Monday, April 28, 2008

North Carolina Psychological Association: CAUTION: DIPP's at work

Marsha V. Hammond, PhD: Licensed Psychologist, Asheville, NC 828 254 2013, office
e mail:

April 28, 2008

I've thought about this post in terms of any ethical duty I have as associated with my profession. And indeed, the APA Code of Ethics seem to support my intention to highlight NC's Psychological Association non-attendance of profound difficulties as re: NC mental health reform: (from the APA Code of Ethics and Conduct):

"..... Psychologists do not knowingly make public statements that are false, deceptive, or fraudulent concerning their research, practice, or other work activities or those of persons or organizations with which they are affiliated.....

Principle D: JusticePsychologists recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists......

Conflicts Between Ethics and Organizational Demands:

If the demands of an organization with which psychologists are affiliated or for whom they are working conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and to the extent feasible, resolve the conflict in a way that permits adherence to the Ethics Code.."

Let it be known that I have expressed my deep concern to the Executive Director of NCPA re: the harm that is taking place re: NC mental health reform as regards Medicaid and state funded clients.

And I have not been answered.

Here are my 4 points as re: April NCPA board meeting minutes:

1. NCPA seems to have an inexhaustible ability to ignore and not comment in any shape or form about NC mental health reform fiasco and how it is affecting providers and clients as re: its minutes.

2. Just what is DIPP (Division of Independent Professional Practice; too funny, really) doing re: this: "DIPP is working to rescend Medicare reductions." ??

3. So, NCPA is supporting NCMentalHealthvote. Sounds good, but just what is it?

Founded by the NC Psychiatric Association: "NCMentalHealthVOTE is a non-partisan project that aims to create a more informed candidate and voter on issues concerning North Carolina’s Mental health system."

They state that their purpose is to shed light on the issues. But then, when you look at their 'Solutions', what you see are references to conservative think tanks and a diss'ing of those providers (gasp) who were trying to make a living: this is what you see:

a. conservative John Locke foundation represented with notions of this: "Lower costs and better outcomes are the goals for all involved. Loosening state control is an essential step in the process. " John Hood's Daily JournalBetter Mental Health Through Less State Control (hint: even the leading Republicans running for governor are not adovcating for loosening state control).

b. "....And then there were the caregivers, using that term loosely, who took advantage of a type of service called "community support," in which workers with high school diplomas were assigned to assist the mentally ill in day-to-day chores.

Sorry, News Observer: but NC DHHS Service Definitions created in 2005 allowed for this.

So, of ALL the HUNDREDS of articles in the news services, editorials, etc., THIS is what is chosen? Oh yes, its perfectly clear what the agenda of NCMentalVote is: to continue to say nothing about what is going on.

4. Only bright spot on the entire set of NCPA minutes was associated with 'closing the loophole' (sorry: you cannot cut and paste those valuable minutes) about psychologists being involved in interrogations/ torture.

Otherwise, it appears that NCPA is simply re-arranging the chairs on the deck of the Titanic, otherwise known as: 'how to rid the state of all the well qualified providers.'

All those 'wonderful' solutions about how to get more providers INTO the state will be for naught if no one wants to work here BECAUSE WE CANNOT BE PAID A LIVING WAGE.

Friday, April 25, 2008

Bob Orr (R) gubernatorial candidate: in support of an Outcomes Based Model (which could be hybridized w/ Direct Billing for state funded clients)

The following is a review, by Marsha V. Hammond, PhD, Clinical Licensed Psychologist (Asheville, NC) of gubernatorial candidate, Bob Orr (R), as associated with information on his website, re: his thoughts on NC Mental Health Reform.

Basically, if an Outcomes Based Model were in place, rather than a Fee-for-Service model, $$ could perhaps be saved if a hybrid Outcomes Based / Direct Billing (for state funded clients) were created, which would free up the LME's to move into managing Medicaid services.

*** Orr mental health comment: "State versus local responsibilities: under the current reform, the state is responsible for long term institutional care through state facilities (four regional psychiatric hospitals, four developmental disabilities centers, and three substance abuse treatment centers). Ongoing care and support services are to be provided by community providers and managed by Local Management Entities (LMEs) that have no clinical employees and provide no direct services. Properly implemented, this division of labor would provide consumer choice and consistent care closer to home and at a lower cost. We have not met this intent consistently across the state, which indicates that we must"

......... "Provide clear and specific operating guidelines for the LMEs with the appropriate flexibility and funding to create provider networks"

Hammond comment: Its the details that are important, Mr. Orr, and you've done a pretty good job of outlining the problems : the networks are created; the problem is there is no pay and in particular as you start up a client, begin to see them. The paperwork to start a state funded client is massive. NC mental health reform is so far, mostly about how to render care to the state funded clients.

The more recent Mercer Report, requested by Governor Easley,
was an attempt to understand whether the LME's are ready to tackle the administration of Medicaid. They are NOT, given all their problems so far. And in particular, they are not, as associated with the troublesome FEE FOR SERVICE
model that is guiding NC mental health reform.

Thus, the admonition on madame defarge that we have an OUTCOMES BASED model rather than FEE FOR SERVICE model which is nickel and diming us to death.

***Orr MH comment: "Give the LMEs the primary case management tasks with the requisite authority to be the funnel for all care and services."

Hammond comment: In that the LME's differ so vastly re: how they

manage their money, I'd have to say ABSOLUTELY NOT.

Detail: Smoky Mountain Center LME has put most of its eggs in the basket, as pertaining to state funded clients, of Meridian Behavioral Health, headed up by a retired employee of Smoky Mountain Center. This has prevented other providers from working efficiently with state funded clients. Contrarily, Western Highlands Network LME has not created such a barrier to the mental health care of state funded clients, the 'working poor' and they are MOSTLY what NC mental health reform is about.

Neither is the solution, as Bev Perdue would have us believe, to ramp up, as was in place before mental health reform, case management---a service which provides no actual services to the client other than gathering information and outlining a plan of action.

