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. "