In support of an expanded vision of 'medical necessity', more in keeping w/ mental health needs, distinctly NOT NC DHHS's 'rehabilitation' model

The term 'medical necessity' is linked to the authorization of both physical and mental health services. It is deemed to be necessary in order to create services.

Why is an understanding of the term important? Because it can be used as a reason to deny services.

What is the problem w/ NC DHHS's 'rehabilitation model' which is based on medical services authorization?

It does not take into account the common chronicity of mental health issues.

The below attempts to outline an expanded definition of 'medical necessity' more in keeping with the usual trajectory of mental health issues.

The brain is not an organ that can be taken out and repaired like your hip can be replaced or your cancer removed.

********************

The National Psychologist September/ October 2008, p. 9, article, entitled:
'Data Mining Programs' intensify scrutiny of Medicare claims', by Paula E. Hartman-Stein, PhD, states:

"The definition of medical necessity used by CMS is "services or items reasonable and necessary for the diagnosis of treatment of illness or injury or to improve the malfunctioning of a malformed body part." Georgolulakis said when a patient reaches a point where further improvement does not appear to be indicated or there is little expectation of improvement, the services are no longer considered reasonable or necessary."

**************

WIKIPEDIA states:

http://en.wikipedia.org/wiki/Medical_necessity

"Medical necessity is a United States legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate...."

************
Tony Puente, PhD, Neuropsychologist based in Wilmington, NC, stated at APA, 2008, Boston: "Medical necessity is whatever your contract says it is."

*********************************************
The National Psychologist author contributed this:

"According to Georgoulakis, mental health may be an easy target for the Recovery Audit Contractor (of Medicare) program because the criteria for medical necessity is not as straightforward to pionpoint compared to physical medicine. Medical necessity MUST BE SUPPORTED by the patient's progress in therapy and a plan with clearly identified goals. "In mental health if we're not doing treatment plan revisions every 30-60-90 days we can really get nailed." .....

He said the clinical record should document target symptoms, goals of therapy, methods of monitoring outcome and how the treatment is expected to imrpvoe the health status or functioning of the patient."

***************
Vicki Gottlich, J.D., L.L.M., of Washington D.C.'s Center for Medicare Advocacy stated, in an overviewing of how Medicare works well----or not---for people having chronic illnesses (Jaunary, 2003: http://www.partnershipforsolutions.org/DMS/files/
MedNec1202.pdf; pgs 3,4)

"Medicare standards for making medical necessesity determinations in individual cases do not always address the particular needs of beneficiaries with chronic illnesses....for certain services such as outpatient therapy, Medicare policies impose improvement standards that are inconsistent with the statutue.....
Medicare policiers concerning medical necessity determinations in individual claims should be revised to recognize that the overwhelming majority of beneficiaries have at least one chronic condition whose method of treatment and treatment goals are different from the method of treatment and treatment goal for acute illness or injury.....maintenance of abilitry, prevention of deterioration, and patient education should be erecognized as treatment goals for beneficiaries with chronic conditions."

NCPA's 'FACTUAL INFORMATION' re: their efforts associated w/ NC Mental Health Reform

I have been assigned to Dave Weisner, recently the president of NC Psychological Association. Like the pope, he is supposed to be my go-between associated with getting answers (my! I could get answers!) on matters impacting providers and clients in western NC pertaining to NC mental health reform problems.

Well, we keep missing each other via the phone; so I have not gotten any answers. He did leave me a message and tell me that I could submit 'facts' as associated with a newsletter article-----
'not emotional'----which is a prety amazing thing associated with the practice of psychology given that we see and hear people crying, moaning, and ranting every working day.

What would I like answers to has very much to do with what NCPA could do.

The lack of standardization of the Utilization Review Departments within the LME's is a matter to be tackled by a professional organization.

Basically, my problem w/ NCPA is associated with the lack of detail or ability to see 'inside' their processes and the demand that I use the pope to get to God.

Specifically, as associated with the Public Sector psychologists, no e mail has ever been answered and in keeping w/ the closed door to the membership of NCPA, is the below following statement:

NCPA's public Sector Committee held a retreat this summer and recently released a new Position Statement on Mental Health Reform that was sent to key state legislators.

WHERE is that Position Statement?

There is nothing at the NCPA website: http://www.ncpsychology.com/

Google pulls up nothing when using the descriptor: 'position statement Public

Sector NCPA'

I have sent an e mail to Dr. Weisner and Verla Insko, co-chair of the Joint Legislative Oversight Committee, NC STate Legislature ("Verla Insklo" and her assistant re: mental health reform matters ("Rennie Hobby" ) to try and turn up the 'position statement' which, to my mind, should have been posted at the NCPA website.

The following is an outline of what NCPA has stated it has done re: NC MH reform, as stated by Annette r. Perot, PhD, President, NCPA, as copied exactly from the WNCPA newsletter, September, 2008:

"Dear WNCPA Members:

I am writing to provide factual information about NCPA's activities in response to recent comments in the last issue of your newsletter.....

In terms of state mental health reform:

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 versios of the Department of Health and Human Services STate Plans. Some of these comments resulted in changes to policy.

NCPA has been involved in, participated with, and monitored the established Legislative Oversight Committee, giving testimony when appropriate.

NCPA's lobbying team has had numerous contacts with key legislators and DHHS staff on issues involving mental health reform.

NCPA lobbied successfully for full inclusion of psychologists as directly enrolled providcers in Medicaid. Prior to this inclusion psychologists were not recognized as independent providers by DMA.

NCPA has written several letters of concern, with recommendations about the reform process, to the Division of MH/DD/SA and the Department of Health and Human Services.

NCPA leadership has met with and has been involved with Secretary Benton concerning MH reform.

NCPA worked to get a psychologist on Secretary Benton's panel looking at planning for state psychiatric hospitals.

NCPA has worked on various committees to express concern and provider expertise regarding specifics of the state's reform plan (e.g., services definitions, definitions of target populatikons,etc._)

There have been several articles in various issu of The North Carolina Psychologist about various aspects of mental health reform.

NCPA's public Sector Committee held a retreat this summer and recently released a new Position Statement on Mental Health Reform that was sent to key state legislators. ..."

**************

"Chapter Five : “Feed the Backlash” from, Taking on the System: Rules for Radical Change in a Digital Era, by Markos Moulitsas Zúniga (2008, Celebra):

“When your enemies (wish they were friends) begin to notice you – and attack you – you have arrived. Instead of avoiding confrontation with gatekeepers and opponents, embrace it and feed it. ..."

