Wednesday, December 31, 2008

DUH: What's NC taxes got to do with NC mental health reform?

Wonderful piece from NC Policy Watch on the relationship of taxes to the needs of NC citizens: learn from the Obama administration model:

Charting a smoother, steadier course
Tuesday, December 30th, 2008
By Rob Schofield

(cut and paste):


".....For years, experts, academics and multiple study committees have concluded that North Carolina's 1930's-era tax system needs modernization. The shortcomings are obvious and include:
The sales tax is still designed as if the state's economy was exclusively goods-based rather service-based.

Business taxes are rife with loopholes and special breaks that let many large and profitable corporations escape income taxation altogether.

The personal income tax hits lower income working families at almost the same rate as the super rich.

All of these flaws contribute to the system's nagging inadequacy and current, painfully obvious volatility. Even before the current shortfall that's afflicting the state, revenues were not keeping up with inflation and population growth - much less the dire need for improved public services in everything from education to mental health to criminal justice. Now, of course, the situation is at a crisis point with lawmakers confronting a shortfall of as much as $3 billion if they hope to keep services merely at present levels in 2009-'10.

A new and smoother road

Happily, the solution to all of this does not involve rocket science. It lies in the adoption of a more modern, broadly applicable tax system. To put it simply, North Carolina must cast its revenue net in a wider and fairer pattern. Instead of just taxing the same things and constantly raising rates merely to stay even (as we've been doing when it comes to things like the general sales tax rate and tobacco and alcohol taxes) North Carolina must tax more transactions that currently escape taxation altogether. Cast the net widely enough and the state will actually be able to lower the sales tax rate while bringing in a comparable (and more predictable) pot of money.

The same is true when it comes to corporate income taxes. If we do away with the morass of tax breaks and exclusions and costly and unproven corporate "incentives," North Carolina can actually lower the overall corporate profits tax rate while collecting more revenue in a fairer and more predictable way.

A similar approach will work with the personal income tax where the state's essentially flat rate structure (along with federal deductions and other breaks) currently allow the wealthy to pay a much lower share of their incomes in total state and local taxes than is paid by the middle class and the poor. To cast the net in a wider, fairer and more predictably reliable fashion, the state ought to adopt a larger number of income tax brackets. As with the sales and corporate income taxes, this would permit the actual lowering of rates on people in the middle and the bottom while creating an overall pot that stays much more in sync with the general economy.

Mustering the political courage

As noted, the real challenge in effecting such a transformation of the state revenue system is not a matter of "how." State leaders have known for years of the merits of modernization and reform and have pussyfooted around the issue on multiple occasions. The problem of course is in the politics. How does one muster the political "umph" to take on and overcome the daunting roadblock posed by numerous special interest lobbies - the lawyers, the architects, the entertainment industry - in tandem with the market fundamentalist, anti-government crowd who hope to use the current crisis to completely disable and de-fund our system of public structures?

The answer, it seems, must come from an emulation of the approach taken by the incoming national administration in three obvious areas:

Win over the business community. Sure, corporate executives hate change and hate taxes, but most of them hate instability and a crumbling public infrastructure even more. If North Carolina's new leaders really work together in a concerted and thoughtful way, it is likely that they can win over enough of the business establishment to make a political difference.

Kill them with facts. As in most areas of life, there's no substitute for being the smartest, best prepared person in the room. Like the new team in Washington, North Carolina's new administration can win a lot of policy battles and new adherents by soberly and methodically marshalling and disseminating the facts and analyses that support the case for real reform.

Level with the public. For too long, North Carolina leaders of both parties have made pandering to voters' worst instincts (especially on things like taxes) their default political strategy. While many will continue to adhere to this practice, it seems worth a try for the Perdue administration to try something new. It may be a hard sell, but with the Obama administration poised to make real headway via such a "high road" approach that features an open call for people to pull together in short-term sacrifice, it would be tremendous waste not to follow suit in North Carolina...."

Monday, December 29, 2008

Death by a diff set of Forms: Western Highlands Network LME new Mental Health Basic Level Services : improvement or same paperwork nightmare?

This was posted by Western Highlands Network LME on 12.23.2008. Thankfully, this LME is listening to providers' complaints about paperwork nightmares.

So, what's not to like?


1. This benefit is for all new MH Child and Adult consumers entering the Western Highlands Network system. This initial basic benefit includes:

• minimal paperwork to activate the consumer

• an authorization for 1 year to include:

o 1 event of assessment (90801 or H0031 or T1023)
o 1 event of medical evaluation (90801)
o 8 sessions or 32 units total unmanaged outpatient therapy package. This is the same number of sessions as last year. And the year before. And this is for state funded clients. And I would like to know is this: when the LME's start to authorize the Medicaid clients, are the providers going to have to create all of this paperwork for Medicaid also?

Please note that no activity in 60 days could result in WHN administrative case closure. Re-activation paperwork would be required to re-activate the case. So, what happens when the 8 sessions run out for the year? I guess you get to re-create the paperwork the next year.

2. There is a minimal expectation of paperwork with these consumers for the LME purposes.

Consumers must be registered or screened, and case responsibility assigned. (By the LME?)

Review of PCPs, however, would be retrospective and not required prior to the delivery of these services. What does this mean? That the PCP has to be done sometime during the year----the long version or short version or some other version? would have been useful to have a link to the PCP form expected and statement as to what this 'retrospective' thing is.

• The ONLY paperwork expected for this period is for case activation which cannot turn up via the 'search' box but via the 'provider' tab; then 'access and registration'; then click on the 'all WHN forms' link:

STR, LCAD, IPRS, DCCI and Assignment of Case Responsibility

#1. STR

#2. LCAD It must be this but you sure cannot tell from the acronym, LCAD:
LME Consumer Admission and Discharge Form (12/08/08) (PDF) (Word) : this appears to have been created by NC DHHS and so wnhy can't all the LME's just use this form w/ all the basic information instead of creating all these other sub-forms with repetitious information?
48 (so far) items associated w/ demographic data, etc.

#3. IPRS

#4. DCCI I guess its this one: Description of Consumer Clinical Issues form 092107 ;

#5. Assignment of Case Responsibility


turn this all in within 5 days of the assessment. Do they mean within 5 days of the Diagnostic Assessment? or what? .

FAX TO 828-225-2779 Another new fax number!

• The initial basic benefit does not apply if additional services (other than the
assessment, medical evaluation or outpatient therapy) are requested.

3. Additional services are requested through Concurrent Review (Utilization Management) for
re-authorization. The Basic Benefit services for Adult/Child MH can be reauthorized at any
time, as shown in the table below. Where is the concurrent review information? It does not come up via the 'search' tab at the WHN LME URL. You only get referred back to the original memorandum.


So, in summary:

* we still only have 8 sessions
*there are still 5 repetitive information forms
* who do you contact to ask questions?
*why can't there be links in the memorandum about all these matters, which take you to the forms on the WHN LME webpage?
*what is the turn-around time for the LME when the provider turns in all this information?
*what is the turn-around as associated w/ this 'concurrent review'?
*if one wanted to have more than 8 sessions, who do we contact?
*will they answer their e mail?
*where is the information for this 'concurrent review'?
*who do we contact?
*will they answer their e mail?
*is the PCP expected? which form? short or long or something else?
*why can't they combine all of these forms?
*why isn't the form that appears to have been created by NC DHHS, the LME Consumer Admission and Discharge Form (12/08/08) (PDF) (Word), good enough?
*what is the purpose of the 'Description of the Consumer's Clinical Issues (September, 2007----is that even a CURRENT form) if there is also a PCP to be done on some sort of retrospective schedule of whose making?

man, alive.

BRING ON 1199: Unionization of the public mental health hospitals in NC would strike fear in the hearts of NC DHHS administrators

Nothing strkes fear like the word UNION as per hospital and government administrators.

The union 1199----which attempted to uonionize Atlanta hospitals in the 1980's-----did more to change working conditions, increase salaries, and accelerate patient care----than any other litany of excuse-making could ever do.

They should start w/ Cherry Hospital: ITS RIPE FOR THE PICKING.


Physician assistants vote overwhelmingly to join 1199SEIU
“Unity, stability, a voice on the job, and a guaranteed yearly raise--that’s what 1199 means to me.” -Gennadiy Shamalov, Physician Assistant


Hospital Workers

» Crouse Hospital Campaign
» Boston Medical Center RNs and LPNs Reach Memo of Agreement

Number of Members:

1199SEIU represents nearly 100,000 hospital workers at over one hundred academic medical centers, hospitals and satellite facilities in New York City and its Long Island and northern suburbs, and throughout New York State, Massachusetts, Maryland and in Washington D.C.

