Asking McCrory for an audience: PLEASE STANDARDIZE UTILIZATION MANAGEMENT of the LME's across NC

June 30. 2008

Dear Mr. Coletti:

Thank you for your article: North Carolina Seeks to Hike the State's Beer, Tobacco Taxes
The Heartland Institute - Chicago,IL,USA

In the interest of not raising taxes (this time), I would like to suggest that there are ways that have not been entertained that would make mental health care more efficient in NC. One would be a standardization of the Utilization Management within the various LME's. They all operate differently and therefore citizens across the state are accessed to different levels of services.

What does the Utilization Management Department of an LME do? They authorize treatment. Without authorization, you can treat people 24/7 but you will never be paid.

Its scary as hell for this provider to think that the LME's might be overseeing Medicaid.

These are just some of the range of how the Utilization Management Departments function across the state----which I am aware of at this time.

* In the middle of the state, it appears that clients receive the same services as would be accorded Medicaid clients.

* In Asheville, clients receive 8 therapy sessions and no more unless they have personality disorders and even then, they can receive more therapy if they also receive group therapy.

* In Waynesville, under Smoky Mountain Center LME, no therapy is available except under the constantly defunded Community Support Services.

I am asking for an audience w/ Mr. McCrory. I am a registered Dem. However, the Dems seem to be tone deaf. If you see McCrory or have some leads on this matter, put in a word for me, if you can.

Sincerely,

Marsha V. Hammond, PhD

The Future of Mental Health Care in NC: consumer driven / diminished provider input & loss of mental health providers

There has been a very informative discussion taking place amongst mental health advocates/ consumers and this provider as associated with the establishment of NC-CANSO, a consumer driven group being supported by NCCCP, the lobbying arm of the LME's in NC.

Consumer driven mental health groups have as their advantage the creation of social support and disbursement of psychoeducational model information e.g., Dialectical Behavior Therapy, for instance.

Consumer driven mental health groups have as their disadvantage the creation of groups without professional knowledge or expertise except as associated with the 'hidden hand' or the creation of the psychoeducational body of information which is disbursed by the alpha/ leader consumers.

The hidden puppeteer's hand is more cleverly disguised without the direct input of the mental health provider groups. Unfortunately, consumer groups and those who benefit the most, the LME's or the administrators of mental health benefits, cannot, or will not, state what the activity is that is taking place behind the stage.

Consumer driven groups are tethered to the notion that they need to be more empowered as re: their own mental health welfare and so grasp at the reigns of power.

Meantime, the LME lobbying group has basically won the day by maintaining a stance of 'we're glad to help you if you want our help.'

Its hard to bite the hand that feeds you, it seems.

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MY POST TO THAT GP OF PEOPLE ON THIS SUBJECT:

remember: just because it is 'consumer driven' does not mean that someone is not sitting the background scooping up the $$ re: the development of materials and issues which they, as 'expert', deem to be appropriate for this consumer driven model. Thus, is the 'consumer driven' model disingenous in terms of who is moving the puppets around on the stage. The hand is simply not as evident.

Let me advise people how this consumer driven model has been used in Smoky Mountain Center LME. Joe Ferraro, retired employee of SMC LME, created Meridian Behavioral Health. Given his connections (my speculation here, to be sure, and I am not on the inside of any of this information), he has garnered most of the mental health $$ flowing from NC DHHS----best I can tell.

Yes, there is the ACTT people (also part of Meridian) and the 'core team' associated w/ staying up with people who have recently attempted suicide (also part of Meridian); there is Summit Counseling, founded by the very trustworthy Carl Losacco (who, incidentally was also a SMC employee), that has a contract w/ Haywood County Schools system.

In that I no longer (as of about 9 mos ago) participate w/ the provider gp of SMC LME, if there is newer information, I do not know it. However, the players at the LME are all the same in terms of the administration and they marked their territory long ago.

When I, a doctoral psychologist, licensed in NC, have been forwarded former ACTT clients, who did not have Medicare or Medicaid, in other words they were state funded clients, Steve Puckett, PhD, the clinical director of SMC LME, has INSISTED that clients be moved into the REC. Yes, SMC LME would authorize me to see them for a very short period of time, but basically, they were to go to Meridian and participate in REC.

I have quite a few clients who participate in REC. It is helpful to them. It is a psychoeducational model which utilizes cognitive therapy thinking a la Marsha Linehan's Dialectical Behavior Therapy and such. Indeed, all good therapy has some components in keeping with these psychoeducational models. I assume that there are components of this in the talk to which you allude that was sponsored by NCCCP.

Given the SMC LME clinical director's insistence-----which was the policy of the LME-----I could not obtain authorization to see clients who were state funded clients. I gave up; many providers have given up working w/ clients in SMC LME catchment area.

My client did not move into REC; it is not convenient and it is far away; she did not want to expose herself to grp therapy. I have pushed her towards Medicaid; she has been denied (of course); she is appealing it; that will take years. Meantime, she gets very minimal therapy fm me which as per her statement has been helpful. At the very least, I have encouraged her to take her meds which keep her anger intact so that she does not (hopefully) suicide. I believe we were making good progress in therapy; we have moved through a lot of the abuse in her history. This is intimate knowledge. Could this have been done utilizing a psychoeducational model? NO, I do not believe so.

NC Mental Health Reform is also about power relations. : who gets the authorizations; who is put into a position of seeing clients; how to clients 'get better'? how do clients stay better? what are their main concerns? how independent are they seen to be in terms of making their own choices? what are the social pressures to 'keep them in their place'? how are policies created which in fact DO keep them in their place? what are the rolls of professionals vis a vis the clients w/ mental health issues?


While mental health consumers need to be very invested in their own mental health welfare, there is a tremendous struggle taking place here which is under the table as associated with how this will take place.

The State is, of course, invested in the cheapest option or perhaps better said what is the maximum number of people who can be serviced using the least amount of $$. Thus, will this mental health consumer empowerment issue rule the day----and maybe it should.

However, the price is this: you will lose your mental health provider base.

Meantime, until this culture evolves into a place wherein people w/ mental health issues are considered to be 'idiosyncratic' (something which takes place more in British culture, for instance), and wherein people can compassionately assist their not so well neighbor, what is the useful combination of use of professional time and psychoeducational approaches which are much more consumer driven.

And so the question is this: when/ where is it that clients, w/ their mental health issues, need/ should utilize the services of a professional?

The professionals are being shut out of mental health care in NC. These matters of what role do the professionals have re: mental health care in NC, are not being overseen by:

a. NC Psychological Association (long story there; see Defarge)
b. CFACS
c. NCCCP
d. NC-CANSO.
e. some support and interest re: NC Psychiatric Association (but frankly psychiatrists are the least impacted by all of this and so interest within that group does not trickle out into the larger professional groups).

Have concerned providers attempted to coalesce and move together in order to address some of these issues? Yes, and it was unsuccessful. Why was it unsuccessful? We are all busy people.

I maintain that NCCCP created via channeling funding for NC-CANSO in order to support the notion of 'most lives covered for least amount of money.'

That is the tension between this matter of patient/ consumer sponsored and run psychoeducational processes vs professional expertise. I don't know the answer.

In the best of all possible worlds, consumers would have open access to both and could choose a la carte. However, that is not the way the mental health $$ flow : there is a tug of war re: the authorizations and what will win out is that the cheapest option will continue to be pushed by the likes of SMC LME.

Yes, I am very much in the position of defending the worthwhileness of my training: what is its value; does it have value? for whom does it have value?

I understand and completely agree that it is important for them to be invested in their own welfare. However, also bear in mind that mental health reform was SUPPOSED to be about patient choice (that is long long gone).

Meridian is paid to oversee a person's mental health needs. (I do not know anything about their actual contract and I am speculating here). I believe they have what is called a 'capitated' contract. That is, they are paid a certain amount of money for the state funded clients, and no more. However, they must be paid on a 'head' basis, in some way.

So, here is my prophecy: mental health reform in NC will move the way of this NC-CANSO/ NCCCP LME supported model which is consumer driven; fewer and fewer mental health providers will be utilized and so they will not stay in state, regardless of all the educational programs that Perdue would recommend. Some time in the next 20 years, groups will look around and wonder: where are the mental health professionals? And it will then occur to people, who have some sense of the history of what has taken place, as to what has happened.

But maybe things will be better if matters are consumer driven.

There will still be the stigma of mental illness, however, given the very real different kind of functioning that people w/ mental health issues can, at times, have, they will still be cut out of the decision making process for the most part, for humans are social animals and they react to herd members who act differently.

McCrory, the Republican gubernatorial candidate, shows he can think : KEEP DIX OPEN

N&O letter 6/27/08 Keep Dix open http://www.newsobserver.com/print/friday/opinion/story/1122013.html

I agree wholeheartedly with your June 24 editorial on the need to keep Dorothea Dix hospital open.

Earlier this month, I held a news conference in Raleigh calling on the General Assembly to keep Dix open for another year.

On Monday, June 23, I wrote Gov. Mike Easley, Lt. Gov. Beverly Perdue, Sen. Marc Basnight and House Speaker Joe Hackney urging them to personally intercede in this matter.

With the problems surrounding mental health escalating, the current administration appears to be implementing changes without proper planning.

