Sunday, February 24, 2008

Pulitzer Prize winner overviews mental health (and ignores the background information)

Dear Mr. Pat Stith:

Its always a pleasure to have a Pulitzer Prize winner writing.

I wanted to make some comments on your recent MH article, 'State starts getting a grip on spending : Stricter limits kick in next month', by Pat Stith, Staff Writer

I will comment within the body of the article. You are missing a lot of background information and the title creates the effect that the over-spending was on the part of the providers, furiously cranking (un-necessary, it is implied) services. Nevertheless, I appreciated your 'just the facts m'am' writing style here.

First of all, your background information did not include this; the information is accurate and can easily be googled, I believe: "North Carolina ranks near the bottom in the nation in per capita funding for mental health care at $16.80, compared with the national average of $91.12." (Point of View: unknown paper; Published: Feb 24, 2008 Mark Sullivan).

Thus, your article comes off as saving money which would have been recklessly spent by those robber barron Endorsed Provider companies --- when this obviously is not true given the rate/ capita/ mental health services.

Here is the body of your article, in its entirety, with my comments separated by ??? :


"State officials have succeeded in reeling in some of the extraordinary costs of the community support program

???The proper name is Community Support Services or CSS???

...for people who are mentally ill or suffering from substance abuse.Medicaid spending on community support for children and adults still averaged $72 million a month in October, November and December -- about 16 times more than the N.C. Department of Health and Human Services had expected in January 2005.

But payments in those three months were down almost 20 percent compared with payments made during the previous three months."We're not where we need to be to meet our budget," said Dempsey Benton, secretary of health and human services. But spending is moving in the right direction, he said.

Medicaid, a tax-funded program that pays medical bills for poor people, spent about $1 billion in North Carolina last year on community support for children and adults. Community support is supposed to teach skills.

??????CSS ranges everwhere from: teaching skills; emergency services; psychotherapy. I don't think it can be summarized w/ 'teaching skills.' Indeed, at Smoky Mountain Center LME, an LME which does not provide Basic Level Services, which is psychotherapy and psychiatric services, for state funded clients, CSS has to be EVERYTHING. ????

An adult might be taught how to behave on the job; a child might be taught how to get organized to do homework.

???? This is a sad truncation of what CSS is about and given how you have described here if I were a critical citizen I would think, well then, why don't they just dump that? No one taught ME how to behave on the job...????

Since early last year, when officials realized that spending on community support was out of hand and began trying to do something about it, the state has made changes, some mandated by the General Assembly.

???? It would be more accurate to say that when NC actually started to move in the direction of the other United States that their spending for mental health services accelerated such that they began to move into the domain of what other states' spend????

Since last spring, the Department of Health and Human Services has:

* Reduced the hourly rate for community support to $51 from $61, a savings of about 16 percent.

?????This was not as problematic as the post payment reviews which were done retroactively and utilized a DIFFERENT STANDARD on the money that had been spent than the standard which WAS IN PLACE when CSS was created. See my blogspot, Madame Defarge, for more details.????

*Conducted a series of audits and demanded repayment of $59 million. Through mid-January, the state had recovered $14.8 million.

?????They will not get this back as the companies have simply collapsed and gone out of business OR have obtained attorneys to make the point immediately above and on the basis of medical necessity which is a slippery term re: mental health if there ever was one.????

*Stopped allowing new providers in the program except under special circumstances.

* Referred three providers suspected of criminal misconduct to the Medicaid Investigations Unit in the Attorney General's Office, said Grayson G. Kelley, chief deputy attorney general.

* Urged its contractor, ValueOptions Inc., to review individual requests for service more aggressively. In the early months of the program, the company approved almost every request.

???????Value Options has now created impossible CSS demands. I have a young autistic client whose CSS hours have been cut from about 15/ week to 3/ week. No CSS company can make money going to someone's house for 3 hours. YOU NEED TO REMEMBER THAT CSS IS ALL ABOUT GOING INTO THE COMMUNITY whileas this much tauted previous community mental health system NEVER went out into the community but clients had to come in to see them and for shorter durations. And so when you compare the previous community mental health services remember: no one went to see the clients which is what CSS is all about. ????*

Drastically reduced the amount of service an individual can receive without a prior authorization from ValueOptions.Other changes are coming March 1, including:

* Clarifying the definition of community support for children, emphasizing that it is a "rehabilitative, treatment service" and not a social support service, a recreational program or a mentoring program.