****Orr MH comment: "We currently have different case coordination systems in the 25 LMEs and we must have one state standard;

Determine state versus local roles and responsibilities for providing the local safety net of 24/7 crisis response, and act immediately to address our acute care deficiencies.

Public versus private provision of services: privatization was the other principle that drove the current reform, with the idea being that the private sector could deliver ongoing care cheaper and better than the state funded Area Mental Health Programs. Yet we have seen reports of one local provider after another going out of business. "

Hammond comment: 'Privatization' and 'going out of business' do not have a direct connection. Privatization was created as associated w/ a belief that such a structure would encourage competition; the problem is no one wants to compete for the clients who are saddled, no fault of their own, but simply as a fact of they being a state funded client, with massive paperwork. We just cannot do all the paperwork they have us doing and some LME's are worse that others.

Western Highlands networkd LME, nested in Buncombe is considerably more efficient in terms of servicing state funded clients than Smoky Mountain Center LME which is housed in Sylva, NC. The 2 of them cover one-fifth of all NC counties.

Orr MH comment: "We must address this disconnect by:Determining if privatization is appropriate for all categories of care (MH/DD/SAS), and for the rural areas of the state. Many mental health experts assert that there may not be a viable business model for developmental disabilities service providers. Implementing a fair and efficient reimbursement process that pays for actual care."

Hammond comment: You appear to be advocating a hybrid model solution. If you wanted efficiency as re: the state funded clients, the state might create a MH account for them which could be easily managed by a private company in terms of services rendered, much like Medicaid billing.

In this way, you would move the details off the plate and you then might be able to free up the LME's to manage Medicaid-----unless they are going to manage it as a Fee For Service model, in which case, it will not work.

Interfacing with NC Medicaid is, at this time, the most efficient authorization and payment set-up. Much of thet troublesome administrative costs which seem to be sucking down the Medicaid $$ could be done away with if the providers were able to DIRECT BILL.

Orr MH comment: "The pace of change and continuity of service: nearly all the mental health experts agree that the transformation of our mental health delivery system has happened too quickly....

The reality is that we stripped the local mental health programs of their clinical capabilities before the LME-managed private providers were in place. The result has been an alarming gap in care in many areas of the state and a corresponding run on our state mental hospitals. We must put the state hospital downsizing effort on hold, while we address the shortage of beds across the state and focus the reform effort on fixing the community-based system"

Hammond comment: The reform did not move too quickly. NC DHHS had no capacity to create a framework. Thus, unloading reform onto a platform that quickly collapsed or had no frame under it, is what the problem was.

Orr MH comment: " While I am not sure what is more troubling, the recent News and Observer report that approximately $400 million have been wasted on medically unnecessary community support services.

Hammond comment: The $$ were not 'wasted.' 'Medically necessary' is surely one of the most vague terms associated with insurance/ authorization/ reimbusement in existence. It is not particularly pertinent to mental health care and is associated with the medical model of 'do a test and then prescribe the treatment.'

NC DHHS created the Service Definition of Community Support Services (CSS) which included, on their website, the hiring of CSS workers w/o experience and with a highschool diploma. They have since then, required that 25% of the contact with state funded clients be performed by a QP, a person higher up in the management of the Endorsed Provider private company. Neither is THIS a good solution for it breaks up the care. There is nothing to preclude the (mostly) college graduated CSS workers from doing a good job of performing the services outlined in the Person Centered Plan. REMEMBER: the CSS workers do not go out into the community untethered but rather as guided by the PCP.

Orr MH comment: "... Given that many reports claim that mental health delivery in North Carolina is seriously under funded, (NC per capita spending is 55% of the national average, with only seven states spending less), the next governor must bring all the stakeholders together to develop a long-range funding and resource plan.

At minimum, that plan must include:· Mental Health Trust Fund: if we decide to pursue a large scale privatization model, we must fully fund the Trust Fund to bring innovative service programs to the delivery of care and services...

Medicaid: Medicaid payments provide approximately 75% of annual spending. We must work with the most recent federal service definitions and ensure Medicaid dollars are spent on the services that have the most impact on the people who need them the most;· State Mental Health Budget: our annual budget for state spending must complement Medicaid supported services, provide adequate funds for state facilities, and fund Division administration. While it is probable that additional funds are necessary for service delivery, we must streamline and simplify the reimbursement process to make it possible for private providers to operate in the LMEs, and look for every opportunity to reduce the amount spent on administration;"

Hammond comment: if you created accounts for the state funded clients so that providers could direct bill---as with Medicaid----- you would have rid MH reform of a massive amount of inefficiency and you could then perhaps have the LME's managing Medicaid.

An OUTCOMES MANAGEMENT model could then be folded into a

direct billing management of the monies.

Orr MH comment: "Long term supply of mental health care providers: the same shortages of healthcare professionals described in my healthcare policy apply to mental health. We must ensure that our university and community college systems are prepared to provide the increasing number of psychiatrists, mental health nurses, and allied professionals that our growing and aging population will demand. "

Hammond comment: the problem is not that they are not turning them out. The problem is not that there is all of a sudden a 'shortage' of providers. Many providers simply do not want to work with the LME's re: all the paperwork associated currently w/ the state funded clients.

Orr MH comment: " Six years down the road of mental health reform is too late to find out we are way off track. People whose lives depend on these services deserve better, and our tax payers deserve better. We must have a more rigorous and ongoing oversight process. Spending nearly $800,000 on an outside consultant to evaluate LME programs, as DHHS is currently doing, is exactly what a responsible and accountable government should not need to do.

..... Service provider qualifications: the Division of MH/DD/SAS must provide a comprehensive and standardized vetting process, by treatment area, for LMEs to use to determine service provider suitability;

..... Outcome-driven quality control: currently service providers are reimbursed based on the reports they submit. Reports don’t necessarily mean positive outcomes, and we must have a standard Quality Assurance system that pays for quality care, not quality report generation..."