As a result, hundreds of millions of dollars are being misspent, poor medical treatment is being given to mental health patient, and concerns are rising for the safety of patients and staff in state mental facilities.

It is unacceptable that a nurse was beaten at Dix last week due to inadequate supervision of patients. It would be grossly irresponsible to close the hospital without making the necessary preparations for handling patients in a secure environment.

Dix hospital must be kept open and properly staffed for another year. This will give the next governor a chance to evaluate its closing and recommend the best way to address the growing scandal in mental health programs.

Pat McCrory Charlottehttp://www.newsobserver.com/print/friday

Just who is NC-CANSO? : ORWELLIAN sister org is LME lobby group NC Council of Community Programs (NCCCP)

What is the agenda of NC-CANSO?

This is the problem: the LME's function as little fiefdoms and consumers and providers and mental health advocates have little to no ability to impact their decisions.

The mental health provider organizations such as NC Psychological Association, collude with the LME's; the CFAC's, which are supposed to be representative of the consumers basically don't function.

And so you have the PERFECT STORM OF LME'S WHO DO THINGS JUST LIKE THEY WANT TO.

PLUS, THEY GET THEIR FUNDING FROM THE STATE.

Basically, NCCCP is attempting to create NC-CANSO, a group which is attempting to present a 'consumer friendly'face that sits alongside the legislatively derived and empowered LME's. That way they move completely around the CFAC's---if they ever functioned like they were supposed to.

The CFAC's didn't work, due in significant part to the fact that legislatively they are SUPPOSED to have some independence from the LME's.

So the LME's have opted to create an entity which is more under their control, specifically, NC-CANSO.

If you look at the agenda of NCCCP, you will notice the following:

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1. The members of NCCCP are the LME's and companies can pay handsome sums to be sponsored on their website.

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2. What is the agenda of NCCCP?

"The MH/DD/SA System in NC has seen it's fair share of struggles and challenges. People who work in this area, at the LME's, have seen trends come and go as far as service and policyare concerned. At the NC Council we want to support our providers in the best way possible in providing the information and training, support, and encouragement needed to proceed to help our citizens thrive."

('our providers' are those providers who have been willing to pay a significant amount of money to be 'sponsored' by this entity which is composed of the LME's.)

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3. NCCCP aka the LME's want TOTAL ACCOUNTABILITY FOR THE CONSUMER :

"....State hospital bed day plans should emphasize a process to place the management, financing and responsibility for consumer care solely under the LME. This process would give the LME’s full financial and clinical responsibility and total accountability for the consumer.... "

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4. What is NCCCP's and thus NC-CANSO's goal?

"The NC Council of Community Programs is a nonprofit association dedicated to helping its member area Mental Health, Developmental Disability and Substance Abuse Authorities improve their service quality and manage effectively. The NC Council provides its member programs with a strong, cohesive, statewide voice through policy analysis, publications, educational programs, and technical assistance."

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5. What is their relationship to NC DHHS or what would they like to happen?

"Amend Article 4 of Chapter 122C to clearly articulate those administrative and managerial functions that are the responsibility of an LME. Clarify that LME functions may not be removed by the Secretary absent an individualized finding that a particular program is not providing minimally adequate services or is in imminent danger of failing financially. "

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6. WHO ARE THEY LOOKING OUT FOR? :

"A single point of entry into State facilities is necessary; and decision-making on State facility admissions should not be made by those with real or perceived conflicts of interest. "

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EXCUSE ME, BUT THIS APPEARS TO BE A STACKED DECK WHICH PROTECTS THE LME'S WHO ARE DOING A POOR JOB OF ADDRESSING THE NEEDS OF PEOPLE W/ MENTAL HEALTH CONCERNS IN NC.

As Bill Franklin, mental health consumer in Almance County has pointed out: mental health reform is about A CONSOLIDATION OF POWER.

And if you won't play ball because you don't like the way the citizens keep getting struck out when they attempt to obtain mental health services, well, you can just go take a hike.

A way around CSS Defunding?: Mystery Funding for those w/ persistent, severe mental illnesses: THE CASE OF THE 'PERSONAL ASSISTANT'

Dear Dr. Carlyle Johnson, Director of Wake County Mental Health Services (Wake County Human Services Adult Mental Health, 919-250-3100; cjohnson@co.wake.nc.us)


I called you but I understand you are out until July 8, 2008. Thank you for reading my e mail.

I read w/ interest the article by Ruth Sheehan in today's Raleigh News & Observer as associated with her ongoing story of Phil Wiggins, a gentleman who suffers from schizophrenia. I assume, from some of her coverage, that he tests in the Mild Mentally Retarded range.

I believe that many people w/ schizophrenia would 'test' in that range given their cognitive deficits and how IQ tests assess intelligence.

Ms. Sheehan states in that article: http://www.newsobserver.com/print/friday/city_state/story/1122183.html
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"Carlyle Johnson, a soft-spoken man who heads Wake Adult Mental Health, offered a surprise.

He'd talked to one of his colleagues who specializes in assistance for the developmentally delayed or mentally retarded. Patients with those disabilities cannot be "rehabilitated," the new requirement for community support in the mental health field.

However, some people with developmental disabilities and mental retardation do qualify for "personal assistants."

Aha! thought Johnson. A personal assistant could greatly benefit folks such as Wiggins.

It's a wonderful twist for Wiggins, whose plight has helped tell the story of mental health reform -- the benefits as well as tragedies -- but who has undeniably received preferential treatment thanks to all the public attention.

Now, if the personal assistants idea is approved, Wiggins' turn as guinea pig may pave the way for other severely and persistently mentally ill people to get more one-on-one care."
****************

I am interested in information as associated with funding for this 'personal assistant.'

I have several clients w/ schizophrenia who could benefit from such.

Can you please advise me how you turned up such funding? Is it thru Wake County Mental Health?

Is it via the state?

I assume it is not associated w/ the extremely limited CAP Services.

Thank you for letting me know.

Sincerely,

Marsha V. Hammond, PhD

Creation of NC-CANSO, NCConsumer Advocacy, Networking, and Support Organization: BECAUSE THE CFACS HAVE FAILED ACROSS THE BOARD

NC Mental Health Reform associated law has written into it the creation of the CFAC's (Consumer and Family Advisory Council). Each LME has a CFAC whose purpose is to provide a voice to family members of consumers and consumers----those people with the mental health issues.

(Forget the providers concerns; there is no place anywhere for them except in association with their professional organizations which have no apparent impact on NC mental health reform)......

(not to mention): HEEEELLLLOOOO NAMI: WHERE ARE YOU?

However, the CFAC's do not function. They are cut out of the process of working w/ the LME and/ or they simply do not pay any attention to the concerns of the public.....and so the river jumped its banks and simply moved around the useless CFAC roadblock.

Here is the statement online as associated with the functioning of the Smoky Mountain Center (SMC) LME CFAC:

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"While SMC has had several projects that have involved consumer and family advocates, the CFAC represents a more focused and structured way for SMC and other local management entities, to work in “constructive partnership” with consumers and families to infuse their experiences into service delivery models and community collaboration.
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"CONSTRUCTIVE PARTNERSHIP"= NO COMPLAINERS

Thus, do the LME's truncate what the CFAC's can do. Are you a complainer about the lack of services? Why, we'll have to bounce you out of the CFAC.

This psychologist, last year, contacted via US mail and phone the Smoky Mountain Center LME's CFAC Haywood members (Betty Lane, Haywood County; Dan Lane, Haywood County: http://www.smokymountaincenter.org/partners/cfac.asp) re: state funded client 040974 who was being denied mental health services due to SMC LME's non-availability of Basic Services, with therapy services being placed under Community Support Services (CSS) which is constantly being defunded and underpaid.

No one ever responded to me.

I called Mike Mosley who intervened and at least got SMC LME to put their CFAC minutes online.

What did that reveal? That the CFAC meetings were mostly not attended by the members.

So, it appears, that out of desperation, consumers and family members of consumers have created a parallel system OUTSIDE of the non-functionoing CFAC's at the LME's.

Their 'mission statement' indicates a desire to concern themselves w/ people of ALL disabilities; however, they specifically outline this as their agenda: "to strengthen advocacy, networking, and support among people with mental illnesses, developmental disabilities, and/or substance abuse problems.

Yes, this is what the CFAC's were supposed to do

What's that system functioning outside of the LME's (necessarily so): NC-CANSO.

NICE TO SEE YOU ON BOARD, NC-CANSO

It would be even nicer to have functional CFAC's.

This mental health reform is evolving in such a way that we seem to have had to create organizations that can impact the LME's OUTSIDE the LME's. What a lot of work when the CFAC's should function----but do not.
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NC-CANSO

NCConsumer Advocacy, Networking, and SupportOrganization

Interested in a fresh start?

NC-CANSO is a newly formed organization with a mission to strengthen advocacy, networking, and support among people with mental illnesses, developmental disabilities, and/or substance abuse problems. NC-CANSO is being organized as a result of action taken by the North Carolina General Assembly (HB 1888).

