Thursday, May 22, 2008

Where have all the mental health professional providers gone?

"Mental health staffing suffers acute shortage"

Western NC has two LME's that oversee all the state funded clients. These two LME's may be attempting, as per Easley's early 2008, Mercer report, to authorize and oversee Medicaid in the near future.

Currently these two LME's oversee the authorizations and reimbursement associated with state funded clients. They also perform post-payment reviews on private Endorsed Provider companies as associated with Medicaid clients.

They are: Smoky Mountain Center (SMC) LME and Western Highlands Network (WHN) LME. These LME's oversee 20% of NC counties. That's a chunk of control.

Provider loss and burn-out has been outlined in Leslie Boyd's good overview article.

As a doctoral psychologist, and as someone who has some significant knowledge of both LME's, here is a gross outline of the difficulties and therefore, the background information on why NC is losing mental health workers and why it will continue to lose them.

Authorizations for services as regarding state funded clients are extremely time-consuming, voluminous, and have nothing to do with why the client needs services. This authorization process is simply a gate-way in order to access services and so that the LME's have some handle on the money they must pay out.

So, given the difficulties with this state funded system, let the clients who need mental health care go and get Medicaid, you say.

Not so easy, my friend.

In order to apply for Medicaid, you must:

1. file for Social Security Disability (you won't get it but you must file; its a lot of paperwork)

2. fill out paperwork for Medicaid (you won't get that either and so you must create an appeal, depending on your providers to spend more unpaid hours assisting you).

3. wait for some months for your appeal to come up.

4. you can sometimes get 'medical medicaid' but not full Medicaid. This will pay for therapy and medications, amongst other health related services. This does not even address the matter of the disability payments or other kinds of Medicaid, for example, Domicilliary Medicaid.

But, back to state funded clients---which is what NC mental health reform was supposed to be about in the first place---that and taking mental health care into the community---oops: that was Community Social Services which have steadily been defunded over the past year.

In that there are only 8 therapy sessions available to state funded clients----and that's only as associated with Western Highlands LME---its not worth it to providers to create a massive amount of paperwork for therapy which over the course of a year nets the provider about $600.

While a WHN LME provider services director recently indicated to me that more therapy could be obtained via a Dialectical Behavior Therapy (DBT) platform,as writtin into the Person Centered Plan paperwork (10-20 pages of repetitive paperwork, asking the same thing in about 10 different ways, as noted by Boyd's article; NC DHHS created this mess) the Utilization Management Director of WHN LME indicated that more than 8 sessions of therapy was not available except as associated w/ DBT group therapy.

It is terribly time consuming to try and figure out who knows what they're talking about as regards the LME's. You could spend hours on the phone as associated with one client. That's not to even mention the paperwork. More unpaid time for the provider.

The confusion that is rampant appears not to be just within the LME but was originally created by NC DHHS. The LME's have attempted to come up w/ solutions in order to live within the guidelines of NC DHHS Service Definitions. However, these two LME's have done it in vastly different ways.

In order to obtain authorization to see a state funded client (sure: you can see them and never get paid) five to six forms, of some length, have to be submitted. And then you wait for weeks to hear what has happened. If there was a problem, they do not inform you but you continue to see the quite ill client, expecting to be paid. Its either that or the client waits around or suicides or simply attempts to exist until something can be put together in terms of authorizations.

Boyd's article did a good job of outlining the horrific paperwork. It doesn't work. There is nothing in the IPRS paperwork that is creative or useful as associated with the care of the client. It is simply an attempt to move the client into a category deemed as 'serviceable' as pertaining to severity of symptoms.

SMC LME owes me over $1200 re: a mentally unstable state funded client. The hang-up re: that matter was associated with this doctoral psychologist not being willing to sit thru 20 hours of unnecessary and un-pertinent Community Support Services (CSS) training as SMC LME decided that they do not 'do' out-patient therapy for clients.

There are no 'Basic Level Services' at SMC LME. 'Basic Level Services' are the most commonly utilized services, specifically, therapy and psychiatric meds. Rather, at SMC LME, therapy falls under CSS.

However, there is no reason under the sun to go thru (yet more unpaid) 20 hours of CSS training if all you are doing is therapy----which of course is why you went and became a psychologist.

A caveat as re: Boyd's article: Joe Ferraro's company, mentioned in Boyd's article, specifically Meridian Behavioral Health Services, whose main office is in Waynesville, NC, does an admirable job of wrapping people back around to working with cohorts who have mental health challenges themselves. Thus is a community of caregivers created.

However, it is the ONLY model as associated with SMC LME.

Moreover, as related to Meridian's Recovery Education Center, as as pertaining to the aforementioned employees earning a whopping $10/ hour, most are part-time and therefore most do not receive benefits. These are people who have attended a series of classes associated with W.R.A.P. training. That training has been created by Meridian. They are, in every sense of the word, paraprofessionals.

However, the CSS paraprofessionals, who operate under the private Endorsed Provider companies, are dissed on the basis of being 'high school graduates'(high school graduates was acceptable as associated with the Service Definition, created in 2005 by NC DHHS). Many of Meridian's 'paraprofessionals' are also simply high school graduates who have made significant investment in their own mental health.

And Joe Ferraro is a retired SMC employee.

While Tom McDevitt, Director of SMC LME, has been quoted in another news source as indicating that these paraprofessionals are no substitute for professionals, in reality, profesionals cannot be utilized by SMC LME as pertaining to state funded clients as Steve Puckett, the Clinical Director of SMC LME, insists that state funded clients wrap around to Meridian's program as soon as possible.

SMC LME has taken care of its problem in terms of a lack of mental health services by funneling state funded consumers into a secretive contract (yes, Dr. Hammond: you can come to Sylva, NC, and look at the minutes associated with the meeting of the SMC LME Board) with Meridian Behavioral Services. However, I understand that now they are wondering where all the professionals went to.

We went away. Just like many other mental health professionals are doing---and will continue to do---until you can relieve us of all this paperwork and very significantly streamline the authorization process.

Contrary to the $750,000 'independent' Mercer report, demanded by Governor Easley, I see absolutely no reason why the LME's should take on Medicaid authorizations and payment. Its the ONLY system that works efficiently.


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