Hammond comment: unlike anyone in NC DHHS at the current time, and as associated with some of the LME's, in western NC, specifically Smoky Mountain Center LME and their fine-combing of the Person Centered Plans which are the tool that obtains the authorization in order to be paid when the client is given services, It's 'quality CARE' you want....not 'quality paperwork.'

Orr MH comment: "Medicaid: Medicaid payments provide approximately 75% of annual spending. We must work with the most recent federal service definitions and ensure Medicaid dollars are spent on the services that have the most impact on the people who need them the most.....

State Mental Health Budget: our annual budget for state spending must complement Medicaid supported services, provide adequate funds for state facilities, and fund Division administration. While it is probable that additional funds are necessary for service delivery, we must streamline and simplify the reimbursement process to make it possible for private providers to operate in the LMEs, and look for every opportunity to reduce the amount spent on administration;

Regular Financial Audits: with millions of dollars being paid monthly for services, it is inconceivable that DHHS does not have a recurring financial review process with a warning system to notify officials when costs spike.

Mental Health support for our Citizen Soldiers There has been little attention paid to the impact the failed mental health reform may have on providing quality care for our redeployed North Carolina troops. ...

We have the fourth highest number of returning guard and reserve service members, and the ultimate tragedy of this reform debacle would be for them to return to their counties and not be able to get the mental health care that they need.These North Carolinians have made the ultimate commitment to our country and borne the sacrifices that come with answering the call of duty. Some of them will face the challenges of dealing with post traumatic stress, traumatic brain injury, and family readjustment issues. Most concerning, is that they are returning in large numbers to homes in rural counties, which is exactly where our mental health delivery system is struggling the most.

.....In implementing a plan to rescue mental health reform, we must ensure close coordination between DHHS and the North Carolina National Guard, with a specific emphasis on effective liaison with the LMEs. Our Citizen Soldiers truly do represent “Americans At Their Best,” and state government must be at its best in delivering community-based mental health resources where they are needed. "

Wednesday, April 23, 2008

Bev Perdue, Gubernatorial Candidate (D) thinks NC NEEDS MORE CASE MANAGEMENT

Ms. (Kennetha) Smith ("Kennetha Smith" <>), associated with Beverly Perdue's campaign:

Thank you for your correspondence.

This being said, you cannot possibly know how cynical we have become out here in the land of 'let's ignore their complaints and they'll go away.' Let's throw away their e mails and they won't exist.

At some level, Bev Perdue is too little, too late. Additionally, it appears she has no idea what is going on.

No answers to any e mails; no discussions re: mental health matters. And no vote from me, as best I can tell. Mike Arnold sending me an occasional email to important mental health information: 'what do you want me to do with it.'

What would have been useful is some statements, public ones, about mental health matters, and not just a bunch of fluff like what you just sent me:

"We also have to develop a quality case management system through community networks, such as the “medical home” model. We need to extend collaboration, like this kind of community network to the delivery of mental health services....In her view, the concept of a medical home should play a major role in helping to revitalize our badly-tattered mental health system within and outside of Medicaid. Patients with severe mental illness need the security of a medical home as well as strong in-patient professional service. We should also strive to define a basic level of mental health services to which needy patients should have access."

HONEY: we don't need case management. Case management is not the PROVIDER OF SERVICES. Do you even KNOW what case management is about?

Community Support Services (CSS), which this Dem governor, under the wacky Hooker-Odom, de-funded, which, according to NC DHHS CSS Service Definitions, ALLOWED high school graduates and those w/ no training to function as CSS Paraprofessionals, IS ABOUT CASE MANAGEMENT.

As for clinical homes, all clients have these.


Marsha V. Hammond, PhD

Monday, April 21, 2008

Press, Governor. and NC DHHS continue to allow blame of Endorsed Provider private companies for Community Support Services over-spending

Dear Editorial Board of The Daily Tarheel:

Please do your homework prior to feigning shock


Marsha V. Hammond, PhD: Clinical/Health Licensed Psychologist, Asheville, NC e mail:

April 21, 2008


You stated, in your opinion piece: "Shockingly, many of the health care workers employed by private companies to provide services to the community had little or no experience in the field and no college diploma." (see below for cut and paste of this editorial board posting).

A reading of the Service Definitions or guidelines as associated with Commnity Support Services, developed by NC DHHS, as pertaining to the paraprofessionals which provide the bulk of the skills-based training, as pertaining to the services which you are alluding to above, specifically Community Support Services (CSS) indicates the following:

1. high school graduates met the criteria put forward by NC DHHS
2. the one year of experience was waived by NC DHHS back in 2005/2006

Please see: Community Support - Adult MH/SAQuestions and Answers (8/5/05)

Your complaint is with NC DHHS, not with the Endorsed Provider companies.

Moreover, I would not say that the money was 'wasted'; many Medicaid clients received good services on the basis of these Community Support $'s.

If the state was concerned about the delivery, they should have figured it out prior to putting the criteria of the program forward.

The people to write to are: Dempsey Benton, Secretary; Leza Wainwright, co-director of mental health services; Mike Lancaster, co-director of mental health services.

Marsha V. Hammond, PhD
Associated editorial board comment, April 21, 2008
Unhealthy system
Withheld funding apt response to mental health failuresBy: Editorial BoardIssue date: 4/21/08 Section: OpinionJust as citizens have a responsibility to faithfully pay their taxes each spring, governments have a responsibility to ensure that tax money is spent wisely and usefully.

North Carolina's state government has obliterated its end of this unwritten pact by wasting at least $400 million on mental health reform since 2001.

Knowing that, the federal government's Centers for Medicare and Medicaid Services did well to punish the state by withholding $175 million in federal funding from community support programs during the last three months of 2007.

We wish the state had gotten a warning before the money disappeared because reforming the system will likely require money. But the punishment is justified.

We just hope the loss of federal funding will incite state officials to revamp a mental health program suffering from innumerable ailments.