As the public coffers dry up, states (and D.C.) privatize mental health care (which won't work)

Plus ça Change, Plus C'est la Même Chose
(the more things are different, the more they are the same)

This article, by Mr. Fears at the Washgington Post indicates that D.C. is jumping onto the bandwagon already lacking one of its wheels and one that will stumble along until some politician worth more than Steven Sabock's life is willing to explain that privatization of mental health care only puts off the inevitable----namely, the efficient funding of mental health care.

There is no indication that anyone in government 'gets it' : "The Department of Mental Health "is committed to meeting the mental health needs of the uninsured, and will expand coverage as we increase capacity among the private providers..."

Someone should drop them a note re: the unwillingness of private providers to put up w/ the explosion of paperwork and the limited sessions made available linked to voluminous paperwork.

NAH: they won't get it.

Privatization, like anti-depressants, is not some magic fix. People who are angry, depressed, or psychotic do not change their behaviors as the magic wand of medication meshes w/ their metabolism. The medication may give them a leg up but it is no substitute for working w/ someone e.g., a therapist, to change the behavior which was linked to the depression, irritation, etc.

Indeed, privatization of mental health care is no different than all the private CEO's of all those companies getting all those millions of $$$$$$$ in salaries and stock options (!) and bonuses for cranking on a temporary basis----without a look at the future-----stock share prices-----only to have the company collapse and look for a bailout.

As per the below article from WaPo (Washington Post):

"....Private providers are more efficient than the city agency, according to the audit, delivering more care at less cost. The yearly Community Services Agency budget is $33 million, and its revenue is $10.5 million, guaranteeing losses year after year...."

DUH: I dunno: if the private providers cannot get paid and are always running in a deficit, how long do you think they can keep doing their jobs?

Americans seem to get it but the politicians----will they ever? dunno. Not as long as there are closeted Republicans whom, like a jack-in-the-box, jump up everytime someone talks about creating some public money, which should be well and efficiently spent.


See: (cut and paste:

Perdue doesn't want to be hindered by budget
The Associated Press

"....Republicans, again in the minority in both chambers of the Legislature, also sound unified that solving the state's budget woes will require cuts in spending.

"Our usual agenda is to try to hold spending down, but we may not have to struggle too hard on that," said House Minority Leader Paul Stam, R-Wake. "This is not the year to raise tax rates, and I know that was the way to solve the budget crisis in 2001."

Such steadfastness against boosting taxes worries social justice advocates who argue against across-the-board spending cuts by noting inflation adjusted per-capita state spending has actually declined since 1999. Instead, they seek a reformation of the state's tax structure to raise revenue from a broader swath of businesses and service providers....."


How long can the professional providers not get engaged in the matter of not being able to see the 'working poor' (in NC the state funded mental health clients)?

Having private Community Support Services (CSS) companies in NC, as per NC mental health reform, compete for the limited funds, which are ever-diminishing, is not an efficient way to utilize the limited mental health dollars.

'Competition' was supposed to be sitting in the driver's seat re: NC mental health privatization.

I know! I know! You might as well 'give all your $$$$$ to Bernie (Maddoff: as in 'he made off w/ our money).

Jewish financial holocaust. Mental health care debauchery.


cut and paste:

District Seeks To Privatize Services for Mentally Ill

By Darryl Fears
Washington Post Staff Writer
Thursday, December 25, 2008; Page B01

"D.C. officials are planning to privatize the city's mental health agency, a cost-cutting move that union leaders say would put about 200 health-care professionals out of work and force thousands of emotionally troubled residents to seek private care.

An audit of the D.C. Community Services Agency this year found that the city could save as much as $14 million by contracting the bulk of its services to private agencies.....

....Union leaders who represent some employees said the transition is risky. They said city counselors provide care to the most difficult cases, people with deep psychiatric troubles. (all the White-Housers! those people who jumpt the WH fence in order to get to the president; funny how this is happening now that Bush is scramming)

.......Those patients have developed a trust with their counselors and are less likely to make the transition to a private care provider, they said.

In addition, union leaders said, about 200 workers would lose their jobs in the midst of a recession. They probably would seek work in the private sector, where pay is lower and job turnover is higher, the leaders said.

"What they're more concerned about are these vulnerable patients," said Vanessa Dixon, a labor representative for the Doctors Council of the District of Columbia. Unlike private agencies, Dixon said, the city treats patients regardless of whether the program is overbooked. .....

Shannon Hall, executive director of the D.C. Behavioral Health Association, said the shift should have happened years ago.

COMMENT: (and unlike NC, where the psychologists had practically nothing to say and nothing to do w/ NC mental health reform, and the psychiatrists sat tight in their academic posts whilst rendering salivatingly bland judgment on the malfeasant system----oh, scratch that-----as in NC while the providers had no comment based on any kind of reality as they had been able to flee providing care of these clients, for the most part, in D.C. we have some psychologist or psychiatrist (never the social workers: did you ever notice that) promoting privatization.

"....The Department of Mental Health "is committed to meeting the mental health needs of the uninsured, and will expand coverage as we increase capacity among the private providers," the statement said.

But the city has made similar promises before, only to see its plans go wrong. In 2001, when inpatient services were ended at D.C. General Hospital, city officials said Greater Southeast Hospital would take up the burden after an upgrade to its trauma center.

Within months, the city quietly abandoned the trauma plan. The corporation that supported Greater Southeast filed for protection from its creditors after its chief lender collapsed because of a financial scandal....."


They have no idea what they are wishing upon themselves and the mentall ill community.

Sunday, December 28, 2008

Money doesn't talk, it swears: why GA is privatizing its mental health public hospitals

"....State officials are negotiating an agreement that would forestall a lawsuit charging Georgia with violating patients civil rights.Similar investigations in other states have led to massive spending to upgrade or replace hospitals.....

The winning bidder would take over forensics units at Central State Hospital in Milledgeville within another 60 days and would be required to open a new building in about a year.The state hospital in Savannah would close by July 2009, followed in 2011 by the Columbus facility and in 2012 by hospitals in Rome, Thomasville and Augusta, as well as all units except forensics at Milledgeville.The replacement for the Atlanta hospital for patients from North Georgia would open by early 2012...."


GA is evidently privatizing its psychiatric hospitals in order to avoid dealing w/ this matter. It would be very interesting to understand this matter more in-depth.

What do you bet but that the fast-track schedule is related to the law-suit(s) associated w/ violating patient's rights?

(cut and paste):

Next, instead of consulting firms running one of the four public psychiatric hospitals, like Cherry Hospital, serving 36 NC counties (over one-third of the 100 NC counties), we'll be hearing about the privatization of the psychiatric hospitals-----what with the likes of these kinds of testimonies:

(cut and paste):

Cherry Hospital's troubles await Perdue
Abuse of patients plagues hospital
by Michael Biesecker

".....Federal regulators cut off Medicaid money to the hospital in September after declaring it unsafe for patients. Jack St. Clair, Cherry's director for the past three years, resigned earlier this month, and the hospital is being run largely by a consulting firm. Cherry drew national media attention this fall after the forced release of security camera footage documenting the last day in the life of Steven H. Sabock, a patient, in April.

In the past year, at least 10 Cherry employees have been charged with assaulting or sexually abusing patients. In November, two health-care technicians were convicted of beating a patient who mouthed off. At their trial, a state prosecutor characterized Cherry as a violent place where staff members have long believed they would not be held accountable for abusing or neglecting patients.....

after Sabock choked on medication, hit his head and was left sitting in a chair for 22 hours without food, water or medical attention, Cherry administrators sent out an urgent internal memo.

"We are a REAL HOSPITAL," it reminded the workers, pleading with them to perform routine medical tasks required of them......

Ultimately, St. Clair, who supervised the supervisors, could not change the culture.

"I think he was in over his head," said William O. Mann III, a former Cherry psychiatrist. "He was really put into a situation he had no familiarity with. Nor would any hospital administrator. They needed expert advice right off the bat on how to prosecute the abusers and get rid of them."

Mann, whose experience included stints at two state mental hospitals in Pennsylvania, said he saw more cases of patient abuse in the 14 months he worked at Cherry than in the rest of his career. He resigned in disgust in late 2006, after he said he reported a dozen cases of staff members abusing patients but saw little come of his efforts......

Brenda Johnson, a nurse who retired after working at Dorothea Dix Hospital and in the state prison system, took a temporary job at Cherry four years ago. She said the violence got worse during St. Clair's tenure. But she stressed that the assaults went both ways -- with staff working in fear of patients who are increasingly desperate and harder to handle.

On Dec. 9, a male patient attacked Johnson, punching her and choking her for nearly half a minute before other employees could pull him off.

"When I walked on the ward that night, I felt like it was like a volcano waiting to erupt," said Johnson, 65. "The man tried to kill me. I honestly felt safer working with death row inmates than I did working at Cherry Hospital."