The SO FAR critical safety issues at Central Regional Hospital---the stand-in for DIX

Unbelieveable. To work there is to risk suicide or homicide.

Here is the list, as enumerated accordingly: "the physicians and psychologists authorized us to send you this letter of concern." Signed by: Nicole Wolfe, M.D. Margaret Champion, M.D. Richard Rumer, Ph.D.

When submitted to NC DHHS: September 19, 2008

items:

1. There is still not a fully operational paging system or voice-over-internet phone system (someone has an emergency and they cannot call for help on a dependable basis)

2. indeed, there is :"The Code Blue/Duress alarms system continues to generate many false alarms" (the sky is falling! the sky is falling!, which inevitably leads to lethargic responses)

3. there is no: "complete fire alarm/defend-in-place drill" (what do we do when we have an emergency)

4. females on the forensic units w/ the murderers: "We are informed, for example, that the Forensic Maximum Security Male Unit (staffed at DDH with male health care technicians) will become staffed at CRH with a large number of female and male health care technicians from John Umstead hospital who have not worked in a forensic unit and have not yet received forensic training. "

5. nursing and other staff are not protected from the murderers and other violent offenders: "There is no ability to restrict violent forensic patients from entering the nursing station and harming staff or property."

6. Dix Hospital personnel will be depleted of crucial elements: "There is currently no plan in place for staff to respond appropriately to very dangerous patient behavior once the Forensic response team is moved to CRH.

7. Emergent admissions to Dix would be examined by a non-psychiatrist: "Currently, the physician at the unit is planned to be an internist, not a psychiatrist. ....This appears to be in violation of the proposed CRH credentialing and privileging manual, and departs from the standards of practice of the other North Carolina state psychiatric hospitals. "

NC DHHS : Mental Health Providers must master PAPERWORK PROWESS: the clients be damned: Losing providers who provide mental health care

CRUSHING THE PROVIDERS WITH THE PAPERWORK: NC DHHS/ Value Options/ LME's can get pristine paperwork or they can have the services delivered to the clients.

They won't get both. There's not enough hours in the day.

See previous Madame Defarge's associated w/ Value Options, the authorizing agent for NC Medicaid for further documentation of paperwork prowess.

Bear in mind that ALL the Community Support Services training mandated by NC DHHS has NOTHING to do w/ anything but PAPERWORK. There is no attention paid to clinical matters.

Below is further indication of just what is important to NC DHHS.

If they are being hammered on by the fed DHHS, then one would surmise that someone
in their administration make a case for the lack of mental health care being provided whileas the paperwork is assumed to reflect all that was done.

One provider company's representative identified below:

"Those infractions had to do with the way we were documenting our services not related to the way we were providing the services themselves,"

****************

http://www.yesweekly.com/
article-788-formerly-homeless-clients-find-services-lacking.html
by Jordan Green at Yes! Weekly
jordan@yesweekly.com

"There were lots of paybacks from the provider community," said Susan Campbell, manager of access and care management at the Guilford Center.

At least two agencies used by clients of the housing support program in Guilford County were flagged during

the Guilford Centers' post-payment reviews in the summer of 2007. One was Asheville based RHA Health Services, an agency used by James and Graham that serves clients across North Carolina and Tennessee.

Another was Star Care, the agency chosen by Kallam after he dropped RHA Health Services. "Those infractions had to do with the way we were documenting our services not related to the way we were providing the services themselves," said Rhoades of RHA Behavioral Health.

A team from the Guilford Center visited the company's High Point office and determined that it had satisfactorily corrected its deficiencies, Root said. Of the 34 agencies flagged by the local management entity, Star Care is the only one still serving clients in Guilford County that has not completed its corrective action plan. Root said the Guilford Center has an agency site visit scheduled for this week. Administrator Martina Ukattah said Star Care is prepared for the local management entity's visit.

"The service definitions were not defined for the providers," she said. "For us to be in line with the service definitions, we have to know what they are. [Root] said they had a plan coming out. They keep changing on the service providers."

While some agencies have struggled to get out of corrective action, others have found their endorsements in jeopardy because of difficulty meeting new state requirements mandating that at least 25 percent of billable hours be provided by someone considered to be a "qualified professional."

Phoenix-based Recovery Innovations of North Carolina, an agency that operates its local office out of the same county-owned building that houses the Guilford Center, was notified on Aug. 13 that its endorsement for adult community support services was being withdrawn. Jamestown-based Family Service of the Piedmont received notice the same day. Both agencies successfully appealed, and had their endorsements were restored on Sept. 8. Recovery Innovations was the first of a succession of service providers used by James. ....."

Western NC MENTAL HEALTH significant news: McDevitt Resigns as Executive Director of SMC LME

Tom McDevitt was trained as an accountant. He ran SMC LME like an accountant would. He well understood the bottom line and surely it is due to his ability to calculate 'how much will it costs' that SMC LME becamse the biggest LME in NC.

A physically imposing man, he speaks directly and in a well organized manner. Bill Hambrick answered the clinical questions, equally clearly, in SMC LME provider meetings I have attended over the past 5 years.

I am betting there are a lot of mixed feelings about this resignation at SMC LME. There's a lot of problems there re: provider complaints:

1. outpatient therapy is only available under Community Support Services which has multiple barriers associated w/ its usage and is constantly being downsided.

2. The Utilization Review Department, run by Charles Barry, was vindictive towards this provider, threatening the Endorsed Provider company which NC Mental Health reform, with a large audit if I tried to advance outpatient therapy for state funded client though I had not had the useless, completely unnecessary, unpaid 20+ hours of Community Support Services training. I have sense gotten her access to Medicaid.

So, is Hambrick going to take his place? He is less than 5 years from retirement, himself, I believe.

********************************

Embattled director of mental health agency resigns
By Julia Merchant • Staff Writer

--------------------------------------------------------------------------------

The board of Sylva-based Smoky Mountain Center for Mental Health accepted the resignation of agency director Tom McDevitt last week (Sept. 16) following a six-hour, closed-door interrogation into allegations that McDevitt had abused his power and taken advantage of his position for financial gain.

The Smoky Mountain Center provides mental health care to 15 western counties and is the state’s largest such agency geographically.