In September 2007, a group of interested people formed an organizing committee that has been working to establish the new organization. It is the intention of the NC-CANSO organizing committee to create something new. NC-CANSO wants to create new ways for people from all disability arenas to communicate and self-organize. It is also the intention of NC-CANSO to strengthen the consumer movement by adding value to existing organizations and groups that are interested in the needs and wishes of people with disabilities

Community Support Services radically cut (again): Providers and clients SUCK WIND

Families of disabled lose assistance
State budget situation prompts demonstration
By Vicky Eckenrode
Staff Writer: Wilmington Star
Published: Saturday, June 21, 2008

http://www.starnewsonline.com/article/20080621/ARTICLE/806210307/1004

I continue to be amazed at how quickly the LME's can jump on the providers.

Admittedly, you no longer hear about all those money-grubbing providers who render services and expect to be paid. Now, its more subtle, for, you see, we're supposed to 'work together.'

And so, as anticipated, Community Support Services (CSS) are being radically cut across the state.

The Director of Southeastern Center, SEC (http://www.secmh.org/) LME (this DD/MH/SA entity is not noted to be an LME at its online site and so I called to be sure), a Mr. Constantini, stated: "I was surprised of the reaction of putting clients out of services....I had anticipated more of working together to provide services of those clients."

And so how are we supposed to 'work together'?

Is 'working together' all about the providers not getting paid but continuing to offer the same 'Enhanced' CSS services?

Or about how to make the diminishment of services more palatable to the clients?

It would be useful to know just what Mr. Constantini means when he suggests "we work together."

I see that in a memo on the LME's website they are cancelling the group meeting on June 27, 2008, to discuss 'how to work together' and instead will discuss 'individually' with the various Endorsed Provider companies, 'how to cut a deal.'

All the way back to the western part of NC, how are we supposed to 'work together' as associated with Smoky Mountain Center (SMC) LME having all of its therapy services under CSS which is constantly being cut?

Hmmm?

Marsha V. Hammond, PhD: Clinical Licensed Psychologist: hammondmv@netzero.com
NC Mental Health Reform blogspot:
http://madame-defarge.blogspot.com/

Sheriff chokes mentally ill patient in ER : will police training contract be given to Meridian Behavioral Health Services too?---like everything else?

Training Police for Mental Health Emergencies : Will Meridian Behavioral Services Get this Contract too?

Tom McDevitt, director of Smoky Mountain Center, LME, the largest LME in NC, stated, as regards money that could be set aside by the state and given to the LME's to offer training for public safety officers inclusive of the sheriff's department and various city police departments:

"McDevitt says his agency and others suggested that the state set aside the money that would be given to each LME and pool it together to create a training program."

(http://www.smokymountainnews.com/issues/06_08/06_18_08/fr_cops_patients.html)

Marsha V. Hammond, PhD, replies:

Tom, are you going to give it all to Meridian Behavioral Health, run by SMC retired employee Joe Ferraro, so that Meridian can continue to expand under SMC LME catchment area?

Are you going to continue to work against the use of professional mental health providers by continuing to deny Basic Services, inclusive of professionally driven services, to SMC LME catchment area state funded clients?

For the past several years, SMC LME has chosen to exclude a large body of mental health professionals from being able to work with citizens in western NC in that no therapy services are available outside of Community Support Services (CSS), which requires 20 hrs of non-paid, unnecessary training for people already holding doctoral degrees as psychologists. Additionally, CSS is constantly being defunded.

Thus, recent complaints of the significant loss of provisionally licensed (have completed their formal education but not the required supervision) therapists in western NC is diminished by the fact that SMC LME has, in a determined manner, moved against the use of professional mental health care providers as associated with their authorization procedures.

(see: Dr. Turpin's Opinion piece re: effects of potential loss of provisionally licensed therapists : http://www.smokymountainnews.com/issues/06_08/06_18_08/op_another_bad.html)

It appears that SMC LME has done this in order to utilize non-professional, poorly paid, Recovery Education Center (R.E.C.: Meridian-run) employees.

Can we see the accounting books re: how SMC LME money is spent, Tom?

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

The Monster We Have Created Called Mental Health Reform

The Monster We Have Created Called Mental Health Reform

By Marsha V. Hammond, PhD, Licensed Psychologist, NC

Almost 200 years ago, a 19 year old woman, Mary Wollstonecraft Godwin, was holed up with her to-be husband, Percy Bysshe Shelley, at Lord Byron’s place outside of Geneva, Switzerland. Like many others, instead of hiking during that summer of 1815, also known as the "Year Without a Summer"---due to the volcanic explosion of Mount Tambora far away in Indonesia--- these writers made a bet as to who could create the scariest story.

And so Mary, daughter of Mary Wollstonecraft, who wrote in 1792, "A Vindication of the Rights of Woman", wrote the first science fiction novel. Her famous mother had died birthing her. The daughter then created with pen and paper the famous monster so well portrayed by Boris Karloff in 20th century Frankenstein movies. While they did not realize it, Mary’s creation was due, in part, to pollution and self-imposed isolation. Day after day during this sunless summer, she envisioned something fantastic and unique, with a transportable theme.

In her book, Victor, the mind behind the monster, a well educated man also harboring a desire to create life, created something living, though out of odd body parts that didn’t exactly fit together. As you know, the monster was horrible to behold and in his loneliness, the monster demanded that Victor create a companion to relieve his loneliness and alienation.

Time moved along, the monster had his own life, and things took place----as they do----such that Victor became convinced that the monster which he has created had murdered another human. The heat was on Victor to do something and so he spent years tracking down his creation in order to destroy it. This, understandably, sucked the wind out of Victor and the story ends with the monster standing over the dead body of Victor full of remorse, sadness, and loneliness.

In the waning days of the 20th century in NC, advocates of privatization within the state legislature as well as consultants and key personnel in NC Department of Health and Human Services (DHHS), under the supervision of Governor Easley, were captivated by the idea that mental health treatment might be an avenue for reform which might even kick-start privatization of health care across NC. Blue Cross/ Blue Shield NC (BCBSNC), a non-profit insurance company, overseen by the state legislature with a CEO earning three million/ year, and basically the only game in town outside of Medicare and Medicaid, was undoubtedly pleased with this idea.

There had been some spotty problems associated with the providing of mental health services in the state and these creators believed that a better system could be had out of the various usable parts associated with the community mental health centers which had been the on-the-ground, community based settings for the provision of emergency as well as mundane mental health services.

The stirrings of life for this new project gave optimism to the project and mental health reform was created legislatively and made manifest over the course of seven years under Governor Easley.

NC DHHS, under Secretary Carmen Hooker Odom, wrote the Service Definitions which were the blueprints for how mental health services were to be provided to the "working poor", state funded clients. A new service, entitled Community Support Services (CSS), would replace Community Based Services (CBS), commonly and previously provided to developmentally disabled citizens. CSS would fold into its Service Definition federal mandates which denigrated ‘hand-holding’, instead requiring citizens to be ‘rehabilitated.’ Never mind the chronicity of mental health issues.

In fact, CSS was seen as such an exciting avenue for taking mental health care directly to the citizens who would---or better----- undoubtedly step up to the plate of their responsibilities, serving the dual tenets of privatization as well as usage of non-professional mental health workers, admittedly to be supervised by professionals, that accolades abounded. Criticism was seen as unwanted, spiteful, inappropriate, and even corrosive to the creation of this new endeavor which had all the earmarks of a successful enterprise. Reporters were leashed; critical opinion pieces by psychiatrists, psychologists, and other mental health workers, were not accepted. Secretary Hooker Odom cut ribbons across the state associated with various new projects.

The years wore on and the discombobulation entitled NC Mental Health Reform veered off the road and hit some potholes. A few people got killed at the indirect hands of this monster.

Seeing the carnage of expenditures, Secretary Hooker Odom lamented loudly in March, 2007, about the bad apples amongst the private, Endorsed Provider companies whom were obviously over-utilizing CSS. Post payment reviews were created and the LME’s, wolfing down a great deal of the mental health dollars just to operate and oversee the Endorsed Provider companies, became the whipping boys for the Secretary. Endorsed Provider companies collapsed as they had paid their employees and themselves and the money was basically gone/spent/ used up.

The public stirred as advocates and excluded mental health professionals spoke out. Secretary Hooker Odom got out of town without having to repair or kill the monster. The professional organizations who were supposed to be representative of the professional mental health providers whistled past what was sure looking like a stinking corpse, alluding to the fact that the monster had been in circulation so long now that there was no going back. Peeeyeww!

Unlike the creator in Mary’s novel, no corrective moves were made until it became obvious that CSS was being vastly utilized, particularly as there were no longer any professionally driven, basic, mental health services, to speak of, any longer. When the massive, shocking bills came due in March in March 2007, with the state legislature, seeing their re-electibility as hoisted on the petard of the expenditure of this bits-and-pieces CSS, this magnificent creation then became the monster to be tracked down (don’t lose your life, your job, or your elected seat over it, of course).

Forays deep into the forest were made by the co-chairs of the Joint Legislative Oversight Committee, Verla Insko (D-Orange) and Martin Nesbitt (D-Buncombe). Though they didn't come back dragging the corpse, this legislative committee and their champion overseers, resurfaced with pieces of the monster’s shirt; they demanded to know by January, 2009, why so much of the money was being returned to the state as associated with the non-use of previously professional rendered services.

Stay tuned; there’s always a sequel.