......Since Sabock's death, administrators have hurried to squelch rumors circulating around Goldsboro that Cherry would be shut down. The hospital is a major job-generator in Wayne County, having employed generations of local families.

Low pay for employees in state mental hospitals has long been an impediment to attracting top-quality staff. Dempsey Benton, the secretary of health and human services, asked the state personnel office last summer to consider raising salaries for health-care technicians and other low-ranking positions where high turnover is common.

Becoming a health-care tech requires no special certification beyond a high school diploma or GED. Starting pay is $11.42 an hour and doesn't get much better with years of experience. About a third of those hired quit within the first year......

Harold Carmel, a consulting professor of psychiatry at Duke University and a critic of the state's mental health reforms, said the state should consider having East Carolina University manage the hospital and its clinical operations.

"I think it's an obvious solution that has been overlooked," he said......

Close connections are good for both universities and hospitals, Saeed said. The university benefits from expanded teaching opportunities, and state hospital patients get cutting-edge treatment and high-quality care. Any proposal to have ECU run Cherry would require close study and approval from the chancellor, Saeed said...."

Saturday, December 27, 2008

New River's continuous cash flow unable to meet mental health needs: Is outpatient psychotherapy even a viable entity under NC Mental Health Reform?

I'm missing something here: how is it that a 'continuous cash flow' is supposed to save money or make services more efficient? Indeed, New River Behavioral Health, chosen in order to see if utilizing a 'continuous cash flow' would be beneficial, appears to be crashing:


"......"It's almost impossible to break even on the cost of the basic outpatient services," said Pam Andrews, the chief executive of New River. The agency operates in Alexander, Alleghany, Ashe, Avery, Iredell, McDowell, Surry, Yadkin, Watauga and Wilkes counties......New River's financing model was meant to ensure a continuous cash flow to provide all the mental-health services in the mountain counties...."

New River mental-health service reports a big loss
New financing model runs into problem as client base grows, strains budget

By Sherry Youngquist


Published: December 27, 2008

BOONE - More than a year ago, New River Behavioral Healthcare began experimenting with a financing model that some hoped might solve part of the puzzle surrounding North Carolina's mental-health-care crisis.

But now New River, one of two public providers of mental-health care in the state, is reporting an operating loss of more than $1.5 million.

State officials say that it's still too soon to say whether the model will work. Three to five years are probably needed to see how successful New River can be, said Dick Oliver, a spokesman for the N.C. Department of Health and Human Services.

"They will have to watch their costs," he said.

New River's financing model was meant to ensure a continuous cash flow to provide all the mental-health services in the mountain counties. The agency, which is based in Boone, provides a comprehensive list of services, including substance-abuse treatment, family therapy and day treatment programs for the chronically mentally ill.

The idea behind the financing model was to spread the money around. Where one service, such as psychiatric care, lost money, others wouldn't.

But reimbursements did not equal the true cost of care, no matter how hard New River tried, officials say.

The loss was covered by New River's fund-balance reserves....."

Pretty much the level of dysfunction currently associated w/ this LME can be summarized as associated w/ their web page. You can get information on what numbers to call should you have a psychiatric emergency, but there is no information on available providers or what services are available.

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Is outpatient psychotherapy even a viable entity under NC Mental Health Reform?

Thursday, December 25, 2008

Local psychiatric beds 'work' in terms of diminishing mental health emergency admissions: WHAT WE'VE FORGOTTEN

Nick Stratus, MD, a psychiatrist in eastern NC, was formerly the director of mental health services in NC...back in the 1960's/ 1970's. He is weighing in re: the use of local hospital beds which have been set up as associated w/ Haywood Regional Medical Center in Clyde, NC, next to Wayesville NC. It services Haywood county in western NC.

How we got so far away from that is amazing to me. We seem to stupidly re-invent the wheel about every 1.5 generations (with a generation being 20 years).

This is what he stated re: the matter of local psychiatric beds and how it worked back then:

"This definitely works!

In the late 1960s and early 1979s I with the support of Governor Bob Scott at that time adapted a systems approach and analysis of the southcentral region's 20 counties launched a regional - local based treatment program for substance abusers as an alternative to building a 4th state Treatment facility as existed in Butner for the Northcentral,, Greenville for the East and Black Mountain for the West. We were successful in developing local detox units and significantly decreasing admissions to state institutions and avoided completely the building of yet another treatment center.

Ultimately we came to have not only inpatient units in general hospitals Lumberton (4 counties), Fayetteville (2 counties), Pinehurst (5 counties), Sanford (2 counties), Johnston (1 county), psych beds in 3 of the other counties leaving 3 with only Dix, but also outpatient, 24/7,emergency, day hospital, consultation-education and inpatient for all 20 - Three of those programs covering 10 counties actually stopped admissions to Dix totally.

Monday, December 22, 2008

Director of Mental Health issues at the Carter Center weighs in re: GA mental health reform : TIP: private psychiatric beds won't work

This is what seems to be working in NC as re: psychiatric hospitalization...after almost 8 years of trying to put things together:

The state DHHS or DHR (GA) pays pays for the psychiatric beds as associated w/ a small behavioral health unit at a local hospital----thus keeping the patients close to their families, therapists, etc.-----and as per NC State Senator Martin Nesbitt, Medicaid has been found to kick in about 2/3 of the cost of the hospital bed cost fairly quickly. Senator Nesbitt spoke this past week to the Buncombe county (Asheville, NC) NAMI meeting. See my blog for an outline of that speech, specifically, this post:


Tuesday, December 16, 2008

Local hospital psychiatric beds saves $$; diminishes admissions at state psych hosp; keeps patients close to home: WIN. WIN. WIN.

Haywood Regional Hospital just opened up a Behavioral Health unit. This was put together by Smoky Mountain Center (SMC) LME and in particular was headed up by the very excellent Doug Trantham of SMC LME. ....

NC State Senator Martin Nesbitt, indicated last night at the Buncombe NAMI meeting, that there is clearly a distinct need for psychiatric hospital beds which are community based and that the Legislative Oversight Committee (LOC), of which he is co-chair along w/ Verla Insko, are moving funding forward for this to take place across NC. He stated last night that the state legislature is 'paying for these beds', also commenting that as Medicaid kicks in for the people who are patients in these beds, it becomes evident that state $$$ have to pay for "5 out of 15 of the beds."


Creating a small number of beds in local hospitals allows the state to:

1. address the issue of emergency psychiatric services

2. keep the patients close to home, important as re: rural areas, thus diminishing cost also at the level of transportation by sheriff's departments who are ill trained to work w/ these people at this point in time don't pay for 20 years worth of private psychiatric hospitals whose agenda is to get people out as quickly as possible.


GA better understand what in the world they are up against.

(cut and paste):

Thomas Bornemann is director of the mental health program at The Carter Center.

"Georgia continues to experience the effects of a mental health system that is tragically broken. Georgia Department of Human Resources’ (DHR) has responded with some new proposals, one of which is privatizing and downsizing state mental hospitals.

In their 2007 series “A Hidden Shame,” Atlanta Journal-Constitution reporters Andy Miller and Alan Judd exposed 115 suspicious deaths in Georgia state mental hospitals from 2002-2006, and even while the state of Georgia was under investigation by the U.S. Department of Justice for that, the reporters found that the number of questionable deaths as a result of abuse, neglect and poor medical care climbed to 136. ...

Privatization is a tactic done in the service of reform and should not be viewed in and of itself as a broad strategy. The issues associated with hospitals are part of a larger systemic problem. The system is under-funded, fragmented and plagued by serious service delivery gaps..........

.....The proposal is expensive. While private companies may pay construction costs up front, Georgia taxpayers will pay for those costs (plus profits) for the private companies over the next 20 years.

This time of crisis calls for a new way of doing business that opens the doors to policy-making through optimal transparency and public engagement. The DHR must do a better job of soliciting public comment, especially by those most affected —- consumers, families, and mental health professionals —- before decisions are made, not after.

The recent settlement between Georgia and the U.S. Department of Health and Human Services Office of Civil Rights in the Olmstead case requires that the state involve consumers and advocates in “planning how best to provide adequate community services that will meet the needs of all Georgians.” A great deal can be learned from their experiences.

Georgia will be better equipped to address its mental health crisis through an inclusive, deliberative process that involves consumers, families and other key stakeholders, rather than the current rush to privatize. We cannot ask for less for those with mental illnesses who have been entrusted to the state for safe, humane and appropriate care........."

Tuesday, December 16, 2008

Local hospital psychiatric beds saves $$; diminishes admissions at state psych hosp; keeps patients close to home: WIN. WIN. WIN.

Haywood Regional Hospital just opened up a Behavioral Health unit. This was put together by Smoky Mountain Center (SMC) LME and in particular was headed up by the very excellent Doug Trantham of SMC LME.