The 30-member Smoky Mountain board in July began questioning some of McDevitt’s actions, including the salary he earned as director of the agency’s non-profit Evergreen Foundation, the employment of his daughter, and profits his wife made from property transactions through the Foundation.

http://www.smokymountainnews.com/issues/
09_08/09_24_08/fr_mcdevitt_resigns.html

BARRIERS to mental health care in NC: no standardization of Utilization Review & Massively Disorganized Authorization Process

From: Marsha V. Hammond, PhD: Clinical Licensed Psychologist in private practice, working mostly w/ indigent clients in western NC
E mail: hammondmv@netzero.com

To: Joe Morrissey, PhD, Professor of Health Policy and Management, Sociology & Psychiatry, UNC
E mail: jmorris@cnsmail.com, joe_morrissey@unc.edu

RE: computer models for mental health care in NC

September 22, 2008

Dear. Dr. Morrissey:

I listened with interest to this information associated w/ computer models pertaining to NC mental health reform problems, in which you outlined, grossly, such models: http://www.healthlimited.com/2008/09/mental-health-system-improvement/.

I went to google scholar and was curious about this article, particularly as it hints at matters associated w/ Utilization Management/ Review, which, I believe, is at the heart of problems associated w/ NC Mental Health Reform: Comparing provider perceptions of access and utilization management in full-risk and no-risk medicaid programs for adults with serious mental illness : http://www.springerlink.com/content/n184816313h8v114/

While, as per the video, which you explained is a simple model associated w/ matters such as patients coming into a psychiatric unit and those being discharged, would be helpful in terms of planning psychiatric beds at various locations, the problem w/ mental health reform is much bigger and problematic than this.

I would list these problems accordingly (and I am afraid I am not advanced enough in understanding the matter though I have followed it in detail for the past several years, in order to rank order the following):

1. Utilization Management/ Review departments within the LME’s operate without any standardization across the LME’s. This means that in central NC we have an LME that purportedly utilized a Medicaid standard in terms of mental health treatment, which is associated with 8 outpatient therapy sessions and then more as associated with an authorization request by the provider VERSUS Western Highlands Network LME in Buncombe county which allows only 8 outpatient therapy sessions/ state funded client/ year VERSUS (the other western NC LME, Smoky Mountain Center LME) which has no outpatient therapy sessions except under Community Support which is constantly being defunded.

Yes, the LME’s only, at this time, oversee state funded clients.
HOWEVER, the agenda is to have them oversee Medicaid clients and that is very problematic re: their inability to create ‘stable’ paperwork as associated with the state funded clients.

2. Value Options, the authorization agent for NC Medicaid clients, is
up to its ears in paperwork. For, you see, the paperwork that they require of us providers is then sent BACK to them and they sit on it for weeks if not months as they utilize their fewer than 300 NC employees to hack thru this mountain of useless paperwork inclusive of 20 page Person Centered Plans; ITR’s; etc. Those Community Support Services which are in appeals have to be aggressively pursued for they have, apparently, simply lost track of the paperwork. Yes, the ‘word’ is that VO will lose its contract; however, that will relegate the authorization process to the LME’s which have a very poor track record of being able to keep up with said paperwork.

The computer model is, as you mentioned on your video, for ‘fine-tuning.’

Contrarily, we are no where near fine-tuning this process but rather we, as providers, working w/ Medicaid clients, are simply trying to stay alive until a new governor gets elected----whom may, or may not, have any idea about what to do about the paperwork onslaught and the multiple Barriers to mental health care.

As a sociologist, I presume that you know about the Health Belief Model; my dissertation was associated with an investigation of Older Women’s Breast Cancer Screening Behaviors and my participants were those affiliated w/ the Women’s Health Trial at UAB.

Let me just say that the Barriers to mental health care----with Barriers being a core construct associated w/ the Health Belief Model---- in NC are MASSIVE and I have only mentioned the 2 most glaring ones from my perspective.

Marsha V. Hammond, PhD

Persistent mental health problems defined by Congress to be DISABILITY: What does this say about NC DHHS Rehabilitation Model and Medical Necessity?

"Lawmakers said that people with epilepsy, diabetes, cancer, multiple sclerosis and other ailments had been improperly denied protection because their conditions could be controlled by medications or other measures.....In deciding whether a person is disabled, the bill says, courts should not consider the effects of “mitigating measures” like prescription drugs, hearing aids and artificial limbs. "

*********************

So, NC Mental Health Reform and NC DHHS's direction re: NC mental health reform is associated with a stated 'rehabilitation model.' How does this over-riding federal law affect that matter? If someone is persistently mentally ill----as are many of the people who could/ would/ did/ do receive Community Support Services or other mental health associated services----as disabled people are they not entitled to rights associated w/ their disability that could, assumably, be DEPENDABLE services? Not services that are willy-nilly cut due to a dysfunctional Value Options or an LME w/ a Utilization Review Department that decided that there is no outpatient therapy?

Moreover, what does the passage of this expanded disability law say about the matter of 'Medical Necessity' ? 'Medical Necessity' continues to be one of the least understood & most universally utilized terms associated with health insurance benefits. And, from my perspective, it seems to be a term that is thrown around to the advantage, mostly, of the insurance companies who pretty much can say that something is medically necessary or not.

I think this new law could potentially have a HUGE effect on these matters.

At APA Boston, at a lecture, Tony Puente, PhD, a neuropsychologist based in Wilmington NC, who has does an enormous amount of free work for psychologists across the US in terms of driving up the rates that psychologists can command for services, stated the following: "Medical Necessity is whatever your contract (with the insurance provider) says it is."

Is it?
*****************

NYT: 9.18.2008

Congress Passes Bill With Protections for Disabled


By ROBERT PEAR
Published: September 17, 2008
WASHINGTON — Congress gave final approval on Wednesday to a major civil rights bill, expanding protections for people with disabilities and overturning several recent Supreme Court decisions.

The voice vote in the House, following Senate passage by unanimous consent last week, clears the bill for President Bush.

The White House said Mr. Bush would sign the bill, just as his father signed the original Americans With Disabilities Act in 1990......

The bill declares that the court went wrong by “eliminating protection for many individuals whom Congress intended to protect” under the 1990 law.....

In an effort to clarify the intent of Congress, the bill says, “The definition of disability in this act shall be construed in favor of broad coverage.”.....

