Monday, October 06, 2008

Federal mental health parity: again, the problem is w/ the UTILIZATION REVIEW departments

Bailout Provides More Mental Health Coverage

Published: October 5, 2008
WASHINGTON — More than one-third of all Americans will soon receive better insurance coverage for mental health treatments because of a new law that, for the first time, requires equal coverage of mental and physical illnesses.


Fewer and fewer people have insurance thru their companies.

"The percentage of people (workers and dependents) with employment-based health insurance has dropped from 70 percent in 1987 to 59 percent in 2006. This is the lowest level of employment-based insurance coverage in more than a decade."

National Coalition on Health Care:


Here's the rub re: federal mental health parity and its the same problem re: mental health parity in NC, which just a couple of months ago passed mental health parity.

NC State Legislature is run by Democrats. Bear this in mind as you consider the matter of 'free enterprise run amuck' and its apparent appeal beyond the confines of the Republican party.

The state legislature has liasons between BCBSNC, a non-profit, overseen by a standing committee of the state legislature. However, those liasons are employees of BCBSNC and my fierce conversations w/ them indicate that basically BCBSNC does what it wants to do. Moreover, BCBSNC was allowed to opt out of NC mental health parity or mental health parity was not going to go forward. Period.

The model which was held as sacrosanct, namely Reaganesque 'let competition create better services' is what undergirded NC mental health reform.

My goodness, that sounds familiar.

These are the following populations served re: mental health services:

**state funded clients (overseen by the LME's; the working poor, w/ no health insurance; providers have to complete reams of paperwork and several forms )

**medicaid (authorizations are obtained via Value Options who is under thumb of NC DHHS; Medicaid recipients receive SSI and as associated w/ that more restrictions re: working vis a vis Ticket to Work work incentives program should they want to work)

**Medicare/ medicaid dually eligible (unlimited authorizations, basically; recipients receive SSDI; many have to pass thru 'doughnut hole' re: medications which is problematic; if they want to work, they must utilize the PASS program which is very very confusing)

**Medicare-like Advantage plans: (Humana is the only one I have attempted to work with and this is the only insurance company I will not do business with; only outpatient therapy available is 90806; pays doctoral psychologist about $50/ 90806 session; no 90808; no H & B codes, 96152; requires session notes for frequent billing; creates endless hurdles; appear to have their provider services people in India who excel at another level of creating paperwork barriers)

**Private insurance plans


The purposes of NC mental health reform had to do with:

1. allowing 'choice' for the consumers (this went away a long time ago as private Endorsed Provider companies failed or moved out of areas re: barriers created by LME's and by default, NC DHHS; Carl Rogers notion of 'person centered' was stood on its head as NC DHHS utilized 'Person Centered Plans' which are outlines of services which are usually 20 pages in length and require numerous 'wet' signatures, all of which is sent to the LME's for them to sit on it for a few weeks----or a few months; no services prior to authorization. You guessed it: go to the emergency room and get admitted to psychiatric hospital because there is no way to get to outpatient services otherwise; ka-ching: spend the tax-payers $$ related to the closing of Broughton Hospital and Cherry Hospital to Medicaid/ Medicare $$ due to the mismanagement of these hospitals by NC DHHS)

2. the tired old beliefs about competition which assumes that competition will create more services and better services. This notion was assumed to be applicable to NC mental health reform. Whoops: we forgot: no one can make money on clients who need such intensive supports.

3. taking mental health into the community vis a vis workers, Community Support Services workers, who would work fairly intensely w/ Medicaid consumers (only these get these services; state funded consumers get so little that they get none at all and this does not apply to Medicare or dually eligible clients or private insurance clients). Ah, you say that the difficulties with the Work Incentive Programs (e.g.,: PASSS for SSDI clients and Ticket to Work for SSI clients) makes it difficult to actually put into practice CSS: you'd be right. Additionally, another problems w/ use of CSS for impoverished Medicaid consumers is that there are so many basic matter lacking in their lives e.g., no transportation; lack of money for food, etc., that CSS $$ are spent trying to deal with THAT rather than the returning to work. There is some benefit to Medicaid recipients being able to work and sheltered workshops can hire them, via Voc REhabilitation Services, but the slots are few. It is not true that it is easy to lose your Medicaid if one works; it is not. However, this notion has been fostered for decades by Vocational Rehabilitation Services and so the belief is embedded within this population and even some of the people who work w/ this population.