I learned last night at the NAMI Buncombe meeting that The Balsam Center, which was the small psychiatric hospital just outside of Waynesville, NC, which had been such a unit, is closing. They cannot have both of them, it seems.

NC State Senator Martin Nesbitt, indicated last night at the Buncombe NAMI meeting, that there is clearly a distinct need for psychiatric hospital beds which are community based and that the Legislative Oversight Committee (LOC), of which he is co-chair along w/ Verla Insko, are moving funding forward for this to take place across NC. He stated last night that the state legislature is 'paying for these beds', also commenting that as Medicaid kicks in for the people who are patients in these beds, it becomes evident that state $$$ have to pay for "5 out of 15 of the beds."

Thus, there appears to be a savings associated w/ creating local psychiatric beds within existing hospitals. It also keeps the patients in their communities and then the people who care for them, as well as family members, can visit them.

So, you got:

1. $$$ saved
2. psychiatric patients get to stay close to home
3. fewer people go into the 4 public psychiatric hospitals which diminishes churn which has been accelerated as associated w/ defunding mental health in NC.


I can't believe it! Something happened right!

Former hospital staffer: Why I quit social work at Umstead
Violence, staffing vacancies took toll
Sheila Read - Correspondent
Published: Tue, Dec. 16, 2008

Sheila Read is a graduate student at the UNC-Chapel Hill School of Journalism and Mass Communication. This story is about her time working as a social worker at John Umstead Hospital.

".....Record admissions

A few months after I started work, the adult admissions unit achieved a record. The unit had admitted more than 400 patients that month.

In a staff meeting, we were handed red stars cut out of construction paper. The number of admissions was marked in the star's center. This was something to celebrate? I looked at a colleague and rolled my eyes.

Before mental health reform, even 300 admissions per month were rare, veteran employees said.

The state's four psychiatric hospitals saw the number of patients admitted increase by more than 82 percent between 2001 and 2005, The News & Observer reported in its series on mental health reform. During that five-year period, the state cut $15 million from hospital budgets.

NC Medicaid recipients who own or buy their homes cannot get access to dependable Medicaid & have increases in hospitalization

IN NC, Medicaid eligibility is re-determined every 6 months for people who utilize a deductible to get to Medicaid (which can then pay a healthy portion of their back medical bills).

If the state wants to save money as associated w/ increased rates of hospitalization of these people, then dependable Medicaid seems to be associated w/ more outpt services and less hospitalization-----which costs more money.


I have a client in western NC, Haywood county, whose husband is retired and he receives middle class level retirement benefits from his years of factory work. They are buying their house. They own a car. She cannot get dependable access to Medicaid in NC. Why? Because there is too much income coming into the household, approx $20,000/ year. She was not able to work during her child-bearing years because she had three chronically ill children. Thus, she was not able to vest in Social Security.

Haywood County DSS has advised her that if she wants to 'crank' her Medicaid, she has to do into the hospital on a particular day of the month. Then her Medicaid kicks in for 6 months, pays the big hospital bill, pays for her medications, some of which are cardiac, and then drops off again.

Then she has to accumulate MORE medical bills in order to apply the deductible against the sum of money coming into the household. Its usually about $6-10,000 of medical bills----in terms of what can be applied against the household income----that will allow Medicaid to kick in for 6 months.

This has gone on for years. She has had many hospitalizations which were not necessary in order to crank Medicaid.

This is silly. And it is a bad usage of NC tax $$$$$$.

Here is an article supporting the notion that states are spending more money as associated w/ hospitalizations when Medicaid comes and goes in spurts.

Wanna save money, NC? Then get smart about how Medicaid is utilized.

(cut and paste):

Medicaid insurance coverage interruptions linked to increased hospitalization

".....The study suggests that when states require enrollees to demonstrate eligibility on a more frequent basis, they may see an increase in hospitalizations for common health conditions: lacking insurance to cover the costs of primary care, many former Medicaid enrollees end up in hospitals and are then re-enrolled in Medicaid. The study of California adults, conducted by researchers at San Francisco General Hospital (SFGH) Medical Center and University of California San Francisco (UCSF), was supported by the Commonwealth Fund.

Federal rules require states to re-determine Medicaid beneficiary eligibility at least once every 12 months but some states do so more often. During most of the time of this study, 1998 to 2002, California - which has the largest Medicaid program in the U.S. - required beneficiaries to report on their eligibility every 3 months. California has since reduced the frequency of eligibility determination.

"Although states may attempt to save money in the short term by dropping Medicaid coverage for those who cannot keep up with frequent reporting requirements, this study shows that disruptions in coverage come at the risk of increased hospitalization for conditions that can typically be treated in a less expensive primary care setting," said lead author Andrew B. Bindman, M.D., a professor of medicine at UCSF and chief of general internal medicine at SFGH.

The analysis of Medicaid enrollment and hospital discharge data for more than four million California adults examines the number of Medicaid beneficiaries who experienced interrupted coverage and their hospitalization rates between 1998 and 2002.

During the study period, one in six Medicaid beneficiaries in the U.S. resided in California. More than 62% of eligible beneficiaries experienced interruptions in their Medicaid coverage during the study period, with an average interruption of 25 months.

The study authors recommend that states implement policies to reduce the frequency of interruptions in Medicaid coverage, to help prevent health events that require hospitalization and thereby reduce high-cost hospital spending...."

NC Senator Martin Nesbitt's talk to Buncombe NAMI summarized: mental health moving back towards professional providers

Mr. Nesbitt gave Buncombe NAMI an informative, open-minded talk this evening at the Buncombe NAMI meeting. I am summarizing below what I heard him say (and if he wants something changed, he can tell me and I'll do it).

What he has to say is important as he is the co-chair, along w/ Verla Insko, of the Joint Legislative Oversight Committee for Mental Health Reform. He stated that he and Rep Insko are, 'like Frick and Frack', indicating that they see eye to eye on most matters. At least they get along.

Senator Nesbitt suggested that if we could all work together on mental health reform, that he believed we could move the matter along. He stated that he sees dysfunction in all parts of 'the system.' (this lead me to a new definition of systemic dysfunction: its when all the associated parties to not agree on the important components of the goal; more on that later).

As is prevalent within the legislative circles, it appears that the mantra about those 'bad apple' Endorsed Provider companies, greedily lapping up the Community Support Services $$$---continues to be a popular story.

Mr. Nesbitt did indicate that the former Secretary of NC DHHS, Carmen Hooker Odom, put that into play, however. The fact is that the Service Definition associated w/ Community Support Services ENDORSED the usage of lesser qualified CSS workers. It was written INTO the Service Definition. Additionally, Hooker Odom doled out the Medicaid management to Value Options (and we may never know just whose pockets got padded re: that matter, will we).

If you are using a business model which includes competition and privatization, then don't turn around and bemoan the entrepreneurial greed. The mental health 'industry' is not composed of saints, you know.

And while we're talking about business models, the mental health industry is the only one that entails you fixing up your customers so they no longer need or want your services.

Think about it: you go to the bank: they treat you well; you want to stay w/ them. You get a cell phone, it works or not, and you stay---or not w/ the company. You go to the bakery; you enjoy the'll be back. You go to your physician: he's a nice guy and listens to'll go back.

BUT: you go to the mental health provider----they treat you for mental illness----and then you understood yourself so well that you never needed to go back: NOT SO FAST, says the mental health provider who just spent 10 hours filling out all the forms and getting the signatures and faxing all the stuff and talking to all the Value Options people and the LME's support staff.

If the advocates/ the families/ the LME's/ the Legislative Oversight Committee/ the Providers/ the warehousers of people having mental illness e.g, the personal care homes: IF you want the people to get BETTER, then you need to have the same GOALS.

Distinctly, the providers----due to their investment in non-paid/ exasperating paperwork---and the personal care home warehousers otherwise known as the personal care homes----who VERY MUCH do not want their inhabitants to get better---very much have a vested interest in people not getting better.

I told Mr. Nesbitt: Value Options has a one page form that I sent in re: request for observation. The LME's have SIX FORMS, all w/ significant pieces of information to be filled in. Remove the paperwork problems and you will get the providers functioning efficiently.

I don't know what you do about the warehousers. The Departments of Social Services pay a large amount of money---in addition to the Social Security Disability checks that are received by the inhabitants of these fairly sub-standard houses----for warehousing. The warehousers give them back pocket change. These are some of the main consumers of CSS. It would be very interesting to know how many Medicaid clients are warehoused in this manner. My understanding is that its their Medicaid funds that are plumbed.

So, if all the entities involved w/ making mental health care work are going to AGREE on a goal----which seems to be critical----then the addressing of the very significant barrier to care, namely the PAPERWORK,

Mr. Nesbitt indicated that the CSS definition was being massively re-worked. And he indicated that the matter of 'standardization of paperwork' across the LME's, he thought, was one of the top matters to be addressed by the new Secretary of NC DHHS (whoever that is).

