Sunday, February 28, 2010

What happens to Mentally Ill People who are thrown in jail due to side-effects of their medications?

The Critical Overlapping Issues of Police Training & Medicaid Cuts for Citizens with Mental Illness

By Marsha V. Hammond, PhD
Licensed Psychologist, NC

In December, 2009, NC Medicaid began requiring an additional tier of pre-authorizations for many medications. This simply resulted in an increase in the use of emergency services and caused the police to be engaged for mental health events bought on by mental health care deficits.

Overlapping with this matter, within the past year, the Centers for Medicare and Medicaid Services have been approving the use of telemedicine (the psychiatrist is not local and a video cam is utilized). This is a good idea but loses significant effectiveness if the local provider cannot interface with the telemedicine end of things. Continuing cuts in public mental health causes loss of providers and since necessity is the mother of invention, telemedicine was certainly something to be considered. At this time, the Balsam Center, associated with Smoky Mountain Center LME, is considering bids for telemedicine contracts.

Recently, a client of mine with a well known (to the local police and hospital) mental health challenge was taken to the Hazelwood jail facility where she was left for five days without any of her medication; this endangered her life. Prior to this event, she had been taken to the local emergency room where she was dismissed as ‘drug seeking’ due to a chronic pain condition which could not be treated by her primary care provider efficiently due to the NC Medicaid prior authorization demand, causing her to be without her non-narcotic medication for weeks.

At the Hazelwood jail in Waynesville, collect calls are apparently very expensive (thus, family members cannot become involved); the heat is shut off come bed-time at the jail; drinking water comes from the top of the toilet. Such treatment is even worse than what occurred last winter at Haywood Regional Hospital when the mentally ill man was chained to the hospital gurney for days before a mental health hospital bed could be found. The jail nurse saw my client exactly five days after she was admitted there and she saw no medication until her sister-in-law bailed her out.

When the police were called due to she throwing a salt shaker at her 17 yr old son due to the ‘unfortunate’ delusional side effects of Thorazine which had been prescribed for sleep by the Balsam Center telemedicine psychiatrist (this psychologist advised that psychiatrist’s nurse of worrisome side-effects of the Thorazine four days prior to the police being called), the client was advised by the police not to take her purse or meds with her. She was rebuked by the police due to her slurred speech and ‘Thorazine shuffle. ’ DSS was engaged due to her son being a minor.

She has never been in jail before but her bond was held in place by the court without any apparent attempt to consider her history of mental illness and multiple admissions which are not unrelated to the medication boondoggle created by NC Medicaid’s attempt to curtail usage.

Each time an ambulance is called it costs Medicaid about $500. Emergency admissions cost a lot more. When the police are called, they necessarily are not able to respond to other demands. NC Medicaid would do well to consider the strain that additional paperwork is creating such that psychiatrists are lost and providers in the community have less time to work with patients due to being demanded to fill out more paperwork.

Paperwork is nothing other than an attempt to truncate services by burying the providers so that they will not render services----or simply quit or avoid working with certain populations of citizens needing health care. Additionally, a refresher course regarding how to best work with citizens with known mental health challenges seems to be in order as regards the local Haywood County police.

Preventive care, coupled to efficiency, is money saved; emergency events cost a lot of money, impact multiple agencies which cost money to operate, and create profound hardships for citizens with mental and physical health challenges.

Thursday, February 18, 2010

Telemedicine : Psychiatry is using it w/ modifiers: why not Psychology?

Here is an e mail to my colleagues at the Div 42 listserv in order to try and determine if anyone in psychology knows anything about how to utilize telemedicine and why psychologists would be required to use a camera when they are not doing a physical exam ----particularly salient to (1) rural clients (2) rural clients trapped by snow (3) psychologists who know well their clients.

Anyone knows anything out there, give me a shout:

here is what I have asked of APA's Diane Pedulla ( and Tony Puente, PhD, whom was doing a lot of work on CPT coding for many years: thanks Tony for that good work):

"Hi Division 42, Independent Practice of the American Psychological Association listserv colleagues:

Medicare is beginning to utilize telemedicine. I have a lot of rural clients whom I see in their homes. I want to make the case that telemedicine would serve them well.

In western NC,which is mostly rural, Smoky Mountain Center LME, the administrator of mental health services, is utilizing psychiatric telemedicine and the director of emergency services indicates that there are modifiers associated w/ that.

Does anyone know about this re: the work that psychologists do? It seems to me that the purpose of the camera, if that is the sticking point, is associated w/ being able to identify the patient. If you KNOW the patient from having seen them, then why the need for the camera?