BCBSNC Gets Shielded by Professional Organizations : no parity for BCBSNC PPO ‘State Plan’

BCBSNC Gets Shielded by Professional Organizations : no parity for BCBSNC PPO ‘State Plan’

IMPLEMENTATION OF MENTAL HEALTH PARITY - HOUSE BILL 973

EFFECTIVE DATE OF PROVISIONS JULY 1, 2008


I would like to know why, when people talk about this vague ‘State Health Plan PPO’ (see below, Cameron statement), they do not mention the fact that we are talking about basically the only game in town in terms of group plans for families and individuals who are not members of group plans (read: they have no employer sponsored health insurance).

State Health Plan PPO = BCBSNC PPO Plan.

They are avoiding stating that it is associated w/ BCBSNC, that’s why.

It is unbelievable that BCBSNC is supposedly overseen by NC State Legislature. When you call a state legislator’s office, they advise you to call the BCBSNC ‘Government Affairs’ employees.

These ‘Government Affairs’ employees are hired by BCBSNC to keep a lid on complaints while the state legislators apparently look the other way.

My 3 member family has BCBSNC PPO. We pay over $650 month for this PPO. There are over 2 million PPO BCBSNC members in NC.

BCBSNC PPO plans will not pay for clinic based screening colonoscopies (see referenced information at: http://madamedefarge2scutinizingbcbsnc.blogspot.com/).

There are NO gastroenterologists in western NC who will do an ‘office based’ screening colonoscopy except for one practice in Boone, NC, fully 2-3 hours away from the most populated part of western NC, specifically, Buncombe county, the location of Asheville.

Now you’re telling me that BCBSNC somehow got out of having to adhere to mental health parity (H973) which was signed into law.

Moreover, NC Psychological Association is stating, as per Sally Cameron, Executive Director:

“…The parity law does not cover the State Health Plan PPO plans…. a strategic decision because the PPO plans have a broader benefit and includes parity for substance abuse…..”

Physicians are able to bill BCBSNC at an 80/20 formula with the patient or other carrier picking up the 20% while mental health providers are stuck at the 60/40 level as associated with mental health coverage.

Furthermore, in terms of ‘implementation problems’ how are state funded clients as managed by the LME’s included----(OR NOT)-----as mental health parity ‘supposedly’ created this (as per Cameron):

“HB 973 provides that nine (9) diagnoses are covered at full parity with physical illness “ bipolar disorder, major depressive disorder, obsessive compulsive disorder, paranoid and other psychotic disorder, schizoaffective disorder, schizophrenia, PTSD, anorexia nervosa and bulimia. The means there can be no durational limits set in insurance/managed care plans for these nine diagnoses. Insurance/managed care plans can use utilization review criteria to manage a mental health benefit.”

Western NC has 2 LME’s which cover 25% of NC 100 counties. They manage state funded mental health clients, the 'working poor' who have no health insurance.

Governor Easley, and assumably subsequent governors are advocating that these LME’s also manage Medicaid. This means that their ability to impact psychologists is going to INCREASE not decrease.

Western Highlands Network LME has stated that only Personality Disorders will receive more than 8 sessions of therapy and then only if Dialectical Group Therapy is included.

I would like to know how H973 applies to this matter.

Smoky Mountain Center LME has stated that no Basic Level Services are available for state funded clients. All therapy is subsumed under Community Support Services which is being rapidly defunded; is scrutinized under post payment reviews; and requires people who utilize it to undergo 20 hours of unpaid training.

I would like to know how H973 applies to this matter.

You asked, Sally, that NCPA members give you some feedback re: this implementation matter:

“Please note the FOLLOW-UP section and let us hear from you about an implementation issue. “

This is my statement about this implementation: BCBSNC is being shielded by professional mental health organizations in this state.

DRAFT BILL : NC DHHS is supposed to figure out why the money is not being spent (!!!)---by Jan 1, 2009

I can tell you why the $$$ are not being spent. Because the BARRIERS to providing care to the state funded clients are INSURMOUNTABLE.

What are the barriers? (as I've said before):
******************************

Smoky Mountain Center LME requires that all therapy move thru Community Support Services.

Why is this a problem? Because anyone who utilizes that as an authorization code must undergo nonpaid, irrelevant training vis a vis NC DHHS.

SMC LME throws all of its state funded clients into Meridian Behavioral Health Services which has as the CEO a retired SMC LME employee, Joe Ferraro.

* Western Highlands Network LME (together the 2 make up 25% of all NC counties) will not authorize more than 8 therapy sessions and then only for PD's and then only if PD people are also accessed group therapy.
************************

http://www.ncmentalhealthvote.org/pdfs/LOC_Draft_Bill_2008-04-23.pdf

SECTION 1.6. The Department of Health and Human Services shall
17 determine why there have been under- and over-expenditure of State service dollars by
18 LMEs and shall take the action necessary to address the problem. In making its
19 determination the Department shall consult with LMEs and providers. Not later than
20 January 1, 2009, the Department shall report to the House of Representatives
21 Appropriations Subcommittee on Health and Human Services, the Senate
22 Appropriations Committee on Health and Human Services, the Fiscal Research Division
23 and the Joint Legislative Oversight Committee on Mental Health, Developmental
24 Disabilities, and Substance Abuse Services on actions taken to address problem of LME
25 under- and over-expenditure of service dollars.

Perdue's MH Reform platform reveals a lack of knowledge about the BARRIERS preventing mental health care from being DELIVERED in NC

my comments to Perdue's outline of mental health reform matters on her webpage are discriminated by ***

marsha hammond, phd

THIS IS WHAT IS ON PERDUE'S WEBSITE RE: MENTAL HEALTH REFORM IN NC: http://bevperdue.com/release_details.asp?id=1070

"Specifically in the mental health arena, my priorities include the following:

1) Extend Community Care model to mental healthNorth Carolina's Medicaid program has recently moved to the forefront in emphasizing the importance of a "medical home" for the primary care of adults and children.
____________________

*****state funded mental health care clients have a 'clinical home' and so what is she talking about? Is she talking about putting all the mentally ill under a PHYSICIAN such that we are back to square one wherein no doctoral psychologists have any control over what takes place w/ their clients? This is, of course, something for NCPA to attend to. However, what I get from NCPA is sad shakes of the head and absolutely no sense of 'hey, we should tackle that.'****
_______________________

..... Our Community Care of North Carolina has developed a very cost-effective and quality-driven model of statewide case management through health care community networks. As Governor, I will extend this kind of collaboration and community network to the delivery of mental health services. Every person served by the mental health system should have the benefit of strong and effective case management to maximize treatment and service plans. In my view, the concept of a medical home should play a major role in helping to revitalize our badly tattered mental health system, for Medicaid recipients and others served by the system as well.

As North Carolina's next Governor, I also want to establish the national model for an integrated approach to behavioral and primary health services for patients with mental health, development disability, and substance abuse problems. One of my top goals will be to break down the barriers to the coordination of mental and physical health care.

2) Establish a “safety net” for those in needWe must also develop a basic safety-net which those in need of mental health services will have available to them.
________________________________

*****This is terribly terribly vague. There ARE safety nets in terms of the 'clinical home' and backing that up, the LME's and their 'core' people who will see to someone who cannot get to their 'clinical home.' It just seems that she has no idea what is already in place and therefore no idea what needs to be fixed. What needs to be attended to is the REMOVAL OF BARRIERS so that professional providers can provide the necessary services. If I have to fill out 8 forms, 5 pages long each one of them, in order to advantage someone to services, how quickly are they going to obtain services?

*****If, like Western Highlands Network LME, in Asheville, states that there are no more than 8 therapy sessions unless someone has a personality disorder, and then only a continuation if you also make available DBT oriented group therapy, how helpful is that?

**********If you have the other LME in western NC, Smoky Mountain Center LME, who allows NO THERAPY to state funded clients except under the continually diminished Community Support Services, how helpful is that?

*******I have mentioned these 2 problems over and over and over to NC Psychological Association, Nesbitt, Insko, Janet Fisher, Dempsey Benton, the LME's themselves.
_________________________________

......These core elements will provide a strong foundation for a true community-based system of care. Today there are just too many opportunities for people in need to fall between the cracks. The quality and degree of care cannot be dictated by zip code. That is why I will take such immediate steps as expansion of the Office of Rural Health's loan forgiveness initiative to place more mental health professionals in the rural parts of North Carolina where they are desperately needed. This kind of state incentive can make a huge difference in the choices young students and professionals make when they are considering careers in mental health. As chair of our state's Health and Wellness Trust Fund, I have already developed an innovative loan assistance initiative to help our rural hospitals modernize and provide more up-to-date services across the board. Modernizing hospitals as well as attracting new health care providers will represent significant boosts to economic development in our small towns and surrounding rural areas, while at the same time enhancing the level of care for some of our most vulnerable citizens. I know that we cannot neglect the need for strong in-patient services. To the extent possible, these services should also be community-based, close to home, family, and other resources. But the state cannot walk away from its obligations. If needed services are absent in a local area due to a lack of private providers, we must work to put them into place through public facilities.