????? This has already been made clear. Companies now write their notes (and do the same work as before) with an eye towards this 'rehabilitation' theme. The work has not changed for the most part; the paperwork, which is BS, has changed.????

* Clarifying the roles of employees of community support providers based on their education levels. The department found last year that 98 percent of those services were being provided by high school graduates.

?????? And so now you have the Qualified Professional (QP) supervisor going out to the home for a brief period of time, to do nothing more than to 'catch up' on what has been taking place rather than the well-trained and ever better trained 'high school graduate' who didn't just call up the Endorsed Provider (private) company and say, 'hey, I need a job.' They were people w/ previous experience in this field who continue to obtain training, basically, on how to write their notes so that post payment review does not blow up the Endorsed Provider company.?????

* Establishing a limit on how much community support an adult can receive.

?????? This is already in place. 15 hours/ max/ week is what is possible; most get far less than this. ????Benton can tweak the new array of community services the department rolled out March 20, 2006, but he can't make basic changes without the approval of the federal Centers for Medicare & Medicaid Services. Going back to that agency is risky.

????????? Thank god. ?????

"That's what people tell me," Benton said. "The staff says that when we go back to Medicaid [CMMS], they may want to totally change the program. That's the risk."

???????? Medicaid clients receive better, more comprehensive services than state funded clients, the 'working poor'. For state funded clients the provider and recipient can expect: poor pay for provider; extensive paperwork which will drown you; frequent authorization problems; post-payment reviews; scrutiny of the doctoral level person's paperwork by the clinical supervisor so as to tie up all the paperwork and not deliver the service----yes, that's right, that's me and that would be Smoky Mountain Center LME that I am talking about.

Medicare clients, if the psychologist, such as myself, uses psychotherapy CPT code 90804 (25 min); 90806 (45-50 min); or 90808 (70-90 minutes of psychotherapy when you are at the home of the client...a sure fire way to get audited by CMS if you are in the top 10% billers at the end of the year), you will be paid 62.5% of the 'usual and customary' fee.

If the client is dually eligible, your Medicare billing will automatically wrap around to Medicaid and you will get a few dollars more. If your client doesn't look too lean, you can ask for a co-pay.

If you have a chronically ill person, you can bill at CPT code 96152 at the usual 80% which is the medical reimbursement fee.

And so once again, unless someone is medically ill, mental health reimbursement is 20% LESS across the board than medical illnesses.

OH, and don't forget that all psychotherapy for 2008 is paid 10% LESS than 2007. So, instead of a pay increase, we have had $$ taken from us.

Discrimination coming and going.

Thursday, February 14, 2008

Dear Gubernatorial Candidate: Endorsed Provider companies collapsing across state under duress of post-payment reviews and CSS $$ reduction

Dear Fred Smith, gubernatorial candidate, NC:

I would like to comment on some of your recents points pertaining to NC mental health reform. You're on the right track. Specifics as to where you might like to head are in order. They are alluded to in the statements attributed to you, below. I would like to provide you with information from an 'on the ground' mental health practitioner who has seen from the beginning just what mental health reform appears to be about.

Quite pointedly, I would like to put forward that the non-inclusion of providers to any significant degree has hampered NC mental health reform efforts. Providers have been relegated to 'those who need to be watched', lest we make off with the $$$. This continues to be true, PARTICULARLY as associated with western NC---more rural and dispersed.

The problem has not been one of a lack of desire to participate; rather the problem is associated with DHHS NC determinedly persuing their own direction, the mental health delivery system be damned.

You stated, Mr. Smith, as per information passed to me in conjunction with a conversation with MHA/NC and the ARC of NC, that these are some of the overarching problems :

"The lack of consistent structure, processes, and application of rules across the State and among LME's.... · A provider reimbursement and regulatory system that fails to adequately promote the development of the necessary community service capacity. ....Failures in the implementation of the reform plan have resulted in: · Inconsistencies and loss of services to some of our most fragile citizens. ·

A substantial loss of public confidence in the reform effort especially among consumers, their families, and care providers. ·

A current service delivery system that is extremely fragile and incomplete. ...