In 2001 evidence indicated the N.C. state government leaned too heavily on state psychiatric hospitals, and legislators responded by enacting reforms to treat more mental health patients in their own communities rather than the state's four overcrowded hospitals.

Under the new system, private health care providers replaced local governments in the delivery of mental health services.The community support program, intended to cost the state less than $5 million per month, soon cost more than $50 million because of bloated private health care bills, money-hungry providers and a government that seemed to ignore it all.

Shockingly, many of the health care workers employed by private companies to provide services to the community had little or no experience in the field and no college diploma.

Regardless, the state paid these workers as much as $61 per hour for services deemed "unnecessary" 89 percent of the time by a Department of Health and Human Services review.

Rather than delivering useful services to patients in need, providers often took clients shopping or to the movies, all at the expense of N.C. taxpayers.

While private health care providers cashed in on this faulty system, the state's 210,000 residents who seek state help each year received worse service.

From March 2006 to January 2008, the government spent $1.4 billion on the wasteful community support programs and only $78 million on services statistically more effective at decreasing the chances of hospitalization.

Luckily, the federal funding is being taken from the community programs. In this case, less is probably more.

A plan for NC Mental Health Reform to entertain an OUTCOMES BASED rather than FEE FOR SERVICE model re: mental health care

Marsha V. Hammond, PhD Clinical Licensed Psychologist, NC e mail: cell: 404 964 5338

April 21, 2008

Dear Senator Garrou:

Thank you for creating a forum this evening, Monday, April 21, 2008 , re: mental health reform concerns. I am sorry I will not be able to attend.

I would like to make a comment as a clinical psychologist in the trenches, treating medicaid/ medicare and state funded mental health clients.

First of all, it is a terrible mess. And it is mostly a mess as there are, as a (unnamed: "I would lose my job") administrator of Western Highlands Network told me on Friday, there are "too many cooks in the kitchen and no one taking responsibility."

While Dempsey Benton may be a nice man, he has no experience managing mental health.

The Democratic party gubernatorial candidates are avoiding the subject and though I am a determined Dem, I'm telling you...the Republicans are looking pretty good as re: their candor while the Dems whistle past the mess.

I'd hate to see a Republican governor in NC as I know what happened in GA when that happened but the Dem party is squandering its chance to make things right. Many Dems feel exactly as I do.

Along those lines, and as re: conversation with that WHN administrator, I am in complete agreement that DHHS (where many are to retire quite soon, I'm told: Wainwright; Lancaster, the co-directors of mental health, bearing in mind that Moseley, the director, just retired) has completely mucked the thing up while the LME's are the messengers, with some doing a better job than others in protecting 'their' providers.

I am informed by that administrator that NC DHHS 'appears to be seeing the light somewhat' as re: an Outcomes-based platform associated with services.'

We cannot go backwards and we cannot stay in this no man's land of fee for service and so we must evolve to this outcomes based place.

The entire matter needs to move away from piecemeal fee-for-service and towards OUTCOMES BASED reimbursement.

What would this mean?

1. Emergency and critical mental health services would not be held up at the bottleneck of 'how am I going to get paid' re: services for quite ill citizens coming out of the hospital or urgently needing services.

There is not a lack of providers; there is a lack of providers willing to work w/ the LME's and thus NC DHHS given the authorization/ billing/ payment structure.

You have no idea how much paperwork is associated with a state funded client and how much paperwork is associated with Community Support Services for Medicaid clients as associated w/ post-payment reviews mandated by NC DHHS.

This it not to say that Endorsed Provider companies should not be overviewed. We all are very clear now as re: the country's mortgage / banking fiasco re: just what happens when capitalism is given free reign.

2. Providers would be able to compete with each other but not at the level of fee for service. As it is, every little piece of service has to be authorized, billed, paid for.

The LME's miraculously return money to the state legislature while the citizens go un-served. Why? Because the providers cannot make a living given the structure of mental health reform as envisioned by NC DHHS.

Basically I have given up having more than one or two state funded clients. I cannot afford to take the time to create the paperwork.

If there was an Outcomes based model being utilized, Endorsed Provider companies, now in place, and as associated with this pretty painful rather unnecessary evolution of Mental Health Care Reform in NC, then companies would contract w/ the LME's to provide services for blocks of clients.

The companies would function as capitated HMO's wherein the company would most benefit----financially----by keeping its patients/ clients WELL rather than doing a piece by piece care plan which has to be OK'd at every step.

This will not work, what is in place. And it is very evident that it is not working.

Will some Dem please step up to the plate and create another model which is in the wings?

I thank you for any attention you can give to this matter.

Sincerely, Marsha V. Hammond, PhD: NC Licensed Psychologist cc: Madame Defarge NC Mental Health Reform blogspot