........3) Overhaul system to focus on outcomesThe state's overall approach to planning and implementation in mental health care must also be overhauled. We need a fundamental shift to a focus on outcomes – setting high program and service standards and then clearly stating what results we can and should expect while setting up the conditions most likely to achieve the best possible outcome for each person. One way we can foster the highest quality services is to actively promote the best practices in the field.
________________________

******************Again, this 'best practices' belies a knowledge lacking in what is already in place and any information about what the BARRIERS TO CARE are. Best practices are in place across the board. We are not out here doing voodoo and poking dolls with pins.
_________________________

...........My vision is for the state to develop centers of excellence within our colleges and universities to advance evidence-based models and continue to build capacity for high-quality services across the state.
____________________________
***********You will have no takers re: people willing to be trained in NC and then STAY in NC as providers if you cannot remove the Barriers to Care. We have ALL the models we have ever needed and all are blocked by very specific barriers that are simply ignored.
_____________________________
......Through these evidence-based models we can point the way to more effective and efficient services. We can also better support the ongoing training and development of our professionals who work in the fields of mental illness, developmental disabilities, and substance abuse services.I know that changing mental health care in North Carolina is something far more easily said than done. Yet we cannot stop until we have a system that achieves access to high-quality mental health, developmental disability, and substance abuse services for all North Carolinians. We certainly need better funding. Our low standing in the National Alliance on Mental Illness' rankings of expenditures per capita is inexcusable. But funding is only one piece of this puzzle. We must work on many fronts to achieve the changes and improvements we need. Many people, both professionals and volunteer advocates all across this state, are working their hardest every day to improve our system. The scale, complexity, and rapidity of change that they have endured over the past few years have been daunting but they are committed and determined. Our state needs the benefit of multiple perspectives as we work through the serious issues now facing our system. We will need to adopt a disciplined approach to maximizing system improvements. And we must make sure that government officials and the mental health community listen to and learn from one another. As North Carolina's next governor, I will be directly involved in meeting our mental health challenges. I understand that our efforts will need sound leadership, accountability, policies, and coordination throughout state government and the system of services for mental health, developmental disabilities, and substance abuse. We all know someone – a family member, a friend, a co-worker – who is dealing with the challenges of mental health concerns. These are deeply personal issues for all of us. And they are critical issues for building a better North Carolina as well. I pledge to be the leader our state needs to establish a system of high-quality services that yields the best possible outcomes for those it serves.

McCrory / Perdue in dead heat : WHY THIS REGISTERED DEM WILL VOTE 4 THE REPUBLICAN

Perdue, McCrory in dead heat for governor Posted: Jun. 12 Raleigh, N.C. -

Lt. Gov. Beverly Perdue and Charlotte Mayor Pat McCrory are neck-and-neck in the North Carolina gubernatorial race, according to a new WRAL News poll.

A survey of 500 likely voters on Tuesday by the polling firm Rasmussen Reports showed Perdue, the Democratic nominee, with 47 percent of the vote and McCrory, the Republican nominee, with 46 percent.

The poll has a margin of error of plus or minus 4.5 percentage points.Perdue erased the slight lead McCrory held immediately after the state's May 6 primary.

In a poll conducted then, McCrory held a 45 to 39 percent lead. The latest poll shows a reverse gender gap: Perdue holds a slight lead among male voters, while McCrory leads among female voters.

Perdue leads among voters ages 30 to 49, and McCrory holds an edge with both younger and older voters.

Perdue holds a sizable lead among voters with children in the home and in most income brackets.

Fifty-nine percent of those surveyed have a favorable view of McCrory, and Perdue's favorable rating was 52 percent.

....Fifty-eight percent of those surveyed are in favor of increased taxes on cigarettes and alcohol, which Gov. Mike Easley has proposed to generate money for teacher raises and mental health programs.WRAL.com. http://www.wral.com/news/local/politics/story/3035773/
_________________________________________________________________
I'm voting for the Republican. I'm a registered Dem as far left as they come.

The NC Dems need to understand just how much damage Easley's administration has done re: mental health reform in NC.

Nothing else seems to get their attention and so perhaps when the Dems are shoed out of the governor's house, they will sit up and start listening to consumers and providers associated w/ mental health in NC.

Perdue has never answered any of my e mail I have sent re: concerns.

She does have a helpful person in her office, Mike Arnold, but when I have talked to him a year or so ago, he wanted to know 'what should I do' with your concerns?

I dunno: maybe you should have considered that a psychologist in western NC was concerned enough to call you and put it on a list of things to address and keep said psychologist informed about how this was being addressed.

As it turned out, everyone in Easley's administration has walked around the stinking corpse of mental health reform.

I reckon Perdue dumped it just like Easley dumped his e mail until this all came to light as associated with the firing of the NC DHHS Communications Director-----when she spoke to this matter.

I'll go you one better: Orr, far-right, had the most sensible things to say about how he would address issues re: mental health reform.

Here's the real question : do the Republicans have the stomach to find the money to fix NC mental health reform?

RL Clark (R-Buncombe), running against Martin Nesbitt (D-Buncombe, co-chair of the Joint Legislative Oversight Committee along w/ Verla Insko: D-Orange) has stated:

__________________________________________________________
RL Clark [mailto:rlpclark@charter.net] Sent: Saturday, May 31, 2008 5:07 PMTo: 'lboyd@citizen-times.com'Subject: FW: N & O 5-31-08 ( Reports hammer state mental health care system)

Ms. Boyd,

Most of the Staff Writers at The Asheville-Citizen are on opposite ends of the political spectrum from me.

However I have read your recent articles of your personal experiences and those of others and I am forwarding to you a copy of an email I sent to Diane Bauknight with cc's to N & O and ACT.

Some days ago when I wrote Diane and mentioned the ¾ billion dollars needed I conveyed to her the Legislature would use the excuse taxes would have to be raised!

In my opinion ample funds are already in the State Budget by using the funds going to a multitude of "feel good" programs such as using large amounts of tax dollars for bike ways, conservation easements, unnecessary legislative and executive department studies, greenways, additional parks, and the list goes on and on for the plenitude of VOTE BUYING pork authorized by the General Assembly and signed by the Governor.

Regards,

R L Clark
Candidate N C State Senate District 49
________________________________________________________________

The Dems don't and those were flush years when Easley was in.

Now we're in a financial quagmire across the US.

True, Mr. Benton is making efforts but Easley allowed and condoned Carmen Hooker Odom for 7 years as she did her damage.

And now, for the most part, we are too far down river to go back (if there was ever any going back).

So, yes, I guess its a vote 'against' rather than a vote 'for' anyone.

marsha hammond, phd, clinical licensed psychologist,NC Mental Health Reform blogspot: http://madame-defarge.blogspot.com/

NCPA's Public Sector Committee Chairs never answer any inquiries re: Medicaid / Medicare / Mental Health Reform difficulties

Dr. Hammond, I am not connected with the legislative committee.

You may have me confused with someone else.

I have been the President of DIPP.

As you know, issues around Medicare and Medicaid are handled in NCPA through the public sector committee. I trust that they can answer your questions better than I.

Jim Hilke
________________________________________________________________
Thank you for getting back to me, Dr. Hilke. I do like psychologists and enjoy their company; unfortunately I cannot make a living on the basis of that.

Unfortunately, the Public Sector committee of NCPA has never answered any of my e mails.

Dan Cogswell, the WNCPA liason w/ NCPA, gave me their e mail addresses at the Christmas dinner of WNCPA in December. The chairs of the Public Sector are, I believe, and according to Dr. Cogswell:
Elizabeth Huddleston, Psy.D. Office - 828-433-2282
elizabeth.huddleston@ncmail.net &
James Phillips, Ph.D. Office - 919-575-1258
jim.phillips@ncmail.net

Prior to that I guess I was e mailing someone else that was identified at NCPA as being part of that Public Sector committee.

No one has ever e mailed me or better said, I think ...think...that Elizabeth Huddleston e mailed once before she went out of town saying she would get back to me but she did not.

This has been very frustrating and I have felt distinctly like it did not matter to them that NC psychologists were having a hard time w/ various issues re: Medicare.

what issues?

* no behavioral health codes (I've started an investigation of that on my own; see below); .these would mean 80/20 rather than 60/40.

* no wrap around to Medicaid for dually eligible clients*no attention paid to the massive paperwork associated w/ NC mental health reform.

* no statement of any kind like "we'll look into it" re: problems w/ the LME's in western NC?

what problems?

* Smoky Mountain Center LME requires that all therapy move thru Community Support Services.

Why is this a problem? Because anyone who utilizes that as an authorization code must undergo nonpaid, irrelevant training vis a vis NC DHHS.

SMC LME throws all of its state funded clients into Meridian Behavioral Health Services which has as the CEO a retired SMC LME employee, Joe Ferraro.

* Western Highlands Network LME (together the 2 make up 25% of all NC counties) will not authorize more than 8 therapy sessions and then only for PD's and then only if PD people are also accessed group therapy.

I'm pretty frustrated. I sense no support and not even a sense of 'gee, we should check into this.'

Oh yes, Dr. Weisnert, the NCPA president did jot down on his paperwork the matter of the 20 hours of CSS training which is supposedly associated with using highschool graduates to do CSS.

I've sent letters to Benton, Lancaster and Wainwright about this.

I undoubtedly will never get an answer.

marsha hammond, phd

Why can't NC Psychologists be paid for the 80/20 Behavioral Health Codes ? : working w/ APA to solve this mystery for NC psychologists

I am trying to figure out why NC psychologists are not being paid for Behavioral Health Codes e.g., 96152.

