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: firstname.lastname@example.org
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 http://www.johnlocke.org/site-docs/research/JLFmentalhealth.pdf, 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