... Since long promised reforms have failed to meet the needs of our mental health care delivery system, it is important that we move forward with a plan that creates a structure of clarity, certainty, and confidence, providing appropriate leadership and a plan that more clearly identifies the roles and responsibilities of the State, the Local Management Entities (LME's), and the care providers.

To accomplish this we must: Place clear responsibility on the State for providing care for the long-term and more difficult chronic cases of mental illness and disabilities that cannot be appropriately served in the community and require the expertise and services provided through our state psychiatric hospitals and facilities for the developmentally disabled.

Develop the community capacity for short-term acute psychiatric care by working with our LME's, community hospitals, and other providers to establish and reinforce our abilities to serve consumers in crisis, providing a hub around which to build community services while reducing dependency on the State's psychiatric hospitals.

Develop the community capacity to provide individuals with mental illness, developmental disabilities, and substance abuse with appropriate on-going assistance and services necessary to provide the greatest opportunity to live a productive and quality life."
These are my specific comments and please do consult my blogspot, Madame Defarge, for specific details and a time-line of malfeasant efforts by NC DHHS as re: mental health reform in NC.

(1) The STATE, as per your item above, does not need to take 'more responsibility' in terms of a move back to the LME's of associated care as pertaining to the care of the 'most fragile.'----if by 'take responsibility' you mean they should revert to their old selves, Community Mental Health Centers.

NC Mental Health Reform was moving right along until Hooker Odom, seeing that the services were being utilized, pulled the brake and threw all the passengers up against the walls of the train and sometimes out the window by first of all, reducing Community Support Services $$, and THEN, something which is continuing into Dempsey Benton's time, bit by bit, post-payment review by post-payment review-----reduction of CSS hours from 'whatever the client deemed to be useful' to the NOW 3 hours/ week. IF CSS is one of the lynchpins of NC Mental Health Reform, then instead of vacillation about just what it entails (mastered by Hooker Odom) and continued massive reduction of use of this service which includes everything from skills training to emergency services----then NC mental health reform has ALREADY failed.

A case in point: state funded clients' services associated with Smoky Mountain Center LME and Western Highlands Network LME are:

**difficult to obtain in terms of the authorization process e.g., the paperwork is massive as associated with Person Centered Plans (15-20 pages of non-paid, non-reimbursed, time-consuming paperwork which must be frequently updated in order to move through blocks of psychotherapy sessions which interface with psychiatric mental health care); the authorizations are time-consuming in that you cannot speak to the person who creates the authorization; you have to call and call or e mail and e mail----- causing providers to simply want to avoid the MAIN clients that NC Mental Health Reform is supposed to attend to.

While the money is so tightly controlled as pertaining to state funded clients that you might as well say that there are no services available, as regards Medicaid services, the post-payment reviews, which are an attempt to push back the Person Centered Planning----WHICH THE STATE DEMANDS----and which is a consensus between the client, pertinent family members or community members, and the provider------finish off what is left of the Endorsed Provider companies.

I am frankly amazed that more Endorsed Provider companies have not collapsed. And indeed, it is only as associated with the Endorsed Provider companies obtaining of attorneys (yet more of their money gone awway) that there are any left. Gather some information about the use of attorneys to push back on the LME's in terms of these post-payment reviews and you will witness a system which is imploding under the weight of malfeasant post-payment reviews by the LME's, and by default, NC DHHS.

If you couple that morass of paperwork associated with authorizations for state funded clients to an overly zealous Quality Management team, such as is commandeered by Smoky Mountain Center's LME's Charles Barry, the director of QM there, you have the boondoggle of not only the required massive paperwork but the ensuing post payment reviews which suck the very life out of the Endorsed Provider companies.

Witness the recent collapse in Orange and Chatham county as reported on this week by the Raleigh N & O. Witness the collapse just over a year ago of the exact same kind of large provider, overseeing 10,000 lives in Western Highlands LME, just over a year ago.

If NC DHHS keeps it up, and by default, the LME's keep up their aggressive, mega paperwork agenda----coupled to the reduction in Community Support Services dollars----coupling THAT to the post payment reviews which causes the companies to pay back the services that they have ALREADY offered-----then you will have a continued recipe for failure----county after county----LME after LME----across the state.

Marsha V. Hammond, PhD: Clinical Licensed Psychologist