“This is one of the most important pieces of civil rights legislation of our time,” said Representative Jim Langevin, Democrat of Rhode Island, who uses a wheelchair......"

**********************

This week's difficulties (so far) re: Value Options creation of mental health care BARRIERS to NC CITIZENS

NC DHHS Update # June 2, 2008

"Until a provider receives an authorization from ValueOptions, they are at risk for nopayment for any services delivered."

http://www.dhhs.state.nc.us/MHDDSAS/servicedefinitions/
servdefupdates/dmadmh6-1-08update44.pdf

If there is no authorization from VO----FOR WHATEVER REASON----the client cannot receive Medicaid related services. If they do, the provider company is completely at risk for losing thousands of $$ / client.

Given the terribly slow rate of processing paperwork associated w/ Medicaid authorizations at VO, 'continuity of care' is now no longer possible. Thus, what we have is some care.....no care.....some care.....no care.....

Progress as associated w/ mental health issues is benefited by a sustained attention to matters.

***********

Dr. Land has stated, in an Editorial piece (fair & balanced!) at the Raleigh News & Observer: (you may need to cut and paste this link:

http://www.newsobserver.com/opinion/letters/story/1216906.html):

"...After months of hard work to get on top of the overwhelmed system we inherited, ValueOptions is now on track to help the state save roughly $500 million a year. .."

Let's forget that this money has no meaning in terms of what it refers to, for a

moment. $500 million related to what?

How is it, Dr. Land, that you are going to save this money? Basically, you are going to save it as associated with the creation of barriers to continuation of care as pertaining to a two-level perusal process associated with the admission of ANY paperwork. First the lower level clerical people look it over for mistakes, sending it back again and again and THEN those above them look over the paperwork.

Just think of all the money being expended and being paid for by NC citizens associated with the creation of correct paperwork.

**************************
One of the VO NC employees made this post at the News & Observer article site:

"Posted by:
givingback
2008-09-15 12:03:42
Rated: 1 by 1 users.
Here we go again

Dr. Lane needs to get her facts correct. The staff at the NC office does work hard and try to do a good job. However, VO puts up barriers, does not give staff resources and does not comply with its contact with the state. All of this leads to a very poor working relationship with providers across the state. The complaints from the providers continue to increase each day.

*****************************

Item: tonight I sat on my cell phone for about 30 minutes, off the expressway, listening to the mother of a schizophrenic young man who has been placed in a mental health residential home in western NC. She called up the Endorsed Provider company, CNC Access, a large company providing Community Support Service (CSS) in western NC (I have no affiliation w/ them), and they advised her that they were stretched to the breaking point and there were no immediately available CSS workers for her son.

Today she asked the manager of the home if she would know what to look for in terms of psychosis if her son becamse psychotic----entirely possible given that he just spent almost half a year in Broughton associated with trying to get him to a stable place.

The manager stated she had never witnessed a psychotic episode.

VO stands to save NC money re: the non-availability of this large company's Community Support Services as basically the companies are staggering under the barriers that VO has been creating associated with the clerical combing over of the 20 page Person Centered Plans (remember: this has nothing to do w/ the work being delivered...it is a guide for the work that is to be rendered; the PCP is not reimbursed though it takes hours and hours to develop).

In the case of 3 other clients associated with CSS services which have been in place for months, AFTER the clerical people combed over the documents, rejecting them over and over----COME AUGUST 1----when the number of hours of CSS were reduced-----THEN THE PAPERWORK WAS ACCEPTED AS ASSOCIATED WITH THE DIMINISHMENT OF THE ALLOWABLE NUMBER OF CSS HOURS.

See: http://www.dhhs.state.nc.us/MHDDSAS/servicedefinitions/
servdefupdates/dmadmh9-2-08update48.pdf

Maintenance of Service for Adults Receiving Community Support Services
"Please note that Maintenance of Service authorizations for adults receiving Community Support Services are limited to 32
units per week as of August 1, 2008. "

*********************

Were barriers increased as per a demand from NC DHHS? We wil be finding out over the next few days as associated w/ querying Tara Larson who is purportedly the liason between VO and NC DHHS and by default, the LME's.

Barriers to NC mental health care participation: NC Psychiatric Association keeps Dr. Lancaster to themselves behind the $450 fee gate

Some people probably think that I like to write judgmental pieces like this. The premises associated with this kind of writing makes me sad, actually.

And I didn't go to the NCPsychiatric Association meeting in order to get a line on something so I could gig that organization, either.

However, I lived in Denmark for a while, the land of well disciplined people and children. There, you never heard a parent raise their voice to reign in the behaviors of children; their strategy is more effective than this: they shame them.

Relatedly, today, Mike Lancaster, MD, a psychiatrist and the co-chair of The Department of Mental Health within NC DHHS, gave a 1.5 hour talk on NC Mental Health Reform at the annual NC Psychiatric Association meeting in Asheville, NC. His was the last talk of their conference.

I don't know what he said; I was not willing to pay $450 in order to hear a public official talk to his colleagues.

Yesterday, in anticipation of this possibility, I drove up to the Renaissance Hotel in Asheville. I figured there had to be something going on as re: the state psychiatric association pertaining to NC mental health reform.

I introduced myself to the Executive Director, Robin Huffman, MD, a nice woman with a friendly smile. I should have asked her yesterday if there was a fee for sitting in on this talk. That way, I could have worn my wig and slid in.

In my student days, I scammed many an expensive conference by picking up lost name tags on the floor and slipping around corners. She was friendly again today as she advised me of the $450 fee to hear Dr. Lancaster talk. There are no one day passes, she stated.

Call me paranoid, but I had already been thrown off of the NC Psychiatric Association's listserv as associated w/ hammering on matters. Today, I had the feeling that she had talked to other members of the NCPA board and they might have said, do you know who Dr. Hammond is?

IN attempting to maybe get to some other price of admission, other than $450, I advised the clerks at the table, "I don't need any CEU's" to which one of them rather smugly replied, "We don't give CEU's...we give CME's." "Well, I don't need those either", I smiled.

In any case, I was expecting and hoping to be able to sit in on this apparently sacrocanct talk. I had my two questions in my head:

1. What happens if NC elects a Republican governor? (he's leading you know)

2. Is it possible to have some standardization of the Utilization Review departments in the LME's?

I have asked this latter question of the other NCPA, the NC Psychological Association, several times over the past year. I'm even a member, though I debate on the reason to join again. From them, I get the usual, "We'll get back to you." Never happens. No one ever gets back to me.

