-07map.xls

A significant amount of the problem, I think, is this: the Local Management Entities (LME), which primarily manage state funded clients authorizations and payments (the LME's are regulation entities), have a variety of ways of managing these funds for state funded clients. Medicaid and Medicare clients are fairly well taken care of so I do not believe that the people of whom you spoke on your program have Medicare or Medicaid.

The clients which your news program covered are probably state funded clients.

Who are state funded clients? They are the 'working poor.' They are people w/o Medicaid/ Medicare, or 3rd party insurance. They are increasing in numbers. They are people who are between jobs or w/o jobs. They are people over 21 but not yet 65 who have not have the gumption to wind their way through the disability system, if they have mental health issues. As you may know, in NC, as indicated by this past week's NYT's article, NC's diability process now takes up to 3 years.

I will give you a case in point and that client is not dissimilar to the ones you have featured on your TV show: a 26 yr old woman, married, w/o children, involved in the mental health care system even as an adolescent re: history of abuse in the home where her mother re-married to a very abusive man, and the client was severely beat. Other forms of abuse were also present.

As is not uncommon, in an attempt to re-create reality, the client went on to become dissociative (multiple personalities is the earlier way Dissociative Identity Disorder was described), w/ associated depression, rages, and self-harming.

This client is a state funded client, w/o Medicaid/ Medicare/ or any insurance of any kind and her husband works at low-paying factory jobs which are associated w/ not infrequent lay-offs.

This is what the client needs: outpatient psychiatric med follow-up and outpatient psychotherapy on a weekly basis w/ more frequent psychotherapy if there is decompensation associated w/ self-harming. This is what 'best practices' would recommend.

This is what Smoky Mountain Center LME (SMC LME) will allow: outpatient psychiatric med follow-up and heavily regulated psychotherapy.

What does 'heavily regulated' mean? It means the re-creation of 20 plus pages of paperwork every several months; it means calling the ACCESS center at SMC LME in order to speak w/ one person who is working w/ me on this client (she is frequently not there); it means I have been paid for less than half of my therapy rendered----at the client's home; it means no answers forthcoming from SMC LME re: services which were mandated by DHHS in June, 2007 but which only some LME's choose to offer.

What services am I talking about? Psychotherapy services for state funded clients are only to be had as associated w/ 2 different formats:

1. Community Support Services (CSS)
2. Basic Level Services (BLS)

What are these services? CSS includes everything from emergency services on the part of the provider e.g., calls in order to manage crises, to skill building, to outpatient therapy.

BLS includes only 2 things: psychiatric medication management and outpatient psychotherapy.

Why do some LME's refuse to advantage state funded clients to CSS?

1. CSS is being heavily managed by DHHS and Hooker Odom curtailed a significant amount of these services in April, 2007.

2. CSS is being 're-written' to allow psychotherapy to be provided by non-professional people e.g., CSS workers (see the new Service Definitions for CSS on the DHHS website in order to have an overview of what is taking place)

BLS is only provided by some of the LME's. It is not clear to me how many refuse to offer BLS. Smoky Mountain Center (SMC) LME is one. It is now the largest, in terms of counties, covering mental health services for state funded clients in NC (see the map). Western Highlands Networkd (WHN) LME is the other western NC LME and does offer BLS.

What are the advantages to psychotherapy being offered as a BLS?

1. well trained professionals are utilized, rather than CSS workers who only need have a high school education. Thus, the LME's and citizen/ clients obtain better services for their dollar.

2. psychologists and other professionals are not required to sit through 20 hours of CSS training which is completely unrelated to providing psychotherapy. This allows providers to do what they are trained to do rather than jump thru an unnecessary hoop which is a barrier to the rendering of services.

Your story, I believe, could benefit from some detail about state funded clients and how they are being served in your area, which is associated with Wake LME, I believe. The LME's main job is to manage state funded clients' services.

Thus, your story is about the mis-management of state funded client services, I believe.

And the details, in part, are associated with the understanding of the various services and who provides them.