Why does this matter? Because the Behavioral health Codes (please see: http://www.apa.org/practice/cpt_2002.html) pay at the 80/20 rate vs the therapy rate of 60/40.

American Psychological Association obtained 'privileging' for American psychologists as associated with this 'medical arm' of the billing structure, in 2002.

However, NC psychologists are not being paid when they bill using a Behavioral Health Code.

I have talked w/ Diane Pedulla (dpedulla@apa.org) at APA in D.C. re: non payment of Behavioral Health Codes in NC.

This non-payment is associated with Medicare, not Medicaid.

I understood Ms. Pedulla to state that 'just because it is not listed as not being paid for, does not mean it will not be paid for.'

I also understood her to state that Medicaid does not commonly pay for the behavioral health codes, which is in keeping with the document that was passed to me by a member of the NC Executive Board on Friday, June 6, 2008, in Asheville, NC (http://www.dhhs.state.nc.us/DMA/bh/8C.pdf

This is not a problem for NC psychologists as Medicaid pays quite well when it is the primary carrier.

It is only the primary carrier for clients receiving SSI (this means they did not vest enough into the social security system to receive SSDI, which would give them Medicare as primary carrier, w/ Medicaid as secondary).

Medicaid is also the primary carrier for those under 21 deemed to be 'disabled.' What I turned up is the following as associated with looking at the below documents on the CIGNA government web page, utilizing the descriptor '96152.'

I understood Ms. Pedulla to state that 'just because it is not listed as not being paid for, does not mean it will not be paid for.'

What I turned up is the following:

1. CORF, Comprehensive Outpatient Rehabilitation Facilities, can utilize 96152, behavioral health code, which pays at 80/20, medical side of payment 'tree.'

2. It appears, per Item 5 below, that physicians can be paid for 96152.

Thanks for your help, Tony (Puente) and Diane (Pedulla). marsha hammond, phd__________________________________________________________________________________________________________________________________item 1: http://www.dhhs.state.nc.us/DMA/bh/8C.pdfpdfThis is associated w/ Medicaid only. thus, there being no Behavioral Health Codes for Medicaid is not new. This is the document you bought w/ you to the executive board meeting on friday, Dr. Dick Rumer. Ms. Pedulla stated that this is the usual re: Medicaid

___________________________________________________________________Item

2: the psychologists in the room at the executive board meeting on friday stated, as we spoke about the matter, that none of them were being paid for Behavioral Health Codes, that in order to be paid, they gave up and simply ran thru the 60/40 therapy codes e.g., 90806.

There was agreement that this was so from the 25 people that were there, at least some who knew exactly what we were talking about. ___________________________________________________________________item

3: CIGNA, jurisdiction 11, is contractor for Medicare for NC. We researched at the CIGNA site, LCD, Local Coverage Determination. Pedulla and I both looked at it online. http://www.cms.hhs.gov/mcd/results_index.asp?from= ***********************

Item 3a. L6442 Psychiatry and Psychology Services 09/15/2005 10/01/2006 N/A 11/15/2007 LCD for Psychiatry and Psychology Services (L6442) http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=6442&lcd_version=31&show=all

no mention of 96152 anywhere in the above doc **************************************************************

Item 3b: L6460 Psychological Services Coverage Under the “Incident To” Provision for Physicians and Non-physicians 01/31/1999 02/09/2005http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=6460&lcd_version=8&basket=lcd%3A6460%3A8%3APsychological+Services+Coverage+Under+the+%E2%80%9CIncident+To%E2%80%9D+Provision+for+Physicians+and++Non%2Dphysicians%3ACarrier%3ACIGNA+Government+Services+%2_________________________________________________________________________________________________________________Item

4: PDF] Bulletin Number: xxxxxx... for Social Work and Psychological Services in a CORF - CORF providers should billsocial work and psychological services using only CPT code 96152; Health and ... www.cms.hhs.gov/MLNMattersArticles/downloads/MM5898.pdf - 2008-02-25 - Text Version96152 can be billed in a CORF:

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5898.pdf

Comprehensive Outpatient Rehabilitation Facilities (CORF)Billing for Social Work and Psychological Services in a CORF - CORF providers should bill social work and psychological services using only CPT code 96152; Health and Behavior Intervention, Each 15 Minutes, Face-to-Face; Individual. CPT 96152 may only be billed with revenue code 0560, 0569, 0900, 0911, 0914 and 0919. _____________________________________________________________________________________________________________________Item 5: seems to indicate that physician can bill to carrier; no mention of psychologistProgram Memorandum Department of Health &Human Services (DHHS)Intermediaries Centers For Medicare & MedicaidServices (CMS)Transmittal A-01-135 Date: NOVEMBER 30, 2001http://www.cms.hhs.gov/SNFPPS/downloads/a01135.pdf

page 396152 Intervene hlth/behave, indiv Yes NA NA Code Effective 1/1/2002Physician billing to Carrier

MEDICARE: NC's two Republican senators will not vote for psychologists to have a decent wage : (& NCPA is not working on it)

I talked to Diane Pedulla, attny associated with American Psychological Association in D.C. (as per below).

ALL Medicare providers will benefit as re: the Save Medicare Act re: blocking the cut.

There is no gain; there is simply no (further) loss.

The Baucus/Snowe bill would benefit psychologists in terms of the below detail matter.

It would allow me, a licensed psychologist, for instance, BY 2014 to be able to use 96152, the Behavioral Health Code (80/20 rate) which APA talks up.

However, in NC, psychologists are not being reimbursed using this code and are stuck at the reimbursement rate of approx $55/ 90806 (45-50 min of therapy).

I am asking Tony Puente what he knows re: if ANYONE who is a psychologist in NC is being reimbursed for the Behavioral Health Codes.

*****You would think that NCPA would be working on this matter*****

marsha v. hammond, phd
_________________________________________________________________
Dr. Hammond: Both the Save Medicare Act (S.2785) and the Baucus / Snowe bill would block the pending 10.6% SGR cut and replace it with a positive update through December 2009.

This would increase payments for all Medicare services.

However, we are urging members to ask their Senators to support the Baucus / Snowe bill because it contains important provisions that would greatly benefit psychologists.

Specifically, the Baucus / Snowe bill includes:

***Extra money for psychotherapy: Under the Baucus / Snowe bill,

***Medicare payments for psychotherapy services would be increased by 5% for the period from July 1, 2008 through December 31, 2009.

***Medicare mental health parity: The Baucus / Snowe bill would eliminate the outpatient mental health treatment limitation. This would be phased out over a six-year period so that mental health would have the same co-pay (80/20) as other services by 2014.

**Increasing the pay for reporting bonus: The Baucus / Snowe proposal would raise the bonus payment under Medicare pay for reporting program from the current rate of 1.5% to 2% for 2009 and 2010.

I hope this information is helpful to you.

Diane M. Pedulla, J.D. Director, Regulatory Affairs -

Practice American Psychological Association

750 First St., NE Washington, DC 20002-4242

Phone: 202-336-5889 Fax: 202-336-5937 E-mail: dpedulla@apa.org

Mercer II Reports: comparing western NC's two LME's: 25% counties of NC's 100 counties

Overall Mercer II Report:
http://www.ncdhhs.gov/mhddsas/statspublications/reports/mercer-lme/index.htm
*Note: the purpose of the series of Mercer Reports, grossly, as stated in the news services and attributed to the governor's office, are associated with 'whether the LME's are ready to oversee Medicaid.'
______________________________________________________________________
Smoky Mountain Center LME (SMC) LME report within the larger one:
http://www.ncdhhs.gov/mhddsas/statspublications/reports/mercer-lme/Smoky%20TA.pdf

SMC LME: failed 17/40 possible items; all items are not 'weighted equally' in terms of importance. Document will not allow you to cut and paste. remember that SMC LME is run by accountant Tom McDevitt and most consistent approval rating as per Mercer Report is associatted with first criteria, specifically, Operational Category.

Failure items include matters which I have taken SMC LME to task about, and which are also regarded in the Haywood county community to be lacking:

* no separation of system management from service delivery functions

(Stephen Puckett, PhD, is the Clinical Director, and he has the capacity to blockade services, which has occurred as per this practitioner, as well as he feeds into the management of SMC LME. In other words, there is no separation of duties and the clinical director's job is impinged upon by the over-riding financial desires of SMC LME's financial concerns. How does this play out re: SMC LME specifically? All clinical care is thrown to Meridian Behavioral Health Services, run by Joe Ferraro, retired SMC LME employee)

*no check re: 'UM/UR committee'

(Months ago I asked why SMC LME did not have on its website information about its CFAC, which is the consumer/ consumer's relatives committee which tackles problems within the LME from the perspective of people outside the LME. After pressure from NC DHHS, the notes were put on line. what did they reveal?: a CFAC which was mostly non-attended.