My devious head can pretty quickly get engaged by these kinds of barriers: I could charge it and then block it; I could write a check and cancel it; I could beg and plead but that's too painful.

Think of what a public service the NC Psychiatric Association----with its well-heeled psychiatrists could front to the interested public----think of what they could offer...what they could do if they advanced the notion that the public has a vested interest in these kinds of matters.

Nah: won't happen.

They created a massive barrier to the dessimination of information from a key player in the NC Mental Health Reform. And they did it 5 hours from Raleigh.

Just like I am not going to pay $450 for a 1.5 hour talk by a public official who is supposed to serve the public, neither am I going to drive 5 hours to Raleigh.

I can imagine that the NC Psychiatric Association needs to make its money on its conferences. I get that. This is not what I am writing about here. I am writing about the vastly neglected role of professional organizations working in a welcoming way as regards the public----whom it is they are (supposed) to serve.

All the talk about how we create licenses and medical boards has a different meaning (read: bullshit) if come the opportunity for the desimination of information----the door is shut and the professionals stay to their professional-selves.

And so, quid pro quo: I had advised Dr. Huffman yesterday about a professional red alert, the Health and Behavior CPT codes which mental health workers can utilize which pays on the 80% medical side of services instead of the grim 62.5 % psychiatric side of services. I told her I would write to her about it.

Will I? dunno. I had something to exchange with them, something of value, something that can make money for psychiatrists if they don't know about it---something that would allow them to do something other than churn out a bunch of medication-check codes. Dr. Huffman didn't know about it; how many of them don't know about it?

I wrote the 96152 Behavioral Health Code matter up for both the WNC Psychological Association newsletter and the NC Psychological Association newsletter. They didn't ask me to. It just amazed me that no one was using it or knew how to use it when the NC Psychological Association Board came to Asheville about 4 months ago. NAH: give up, other said: you can't get it through.

I have, I did, I will. (Vini Vidi Velcro as a sign in Asheville stated).

Maybe WNCPA/ NCPA will use the information I have turned up which American Psychological Association says is not supposed to be so. Or they might just spite their own selves as they have determined me to be a trouble-maker.

I am afraid that my verdict stands as re: the NC Psychiatric Association: they have had opportunities to work w/ advocates and the public and other professionals re: NC Mental Health Reform. Yesterday I stated to her that I do not believe that the NC Psychological Association does a very good job of advancing the interests of its membership.

She maintained that she and Sally Cameron, the Executive Director of NC Psychological Association, work hand in hand w/ representatives of other mental health professional organizations e.g., social workers, etc. She maintatined that Cameron is a very good representative for NC psychologists.

She stated that the mental health agenda that the mental health professional organizations utilize is to press for advances on behalf of patients---and this makes complete sense.

She bemoaned the powerful lobby associated w/ BCBSNC. I made the point that BCBSNC had been allowed to opt out of NC mental health parity. She indicated that BCBSNC had to give the green light to mental health reform before it evern got as far as it did.

I advised her of the payment for a 15 minute unit of 96152 CPT Health & Behavior code. She told me that on professional listservs professionals cannot discuss these fees as legally they can be considered to be colluding---by the health insurance agency. SSSSSSSSHHHHHHHHH : they'll slap our hands and won't take us to lunch.

Let's see: I'll discuss it right here: for 15 min of 96152 for a doctoral psychologist, I get approximately $25 x 6 units at the 80% reimbursement rate and thus also avoid the 90808, 70-90 minute therapy code which only pays me about $80.

Come and get me.

Why, given the perfect opportunity to seguae w/ other mental health professionals---the public even----many who are extremely concerned about mental health matters in NC, did NC Psychiatric Association not open the doors to the public as re: the public official, Dr. Lancaster?

Godalmighty: we don't want a riot in here. That's why the closed door.

No worry: Americans are too damned intimidated to throw tomatoes at their betters.

HOWEVER, the crazy people, those in NAMI, well they just need to stay in NAMI---over there---in their little NAMI meetings.

I found myself thinking about a George Carlin skit in which he describes how he believes it is an utter waste of time to vote given that the powers that be collude----and that he would rather stay at home and masturbate, with he stating something graphic like this: "I'll have something to show for what I did and you, the voter, what will you have to show?"

I'll wear my wig next time and I won't introduce myself.

Barriers to Mental Health Care: Value Options' slow responses put providers at financial risk

More Barriers to mental health care as associated w/ the VO and NC DHHS system which is constantly changing the paperwork and takes such a long time going over the blasted forms that they required you to submit that by the time they get done w/ their job one of the forms has changed and you have to return to GO.

Who can run a business when there are people and procedures over you like this?

A recent news article about Value Options (VO), who is the authorizing agent for Medicaid in NC (and who is feared and abhored in the rest of the country, apparently, according to some correspondence I have received re: Defarge VO oriented posts) has the following quote from a VO official:

"We're able to apply more rigor to the requests coming in," Woodell said, and the company is recommending more intensive mental health treatments or other social services more often." (here is the link: cut and paste it:

http://www.newsobserver.com/2771/story/1211917.html

Contractor fights for screening job -
Raleigh (NC) News & Observer
Lynn Bonner


No, Mr. Woodell, this is not correct, at least from my perspective.

Your 'more rigor' is this: clerks combing over the authorization request for services for several weeks, and should a form be changed in some way, the request is sent back, leaving the provider wondering what is the problem as none of the clerks advised the provider of yet ANOTHER problem w/ the PAPERWORK that gets picked up by the second tier of reviewers at VO.

Moreover, the LME's are also guilty of these kinds of maneuvers.

I have one state funded client under Western Highlands Network LME in western NC.

I sent in all the paperwork last fall that was required as per the WHN LME website and as associated w/ conversations w/ WHN management.

Over 30 days later, they indicate to me that I have to send it in back again as one of the forms had changed.

argh. easier to just see the client for free, hoping he will not ask too much.

Just by ridding the providers and the process of VO will not make the authorization process work any more smoothly. Indeed, my experience over the past several years has been that the LME's----unbelievably----are WORSE than VO in terms of the amount of time and phone calling that it takes in order to drive an authorization through.