************************************************** associated article: health Form tonight w/ GarrouBy Wesley YoungJOURNAL REPORTERPublished: April 21, 2008People with concerns about the delivery of mental-health services in Forsyth County will have two hours tonight to discuss them with state Sen. Linda Garrou.The community meeting will be from 6 to 8 p.m. in the auditorium at the Behavioral Health Plaza, 725 N. Highland Ave. CenterPoint Human Services, the Mental Health Association of Forsyth County and the Forsyth County affiliate of the National Alliance on Mental Illness are sponsoring the meeting.Garrou, D-Forsyth, said it is important for her as a legislator to know what residents are thinking as the state tries to fix what is widely considered a broken system of delivering mental-health services."There is a lot to be done, and a good place to start is to assess where you are and start from there," Garrou said. Garrou is a co-chairwoman of the N.C. Senate appropriations base budget committee. State Rep. Verla Insko, D-Orange, the chairwoman of the mental-health reform committee, will also be at the meeting.Mental-health services were changed in 2001 and the system of locally run public mental-health agencies was dismantled. In its place, the state created a system with regional agencies overseeing the delivery of services through private companies. CenterPoint Human Services is the agency that manages mental-health services in Forsyth, Stokes and Davie counties.Those changes have come under fire. In 2005, the Winston-Salem Journal published a series of articles that outlined evidence that the state's post-reform system of care was worse than ever.In February, the Raleigh News & Observer reported that the state had wasted at least $400 million in an effort to treat mentally ill people in their communities rather than in the state's mental hospitals. Now state officials are talking about reforming the reform.Here, some local mental-health advocates have complained about a variety of issues surrounding CenterPoint's governance, operations and interaction with the mentally ill and their advocates."People who need and who are entitled to services are not able to obtain the services," said Laurie Coker, a local mental-health advocate who serves on a state advisory commission. "That is one of the biggest concerns. The second thing we hear from all over is that services aren't coordinated well enough to prevent people from needing to go back to the hospital more frequently."Local advocates have also complained that they have trouble making their concerns known to CenterPoint. CenterPoint had a roundtable discussion in March, but some local advocates were upset that the number of them allowed to attend was limited.A recent survey of the state's mental-health agencies rated CenterPoint among the top agencies in financial and business management, and in clinical operations and governance. CenterPoint was among the bottom performers in information technology and claims maintenance.CenterPoint officials said they hope that tonight's forum will help the agency better identify problems and solutions."We are looking for themes as we have these community meetings and solicit input," said Ronda Outlaw, the assistant area director for operations at CenterPoint. "I think the issue is that reform facilitated consumer choice, (but) the other side of that is that it created fragmentation of the system." A fragmented system can be harder to navigate for those in the greatest need, she said.¦ Wesley Young can be reached at 727-7369 or at

Saturday, April 12, 2008


Marsha V. Hammond, PhD: Clinical Licensed Psychologist, Asheville, NC
e mail: cell: 404 964 5338

April 12, 2008


I am sending you this notice re: Ann Aakland running for NC State Legislature. Her e mail address is:

While she is not in our catchment area, she is such a straight-talking, reasonable, level-headed, fierce advocate for MH issues (her daughter has a persistent, severe mental illness and Ann and her daughter have frequently been featured in the Raleigh News Observer and on TV news services) that I hope you will consider donating to her campaign.

I listened to her speak during a NC Policy luncheon in Raleigh about a year ago and it struck me that she was the only one who knew----or cared----what she was talking about.

I donated to her and I hope you will also.

Here is Ann Aakland's mailing address: PO Box 1059 Knightdale NC 27545

Here is a link to Ann and her daughter speaking about her mental illness. There's not a better advocate in the entire state and I would trust that she would lead the way to a good solution to NC's mental health reform fiasco.

Marsha Hammond, PhD
multiple articles on Aakland's activism:

Further Reading: "Mental-health math doesn't add up," The N&O, Sept. 26, 2002. "Citizen Awards: Ann Akland," The Independent, Nov. 27, 2002. "The house on Poole Road," The Independent, Nov. 19, 2003. "Raleigh weighs adult day care," The N&O, Jan. 7, 2004. "What do we do with Dix?" The N&O, Jul. 18, 2004. "Club broadens horizons," The N&O, Oct. 1, 2004. "What should Dix be?" The Independent, April 27, 2005. "Crisis clinic funding faulted," The N&O, June 3, 2005. "Advocate breaks silence surrounding mental illness," The N&O, Jan. 22, 2006. Search recent N&O stories.
Ann Akland
To the rescue of Dix Hospital and Wake County's mentally ill population.
27 NOV 2002 • by Bob Geary
Ann Akland: Determined to bring people together on reform.

Alex ManessThe climax of Ann Akland's three-decades-long career with the Environmental Protection Agency came in 2001, when she moved from RTP to Washington for nine months to fill a high-level management post on an interim basis while the new Bush Administration looked for a permanent appointee. It was heady stuff. Akland started at the EPA as a clerk-typist ("I'm probably the model employee for upward mobility," she says), and here she was working at the top of the agency and, coincidentally, living in the same building on Pennsylvania Avenue as her boss, EPA Administrator Christie Todd Whitman.

But when that assignment ended, Akland took early retirement, left her six-figure salary behind, and returned home to Knightdale to become a volunteer leader in the cause that she'd come to realize was now her driving passion--reforming the mental health system. And so she has. In a year's time, Akland has poured herself into the rejuvenation of the Wake County chapter of NAMI, the National Alliance for the Mentally Ill, and put the organization at the front of two difficult battles:

It is pushing Wake County to step up to its new responsibilities under the state's mental health reform legislation.

It is also challenging the state's attempt to flee from its responsibilities before the counties are ready to assume them, and it's fighting to keep Raleigh's Dorothea Dix Hospital, a state facility, from being abandoned.

What happened in Washington? Two things, Akland says. First, she found herself stopping almost every day, on her walk to work down Pennsylvania Avenue, to talk to the homeless folk who congregated around a certain street bench. "They could be my daughter," she remembers thinking. One man, in particular, she befriended. She's certain he suffered from paranoid schizophrenia. Her daughter, Kristen's, diagnosis is schizo-affective disorder. ----------


We can do better!

Do you believe it is time for a family member of a person with a disability to serve in the NC General Assembly to fight for people with mental illness, developmental disabilities, and substance abuse disorders? I know many of you do because people from across the state have supported my campaign with your donations. Many of you have asked your colleagues and friends to do the same. One in 5 families is affected by a mental illness, but there are very few people in elected office advocating for us. Please support me with your donations and if you are in my district, with your vote on May 6.

With your help, we can win this election.

It takes money to get the message out to the voters.

Please share this message with others who care.

Please write a check & mail it before you forget.

Please believe that we CAN do this and WILL with your support.

Many people are working with us as volunteers. Right now our major efforts are devoted to going door to door canvassing and making calls to voters. If you have some spare time, please volunteer to help. We have momentum and are spreading the word about the plight of people with disabilities, the reason for the campaign.

Call 266-0766 to learn how you can help.

Campaign Builds Momentum

Thanks to the Employees Political Action Committee
A Subsidiary of the State Employees Association of North Carolina, Inc.
for your endorsement.

