Thursday, May 15, 2008

Have psychologists lost or won re: NC Mental Health Reform?

Just the Facts: Have Psychologists lost or won re: NC Mental Health Reform?

In review, the purpose of mental health reform in NC was to advantage non-insured (state-funded; the ‘working poor’) clients to ‘choice’ associated with mental health care. This ‘choice’ was reflected in the creation of private companies, Endorsed Providers, who have moved through stages of an accreditation process put together by NC DHHS. Thus, mental health reform was private whereas community mental health centers had been public.

Secondly, the Joint Legislative Oversight Committee for Mental Health Reform, chaired by Martin Nesbitt (D-Buncombe) and Verla Insko (D-Orange), intended for mental health care to be more engaged at the community level. Thus, the lynchpin modality of Community Support Services (CSS) was created.

CSS is distinct from Community Based Services (CBS), the previous (public) mental health services which allowed for interactions between CBS workers and clients without a specific skills-based training purpose.

Bear in mind that at this time, the LME’s are only responsible for the state funded clients. A recent ‘independent’ report to the tune of three-quarters of a million dollars, instituted by Governor Easley, was an attempt to estimate whether the LME’s are ready to manage Medicaid.

Under Secretary of NC DHHS, Carmen Hooker Odom, who resigned in August, 2007 after seven years of unique guidance, CSS was heavily utilized to the point that NC DHHS and Governor Easley paired up to campaign about the ‘abuses’ of the Endorsed Provider companies vis a vis CSS.

Within six months of creating CSS, and upon an after-the-fact reviewing of expenditure of funds, vigorous post payment reviews were instituted by the LME’s at the request of NC DHHS and this resulted in the loss or downsizing of Endorsed Provider companies.

One repetitive criticism leveled at the companies was their utilization of ‘high school graduates’ as the face-to-face paraprofessionals teaching skills to clients, under the supervision of professionals. The Service Definition for CSS, which outlines the parameters of the services which was created by NC DHHS, allowed for these high school graduates. Additionally, there was no limit to the number of hours as CSS was originally instituted.

This left NC DHHS in the position of creating more restrictive (and thus punitive) criteria as associated with these post-payment reviews in order to recover monies spent, a significant chunk which was federal dollars. Providers were scapegoated and clients received services which were then jerked back.

So, in judging the success, or not, of NC mental health reform, and as per the creation of ‘choice’ and the skills based training CSS, has NC mental health reform been a success of failure?

The devil's in the details................

....... as regards the two LME’s in western NC, Western Highlands Network (WHN) LME and Smoky Mountain Center (SMC) LME. Together these two LME’s are responsible for 20% of the 100 counties in NC.

Such an appraisal is not separate from this evaluation which is associated with the bread and butter of most psychologists’ work, specifically, psychotherapy. SMC LME has a rather unique relationship with Meridian Behavioral Health care.

Managed by a retired, former SMC employee, Meridian absorbs most of the state funded clients, utilizing a W.R.A.P. model, taught by mostly minimum wage paraprofessionals. Outpatient psychotherapy for state funded clients is available only under CSS.

The Utilization Management Department of SMC LME demands that in order to obtain authorization for psychotherapy under CSS, the person providing the therapy has to obtain 20 plus hours of non-paid, irrelevant (to psychotherapy) training. Additionally, when PCP’s are submitted, they are reviewed by the Clinical Director who apparently has as an agenda the non-authorization of state funded clients outpatient psychotherapy services. You guessed it: send them to Meridian Behavioral Health services.

As is standard, I believe, across NC, under WHN LME, there are no more than 8 psychotherapy sessions available/ year regardless of severity (the most severe are managed by the mobile ACTT team, with a psychiatrist). Pre-authorization is necessary; five forms have to be processed.

The Provider Relations Director advised me that after these 8 are used up, more psychotherapy sessions could be obtained as associated with a Service Definition associated with DBT for clients with personality disorder diagnoses. Contrarily, the Utilization Management Director advised me that if the individual psychotherapy/ DBT was utilized, group therapy also had to be utilized.

Additionally, the UM Director stated to me that as per ‘research’, public mental health clients (state funded) utilize an average of 4 sessions/ year. I advanced the notion that I supposed that these were ‘sessions’ associated only with checking to be sure the patient is still alive.

In a nutshell, as per psychologists, and as related to their bread and butter duty of psychotherapy, the resounding answer to the question: “Has NC mental health reform benefited psychologists or not?” is ‘No’ as related to the state funded clients.

Moreover, I fear that if the LME’s are advanced to managing Medicaid, that easily negotiated system will be corrupted by the chaos already very evident in attempting to engage with the local LME’s.

Now, tell me where the NCPA has been over the past 7 years in terms of watching out for psychologists and their ability to administer clinically relevant services. Psychologists are not able to provide clinically necessary treatment and it is therefore hazardous to take on state funded clients.

As regards one of the two main tenets associated with NC mental health reform, ‘choice’ has been severely truncated. Endorsed Provider companies have collapsed as related to punitive post-payment reviews as CSS was poorly planned and severely under-finances and un-monitored.

Without a massive infusion of monies based on ‘sin taxes’ e.g., tobacco and alcohol tax, with an incoming non-responsive governor, and with the ever-present, unassailable chaos evident in the two LME’s in western NC (something I assume is repetitive across NC) , I think you can pretty much sum it up and say that psychologists best avoid the state funded clients and carve out their earnings from other paying sources.

Ah, see? NCPA actually realized this and so cut to the chase. What’s that? You think that NC mental health reform was all about bringing more appropriate, relevant, community based, services to the mentally ill?


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