How to get mental health services via Medicaid for someone who does not YET have Medicaid

This is a conversation associated with the example of 'Debbie', a woman with a serious mental health issue, who has been written about by Scott Sexton of the Winston Salem Journal. The link to that article: cut and paste it into your browser:

http://www2.journalnow.com/content/2008/sep/07/
debbies-case-confirms-that-mental-health-reform-fa/
opinion-columnists-ssexton/

Here is my explanation of HOW TO GET MEDICAID FOR SOMEONE. Most people do not understand the process and it is not that complicated and it certainly is not explained well by the various county DSS's in NC.

***************
The woman associated w/ Debbie's care, stated, in a letter to Scott Sexton:

"Where are the trained people who have the common sense to see the problem and not send them away to further destroy themselves."

There is very little transparency re: 'how to get to a provider' re: NC mental health reform.

When NC Mental health reform started cranking in 2002-2003, the notion of CHOICE was foremost in the mind's of the LME's as it was a core agenda item associated w/ NC mental health reform.

Choice meant that clients, whoever they were, were given information about a range of providers from which to choose, should they call the LME.

As the years have proceeded, this is what happened re: choice: there is no choice as there are so many providers now who are not willing to see state funded clients (I am assuming that Debbie is a state funded client).

Why is that?

the paperwork is overwhelming. The time spent to process a patient it prohibitive. I do not have hours to call the LME in order to set up some very very minimal amount of outpatient therapy, begging for it.

This is what I have done. LISTEN CAREFULLY.

Go the county's dss office; get an application for disability which will include an application for medicaid. fill it out w/ for the client. take it back to dss. once you have turned the paperwork in the clock starts. clients can generally be seen by qualified providers e g., psychologist, etc., if they understand how the medicaid system is laid out, immediately and it can be back-billed. sometimes sessions can be back billed beyond even when the paperwork is turned in.

LISTEN CAREFULLY: medicaid applications and ssi applications are turned in at the same time. MEDICAID CAN BE OBTAINED FAIRLY QUICKLY if the therapist or professional who has seen the client will DO THE PAPERWORK and send it to the medicaid adjudicator when the client is INITIALLY DENIED MEDICAID. This kicks in a process such that the adjudicator gets involved.

THE PAPERWORK IS NOTHING MORE THAN ACCURATE, DESCRIPTIVE THERAPY NOTES.

As re: my state funded client which I did this for, I went to the adjudicator's house in Asheville (they work out of their homes, I believe) and explained the situation to him in a 5 min talk; I forwarded my notes to SSA/ Asheville as well as to the adjudicator, my therapy notes, and fairly quickly the client began to receive paperwork from the local DSS so that she could receive medicaid.

IN ORDER FOR THE MEDICAID TO CRANK, THE DISABILITY APPLICATION ALSO HAS TO BE KEPT 'GOING' BY THE SENDING IN OF THE PROFESSIONAL'S PAPERWORK TO THE SSA OFFICE AS WELL AS TO THE ADJUDICATOR WHO FUNCTIONS INDEPENDENT OF THAT PROCESS.

YOU CAN FORGET THE STATE FUNDED CLIENT STUFF; THEY WILL NOT BE ABLE TO GET WHAT THEY NEED VIA THAT LME MANAGED SYSTEM.

REMEMBER: the Community Mental Health Center employees DID NOT go the homes of the clients

Most people seem to forget just how the Community Mental Health Centers used to function. Certainly there were concentrations of mental health providers and people in the community knew where they were but there were no mental health providers, save the ACT teams, which were already in place (psychiatrist goes out to the client's home) that went into the community.

The below is related to an article by Scott Sexton of the Winston Salem Journal, as associated with a client, 'Debbie', w/ schizoaffective disorder. He seems to want to prove w/ one case that mental health reform has failed.

Not so: it took a lot of active and passive work by lots of people to create these problems.

My over-riding question: WHERE WERE THE PROVIDERS WHO COULD HAVE GONE OUT TO HER HOME?

http://www2.journalnow.com/content/2008/sep/07/debbies-case-confirms-that-mental-health-reform-fa/

Debbie's case confirms that mental-health 'reform' failed

By Scott Sexton | Journal Columnist

Published: September 7, 2008

"....Community agencies and private providers were overwhelmed and got little or no support. Promised help from the federal government was slow to arrive -- big surprise there -- and services that had once been available were no longer readily accessible...."


September 8, 2008

Dear Mr. Sexton:

Thank you for your article on a person having schizoaffective disorder, one named 'Debbie.'

I have some comments. I want to make a point here re: how I, as a psychologist, would work with this Debbie: I would go to her house and see her as long as they was OK w/ her. You might say that sometimes I 'push myself' on my clients'; it is done in the spirit (truly) of concern for their well being.

I do not understand why others, like me, did not go out to Debbie's house to see her.

Can you get the answer to that question? I assume that they did not from your story. Community Support Services (CSS) has (had: constant defunding has about killed it) agenda is to go into the homes of the clients.

I admit to being turned off to your story as you took the cheap shot associated with 'strangling the government.'

My dear: the problem w/ NC mental health reform have compounded BECAUSE NC Dems, who run the state, act like Republicans in that they saw privatization as a preferable way of delivering what had been left up to the Community Mental Health Centers wherein people sat in their offices and if people did not show up for their appointments because they were too crazy, had no transportation, or the kid was sick----all the better.

Community Support Services, which has attached to that service, helpful people, WOULD HAVE before it got so severely cut, been able to go to her house and address some of these difficulties.

BETTER YET: pay the well trained mental health professional (we all know those CSS workers are nothing but highschool graduates) to go out to the homes of the Debbies.

This indeed, what the ACT team does: the psychiatrist and others go to the home of the person who has severe mental health challenges.

The AGENDA of NC Mental Health Reform was to take the services into the community. With each defunding and pulling back, this has been less and less possible except for the persistent cusses like myself who do exactly what they want in terms of managing their clients and seeing to their needs.

Additionally, what is not helping these problems to get resolved is that no providers are included in on any of the decision making.

So, what would I do?

I would pay the well qualified providers to see the clients, in their homes, as necessary.

The Terrible Need for Education about those with mental health issues: WHEN THE SAINTS COME MARCHING IN.....

I have a client in a rural western NC county. He had an aneurysm clipped in his head by very very soophisticated neurosurgeons in Charleston, SC. They mapped his language area prior to the surgery in an attempt to preserve it.