No, I'm not taking PAC money. But the EPAC acknowledged that I was very strong on state employee issues. Without the best and brightest working for our state agencies how are we ever going to fix the problems with mental health?
Thanks, EMPAC.
Members of Professional Associations & Advocacy

The Executive Directors fo our MH/DD/SAS professional associations are lobbyists and cannot donate to my campaign. However, if you are a member of the Mental Health Association, the NC Psychiatric Association, the ARC of NC, the NC Autism Society, Association of Retarded Citizens, the NC Psychological Association, NAMI and/or your organization is part of Coalition, please know that I would like to represent all of you and all our providers as well as families and consumers. I will work hard to restore NC's Mental Health System. Please forward this message to your colleagues.

We need $30,000 before May 6 to cover the expenses for our direct mail campaign.

We are moving slowly toward our goal of 1,000 checks of $100 each.

If you haven't donated yet, please write that check or donate online by clicking here:
Ann Akland Web Site

If you can donate more than $100, please do so.

If you can't spare $100, please send what you can.

Everyone can do something even if it's asking your friends
if they have written their personal checks.

Campaign Finance Laws prohibit conributions from registered lobbyists and businesses. I do not accept donations from Political Action Committees.

This message was paid for by theAnn Akland CampaignPO Box 1059Knightdale, North Carolina 27545
and I approve this message.

Friday, April 11, 2008

Is there a shortage of mental health providers in Western NC: (avoid the red herrings on the menu)

The red herring created by Smoky Mountain Center LME :
Mental Health Provider shortage in western NC?

Smoky Mountain Center (SMC) LME's administrative staff, Tom McDevitt, Doug Trantham, and Steve Puckett, PhD, have been cited in the Smoky Mountain News as outlining a shortage of mental health providers in their catchment area. Admitting to a "lack of a broad range of services", with Dr. Puckett indicating that there are "a smaller menu of services....they may get a more generic service”, is to elude the problem.

Basic Services, created in July, 2007 by NC DHHS, consists of psychotherapy and medication management. This is the spine of mental health care. Period.

However, SMC LME, with its rather unique single stream funding of funds, specifically created by the NC State Legislature-----so that they can move their money around to where it is needed----does NOT provide Basic Level Services. Maybe there is a reason but I don't know it.

The clients don't need a greater array of services, rather, they need a greater NUMBER of the generic services, which are not available at SMC LME.

At SMC LME, after the basic and preliminary 8 therapy sessions--- all that's allowed by NC DHHS--- therapy services can be obtained to some degree but they are housed under Community Support Services (CSS). The pay is less, the paperwork is greater, and the personnel who provide the therapy under CSS must receive 20 plus hours of unpaid, non-essential to the matter of therapy, training.

You guessed it: this necessarily draws fewer professional providers (gosh, we're short on providers).

I personally am owed over $1200 by SMC LME associated with a state funded client, in the most severe category. As I refused to spend my professional time sitting in 20 plus hours of CSS training, I was refused payment. Prior to that, the Quality Management Director threatened me with an audit if I would not put up with non-paid, 20+ hours of CSS training.

I severed my relationship with SMC LME.

I always wondered by this LME could not express itself to NC DHHS and point out these kinds of difficulties. Contrarily, SMC LME seems to have mastered the 'its not our fault' stance.

Besides this significant barrier, SMC LME, as Western Highlands Network (WHN) LME, will not authorize (pay) for more than 8 therapy sessions/ year/ state funded client. NC DHHS determined this.

SMC LME will pay for therapy under CSS after Dr. Puckett goes over the PCP, insisting that the client move progressively more into peer support services provider (only) by Meridian Behavioral Health Services, directed by a former employee of SMC LME.

More therapy sessions for the WHN LME client is on the way but only under the guidelines created by NC DHHS as associated with Dialectical Behavior Therapy (DBT), a psychoeducation model of therapy (one hour/ week/ 3 mos/ state funded client).

Nevermind that good therapy, as associated with the treatment of personality disorders, which are rampant and associated with depression, folds in DBT; it does not stand separate. Yet, NC DHHS has created this non-generic DBT category of something that looks like therapy, for personality disorder clients.

No, rather than an array of services, NC DHHS created a menu of choices and then when you asked for the item they decided they had run out and shut down the kitchen.

Please amuse me again about just why SMC LME bemoans the fact that there are fewer and fewer providers for needy clients in western NC. The providers cut bait after losing money and went elsewhere.
associated article in the Smoky Mountain News:

"Help for the sufferingA lack of trained mental health professionals means there isn’t always enough care to go around" By Julia Merchant • Staff Writer

Why this hard-core Dem might vote for a Republican governor : IT'S THE MENTAL HEALTH CARE FIASCO, STUPID

Well, this Dem might have to vote for this Republican, for governor. Can we get a new NC DHHS along with that order?

NC DHHS is hogging the road and won't give up the wheel and refuses to ask the passengers where they'd like to go.

Unlike what Mr. Graham (Republican gubernatorial candidate for governor) has stated (see below), the care was not 'rolled out too quickly'; rather, it was badly planned in terms of services that would be authorized and it appears to have been planned by administrative types rather than by mental health professionals and consumers.

YES, there was a need for community based services, moving the practitioners into the community. YES, this has happened to some significant degree.

And YES the paperwork associated with creating mental health care for state funded clients (REMEMBER: this is ALL that the LME's do currently: they only are managing state funded consumers, the 'working poor') in terms of Person Centered Plans (PCP's); Intakes; IPRS's; ACCESS centers, within the LME's correspondence and telephone calls; and last but not least, Post Payment Reviews, whose agenda is to TAKE BACK the money that was spent. The paperwork is CRUSHING the Endorsed Provider private companies.

Privatization was not a bad thing in and of itself.

The community mental health centers which morphed into the LME's were manned by people who sat in their offices and when their clients didn't show up for a variety of reasons, they continued to get paid. This is not so re: privatization as providers do not get paid unless they see their clients.