This does not, however, address the matter of the 30 pages of paperwork required by the LME's associated with obtaining services for state funded clients and for Medicaid clients receiving CSS.

Standardization will not diminish the paperwork, in and of itself, Mr. Nesbitt.

He reminded me that 2-3 years ago, the LME's were managing Medicaid. But then, Medicaid management got farmed out to Value Options---a national company---which caused the LME's to get rid of quite a few of their employees----only to find out that come 2009 they are to begin picking them up again.

What a lot of wasted effort/ heart-ache/ problems.

AYE: but here's the rub: there will be NO MONEY coming to the LME's in order to manage the 30% of Medicaid (which 30% are we talking about, I asked Verla Insko in an e mail earlier: is it CSS? what is it?: this is important in terms of Endorsed Provider businesses being able to plan but heck, this is mental health and you don't/ can't plan).

So, this means that the LME's which cannot even do the management of the state funded clients will take on the additional burden of managing 30% of NC Medicaid.

I pointedly asked the question----my perennial question: "Why doesn't Smoky Mountain Center LME, the largest LME in NC, and one of two in western NC, have any Basic Level Services (which include outpatient therapy)?" (I know the answer to that but no one's talking: its because SMC LME favored Meridian Behavioral Health Services, its spin-off company, which necessarily excluded all the other professional providers: WHERE, oh WHERE, have our professional providers gone?)

Mr. Nesbitt stated, basically, "I don't know the SMC system that well, not as well as Western Highlands Network LME system. You know, there's been problems down there recently."

That still does not answer the matter of why aren't there any basic level services for state funded clients under SMC LME.

No one wants to answer that question.

And it reminds me of how I felt like banging my head on the table when I talked to one of the CFAC people associated w/ SMC LME, as I told them that I had been the one to ask Mike Moseley, Director of Mental Health (I bet he is glad to retire, man alive) why SMC LME did not have the CFAC minutes on their web site?

BANG. BANG. BANG. The CFAC committee could not have asked to have their minutes put up on the SMC LME website?

YIKES! For God's sake, don't ask for what you want!

Saturday, December 13, 2008

Mental Health 'human rights' as Obama administsration comes on board: 'all persons shall have the right to best available mental health care'

There's an interesting article in Harper's by an attorney who is an expert on human rights/ international law (see: Six Questions for Mary Ellen O’Connell on the Power of International Law By Scott Horton

"Mary Ellen O’Connell, a law professor at Notre Dame University, is a prominent voice in the legal community on international law and the law of war, and the author of a new book entitled The Power and Purpose of International Law. As the Bush Administration exits under a cloud of controversy concerning its accountability for war crimes, I put six questions to Mary Ellen about her book, the legacy of the Bush presidency on the field of international law and the challenges facing President-elect Obama."

In that article, this is discussed (and it bears relationship to mental health treatment and human rights, in general):

'...4. (Harper's Mag: "The idea that international law is impotent, that there is no effective sanction for its violation, seems to be in the background when one reads the torture memoranda. We see a very casual attitude taken towards the Geneva Conventions and the Convention Against Torture, for instance, as if they are not really law. Doesn’t this suggest that the neoconservative theory of international law as “no law at all” is directly connected to detainee abuse in Abu Ghraib, Guantánamo and elsewhere? The neocon theory saw no effective limitations in international law and essentially unlimited presidential powers in wartime. The torture and mistreatment of prisoners was effectively an opportunity to take these theories for a test drive. Does this not suggest that the focus of accountability should be on the lawyers who enabled the abuse?


I see contempt for international law on every page of the torture memos. There are serious errors of analysis throughout—some, perhaps, from ignorance, but there are many errors that even a lawyer who never studied international law should not make, such as interpreting treaty terms by looking at terms in unrelated United States statutes.

And yet the memos were ordered. Obviously, someone understood the widespread belief in and commitment to international law in this country. The decision to torture, disappear, and abuse detainees could not simply be enacted by top officials saying “take the gloves off.” Hundreds of pages of memos misconstruing international law had to be written first. The lawyers who wrote the torture memos must have been particularly frustrated in needing to make arguments about international law. But their poor results—their misconstruction of the law is directly related to the violations of human rights and humanitarian law that have been perpetrated since 9/11.

The CIA, contractors, and military believed they needed clearance from international law obligations. The investigation of crimes, I suggest, should include the lawyers.

The clearest standards these lawyers have violated are standards of professional conduct. Regardless of their personal opinions about international law, the rules of professional responsibility require competent advice on the law. There is nothing of the kind in the torture memos.....'"

And so, as we move into an era associated w/ human rights (whileas before, we looked 'thru a glass darkly'), people who have mental health challenges should be accorded the same rights as others. This is the basis, as I understand it, for human rights. And yet, as re: NC mental health reform, we find that this is not the case.

Indeed, state funded clients are subjected to a variety of interpretations as per the administrative LME's ploughing thru their NC tax-payer money----as pertaining to how to spend the state's money paid for by NC citizens when it comes to the mental health treatment of people with mental health challenges and have no insurance/ no Medicare/ no Medicaid. In a phrase, they are the 'working poor.'

And you do not have to look very far to see the pylon driving down upon the heads of the Big Three automakers employees as the Republicans try to break the back of the UAW union and turn them also into 'the working poor.'

The INTENTION of NC mental health reform was to provide:

*choice of providers for those seeking mental health treatment
*availability of mental health treatment (which precludes choice)
*take the services into the community (which was basically the driving agenda behind Community Support Services)

Some might define these as 'Cadillac intentions on a Chevy budget.'

The problem is: no one ever owned to the fact that this is what took place as the NC State Legislature progressively robbed and defunded the coffers set aside to undergird these purposes.

You can't have any serious intentions about human rights or eye-balling the capacity and failure as pertaining to NC mental health reform until you own up to how the mission was devalued and then fell into a funk.

I don't see anything like this taking place. I just see more of the same bullshit in terms of avoiding addressing the issue.

I see directors of hospitals downsizing into other hospitals. I see tax payer $$$$$$ flying out the window as 2 or 3 of the 4 public psychiatric hospitals cannot re-attain CMS/ Medicare/ medicaid funding---which costs NC tax payers $2 million or more/ month. I see co-chairs of Joint Legislative Oversight Committees of the NC State Legislature unable to get answers to simple questions like: "Why are there no outpatient therapy services for state funded clients under Smoky Mountain Center LME, the largest LME in NC?"

To be sure, the notion of choice of providers ran away years ago and no one even talks about it. The talk now is about finding what there IS and the scramble that takes place as Community Support Services companies yank clients away from each other----depending on who is unhappy this week----is doing nothing but churning CSS.

Oh yeah: did I tell you? Competition----what Dr. Vince Visingardi---the guy w/ the Hawaiian shirts from MI----- envisioned as fundamental to having a healthy, competitive providing of mental health services----is ALIVE and WELL.

Here are the World Health Organization points about mental health human rights:

Friday, December 12, 2008

Dr. St. Clair, mental health Cherry Hosp Dir, was not seen by the staff (and certainly not by the patients) at Cherry Hospital, when he worked there

Great. These people never get demoted and never lose their salaries. They just move on to their next good gig.

Reports from staff at the Raleigh News & Observer article (separate from the below AP article)indicate that staff did not see Dr. St. Clair on the wards of the hospital. NC DHHS needs to find some administrators that have the social skills that allows them to walk the wards and converse w/ the patients and the staff.

Not a real brain-teaser, you know, NC DHHS. The comments associated w/ the Raleigh News & Observer article indicate that employees----who were commenting to the article----did not perceive Dr. St. Clair as having any hands on skills re: the running of the hospital over the past three years. They never saw him. So, how does someone run a hospital like that, particularly, given all the difficulties over the past year or so at these facilities?

Here is the Raleigh News & Observer article: (cut and paste):

Cherry Hospital chief quitting
The mental hospital's problems include assaults and the death of a patient

Here is the Associated Press (AP) article which preceded the above one:

"Director of NC mental hospital to step down
December 12, 2008 15:00 EST

RALEIGH, N.C. (AP) -- State officials say the director of a mental hospital where a patient died and others were beaten has asked to step down and has been offered another job in the state mental health system.

Department of Health and Human Services Secretary Dempsey Benton said Friday that Cherry Hospital director Dr. Jack St. Clair asked to step down effective Dec. 31. Benton said in a statement that St. Clair was offered a job as business manager at the state's Neuro-Medical Treatment Center in Black Mountain.

Until a new hospital director is found, the daily management at Cherry Hospital will handled by an independent management team that was hired in October. The team is working to help the hospital seek reinstatement with federal Medicare and Medicaid programs."