He nevertheless has profound speech problems now. He also has seizures which take place when he gets emotionally over-wrought. He had one today when he was telling me about his life. His wife gave him the prescribed medication; he rested in his chair while we talked outside.

He talks in a very very slow manner as associated with his surgery. His judgment, however, is good to excellent as is his insight related to the stories he slowly, slowly related.

Someone associated w/ the family had contacted me in order to do some testing as associated with this vague (DSS people are supposed to be educated) description of dad as 'medically/ psychiatrically impaired'---and I guess, therefore not fitting to be a parent to his 12 yr old daugther.

He simply cannot express himself very well and he needs more speech therapy by a speech pathologist who does not dismiss him as being 'tongue-tied', and therefore, assumably 'hopeless.'

Psychologically, he merits a DSM IV diagnosis, a mental health diagnosis, Cognitive Disorder NOS. This is the DSM diagnosis for head injuries/ brain infarcts. Just like your heart can have an infacrt (a heart attack) his brain had one.

First the police came over to investigate, upon a call from a close-by neighbor (they live in a trailer park: there is no privacy) associated with the client talking very loudly to someone in his family.

He talks very loudly and very very slowly and he gets louder the more emotionally overwrought he becomes. Thus, the police report.

Well, then the police called up the county DSS workers. They came over and called him 'belligerant.' He was simply talking in his emotionally over-wrought, loud, very very slow voice as the police were undoubtedly encouraging him to tone it down and as he realized they were wondering about his ability to parent his 12 yr old daughter.

His saintly wife and his daughter, who have been with him since his surgery two years ago, explained that he is prone to seizures and he talks very very slowly.

The county DSS worker described the daughter as 'cold', and the mother was also labelled with this odd term. The mother sees herself as extremely organized and attempting to control matters around her husband's health. Ditto the daughter.

I've never ever seen such an organized person.

However, in conjunction w/ the loud very very slow speech of the client and the labeling of the daughter's (aberrant; impaired; unusual for 12 yr old) reactions to her father's condition as 'cold' ----they simply removed her from the home.

Thankfully, they placed the 12 yr old in a 'kinship' home, the home of a good friend of hers who is recovering from being sexually abused by her perpetrator 18 yr old brother.

Oh, he's not in the home anymore; sometimes he just comes around.

The couple can visit their only child one hour/ week/ at the DSS office. In a piece of paper given to the wife by the DSS office, they indicated that there could be no whispering between the parents and the child during their brief visit/ once/ week.

Moreover, the daughter's optometrist and yearly physical has to be attended by the DSS social worker as the mother refuses to leave her husband. On the basis of no information, DSS suggested that dad be placed in an assisted living site such that the daughter did not have to give her father his anti-seizure pills (he has had, count them, 52 seizures since his surgery 2 years ago).

The DSS workers stated that the daughter has been (enslaved?) as associated w/ caring for her invalid father. My goodness! That's why she is so 'cold.'

I left their trailer hearing a song in my head about buying a rifle with a scope, an old song by Loudon Wainwright. Their story made me completely crazy. I had to quit my assessment and simply advise them to get out of town ASAP.

I drove my car to a local site where there is an open mine; you walk up the hill and its as if the Milky Way unfolds in front of you in terms of the starry night, the glittering rocks, the bats swooping down, and the stream cascading over the mica-laden rocks.

The woman is a saint and there are very few of them.

I'm glad I don't own a gun.

Cornell University does SSA one better re: WORK INCENTIVES for those w/ mental health challenges receiving SSI/ SSDI

Cornell University has created an excellent set of documents for people who want to work but are afraid to re: receiving SSI or SSDI and fearing they will simply 'lose it all' should they step out and try to work.

For a list of their publications associated w/ disability benefits (cut and paste this into your browser):

http://www.ilr.cornell.edu/edi/p-wisc-resources.cfm#pubs

To contact Cornell people re: questions associated w/ disability:

Contact Us
Thomas Golden
201 ILR Extension Building
Ithaca, New York 14853
Tel: 607-255-2731
Fax: 607-255-2763
Email: tpg3@cornell.edu


There was a presentation at American Psychological Association meeting in Boston, August, 2008, by Raymond Cebula, JD, from Cornell, as well as some of his colleagues who were psychologists.

The acronym page was worth a lot in of itself. See it here: (for the life of me I cannot this link thing down so cut and paste this into your browser):

http://www.ilr.cornell.edu/edi/publications/wisc/GlossaryofTerms.pdf

******************

When people who are disabled try to return to work, they move through what is called a Trial Work Period (TWP). This is only available to people who receive SSDI---NOT SSI (e mail conversation w/ Ida Campbell, SSA/ NC: ida.campbell@ssa.gov : work incentives coordinator NC). There are protections afforded people during this phase.

Trial Work Period (TWP)

"Unless medical recovery is an issue, individuals receiving Social Security based on disability are entitled to a nine-month TWP, which provides opportunities to test work skills while maintaining full benefit checks regardless of any income earned. The TWP is a work incentive and begins the first month that individuals are entitled to Title II benefits or file applications for disability benefits (whichever is later). Effective January 2006, only months during which an
individual earns over $620 or works over 80 hours in self-employment are
service months and count as TWP months."

*******************************
What I have found re: my clients who have been disabled and are attempting to return to work, is that they are frequently given only pieces or bits of information by SSA.

This matter of Extended Period of Eligibility (EPE) was NEVER given to a client of mine prior to vast manipulations of her SSI/ SSDI/ medicare/ Medicaid----putting, it seems----all of it at risk which of course meant not knowing how much money would be coming in from month to month which of course made her mental health more unstable.

EPE is ONLY available to people who receive SSDI (per Ida Campbell: see above)

"Extended Period of Eligibility (for persons still medically disabled)
36 consecutive months

• Begins the first month after the 9th TWP month
• Receives no cash benefits for months earning over SGA (2006 = $860/$1,450)
after the 3 month grace period
• If work stops or earnings drop below SGA, receive benefits and any earnings.

reference: Cornell
*******************

Now, if you go to the Social Security Administration Red Book, which has to do w/ the matter of people who are disabled returning to work, and you type in the 'search' box "Extended period of Eligibility", you get a confusing array of FAQ's, etc., that don't address the really very basic issue.