Charles Barry, the manager of Utilization Management, almost sole-handedly runs the UM department and Dr. Puckett and Mr. Barry seem to collude re: denial of authorization and threats of audit should the practitioner attempt to forego the Community Support Services (CSS) training which is intended for the CSS highschool graduates, rather than the professional trained mental health practitioners)

*no check re: Crisis Services

Synopsis re: SMC LME:

The non-separation of the clinical arm of the SMC LME and the adminitrative arm of SMC LME is perhaps the most troubling item highlighted in this report. It reveals an LME whose clinical administration, inclusive of making authorizations available to clinicians in the community, is always being monitored by the more carefully monitored financia/ administrative arm of the LME.
________________________________________________________________________
Western Highlands Network (WHN) LME report within the larger Mercer II Report

: http://www.ncdhhs.gov/mhddsas/statspublications/reports/mercer-lme/Western%20Highlands%20TA.pdf

WHN LME failed 10/40 points. all items are not 'weighted equally' in terms of importance. Document will not allow you to cut and paste.

* no check re: UM/UR committee

*no check re: Crisis Services
___________________________________________________________
___________________________________________________________
Comments: (marsha hammond, phd, clinical licensed psychologist)

1. It appears that the non-cut and paste single item related to Crisis Care needs to be broken up into components. There are 2 at the current time. Within the 1st category, there are 6 items.
Given the problems w/ Crisis Services across NC, it is surprising (though maybe not, given the heat on this matter) that it has been accorded 2 checks per the Mercer II Report.

NC Psychological Association : dying to take your $$ but you better write your own letters

Marsha V. Hammond, PhD
Clinical Licensed Psychologist, Asheville & Waynesville, NC
E mail: hammondmv@netzero.com
Cell: 404 964 5338
Mailing address: POB 16974 Asheville, NC 28816

June 8, 2008

Dear DHHS Secretary Dempsey Benton:

It has come to my attention, as a doctoral level psychologist, that LME’s across NC are authorizing vastly different rates and kinds of therapy services for state funded clients in need of mental health services.

I am therefore writing this letter in order to ask you to address the significant discrepancies between the authorization of therapy services across the LME’s of NC.

I specifically am asking about the barriers to therapy services created by Western Highlands Network LME and Smoky Mountain Center LME.

I have asked NC Psychological Association about this matter.

In association with the June 6, 2008 meeting with the Executive Board of NC Psychological Association, a member of that board indicated that that centrally located (in NC) LME’s utilize the same standard as Medicaid in terms of authorization of services.

This is not true of SMC LME and WHN LME, which, combined, oversee 25% of NC counties.

This has created significant barriers to the providing of professional services in western NC.

SMC LME, for instance, does not allow for any therapy outside of Community Support Services (CSS) as per Stephen Puckett, PhD, Clinical Director of SMC LME. As you undoubtedly know, 20 hours of CSS training has been written into the Service Definition by NC DHHS as mandatory. This was created, I believe, as NC DHHS allowed the utilization of high-school graduate CSS workers.

I do not believe it was the intention of NC DHHS to mandate that doctoral level psychologists go through 20 hours of unnecessary, unpaid training in order to continue to do what they do quite well, specifically, provide professional therapy services.

I am asking if you can please address this specific issue and remove the requirement for mental health professionals as this training is not necessary and has resulted in myself, for instance, not working with mentally ill citizens in rural NC.

WHN LME, the other LME in western NC, has a similarly restrictive requirement as pertaining to the rendering of professional mental health services. Marsha Ring, the manager of Utilization Management, has indicated to me, as well as to Dr. Rumer, that 8 therapy sessions is the absolute maximum number of sessions/ year. After this, only clients with diagnoses of Personality Disorders (PD’s) can be advanced to additional therapy, and the further restriction is that group therapy utilizing the well-known, cognitive therapy format known as Dialectical Behavior Therapy (DBT) must also be in place in order for there to be more than 8 therapy sessions/ year.

I agree that DBT provides useful information for clients who have difficulties associated with PD’s.

However, I would like to advocate, that in keeping with other LME’s in NC, that the standard of authorization be similar across the LME’s and that the standard that is utilized be in keeping w/ Medicaid criteria.

As regards Medicaid criteria, and as you may know, after 8 visits, the clinician must obtain authorization from Value Options, for therapy.

The authorization request is not limited to Personality Disorders but includes other diagnoses such as Major Depression, etc.

This is an acceptable manner of authorization and it would be in keeping w/ Medicaid, providing uniformity to services.

Thank you for addressing these concerns, Mr. Benton. I look forward to hearing from you.

Sincerely, Marsha V. Hammond, PhD

cc: Leza Wainwright; Mike Lancaster; NC Psychological Association; Western NC Psychological Association; CPSYLink listserv; Insko, Nesbitt; Douglas Sea, attny; David Janowsky, MD; Donald Reuss, WHN; Marsha Ring, WHN Network; Diane Bauknight, MH advocate; Bill Franklin, MH advocate, Almance county; Dan Cogswell, PhD, WNCPA; Elizabeth Huddleston, co-chair, Public Sector, NCPA; Bill Barley, PhD, WNCPA

My dinner with the Executive Board of NCPA

Dr (Christina) Mickiewicz: (kiewicz@acmhddsa.org; Alamance-Caswell MH/DD/SA)

You are a LME administrator associated with Almance-Caswell MH/DD/SA----is that correct?

I would like to know, as per your status as administrator (I assume), is there a limit to the number of sessions for state funded clients (yes, I understand that they are not 'entitled' as are Medicaid/ Medicare clients) and does your LME demand that everyone that provide therapy services for state funded clients go thru 20 + hrs of unpaid Community Support Services (CSS) training.

I am asking this at the level of trying to understand just how different the LME's are. This is no attempt to entrap you. I truly want to understand why the people from Raleigh had no idea about these kinds of issues. I can only assume that the problems are unique to western NC.

When I talked about these specific difficulties at the dinner meeting of the NCPA Executive Board last night, even the local psychologists looked alarmed. The president of NCPA stated he was alarmed.

And so I want to know are we just saddled with a couple of dudd LME's in western NC, in control of 25% of the states' counties?

I am not able to make a living as a clinical sychologist due to mental health reform issues. These are issues which, I believe and hope, NCPA could address.

My quandary has everything to do w/ NC mental health reform.

As associated w/ the dinner last night w/ the NCPA board, this is what I carried away:

1. NCPA is not able to carve out a 'scope of practice' as doctoral psychologists are represented by NCPA as well as are LPA's, or psychological associates---master's degree people. That means that comraderie (yes, I wish the world was a cooperative place but unfortunately I need to put dinner on the table) is necessarily created between NCPA/ LPC's/ Social Workers as pertaining to issues.

And that means that rather than hire a doctoral level psychologist, any sensible business will hire an LPC/ social worker/ or psychological associate.

When you speak of 'we' needing to fix the matter, I find myself trying to figure out how to look out for my own profession, that of Clinical Psychologist, as well as contribute to 'fixing' it.

And I am afraid that 'fixing it', for me, is the same as carving out a safe place so that I can stay afloat.

The other day I did not resist the impulse to open the mail of a colleague of mine in Atlanta; he temporarily lived in my house there while he was looking for a place to live. He is an old friend who would not have minded; the tax return information indicated that his VA psychologist pay for last year was over $105,000/ year.

I assume that your salary is comparable, is it not, Dr Mickiewicz?

I nevertheless welcome your ideas on how to 'fix it.'

The VA, just after WWII, carved out a 'scope of practice' for psychologists.

Contrarily, as re: NC Mental Health Reform, there has been a distinct effort by DMA and NC DHHS, to treat MH providers as all the same in terms of training/ status/ authorization/ payment-----and this has everything to do w/ my inability to practice within the confines of DHHS-----soon to be expanded to Medicaid, the only safe refuge for clinical psychologists as they can independently bill while as LPA's cannot.

2. NCPA board member, Dr. Rumer, who is on this listserv, verified last night at our dinner meeting in Asheville, just as an example of what I mean when I say that the creation of the LME's has fractured the entire mental health care system in terms of there being differing criteria for each of the LME's as associated with available therapy/ authorization associated w/ such/ payment of such--------that yes indeed Marsha Ring, the Utilization Manager of Western Highlands LME, in a convoluted manner indicated that for PD diagnoses there are indeed more than 8 therapy sessions/ year if DBT gp therapy is coupled to request for therapy sessions.

The barriers associated with working as a psychologist or indeed any of the mental health professions are accelerating----not diminishing. Until the barriers are addressed, there is no fixing of this mental health care reform fiasco.

As a clinical psychologist, I cannot even get to the Behavioral Health Codes (96152) which could pay me at the 'medical' rate, which is 80%. 96152, as passed to me by Dr. Rumer last night, and as verified by other psychologists in the room, is not on the list of NC DMA.

Contrarily, APsychological Association just can't stop tooting their horn about the ability of psychologists to use this behavioral health code. I can't use it or if I can, I haven't yet found the way to do this. If someone knows, please tell me.

I am thus railroaded into seeing clients for 45 minutes, 90806, rather than 90808, which is more productive in my professional opinion and as associated with my frequent home visits (I have a very low no-show rate).

'Pretend' Medicare e.g., Humana, will not pay for anything other than 90806. Medicare minimally pays more for that extra 45 min of therapy. For this clinical psychologist, direct billing CIGNA, for 90806, I get approx $55.

Moreover, as the Executive Director of NCPA stated last night, NCPA continues to try and follow-up on the lack of wrap around of dually eligible clients (those who have Medicare as a primary and Medicaid as a secondary). This would afford me some more pay for the 90806 but I am blocked from getting to it.

No, Dr Mickiewicz, this is not sibling rivalry. This is a matter of a well trained clinician simply trying to put food on the table.