Sincerely, Marsha V. Hammond, PhD
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WBTV, Charlotte, covering mental health crisis in NC: December, 2007

A Closer Look at Mental Health in North Carolina There is a mental health crisis in North Carolina. This week, Eva Nelson was charged with shooting a Burke County deputy while attempting to serve a mental health commitment order. A few weeks ago, Selena Shiuli's children were stabbed inside their Charlotte home. Police said Shiuli fatally stabbed one child and the other one is still recovering.Advocates for the mentally ill say funding cuts and statewide mental health reforms mean there are not enough services to go around.When sick patients don't get the help they need, people around them get hurt.The two largest mental health facilities in the state are facing major problems. The Broughton facility in Morganton is always full and Dorothea Dix in Raleigh is closing next month.This puts more pressure on emergency rooms and law enforcement.What can be done and who should take the lead? How much will it cost each of us if these people are not properly treated?It is estimated that mental illness affects 1 in 5 families in America.The estimated economic cost of untreated mental illness in the United States is $100 billion annually. During our 5:30 newscast Thursday evening, we interviewed Bob Ward who is a public defender in Mecklenburg County. We wanted to get some answers to these and other questions concerning North Carolina's mental health crisis. Press "PLAY" to see this interview. Story Created: Dec 13, 2007 at 5:39 PM EST Story Updated: Dec 13, 2007 at 9:11 PM EST found at: http://www.wbtv.com/home/12484111.htmlYou can make your comments to: telluswhatyouthink@wbtv.com

SMC LME state funded client: twin to 'Phil', mental health consumer of Raleigh N& O

December 12, 2007

Well, this client SMC LME # 040974, is getting to be kind of like the Raleigh News & Observer case study 'Phil', followed up by that paper's mental health writer, Lynn Bonner, I believe, for a number of years, revealing the problems w/ mental health reform.

This client is that client's twin. The Raleigh News & Observor's case study was a Medicaid/ Medicare client, I believe. This client is state funded.

Today, I had my 1.5 hr weekly session w/ the client. I receive no pay for this; I travel to the client's trailer which is 12 miles from the nearest city where I see other clients. Yesterday I spoke w/ Mr. Peterson in Heath Shuler's office in order to ask him to input into the process of this client's application for Medicaid.

SMC LME has refused any state funded clients Basic Level services. Leza Wainwright of Mike Moseley's office verified that the LME was within its right to do so. I severed my relationship w/ SMC LME soon after that.

The client took an overdose of pills last night which prompted the client's spouse to grab the bottle and put the client to bed. The client has a 'friend' who works at the Haywood County Hospital in the ER who passes to the client butterfly needled and plastic tubes which allows the client to fill up the containers with client's blood in order to write (in the future) poems w/ the blood. So, how many vials did you use, I asked? Client walked to the refridgerator, pulled a small one out, indicated there were others. Client is fascinated w/ death and has on laptop computer pictures of coffins.

There is no assurance that client can get Medicaid and I have never heard of a client who is unlinked to SSI or SSDI who gets Medicaid on a reliable basis. The best you ever get in terms of Medicaid w/o linkage to SSI or SSDI is Medicaid deductible for 6 mos/ at a time. The client could use my $3600 therapy bill, unpaid by SMC LME, in order to create the deduction. I cannot get paid if the client uses that bill in order to create a 6 mo Medicaid policy.

Client and spouse were excited last week as they believed they had uncovered, per the local health department, a way to get to Medicaid but then in checking on this, I discovered that 'Family Medicaid' only includes family planning services. No therapy; no medications; no dental coverage to fix the teeth damaged by bulemia.

This client will not be alive in 3 years, the amount of time now documented to be associated with obtaining SSI or SSDI (see NYT article below). Client cannot qualify for SSDI as not enough formal work time. Therefore, under SSI, which client could obtain after several years and the use of an attorney, client will never be able to formally work as client will not be able to earn more than about $200/ month or SSI will disappear, also endangering Medicaid.

This is the state funded client for which SMC LME refuses outpatient therapy.

This is the outpatient client which Leza Wainwright, the deputy under Mike Moseley of NC Mental Health, underlined, as per the LME, that the LME has a right to refuse Basic Level Services to state funded clients (in distinct contrast to WHN LME which does make available Basic Level Services).

This is the 'high cost' state funded client which I discussed today with The Commission's MH/DD/SA chairman Pender McElroy, in order to see if The Commission has the jurisdiction in order to consider whether my proposed suggestion that all LME's render to state funded clients Basic Level Services could come under their jurisdiction.