We're not doing physical exams such as would be useful, for instance, in psychiatry. And I can understand why the camera would be useful for emergency services in order to identify symptoms.

thanks and here is a bit of information I gathered a few months back:

"Sunday, September 06, 2009
Medicare's Telemedicine doesn't work if you don't have a computer w/ a camera

Well, I talked to an employee of CIGNA Government Services which oversees Medicare for NC; TN; ID (weird, true)....
Monday, August 17, 2009

Telemedicine arrives to Medicare


Wednesday, February 17, 2010

Obama administration asks for Mental Health Parity Act: that 'other' Kennedy is moving it forward

People who think the Obama administration is 'doing nothing' are not paying attention. He could beat on his chest and create some fan-fare but all this will create is more tea-bagging.

Comments are due by May 3, 2010.

Here are my comments:

"As a doctoral level psychologist whom treats people w/ Severe Persistent Mental Illnesses, the passage of federal mental health parity is an absolute necessity.

In North Carolina, in 2009, for instance, BCBSNC was allowed to OPT OUT of mental health parity by the NC State Legislature due to their undue influence on the NC STate Legislature. BCBSNC is the largest private insurer in the state of NC. BCBSNC is supposedly monitored by the NC State Legislature.

Thus, very obviously, until there is PARITY in terms of Utilization Review and what the insurance company can DO versus what they SAY----- little to no progress will be made as regarding mental health parity. Undue influence will continue to trump any efforts to obtain mental health parity.

Marsha V. Hammond, PhD: Clinical Health PsychologyNC Licensed Psychologist"

Federal Mental Health Parity Act proposed.

Comments can be stated here:

3 results for keyword "CMS-4140-IFC"
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Posted Date

Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008
Comments Due 05/03/10 11:59 PM ET

Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008
Comments Due 05/03/10 11:59 PM ET

Interim Final Rules under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008
Comments Due 05/03/10 11:59 PM ET

"Today the Departments of Health and Human Services, Labor and the> Treasury today jointly issued the following news release:>> Date: 1/29/2010> Media Contact: HHS: (202) 690-6145> Telephone: 240-276-2130>> OBAMA ADMINISTRATION ISSUES RULES REQUIRING PARITY IN TREATMENT OF> MENTAL, SUBSTANCE USE DISORDERS> Paul Wellstone, Pete Domenici Parity Act Prohibits Discrimination>> The Departments of Health and Human Services, Labor and the Treasury> today jointly issued new rules providing parity for consumers enrolled> in group health plans who need treatment for mental health or substance> use disorders.>> "The rules we are issuing today will, for the first time, help assure> that those diagnosed with these debilitating and sometimes life-> threatening disorders will not suffer needless or arbitrary limits on> their care," said Secretary Sebelius.>> "I applaud the long-standing and bipartisan effort that made these> important new protections possible.">> "Today's rules will bring needed relief to families faced with meeting> the cost of obtaining mental health and substance abuse services," said> U.S. Secretary of Labor Hilda L. Solis.>> "The benefits will give these Americans access to greatly needed medical> treatment, which will better allow them to participate fully in society.> That's not just sound policy, it's the right thing to do.">> "Workers covered by group health plans who need mental health and> substance abuse care deserve fair treatment," said Deputy Treasury> Secretary Neal Wolin.>> "These rules expand on existing protections to ensure that people don't> face unnecessary barriers to the treatment they need.">> The new rules prohibit group health insurance plans--typically offered by> employers--from restricting access to care by limiting benefits and> requiring higher patient costs than those that apply to general medical> or surgical benefits.>> The rules implement the Paul Wellstone and Pete Domenici Mental Health> Parity and Addiction Equity Act of 2008 (MHPAEA).>> MHPAEA greatly expands on an earlier law, the Mental Health Parity Act> of 1996 which required parity only in aggregate lifetime and annual> dollar limits between the categories of benefits and did not extend to> substance use disorder benefits.>> The new law requires that any group health plan that includes mental> health and substance use disorder benefits along with standard medical> and surgical coverage must treat them equally in terms of out-of-pocket> costs, benefit limits and practices such as prior authorization and> utilization review.>> These practices must be based on the same level of scientific evidence> used by the insurer for medical and surgical benefits.>> For example, a plan may not apply separate deductibles for treatment> related to mental health or substance use disorders and medical or> surgical benefits--they must be calculated as one limit.>> MHPAEA applies to employers with 50 or more workers whose group health> plan chooses to offer mental health or substance use disorder benefits.>> The new rules are effective for plan years beginning on or after July 1,> 2010.>> The Wellstone-Domenici Act is named for two dominant figures in the> quest for equal treatment of benefits.>> The late Senator Paul Wellstone (D-MN), who was a vocal advocate for> parity throughout his Senate career, sponsored the ultimately successful> full parity act.>> He was joined by former Senator Pete Domenici (R-NM) who first> introduced legislation to require parity in 1992.>> Champions of the legislation also included the bipartisan team of> Representative Patrick Kennedy (D-RI) and former Representative Jim> Ramstad (R-MN).>> The issue of parity dates back over 40 years to President John F.> Kennedy, and was also supported by President Clinton and the late> Senator Edward Kennedy.>> The interim final rules released today were developed based on the> departments' review of more than 400 public comments on how the parity> rule should be written. Comments on the interim final rules are still> being solicited.>> Sections where further comments are being specifically sought include so-> called "non quantitative" treatment limits such as those that pertain to> the scope and duration of covered benefits, how covered drugs are> determined (formularies), and the coverage of step-therapies.>> Comments are also being specifically requested on the regulation's> section on "scope of benefits" or continuum of care.>> Comments on the interim final regulation are due 90 days after the> publication date. Comments may be emailed to the federal rulemaking> portal at: .>> Comments directed to HHS should include the file code CMS-4140-IFC.>> Comments to the Department of Labor should be identified by RIN 1210-> AB30. Comments to the Treasury's Internal Revenue Service should be> identified by REG-120692-09.>> Comments may be sent to any of the three departments and will be shared> with the other departments. Please do not submit duplicates.>> Contacts:>> HHS: 202-690-6145> DOL: 202-693-8666> Treasury: 202-622-2960>