This is what you get at the SSA Red Book:

http://www.ssa.gov/redbook/eng/guide-employment-supports.htm

******************************
Moreover, recently a client of mine was happenstancedly informed that she could BUY HER MEDICARE to the tune of less than $100/ month even though her medicare was to end!!! Oh that she had been told that sooner (cut and paste into your browser):

http://www.ilr.cornell.edu/edi/publications/
ssa_curriculum/2006_BPAO/2006_PDF_EDITED/
SectionTwo/Chapter%2006.pdf

MEDICARE BUY-BACK OPTION

"It is possible for individuals with disabilities to buy into the Medicare program
once the extended Medicare coverage is exhausted.

(cut and paste into your browser)
"

Merely the patina of providing MH care: NC DHHS requires private companies training ONLY on HOW TO FILL OUT THE PAPERWORK CORRECTLY

I encountered a matter associated w/ a Community Support Services worker this evening when I saw a client of mine in Hendersonville, NC. She advised me that the CSS worker had talked about issues unique to her w/ another client whom we both know. They share a common group home; it would be easy to do.

The client was understandably perturbed that her privacy and confidential information had been violated and shared.

This matter might be termed to be associated with professional training, something you learned under supervision, in school, or somewhere along the way. It has to do w/ the limits of confidentiality, an ethical code, boundaries, what you share and what you do not.

Well, the CSS worker would not have learned it from any of the NC DHHS trainings.

It is sickening what is taking place here, what kind of shenanigans are being foisted upon NC citizens who think that surely there must be something useful that is taking place here, re: NC Mental Health Reform....all that training and how Dempsey Benton surely is pulling things together...how they're so much improved....

And as per the demand by NC DHHS, the Endorsed Provider companies are so busy mandating their employees to go to CPR training, CSS Service Definition trainings, Mobile Crisis Management, how to write the Person Centered Plan, Intensive In-Home Services, Diagnostic Assessment, Targeted Case Management, Crisis Planning and Management-----that there is no time to consider just WHAT is being done from a therapeutic standpoint.

NC DHHS attempts to throw a red herring onto their web page which outlines all that lovely training w/ this statement:

http://www.dhhs.state.nc.us/MHDDSAS/training/
medicaidenhancedbenefitservices.htm

"These trainers hold at least a Master's degree in a Human Services field, at least 3 years direct clinical experience with MH/DD/SA populations, and at least 3 years professional experience in the health and human services field as a trainer of adult learners. They also completed a Division-recognized "training-of-trainers" model in the service definition for which they were qualified."

Doesn't matter. They're not talking about clinical issues; they are only talking about how the paperwork is to be presented, what buzz words to use, how many hours of this can be done, where this fits in.....

The training---ALL OF IT----is only about HOW THE PAPERWORK LOOKS.

NC Mental Health Reform has utterly, utterly failed under Hooker Odom and this continues under Dempsey Benton, a non mental health person.

The mandatory 20 + hours/ year of CSS training is ONLY associated with filling out the paperwork correctly.

No one except those who are forced to sit through the mandatory NC DHHS 'trainings' understands that the training has nothing to do w/ the level of care.

NOTHING.

MOREOVER, the training has not been revised in 2 years as associated w/ Community Support Services, though there have been massive changes to what is allowable.

NC Governor's race : dumbstruck candidates, Perdue and McCrory w/ Mental Health Association, who makes money off of ACT teams, squawking in background

It would be nice if mental health advocates, mental health providers, and mental health consumers could work together in order to create a blueprint for services rather than one constituency playing behind the scenes----either by sitting on their hands or by grabbing the microphone----in order to provide an orderly continuum of services depending on the needs of the client. It would have been nice if MHA had vigorously defended the appropriateness of Community Support Services which to my mind, keeps clients from accelerating into the ACT, more intensive, home-based services. Now that ACT is being cut, MHA is all over the matter. And below is documented from February 2007 when they jumped on the bandwagon to diminish the funding for CSS which went un-monitored by NC DHHS.

********************************

Neither of the major party candidates has anything useful to say about NC Mental Health Reform. Its not as if there is not an enormous amount of information out there. I personally contacted McCrory's campaign to ask for an audience. Never granted. No contact; no interest.

I've been documenting mental health reform difficulties for over a year now, since Hooker Odom decided to use her 'bad apples' argument, which Easley quickly picked up, and the news services ran with as re: Community Support Services 'taking their clients swimming and to the movies.'

Perdue keeps squawking about how NC Mental Health REform was 'too much, too quickly' which cannot be proven; there is nothing to compare what took place to.

What this provider does know is that Easley keeping Carmen Hooker Odom in place for 7years sank the ship as evidenced by her memos to mental health providers, disorganized, each one contradicting the one before----with she moonlighting at her new gig in NYC.

There is no indication that Perdue is attempting to distance herself from Easley's decisions. And so this far left Dem is going to vote for the Republican in order to make a point.

And the Mental Health Association, MHA, headed up by John Tote, who seems to have some profit making ability as associated w/ management of ACT teams across NC (I did not know this until Lynn Bonner's article in the Raleigh News & Observer yesterdaY:

http://www.newsobserver.com/news/story/1199997.html

"John Tote, executive director of the Mental Health Association in North Carolina, called the ACT team cut "completely ludicrous." Tote said his organization has the most ACT teams in the state, serving more than 1,000 clients."; this means that Tote is paid as associated w/ ACT teams, or I'll eat my hat).

Moreover, it appears that MHA has been losing money re: CSS (BTW, the clubhouse model is a good and useful model): from a February 2007 news article from the Raleigh News & Observer:

http://mentalhopenews.blogspot.com/2007/02/community-mental-health-firms-face.html

".....But John Tote, executive director of the Mental Health Association in North Carolina, a private nonprofit organization that provides mental health services, said companies that offer community support are keeping patients and the government payments for themselves, rather than referring them to others that can offer more appropriate treatment.

"It's a monetary issue," he said.

Tote's group operates "clubhouses" where people with mental illnesses get job training, take classes and get help learning to live outside hospitals.

Some of the companies offering community support don't know much about clubhouses and don't recommend them for clients, he said.

Attendance at a clubhouse in Wilmington dropped in the past year, which Tote attributes to people not moving among the options beyond step one...."




From WRAL: http://www.wral.com/news/local/story/3451179/

Patient advocates: N.C.'s mental health system needs fixing


Posted: Aug 31, 2008

"...That would not be true if the gubernatorial candidates are already investigating and discussing the problems the mental health system faces. Advocates say they have not heard any specific plans from either candidate so far, however...."