Pass this to anyone you like. I believe that the profession of clinical psychologist is doomed in the state of NC.

What does this matter to NC mental health reform? Clinical Psychologists are the better trained of the mental health professionals and I believe I can argue with substantiation that we address issues from a research basis and we are very well trained.

I am not saying that LPA's do not have similar training. I have no stomach for an argument w/ the LPA;s and indeed that would be sibling rivalry.

I am saying that the combining of the LP's with the LPA's, so long ago (and I have no idea about this history and would welcome any comments from people) has assigned me to a place wherein I can barely make a living. NCPA has not carved out any 'scope of practice' for either one of the parties it represents.

This being said, this combining is probably negligible in terms of the assigning of authorizations and payment to any mental health provider of whatever ilk---as re: NC DMA and NC DHHS.

For them, we are all exactly the same. And the benefits all go to those 2 agencies while confusion and chaos is what I see all around me re: the disintegration or 'governmentalization' as one psychologist put it last night, of mental health care in NC.

I don't know what the answer here is and the more I find out and understand the more futile everything appears. I walked away from the meeting last night vowing to learn to live more cheaply---and trust me----I'm already pretty cheap.

Marsha V. Hammond, PhD
http://madame-defarge.blogspot.com/
***************************
associated e mail: Dr (Christina) Mickiewicz: (kiewicz@acmhddsa.org; Alamance-Caswell MH/DD/SA)

When will these constant "sibling rivalry" issues finally end. We need to focus all our attention on our patients and keep coming up with more innovative and collaborative approaches and stop this finger pointing- its enough we have to deal with all the politics, etc, but this is enough . Everyone had/has done all they could to prevent this train wreck, to no avail. Now its time to HELP FIX IT! Dr Mickiewicz

NC Psychological Association: a hit dog yelps

June 5, 2008
Dear NCPA/ Sally Cameron, Executive Director of NCPsychological Association:

Let's be clear here. Its me that has been critiquing NCPA. I don't mind being named. And my information is 'factual' also. It is at the level of someone doing the work, interfacing w/ the LME's.

I am all for us being able to work together. And I'm all for working quietly behind the scenes.

However, given how difficult it is for me as a licensed psychologist to even obtain authorizations to see state funded clients and given that no one from NCPA chooses to correspond on what seem to me to be pretty pressing issues, I have to resolve that being noisy will at least get some attention applied to the matter. For months, you seem to have not gotten any of my e mails but but I was using your correct e mail address. You told me, via e mail, that the Public Sector psychologists were 'busy people.'

A hit dog yelps and NCPA appears to be trying to defend its non-assistance to NC psychologists and by default, NC citizens needing mental health care.

There are other psychologists on this listserv who also back channel criticize NCPA.

You stated, Sally: "DIPP’s role within NCPA is to work on issues related to the private practice of psychology including problems with reimbursement, managed care, the State Health Plan, and other practice issues including risk management and practice management. Because NCPA is not a single issue organization, DIPP has taken very little action regarding MH reform, allowing the Public Sector Committee, Legislative Committee and other committees to address this important issue. "

1. The 'other' committee within NCPA, specifically, the Public Sector Committee, has never answered any of my e mails re: reimbursement/ public sector e.g., Medicare, Medicaid issues. No one ever directed me to the Legislative Committee and I have no hope that they would be any more helpful that DIPP or Public Sector Committee members.

2. If NCPA has been working with matters associated with mental health reform, then why are the most basic matters not addressed? These would include:

a. no more than 8 therapy sessions/ year for state funded clients regardless of diagnosis. This was stated directly to me by Marsha Ring, the Utilization Management Director of Western Highlands Network (WHN) LME. To engage with a client w/ the knowledge that this is all that there is----even though a Code of Ethics would defend the practitioner as being subject to these limitations----is potentially very risky.

b. Smoky Mountain Center (SMC) LME, the largest LME in NC, sitting with a policy that shuts out psychologists as associated with demanding that therapy fall under the Community Support Services (CSS) which require 20 plus hours of unpaid training, completely unnecessary for psychologists-----not to even mention the constant defunding of CSS across NC DHHS.

NCPA of course is not a single issue organization. However, NC mental health reform is not some itty-bitty issue that concerns only me. Moreover, what is determined in one areana becomes a guideline in other arenas. Eight sessions of psychotherapy over the course / year sets a tone for other managed care companies.

Show me the specifics of what NCPA has done. I can't imagine a poorer job. I can't even get anyone to correspond w/ me. What we have is this untethered defense of NCPA actions or non-actions.

I'll see you on Friday at 6 pm in Asheville. I would like to ask you to at least weigh in with the above 2 LME's, the only 2 in western NC, as re: these concerns and hopefully to be able, on Friday, to speak to these issues which affect western NC psychologists:

**severe restrictions of 8 sessions of therapy regardless of diagnosis

**requirement of CSS 20 hours unpaid, non-useful training in order to provide therapy. Therapy should not be under CSS which is at continual risk or defunding.

Thank you for entertaining my request. Pass this to any salient person.

I at least want to know what I can expect for NCPA to do re: protecting psychologists' practice which is given in the service of providing mental health care for NC citizens.

If you cannot intervened on behalf of NC psychologists, just say so.

Marsha V. Hammond, PhD
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associated e mail
Colleagues
The North Carolina Psychological Association values the working relationship we have with fellow mental health, developmental disabilities and substance abuse professionals as well as with others in both the public and private sector. In recent weeks there have been statements on this listserv concerning NCPA, including references to unethical behavior. We very much appreciate the comments and cautions from Drs. Schwartz and Bridges. I am posting this on behalf of the leadership of the North Carolina Psychological Association and it is presented in the spirit of providing factual information about NCPA’s activities.
David C. Wiesner, Ph.D. President North Carolina Psychological Association
The North Carolina Psychological Association has taken many actions attempting to influence the state’s mental health reform plans. This is a partial listing of actions the North Carolina Psychological Association has taken regarding reform of the mh/dd/sa system over the past 8 years.
· from the beginning of reform in 2001, NCPA commented on the state auditor’s report, and later on the hired consultant group’s recommendations, as well as on numerous versions of the Department of Health and Human Services State Plans. This includes comments submitted last year on the latest version of the State Plan. Some of these comments resulted in changes to policy. These have been available on NCPA’s website for some time.
0 NCPA has been involved, has participated with, and has monitored the established Legislative Oversight Committee MH/DD/SAS.
1 NCPA’s lobbying team has had numerous contacts with key legislators and DHHS staff on issues involving mental health reform.
2 NCPA lobbied successfully for full inclusion of psychologists (and other licensed mental health professionals) as directly enrolled providers in Medicaid. Prior to this inclusion psychologists were not recognized as independent providers by DMA.
3 NCPA has written several letters of concern with recommendations about the reform process to the Division of MH/DD/SA and to the Secretary of Human Resources.
4 NCPA leadership has met with and has been involved with Secretary Benton concerning MH reform. 5 NCPA had a psychologist representative on Secretary Benton’s panel looking at planning for state hospitals. 6 NCPA has written a letter to the editor (unpublished) of the News and Observer following their story about state MH reform.
7 NCPA has worked on various committees to express concern and provide expertise regarding specifics of the state’s reform plan (service definitions, definitions of target populations, etc.)
8 There have been several articles in various issue of The North Carolina Psychologist about various aspects of mental health reform. I would point you to:
· November December 2007 – Mental Health Reform and Private Practice – page 8 1 May June 2007 – Mental Health Reform and Best Practice – page 7
And Mental Health Reform: A Primer – Part 2
· January February 2007 – Mental Health Reform: A Primer – page 1
We certainly know that our efforts have not produced all that we wished that they could, but NCPA (as well as other professional associations) continues to provide thoughtful critic and helpful suggestions in the MH reform process. We purposely have tried to be professional and not go about bashing or blaming others. We have found that in some cases quiet diplomacy often is more productive than public outcry.
Having over 950 psychologist members, NCPA does at times hear dissent from some members. NCPA works through committees with leadership oversight. We welcome members’ ideas and suggestions, but know that as we use these ideas and make our plans and comments, some individual ideas may not be used, and some members may disagree with our approved action plans.
NCPA’s Public Sector Committee has been the committee that has been most involved with NCPA’s actions in regard to state MH reform. This is a dedicated group. In fact, they held a three-hour meeting this week to further develop some NCPA positions on reform.
In one posting there was criticism of NCPA’s Division of Independent Professional Practice (DIPP), implying that this body is not taking actions regarding state MH reform. DIPP’s role within NCPA is to work on issues related to the private practice of psychology including problems with reimbursement, managed care, the State Health Plan, and other practice issues including risk management and practice management. Because NCPA is not a single issue organization, DIPP has taken very little action regarding MH reform, allowing the Public Sector Committee, Legislative Committee and other committees to address this important issue.
We provide this information to inform and we hope you will conclude as I do that NCPA is acting ethically and responsibly regarding state mental health reform.
cc: NCPA Board of Directors Western NCPA President
Sally R. Cameron, Executive Director NC Psychological Association 1004 Dresser Court, Suite 106 Raleigh, NC 27609 919-872-1005 phone 919-872-0805 fax ncpasally@mindspring.com www.ncpsychology.org