Wednesday, February 10, 2010

NC DHHS Medicaid Waiver Plan: Trojan Horse?---and what are its dimensions?

There's serious stuff cooking re: these Medicaid waivers as per the Jan, 2010 NC DHHS implementation memo: see here:

Which LME's will be chosen? Why will they be chosen? Will smaller providers be hounded out of business?

There is a legitimate place for small or solo providers. I see people in their homes in rural western NC and there is no public transportation outside of Asheville, NC.

Here is the kernel of the Medicaid wavier matter as per that implementation memo:

"Medicaid Waiver Amendment Submission

The North Carolina Department of Health and Human Services (DHHS) announced in the December Medicaid Bulletin and in Communication Bulletin #106 that DHHS is requesting approval from the Centers for Medicare and Medicaid Services
(CMS) for a mental health, developmental disabilities and substance abuse service waiver program.

The Waiver Technical Amendment was submitted to CMS on December 16, 2009. The model for this waiver amendment is based upon the current 1915 b/c waiver that has been operating in Cabarrus, Davidson, Rowan, Stanly, and Union counties since April 2005. The existing waiver is currently administered by the State through PBH (formerly known as
Piedmont Behavioral Healthcare), a local management entity for the delivery of publicly funded mh/dd/sa services. PBH has been working in partnership with DMH/DD/SAS and DMA in support of this waiver expansion request to CMS.

DHHS is asking to replicate PBH’s model with some additional amendments to the current 1915 b/c waiver application and make the waiver statewide with the ability to phase in new LME waiver entities. PBH as a waiver entity, starting as a pilot project, has demonstrated for the state the success of this model. Since 2005 DMA has contracted with Mercer to assist
both Divisions in providing annual monitoring. Based upon the success of this model, DHHS wishes to expand the use of the waiver program.

Based upon CMS approval of the waiver expansion PBH will become part of the State’s Waiver expansion. DMA and DMH/DD/SAS are currently contracting with Mercer to assist in the development of a Request for Applications (RFA) and selection criteria of local management entities who may be interested in becoming an LME waiver management entity.

DHHS plans to methodically select and add on additional LME wavier entities to operate in the same capacity as PBH as a prepaid health plan for the delivery of mh/dd/sa services. The tentative process and timeline for the Request for Application is as follows:
· Prepare and post RFA --- Target date: February 2010
· RFA applications due to DMA/DMH: April 2010
· Desk review and site review of RFA applicants: April - May 2010
· Announcement of selected LME waiver entity(ies): July 2010
· Waiver start date: July 2010 or dependent of several factors:
o Dependent upon CMS approval of submitted Waiver Application Amendment
o Approval of a New Technical Amendment to bring on the new geographical region of the LME waiver entity approved by CMS.
o Transitional timeline of the new LME waiver entity timeline to begin full waiver operation activities.

DHHS will select one or two LME waiver entities to begin operation during SFY 2010/2011 if approved by CMS. An official announcement will be made concerning sites selected to participate in the program. DHHS will issue additional RFAs in the future to establish more LME waiver entities across the state based on the success of waiver programs.

DHHS is planning specific ways for consumers, family members and the general public to participate in the development, implementation and oversight of this project. Additional information about this 1915 b/c waiver will be provided through designated DMA and DMH/DD/SAS waiver web pages, the joint Implementation Updates, DMA Medicaid Bulletins and a special series of waiver Fact Sheets over the course of implementing this project."