When reporters talk about the unavailability of mental health services on the weekend or after hours, they are not talking about any of the mental health providers that I know.

What would the mental professionals suggest? Here's one professional's suggestions:

1. fund mental health reform in NC or stop belly-aching and posturing. NC is 43rd out of 50 in terms of funding : "you get what you pay for"

2. realize the existence of mostly rural western NC and its mental health needs by placing providers and consumers from western NC on key committees associated with DHHS & the LME's. A corollary: team up the mental health providers and the LME's such that the LME's actually have to LISTEN and USE what the providers suggest rather than stage an intermittent dog and pony show----which has no provider input.

3. find clients and clients' family members who will serve on the Consumer and Family Advisory Committee's (CFAC) and give the CFAC's more leverage over the LME's. First thing that will have to happen is that the CFAC's actually work and feed into the LME decision making process. One look at the Smoky Mountain Center LME website as associated with who attends the CFAC meetings and what they do will clue you into how dysfunctional the CFAC's really are. Demand that the CFAC's interact with consumers and providers.

4. fund emergency services (return to step #1) in terms of psychiatric beds for adults and adolescents; step-down beds for those needing a temporary reprieve from life's problems which is aggravating a mental health condition; create more useful group therapy within the psychiatric units re: real world problems.

5. promote Basic Services, that is: psychotherapy and medication management, as tolerated. Community Support Services (CSS), that much ballyhooed entity that has reportedly wolfed down $450 million----all for naught we are led to think-----should issue OUT of good therapy and significant contact with the client rather than be CONCOCTED on the basis of some NC DHHS administrator who thought it was a swell idea whose time had come.

6. hire some good value psychiatric nurse practitioners besides the few that are in the Balsam Center in Waynesville, NC (that's IT for western NC, outside of private psychiatrists, Dr. Mark Lawrence, who is at Balsam, and Dr. Matt Holmes, who is the ACTT team psychiatrist). Remember: western NC LME's are accountable for 20% of NC's 100 counties.

7. significantly streamline the paperwork re: state funded clients. Make clear that state funded clients is preceding universal health care vis a vis mental health care in NC in order that people UNDERSTAND just what is taking place here and its importance. There is no need for the repetitive sections of the Person Centered Plan (PCP) as has been in place for several years now. Moreover, if you're not going to listen to what the client wants, please rename this 15-20 page monster. Its only 'person centered' if you listen and create as a possibility what the client requests. As it stands, there is simply an illusion of doing that. And while you're at it, ask DHHS to PAY the providers for this work which entails meeting with the client, perhaps several times, writing up the report, turning it in.

8. Make more $$ available for state funded clients with the money saved/ time saved by stream-lining the paperwork and as per suggestions from professionals who know what they're talking about. Currently, state funded clients (the working poor) receive only 8 sessions/ year of therapy, regardless of severity of mental illness. Oh yeah: you can tell them that the client has a personality disorder in which case they can be advantaged to psychoeducational information vis a vis Dialectical Behavior Therapy ( one session / week/ 90 days...however no therapy after 8 sessions! ....which is part and parcel of any therapy session for any personality disordered client by any well trained professional). Keep the administrators on their side of the fence and entertain LISTENING to the providers.

9. Community Support Services (CSS) serve a very real purpose and are not associated with hand-holding or taking little Suzie to the pool so that the CSS worker lounges in the sun. Its disgraceful how CSS has been painted by reporters. However, much of what CSS is associated with could be 'cured' by: a decent transportation system in rural areas; more sheltered workshops to provide job training and work hardening for those out of the work force for some time ; education of the population about hiring those with mental health issues; and, JOB CREATION.

10. Ask the North Carolina Psychological Association where the hell have they been re: salient comments re: mental health reform in NC . Given the level of education within that bunch you would think that it would have more to say than it has, which is essentially nothing. Ditto all the other professional organizations in NC.

Here is what Mr. Graham mentioned about mental health reform (which the Democrats seem to be doing an excellent job of ignoring given that the screw-up was made by a 8 year Dem governor):

"....He said the current mental-health reform effort, creating larger regional management entities, was “rolled out too quickly for the care that was going to be delivered on the ground.” Graham wants to go back to smaller, more local management entities, develop more mental-health hospital beds, and keep services closer to home.“We shouldn't have to ship a family member across the state for drug or alcohol treatment,” Graham said.

“This is a Raleigh failure, hook, line and sinker.”Graham said, as governor, he would create a committee made up of mental health professionals and have them deliver a report with recommendations within 30 days. “I figure they already know what they need,” he said...."

Friday, April 04, 2008

Value Options: the authorization agency for Medicaid who can't even get their online forms straightened out

April 4, 2008

Dear Mr. Benton and Tara Larson of NC DHHS:

I believe that Ms. Larson's duties are associated with overviewing Value Options.

I find it vexing that I have to do my job and try to do Value Options' job also.

Value Options has the incorrect form for authorizations under (Providers) 'Forms' at its website, while in another part of their website, (Providers) 'Network Specific', the company has the correct authorization form.

Why are the authorizaton forms a critical matter? If, for adult Medicaid clients, after 8 sessions, no authorization in place, the provider will not be paid if the provider continues to see the client, assuming that Value Options will authorize sessions (as they have always done in the past).

Therefore, any savy provider would, well in advance, submit the authorization request. I did that. I did it in exactly the same manner as I have for the past several years. Every other year it worked fine. This year it did not. Moreover, I used the current form online at ValueOptions.

In trying to figure out what had taken place, a process which took me a couple of hours of unpaid time, I called Value Options today at their provider number. I spoke with a 'Jennifer' at 4:50, Friday afternoon, April 4, 2008.

I had called earlier and been informed that my authorization request for two Medicaid clients had been rejected----which was a surprise to me as I had never received any paperwork on the matter.

That earlier person at the Value Options Provider line stated that I had not entered in my Medicaid Provider number. I thought: strange. I went to check my paperwork, the form taken from online at Value Options.