Monday, December 08, 2008

Even the Co-Chair of the Joint Legislative Oversight Comm on Mental Health cannot get a straight answer from SMC or WHN LME's in western NC

NC State Representative Verla Insko graciously volunteered to ask questions to Smoky Mountain Center (SMC) LME (don't know who she talked to) and to Western Highlands Network (WHN) LME. Even the co-chair of the Joint Legislative Oversight Committee cannot get a straight answer.



"Dear Verla:

SMC LME stated this, as per your e mail:

"Smoky - Dr. Hammond has not been a provider in their area for for 2 1/2 years. She is disputing old cases that she appealed, and went through the review process with no changes to the decision."

Verla: Perhaps I didn't ask if you would ferret out the information in a manner which would not have gotten you a pat answer and completely dismissed your inquiry. I am not disputing old cases. I would like to know why there are no outpatient therapy benefits except under the constantly defunded Community Support Services given the restrictions in terms of funding and as associated w/ NC DHHS requiring that if services are under the Service Definition CSS----then the person associated w/ that----regardless of what they do----has to undergo CSS training----when that has nothing to do re: outpatient therapy and psychological assessment.

Would you mind re-asking the question? Why are there no outpt therapy services under SMC LME except under CSS---with all of its restrictions?

thanks for letting me know if you can ask it. God knows I am not going to shut up.


Marsha V. Hammond, PhD: Licensed Psychologist: NC
e mail: cell: 404 964 5338

December 7, 2008

Dear Mr. (Donald) Reuss (

Verla Insko volunteered to get some information re: my inability to get authorization or even get a response re: client 4------. This is what she wrote me today.

"Western Highlands - Dr. Hammond is a Medicaid provider and not authorized under WH. She billed for services but is not part of the provider panel. The case is over a year old. She could possibly request authorization in the future from WH but they really didn't need any therapists and it wouldn't change the status of these old cases."

I am confused.

First of all, at one of the very first WHN LME provider meetings about five years ago, where I met -------------- I signed up as a provider. However, I am a Licensed Psychologist (LP) and I bill independently to Medicare/ Medicaid/ 3rd parties. The only thing I cannot bill independently for are the state funded clients. Thus, all this massive confusion. .

Secondly, the 'provider panel' associated w/ WHN LME---- you yourself told me about a week ago----are people who must utilize WHN LME's Medicaid billing number because they cannot bill Medicaid independently. I know of this as about a week ago I asked you why their names were there as it appeared to me to be a nice bit of free advertising. You told me that they cannot bill Medicaid independently and you advised me that if/ when the LME's take over management of Medicaid that perhaps I could put my name there.

Relatedly, the LME's only manage state funded clients at this time. The private Endorsed Provider companies are the only banners under which the providers operate as associated w/ state funded clients. Thus, what does this mean, "Dr. Hammond is a Medicaid provider and not authorized under WHN. She billed for services but is not part of the provider panel."?

I originally submitted the paperwork for client 4------- in October, 2007; again in April, 2008; again in September, 2008. I talked to people on the phone at WHN each time. That there is no record of this is concerning to me.

It is true, as per our previous conversations, that WHN LME did not have paperwork associated w/ my formal contract via ----------(Endorsed Provider company) because I had balked at the unnecessary training associated with that being demanded of 'employees' of the private Endorsed Provider companies. Indeed, it is not even a contract; I was required to submit 15 pages of employee paperwork in order to merely be able to do therapy w/ state funded clients. I do specific tasks, namely, assessment and therapy. My license covers this.

Specifically, I had asked you if I had to go and sit through 20+ hours of unpaid, unnecessary CSS training; you graciously went and got that info (and I finally got a call back from Dr. Lancaster a couple of weeks ago). You stated I did not have to have that training as I do not provide CSS. I appreciated that.

This 'missing' piece of paperwork formalizing----for your benefit---my relationship w/ --------------(Endorsed Provider company) was sent to you by the owner of -------------(Endorsed Provider company), -----------, a couple of weeks ago, unless I am mistaken.

And so, in an attempt to again move forward the authorization for outpt therapy on client 4--------, I last week I turned in to you ---by hand----the one page of information outlining all of this. Kimberly Kuhn, whom, I am advised is the intake person, told me last week that you would be getting in touch w/ me re: this client 4--------.

I assume that the person that Verla talked to was someone other than you and maybe that person does not realize the contract that is between myself and -----------(Endorsed Provider company).

Otherwise, is there some reason that -----------(Endorsed Provider company) is not able to obtain authorization consideration for WHN state funded client # 4-------? WHN LME is in receipt of my contract w/ ---------- or at least ------------ tells me this. This means that the authorization proceeds via --------------(Endorsed Provider company).

Can someone explain this statement to me which seems to be associated w/ me not being on some panel? : "She could possibly request authorization in the future from WH but they really didn't need any therapists and it wouldn't change the status of these old cases." This has nothing to do w/ anything. My work w/ the state funded clients (the one I have; anymore work like this would kill me) proceeds via (Endorsed Provider company). 'We', assumably is associated w/ providers who cannot independently bill Medicaid.

Verla Insko seems concerned that psychologists (not you, she stated) are not willing to work w/ the state funded clients. Is it any wonder that this is so? Is this going to happen for every Medicaid client?

I'd appreciate some clarification. I'm completely lost on what is being said here.

Forward this to any pertinent party.


marsha hammond, phd

NC spending less on services even as population expands, including mental health

Its a success! We're spending less money on lots of things, including mental health services!


December 8, 2008
New BTC Brief a must read
Posted at 11:07 AM by Rob Schofield

The N.C. Budget and Tax Center released a very important report this morning. It’s also short and sweet, so don’t not read it because you’re afraid you’ll get lost in Wonkland. Here’s the basic gist:

North Carolina’s per capita, inflation adjusted General Fund spending actually DECREASED over the past decade – from $2,323 to $2,304.

Got that? We’re spending less not more. So much for all the B.S. about runaway spending.

Don’t suppose that could have at least something to do with our collapsing mental health and probation systems.

(From the report itself: from NC Justice Center, NC Budget & Tax Center, compiled by Meg Gray Wiehe: contact 919 856 3192):

"North Carolina has not experienced dramatic growth in general fund appropriations over the past decade. Increases in recent years are better characterized as restoration of recession–era cuts rather than major new investments. As the population grows and costs rise, it is logical that the budget would grow in nominal terms to ensure a continued high standard of living and to meet the needs of the families and businesses. Looking at the budget in terms of per-capita
spending and as a percentage of personal income reveal more about the state’s investments than simply looking at dollar amounts. This data makes clear that cutting back on state spending will not be a matter of “trimming the fat or excess” but rather a matter of making tough choices about the relative importance of state-funded services......

KEY FINDING: General fund appropriations per capita decreased by $19, from $2,323 to
$2,304, between FY99-00 and FY08-09 after adjusting for inflation."

Psychologists do all the work underpinning Community Support Services for mental health & receive no pay for it

Its amazing, really, when you start to understand that Community Support Services (CSS), is completely dependent on the Psychological Assessment. This document, signed by the doctoral Licensed Psychologist is what allows CSS to go through----or not.

Moreover, the Psychological Assessment is necessary in order for state funded clients to receive outpatient therapy.

Under the old NC DHHS system, the assessment of a psychiatrist or psychiatric nurse practitioner, replete w/ the DSM IV diagnosis would do.

Not so as pertaining to the increasingly rigid expenditure of CSS $$$ which demand clear linkages to behaviors and mental health challengegs.

No, for that you need a psychologist. And what does the psychologist get paid for meeting with the client for an hour or more, sitting down and writing up the report?

About $100.

The Psychological Assessment must include:

* the mental health and behavioral history of the client
* check about 20 boxes associated w/ demographic data
* speak to substance abuse history issues and details
* document educational matters
* overview the mental status associated w/ afffect, thought content, attention, orientation,memory, insight, risk of harm,risk to others
* rate current impairments
* render a five axis DSM IV diagnosis
* determine a target population
* fold into the report items supportive (or not) of CSS
* provide an Assessment Interpretation and Case Formulation
* make recommendations; sign your name and put your license on the line.

Absolutely amazing how NCPA has not done anything w/ these kinds of challenges and few psychologists even understand NC Mental Health Reform because no one wants to do this work.

DUH: I wonder why.

Saturday, December 06, 2008

Specific barriers to working w/ state funded mental health clients in western NC's two LME's

Verla Insko indicated she would try and get answers to the questions re: problems w/ authorization of state funded clients at Smoky Mountain Center (SMC) LME and Western Highlands Network (WHN) LME. I have indicated to her that given the incredible difficulty of working w/ the LME's re: getting authorization (read: get paid) for seeing state funded clients, I am completely aghast at the possibility, indeed, the certainty, of the LME's picking up the management of NC Medicaid clients.