4. saving money was in there somewhere but that got lost a long long time ago as more money was spent and the culprit was deemed to be Community Support Services (those intensive services for the Medicaid clients) and the private Endorsed Provider companies were highlighted as greedy entrepreneurs and while there was some truth to this, mostly it was not true but the statements were turned to the advantage of NC DHHS, in particular. NC DHHS, under Carmen Hooker Odom, Secretary of NC DHHS, who was moonlighting at another gig in NYC when she was supposed to be working here for 7 years, did not have a fiscal plan down and became basically horrified when she realized that Endorsed Provider companies were taking NC DHHS up on their invitation to extend Community Support Services to citizens. She's gone; we're left w/ her mess; new governor coming forward and may be REpublican basically as associated w/ the mess the NC Dems have created re: NC mental health reform.


Here is the problem w/ federally mandated mental health parity:

Utilization Review departments can declare that what is available is a very basic level of services and create barriers associated with further services. Thus, it does not matter that the co-pays are less as associated w/ mental health parity.

For instance, in western NC, as associated with Western Highlands Network LME (the old community mental health centers morphed into administrators), there are 8 outpatient therapy sessions for people w/ 'legitimate' mental health diagnoses e.g., depression, PTSD, etc.---the restriction does not sit there.

WHN LME has declared, as per Marsha Ring, the manager of its UR Department, that if the diagnoses include a personality disorder, more therapy sessions can be obtained if group therapy associated w/ DBT is made available. While this is a useful idea, the privatization of mental health care in NC has dismantled the mental health centers and creating group therapy is not possible, particularly as associated with a rural, rather poor population. They can't even get to their appointments.

Oh, I see: you think that CSS $$ should be used to provide transportation. We're back to the matter of lives so basically impoverished that food and transportation are not easily available. Whoops: more defunding of CSS by NC DHHS.


Another model of Utilization Review, with which I am familiar, is associated w/ the other LME in western NC, Smoky Mountain Center LME, the largest LME in NC. Together the 2 LME's oversee 25% of NC 100 counties.

There is NO outpatient therapy available under SMC LME. Outpatient therapy sits under Community Support Services which has been constantly defunded. Besides this, the agenda of this LME appears to be associated with creating tiers of paperwork barriers vis a vis the Utilization Review Department run by Charles Barry who threatened the Endorsed Provider company with which I am required to work re: state funded clients that I could not utilize CSS hours to get to therapy because I had refused to sit through unnecessary 20 + hours of required (by NC DHHS and thus the LME) training; I could dare them or the company would 'be audited. '

More barriers associated w/ SMC LME were associated with the Clinical supervisor, Stephen Puckett, PhD, who decided he has nothing better to do other than to go over the PCP's with a fine-tooth comb and then send them back, over and over, for revisions.

I gave up working w/ SMC LME. I managed to obtain Medicaid for my state fund client by sending all my therapy notes to the Social Security Administration adjudicator. It took 3 months to get Medicaid for her; I had been fighting w/ SMC LME over payment for services rendererd to this client, so seriously mentally ill that she had been referred to me by the intensive ACTT team, for 2 plus years.


These are the two models with which I am most familiar as re: Utilization Review and they do not function. The scary part is that the NC State legislature and via them, the NC DHHS, has has an incipient vision to have the LME's manage Medicaid. Given that Medicaid pays the best for psychologists and given that the authorizations are fairly forthcoming from Value Options, I can envision a system that implodes into a black hole rather than the merely current exploding death star.


Post a Comment

<< Home