Here is that form and I bet that within a week's time, this incorrect form will have been removed from the Value Options website. However, that is because I have taken time to do Value Options work for them and they have been sufficiently embarassed.

I looked at the form I had filled in re: my 2 Medicaid clients, submitted in February, 2008, after I spoke with that person. There is no place on the form (Value Options/Flrms/Clinical/ORF2 is the pathway online) for the provider's Medicaid provider number.

Neither is there a place for any other determining provider number, such as the NPI number.

There is, however, on line 11, on the left hand side of the one page authorization form entitled "Outpatient Review Form (ORF 2) a place something called "VO Provider # (if known)." At the bottom of that one page, in the right hand corner, is this : "Value Options 2005 Rev. 1.03.08"

Thus, it appears that the form was reviewed by Value Options January 3, 2008, and it remains online, the wrong form, for providers to submit and never hear a word about their submissions.

There is no such thing as a 'VO Provider #.' Therefore, the person creating the form, employed by Value Options, had no idea what they were doing.

The correct form is here, which Jennifer identified as I talked w/ her on the phone : (Path: Value Options/providers/network specific/nc Medicaid/ ORF2).

Please note that both of the forms online at Value Options are stated to be the 'ORF2 Form', the form utilized to request authorization to see Medicaid clients.

After speaking with 'Jennifer', I left a specific meessage on Jane Harris's voice mail. She is termed on that voice mail to be a supervisor associated with Provider Relations.

I had asked 'Jennifer' what was the mailing address for Jane Harris. 'Jennifer' stated there was no address. Neither could 'Jennifer' give me Mr. Harris's direct extension when I asked for it.

Mr. Benton: will you please ease the difficulties of being a mental health provider, allowing us to work with clients, by creating a contract with a company that we can work with and who responds to provider concerns?

Thank you.

Marsha V. Hammond, PhD: Clinical Licensed Psychologist, Asheville, NC

State funded MH clients mandated no more than 8 psychotherapy sessions under any level of care: CALLING MR. BENTON

FROM: Marsha V. Hammond, PhD, Licensed Psychologist, NC
Billing address: .......................Asheville, NC 28806
E mail: cell phone: 404 964 5338
Fax: 828 --------------

TO: (1) Dempsey Benton, Secretary of DHHS, NC
FAX: 919 715 4645
(2) Leza Wainwright, Co-Director of Mental Health, NC DHHS
FAX: 919 508 0951
(3) Mike Lancaster, Co-Director of Mental Health, NC DHHS
FAX: 919 508 0951

RE: absolute limitation of 8 pschotherapy sessions for any state funded client in NC

April 4, 2008

Dear Mr. Benton:

I am writing to you regarding the absolute limitation of 8 psychotherapy sessions for any state funded mental health client, under any level of care (A,B,C,D). I have appreciated your recent efforts to improve mental health services in NC.

I spoke with Christine Kudlate (e mail: and Donald Reuss ( via phone and e mail, respectively. An employee of Western Highlands Network LME, Ms. Kudlate was a refreshing change in terms of honesty and information. She stated she had recently moved from Arizona where she worked in mental health, remarking, “I am appalled at the mental health care here in NC.”

She stated that Western Highlands LME realizes that there are significant gaps in services but are necessarily limited in creating authorization for services as defined by NC DHHS. The specific service, psychotherapy, which, as you probably know is a critical one, and is the usual and customary treatment for those with persistent, severe mental health diagnoses such as my client has.

To be more specific, my client has a persistent mental illness, is 29 yrs old, well educated, jobless, and has been intermittently suicidal, and is improving with therapy. His diagnosis is Personality Disorder with narcissistic and borderline features; Major Depression, recurrent.

The treatment for this, a not uncommon diagnosis, is psychotherapy and anti-depressant medication, if tolerated. He does not need ACTT services, a more intensive service which costs tax-payers an enormous amount of money. He has a place to live. He does not need any of the array of Community Support Services if these do not include more than 8 psychotherapy sessions/ year. Ms. Kudlate informs me that 8 psychotherapy services/ year is the limit regardless of the level of care.

I would like to know what you can do about this. I ask this respectfully, assuming that you have a lot to do but with a persistence associated with having tried to obtain psychotherapy services for state funded clients I have had over the past several years and having become completely exasperated with the non-availability of such to the point that I have driven every single state funded client into Medicaid as quickly as possible. This is not particularly useful for them for once they have Medicaid and its associated SSI or SSDI monies, they are then unable to work more than about 20 hours/ week, at a very poor hourly rate, without endangering these benefits.

I have tried working with the CFAC of Smoky Mountain Center LME re: this very same problem and gotten nowhere. I have written letters, sent e mails, made telephone calls. And I am not going to continue to do this and I am not going to try and move thru the Western Highlands LME CFAC. I am counting on YOU, Mr. Benton, to get my clients more psychotherapy sessions.

This is not isolated to my client. This is true of every single state funded client across any LME in NC.

If the LME's cannot be trusted to be able to create services for clients, then may I suggest that we just forget this mental health reform for no professional provider will work with a suicidal client if there are only 8 sessions/ year. Its too risky; its lawsuit material.

And in that the LME's are only assigned to look after state funded clients, if they cannot authorize the services, then please save the taxpayer's some money and dismantle the LME's.

The news services would have us believe that there is a lack of providers for services.

May I submit that there are no lack of providers as is implied by the news services ; there is a lack of professional providers who are willing to do work which is potentially liable and unsatisfying.

Thanks for looking into this, Mr. Benton. I would like to have a response from you, Ms. Wainwright, or Dr. Lancaster by Friday April 11, 2008.

Thank you for your assistance. I am hopeful that my client can be advantaged to more than 8 psychotherapy sessions/ year.


Marsha V. Hammond, PhD
CC: Wainwright; Lancaster; Kudlate; Reuss; Madame Defarge NC Mental Health Reform blogspot