Will the LME's fall down on the job like they have re: state funded clients?

Rep Insko indicates the following:

"When area programs ran everything, they were able to co mingle the funds and make all the money go a lot further. Now, some providers - not you - are willing to see only Medicaid patients. We need to have all providers in the public system willing to take both Medicaid and state paid patients.

The hardest to serve mh patients are often not Medicaid eligible. If we can't integrate them into the system, they end up in EDs, jails and our state institutions. "

My Response: then the LME's should have been able to remove the following barriers which preclude professional providers from servicing the state funded clients. And the NC State Legislative Oversight Committee could have made that possible, I imagine. And the NC State Legislature should have made that happen as re: the Oversight Committee's recommendations.

Money is money. I fail to see how the LME's with their 'culture' of 'you can't find us' is going to change re: Medicaid and indeed I might speculate that they will be overwhelmed and that THEN sure enough, there is going to be complaining by providers.


Specifically, these are the provider BARRIERS to rendering mental health care at these two LME's, who administer 25% of NC's 100 counties.


1. BARRIER #1: MY PSYCHOLOGIST LICENSE DOES NOT 'WORK' AS RE: STATE FUNDED CLIENTS UNDER NC MENTAL HEALTH REFORM. A doctoral level psychologist functions independently. A master's level psychological associate in NC functions under the supervision of a doctoral level psychologist. A doctoral level psychologist bills independently. However, as re: state mental health clients, a doctoral level psychologist cannot do this. This creates a barrier to mental health care re: the extensive paperwork associated with matters which should be protected and made possible on the basis of the license of the professional provider.

2. BARRIER #2: ACCESS CENTERS WHICH ARE SUPPOSED TO LINKS PROVIDERS TO AUTHORIZATIONS SIMPLY DON'T WORK. The ACCESS centers at both of these LME's, which create the authorization so that the professional provider can get paid--- at both LMEs---- require an enormous amount of follow-up by providers to simply get thru an authorization. You can call/ e mail/ DRIVE UP THERE and you will still not be able to get things taken care of.

3. BARRIER #3: NC DHHS CONTINUES TO CHANGE MAJOR PIECES OF PAPERWORK AND THERE IS NO OBVIOUS REASON FOR THIS: PCP forms are changing in January. whoopee! get to do them all over again. WHN LME does utilize a truncated version of PCP for basic level services. Smoky Mountain Center LME does not offer Basic Level Services; all outpatient therapy goes under CSS which is constantly being defunded.

4 BARRIER #4: THESE TWO LME'S HAVE TWO DIFFERENT AGENDAS RE: WHAT SHOULD BE A BASIC SERVICE THAT IS CONSISTENT ACROSS NC: HAfter the limited 8 sessions/ year/ state funded client, the Utilization Review Department of WHN LME, headed by Marsha Ring, has stated that if further therapy is in order, the personality disordered (I guess the others get no follow-up), then DBT training must also be available. WHERE IS THIS DBT TRAINING?

SMC LME has all the outpatient services under the Service Definition, Community Support Services, which is constantly being defunded. In order to utilize CSS, one must undergo, per NC DHHS criteria, 20+ hours/ of CSS training even if one is not providing CSS BECAUSE CSS is demanded to have this. How is it that this 'everything in the kitchen sink' service definition is allowed to be utilized and thus create a barrier for professional providers? How is it that there is such inconsistency across the LME's in terms of such fundamental services??

Tell me, Rep Verla Insko, how the LME's are going to manage Medicaid when they cannot even manage the state funded clients' mental health care?

Breakdown: The will to find a better way
by Taylor Sisk:

".....Among the changes made in the course of mental health care reform in North Carolina was the recruitment of an out-of-state company called ValueOptions to review and process all Medicaid payments.

Chapel Hill’s Rep.Verla Insko, a sponsor of the mental health care reform legislation and co-chair of the joint legislative committee on mental health, says of that decision, “It was a mistake. It undermined the basic goals of reform, which were to have the public sector manage a unified budget – a Medicaid, state-dollar and local-dollar budget – to provide services within each catchment area.” Instead, today we have a two-payer system, further fragmenting the funding and delivery of services.

The Legislature is now taking action to remove ValueOptions, from the equation.

Insko says that LMEs serving 30 percent of the state’s population will this year reassume the management of Medicaid dollars, and that if all goes well 30 percent more will do so next year and 40 percent the next.

Another move in the right direction, according to Insko, is an effort to integrate mental and physical health care services through Community Care of North Carolina, which operates out of the North Carolina Office of Rural Health and Community Care. It’s an effort championed by Governor-elect Perdue...."


My comment to the above article, online:

"I cannot get even ONE state funded client authorized for treatment at either Western Highlands Network (WHN) LME or Smoky Mountain Center LME who administer 25% of NC's mental health care. Medicaid works pretty well under Value Options. Today I went UP TO WHN's office as I cannot get an e mail reply back re: my query pertaining to authorization of a state funded client. Everyone was in a meeting; when I send e mails to the appropriate people, no one answers me back.

Please tell me, Verla Insko and Martin Nesbitt, co-chairs of the NC Mental Health Reform Legislative Oversight committee how I am supposed to manage when the quite well functioning Value Options loses its Medicaid authorization contract and the LME's----who have not been able to authorize efficently the state funded clients----pick it up? I WANT TO KNOW.

Marsha V. Hammond, PhD: Clinical Licensed Psychologist, Asheville/ Waynesville, NC

Wednesday, December 03, 2008

Conservative John Locke Foundation goes for the creation of more government to manage mental health services in NC while this Dem is 4 streamlining

The Republicans and the Democrats seem to be entranced with that childhood game associated with walking around an ever diminishing set of chairs until only one is left being seated at the table. My letter to Mr. Joseph Coletti of the John Lock Foundation as pertaining to his very excellent, thorough overview of NC mental Health Reform. The below is just one of the points to 'take away' re: his important paper.


Marsha V. Hammond, PhD: Licensed Psychologist: NC
e mail:

December 3, 2008

RE: your mental health paper

Dear (Joseph) Coletti of the John Locke Foundation, conservative think-tank:

Thank you for this excellent overview. Even though I know the arena associated w/ NC Mental Health Reform fairly well, your paper provided a surplus of interesting and valuable information.

I have a specific comment most immediately and I would like to try and submit it as a comment to your paper?----is this possible? And I would have others also. All in all, I found it very well written and organized and informative. I thought that the information describing the graphs could have been more clear.

Here is my most immediate comment as per your, entitled:, Mental Health Reform, Steps Towards Improvement, by Josephe Coletti, October, 2008:

1. p. 8: "....Piedmont Behavioral Health (PBH) – the LME for Cabarrus, Davidson, Rowan, Stanly,and Union counties – receives payment from Medicaid for each person it serves through a state-level 1915(b) Medicaid Managed Care Waiver. This waiver allows PBH to combine not just state and local funds, as some other LMEs also do, but to control Medicaid funds as well. With three funding sources, PBH can adjust payments to providers to match services better with consumer needs, and can pay claims sooner....."

I cannot see 'into' how the LME is advantaged by this matter and so I speak from the perspective of the professional provider----those people who keep the clients OUT of the hospital and thus save the state money.

Here is the authorization process for Medicaid after 8 outpatient therapy sessions/ year/ adult: one page of information to be filled in and faxed and/ or mailed to Value Options. Within 10 days, normally, the authorization is approved.

This is usually a once/ year/ client if the provider can anticipate how many sessions of outpatient therapy would be useful. Most professional providers can estimate this and if not, you can always submit another one page authorization request to Value Options. Medicare clients have no limit on sessions. Additionally, Medicare pays for the Health & Behavior codes which pay as well as Medicaid and allow the professional provider to interface w/ the primary care physician and psychiatrist----which is what always should be taking place.

An authorization permits the professional provider, with the NPI number, to get paid. If I cannot get paid, I am not willing to see the client.

I have learned how to move clients who are associated w/ the 'working poor' population into Medicaid within 3 months flat. That's a record, my friend. They don't get SSI or SSDI funding, but they get health insurance which allows me to follow them.

I actively move the state funded clients out of that pool of state funded clients because it does not work. And so, if you observe that Medicaid $$ are being utilized more, bear in mind that state funded $$ are being: cut; mismanaged; boondoggled.

I do see considerable numbers of people for free. This never is taken into account by actuarial data----all the free work that many mental health providers do. I know a retired psychiatrist in Asheville, who carries a load of 20 patients----for free.

Medicaid/ Medicare/ state funded clients do not have funds to pay for outpatient therapy. That is why ease and efficiency of funding is absolutely necessary.