McElroy .state that it would necessitate combing thru the statutes to see if The Commission could consider the matter. McElroy indicated that much of the power re: mental health reform lays w/ the Secretary of DHHS, currently Dempsey Benton, appointed by the governor.

I am not willing, as the long-term provider of this client, to sit thru 20 hrs of CSS training, which I do not provide, in order to continue to revamp lengthy Person Centered Plans and call up the ACCESS manager at SMC LME in order to obtain month by month authorizations for seeing a client requiring intensive outpt therapy.

Mr. McElroy asked me if there were other providers who had experienced difficulties of this type re: other LME's. I advised him that my contacts w/ other psychologists are mostly within the Western Highlands LME network---where there are not these kinds of problems. .

***** Are there any providers on this listserv who can send me, back-channel, information re: other LME's refusing Basic Level Services for state funded clients?

Thanks for your help.
marsha hammond, phd
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references:
Disability Cases Last Longer as Backlog Rises

Jeremy M. Lange for The New York Times
Richard and Vicki Wild of Hillsborough, N.C., said they were mystified when their son Mark’s disability claim was rejected. “We had 10 years’ worth of hospital records,” Mr. Wild said.
By ERIK ECKHOLM
Published: December 10, 2007
RALEIGH, N.C. — Steadily lengthening delays in the resolution of Social Security disability claims have left hundreds of thousands of people in a kind of purgatory, now waiting as long as three years for a decision....

“We had 10 years’ worth of hospital records and unanimous opinions from the doctors,” said Richard Wild, 62, who until recently was a computer analyst. But his son’s initial application was turned down in 2003.

The family had sunk into debt because of medical bills, nearly losing their house of 30 years, but found a lawyer to file an appeal. The son, by then in his mid-30s, had to wait two more years to get a hearing scheduled, with no income and little life outside his parents’ home and the hospital.
As his hearing date in October 2006 approached, Mark Wild told his parents that he feared another rejection. “It was his last chance at any dignity, and he said if they turned him down it would be too much to take,” recalled Mrs. Wild, a nurse.

On Tuesday, Oct. 17, 2006, just a few days before the hearing, Mrs. Wild woke up to find her son gone. On his desk lay his watch, his ring and a bullet.

On that Thursday, Mrs. Wild, 55, got a call at work from their lawyer. “I just wanted to give you the good news,” she said he told her. “Somehow the judge has already approved the disability, it’s a done deal, Mark’s got it.”

Two hours later, a deputy sheriff and a chaplain arrived to say that hunters had found Mark Wild’s body in the woods, dead of a self-inflicted gunshot wound.

“No one can say for sure, but we’re convinced that his despondency and fear about the disability decision contributed to his death,” said Mrs. Wild, who wears a pinch of her son’s ashes in a small tube on a necklace. ..."

http://www.nytimes.com/2007/12/10/us/10disability.html?_r=1&pagewanted=2&ref=us&oref=slogin

DHHS's Trojan Horse: Community Support Services (how to endanger people's lives)

NC DHHS, following federal guidelines, instituted Community Support Services (CSS)as associated w/ NC Mental Health Reform.

CSS was defunded by DHHS Secretary Hooker Odom in April, 2007. CSS includes everything: emergency services, therapy, skill-building. In defunding that, the state psychiatric hospitals were going to have to pick up the slack.

Additionally, CSS has been utilized by LME's, the old community mental health centers, as a way to CAFTA-like, dumb down therapy services. LME's deny Basic Level services for state funded clients, who were to be included in NC mental health reform. Instead, they expect cheaply paid workers, associated with the Endorsed Provider companies, to provide professional psychotherapy.

CSS have become nothing more than a way to disengage mental health professionals from using their professionally paid skills in order to keep people out of the hospital.

If NC DHHS wants mental health reform to work, they need to realize that a format of psychiatric medication f/u, as necessary, and professionally rendered therapy is the model that has traditionally worked. Yes, CSS have a role but their role is associated with dealing w/ psychosocial stressors.

Instead, DHHS NC's new Secretary, Benton, and DMH's Moseley, have created new Service Definitions for CSS which further advance the rendering of sophisticated services such as psychotherapy by poorly paid CSS workers.