Outpatient therapy keeps people out of the hospitals. Hospitals cost money. Better to keep them out of the hospital and manage them on an outpatient basis. Its pretty simple, basically. I keep my clients out of the hospital by being readily available to them---via e mail; via cell phone; via home phone. They know where to find me. They call me; if there is a medication issue, I call the psychiatrist. I get things done. I talk to them when they are in crisis.

Contrary to that simple process, here is the authorization process ANY outpatient therapy sessions/ year/ adult as pertaining to the 'working poor' for state funded clients:

* there is no pre-authorization for any client; there are no 8 sessions available; there are ZERO sessions available from the get-go. Thus, all the unpaid paperwork (10+ pages of signatures and filled in information) must be submitted to the LME; they sit on it; you call them and ask what's going on; you can't get them; you send an e mail; they don't respond; you call them again; sometime in a month or so (by now the client has gone into the hospital or you have seen them for free which cannot be sustained) you will receive authorization.

*An additional significant barrier to the seeing of these state funded clients is associated by the demand by NC DHHS that the professional provider be 'signed on with' or 'employed by' an Endorsed Provider company. This is more paperwork; more waiting; more sending of e mails to see where the information is before the provider can even submit any authorization paperwork.

*There is no reason for me to think that the LME's will not fall prey to simply creating more paperwork for providers if they were to manage Medicaid and particularly so w/ the state moving into the red, financially. Money will simply have been wasted on the salaries of employees at the LME's who sit on the paperwork, tying up the entire system.

Why not pay me directly instead? I keep people out of the hospital. Why not create efficient avenues of funding that remove barriers to me seeing clients efficiently, quickly, on an as needed basis? Why not allow me to do what my license has outlined I CAN do?

I get paid quickly and well by Medicaid. And I receive authorizations in a fairly timely manner. Value Options a year or so ago was more prompt in this authorization task but they are still much better than the LME's in terms of allocating services in terms of timeliness and number of phone calls and length of time I need to spend creating paperwork and talking to someone at the LME ACCESS center.

Indeed, this has been one of my main concerns. this matter of the LME's picking up the management of Medicaid. So, there is no, and even negative, benefit to me, the doctoral psychologist, in terms of the LME picking up the management of Medicaid.

The LME could probably do a better job of managing Community Support Services (CSS) but probably not. The paperwork will not be any different (and it is voluminous).

Why should CSS continue? This is what it offers for clients:

* additional contact w/ a less well trained mental health Qualified Professional (QP), who now is usually a college graduate w/ some significant experience in providing mental health services. What do you get for that? You get the QP DRIVING to see the client, out in the community, spending time w/ them, taking them to doctor's appointments (many Medciaid clients cannot afford the $6 round-trip fee to go to see a doctor), and creating a liason between the client and the more highly trained professional provider e.g., psychologist, psychiatrist, psychiatric nurse practitioner. If CSS does not continue in some significant form, the professional providers will again be hoisted with the extremely time-consuming care of clients who have a variety of needs which basically is associated w/ extreme poverty and a culture that has minimal to no public transportation; fractured infrastructure of ways to house/ feed/ clothe indigent clients.

NC Medicaid authorizes efficiently and pays me quickly and pays me well. All my contacts w/ two LME's in terms of authorizations or paperwork associated w/ authorizations, all paperwork needing to be submitted outside my license in order to provide Basic Level Services (outpatient therapy) is very much more time consuming as re: the LME.

There are two LME's in western NC who administer 25 out of NC's 100 counties. These are the problems w/ one-quarter of NC's mental health care systems.

I do not see state funded clients, the 'working poor' under Smoky Mountain Center (SMC) LME, the largest LME in NC. Why? Because that LME has no Basic Level Services. I spent five years trying to voice my opinion to them and now I simply do it in my blog and as pertaining to letter to the editor and Opinion pieces.

All outpatient therapy associated w/ SMC LME is controlled under the Community Support Services (CSS) service definition. That was administratively determined by that LME in 2003 or so.

CSS, as per the demand by NC DHHS, has at least TWICE as much paperwork. CSS, as per NC DHHS, must be associated w/ 20+ hours of CSS training. I do not do CSS. I do assessment and outpatient therapy. Nevertheless, I cannot see state funded clients under SMC LME. I refuse to sit thru that much unpaid training. I refuse it on the basis of my license which should suffice.

What does that mean, this matter of diminishing professional providers under SMC LME? It means that a bunch of professional providers cannot work to keep people out of the hospital as associated w/ that LME. It means that SMC LME talks about a shortage of professional providers when in fact it is their policy that has created the matter.

I see one state funded client as associated with Western Highlands Network LME. That LME has a service definition associated w/ Basic Level Services. The paperwork is about one-quarter that of SMC LME because, in part, it is associated with this non-CSS services definition and because that LME saw the need to truncate the paperwork and did so.

This being said, I still had the additional barrier of getting all the paperwork in line so that I was known as a 'employee' of that private Endorsed Provider company by WHN LME. I get paid nothing extra for this affiliation. INdeed, I am asked to do a critical service which should be reimbursed, namely signing off on the Person Centered Plan (PCP, indicating that the services are 'medically necessary.'

This would be true of any LME in NC. This means that my license as a psychologist does not 'work' as per the demand by NC DHHS that all mental health providers who provider mental health services for state funded clients be aligned with a company.

What was the purpose of that? I suppose it was associated with trying to keep tabs on data. However, there is no data from NC DHHS re: what has taken place---or at least I do not know of it. There is no data indicating that anything has worked or not worked as per NC DHHS that I know of, for all the massive tons of paperwork being generated.

Therefore, a return to the question: what was the purpose of aligning professional providers with the private Endorsed Provider companies? My answer: indirectly, it was in order to get more free work out of the professional providers as the Endorsed Provider companies must obtain the professional (the psychologist or the psychiatrist) signature on the Person Centered Plan.

Additionally, as of January 1, 2009, the professional provider must have contact w/ the client. These clients are Medicare/ Medicaid clients, for the most part, the people who receive CSS and thus must have the 20 page Person Centered Plan, as demanded by NC DHHS. I do not do the PCP. I do the Diagnostic Assessment.

An assessment for Medicaid pays about $130 for a doctoral level psychologist. There is only one allowable / year/ client. An assessment for a dually eligible client (Medicare is always primary in terms of mental health outpatient services) pays less than $100 to a professional provider. The assessment is pages and pages of information that must be filled in. Thus, it is not a matter of simply seeing the client. The paperwork must be generated also. That means that the doctoral level psychologist, with 6+ years of graduate work, if they type over 100 words / minute like I do, get paid less than $50/ hour.

In the best of all possible worlds, what would take place from my perspective as a professional provider?

1. the license of the professional provider would be proof enough that any mental health service is in their domain. This would remove the barrier of some of the paperwork. If there are concerns about what the professional provider is doing, then take it to the licensing board. That is what they are there for. They create the limitations on the professional providers license and it is up to the professional provider to be cognizant of what they were trained to do----and what they were trained NOT to do. No provider EVER wants to be called onto the carpet of their licensing board.

2. the professional provider should be able to bill directly rather than pass thru the middle-man of the LME w/ all the snags of lost time/ unanswered phone calls/ unanswererd e mails/ generation of paperwork.

3. create one authorization/ one funding system for : state funded/ Medicare/ Medicaid or at least for state funded and Medicaid. While this may be what you are suggesting, Mr. Coletti, the problem is the inefficient appareatus that NC DHHS has saddled the LME's with which has no reason go exist. Presumably NC DHHS created the tons of paperwork for some reason other than creating a significant barrier to care. However, there is no information re: whether anything has been gained by the creation of all this paperwork and thus one is left with the conclusion that it served no purpose other than to create a massive barrier to care in order to cut services in order to save money.

Thus, Mr. Coletti, I am left with the determination that there is no reason, from my perspective of the professional provider, of having the LME's oversee Medicaid as per your statement, reiterated here: ""....Piedmont Behavioral Health (PBH) – the LME for Cabarrus, Davidson, Rowan, Stanly,and Union counties – receives payment from Medicaid for each person it serves through a state-level 1915(b) Medicaid Managed Care Waiver. This waiver allows PBH to combine not just state and local funds, as some other LMEs also do, but to control Medicaid funds as well. With three funding sources, PBH can adjust payments to providers to match services better with consumer needs, and can pay claims sooner....."

In a word, mental health care needs to be STREAMLINED not be made more convoluted by creating more positions at the so far inefficient LME's as pertaining to managing Medicaid services.

Indeed, I am surprised that at the conservative John Locke foundation, there is an impetus to convolute the system rather than streamline it. Instead of 'choking government', there seems to be an agenda to pad it even further.

My, what odd times these are that I should be on that side of the fence and you are on the other. Your paper is nevertheless very valuable and I thank you for the hard work you did on it.


Marsha V. Hammond, PhD