NC Medicaid Moves to Disenfranchise Rural Citizens with Mental Health Needs using LME's as authorizing agents

Marsha V. Hammond, PhD Clinical / health PsychologyNC Licensed Psychologiste mail: cell: 828 772 1127

February 11, 2010

Dear Cheryl Brimage of Centers for Medicare & Medicaid Services (; direct line: 404 562 7116 ):

I understand that you are the the CMS coordinator as associated w/ the proposed Medicaid waiver vis a vis the Piedmont Behavioral Health model which would demand that the LME's oversee Medicaid authorizations. Certainly, efficiency and cost containment is important, even critical.

Unfortunately, the LME's are not efficient and mental health care patients as well as providers will be severely affected if the LME's are allowed to drive mental health care completely in the direction of favoring large mental health care companies. And that will be the agenda. And with that agenda will come mountains of paperwork which only a large company can create. And they will not be creating superior mental health care but simply massive amounts of paperwork that give some illusion that mental health care is taking place.

I work w/ many indigent Medicaid patients. NC Medicaid is very simple to work with: billing is easy; authorizations go thru seamlessly. I follow my clients carefully; they can call me anytime of the night or day; I see them in their homes.

Do you think that a large provider------which is what this Medicaid authorization process will give incentive to------will see the patients in their homes? Western NC, outside of Asheville, NC, has no public transportation to speak of.

Contrarily, my experience w/ the LME's, inclusive of Western Highlands Network LME and Smoky Mountain Center LME has has been exactly the opposite. I do not mean to imply that they are not well meaning people. I mean to clearly state that these two LME's, which cover over 25% of NC 100 counties have created such mountains of paperwork that I refused to work with state funded clients over a year ago. I don't think they concocted the paperwork; I think it was demanded by them as per CMS and NC DHHS.

A system that allows small providers to function is a system that provides efficient mental health care to rural Medicaid clients.

State funded clients, as you may or may not know, are the patients that NC Mental Health Reform was supposed to cover and these clients were to have had access to their choice of health care providers. Those notions flew out the door several years ago related to the mountains of paperwork and impossible authorization process demanded by NC DHHS and created by the LME's, the managers of mental health care in NC.

Now I hear that these LME's are going to oversee Medicaid authorizations. The only money that will be saved will be associated with strangling the health care providers by demanding umpteen requirements to be on a panel when all that should be necessary to know is that I am licensed as a psychologist in NC.

I simply cannot do my work which is to treat people w/ serious persistent mental health challenges and do the paperwork which the LME demands which is nothing more than a strategy to cut out the services and severely truncate my ability to make a living.

I left you a message today on your phone and I look forward to hearing from you soon. If you want an efficiently operating system associated with RURAL mental health care in NC, you will see to it that the small providers are allowed to continue to work efficiently.

Please feel free to pass this to pertinent person or entity. It has been posted on my NC Mental Health Care reform blog.

Please see my recent publication at the NC Medical Journal on exactly this topic.

Marsha V. Hammond, PhDLicensed Psychologist,

Thursday, February 04, 2010

LA Times: Health Care Outpaces Economy Growth: DUH: why might that be?

Add your comments to the LA Times article here:,0,1362585.story

Soaring cost of healthcare sets a record
Spending was 17.3% of the economy last year. The share paid by the U.S. will soon exceed 50%, a study says.

COMMENTS (7) Add Comment

With rising unemployment,the hidden variables of mental and physical health care challenges looms behind the scenes. When people lose their jobs, their mental health concerns accelerate.In terms of their physical health, they lose access to 'amenities' such as healthy food and going to the gym.

The linking of 'inefficiency', in the article, to state and federal governments, is a red herring intended to draw one's attention away from the significantly greater inefficiency of the private health care business.

Medicare, which insures the disabled, utilizes 2-6% of its funds (depending on how the expenses are broken down) on administrative costs. Private health care companies dump these patients, termed to be high-rate medical utilizers.

BCBSNC, the largest private medical insurer in NC spent 15% on administrative costs in 2008.

The inefficiency of Medicare could be reigned in if competition was created for Durable Medical Goods (DMG) and because Big Pharma has lobbied a gullible, though well compensated, Congress in order to block competition.Disabled people on Medicare utilize DMG's for the most part. Contrarily, the inefficiency of private health care companies will only take place if the maddeningly repetitive administrative costs are done away with by creating competition so that the numbers of companies will shrink & drown in the bathtub.
MadameDefarge (2/4/2010)


Here are excerpts from the LA Times article

"Reporting from Washington - In a stark reminder of growing costs, the government has released a new estimate that healthcare spending grew to a record 17.3% of the U.S. economy last year, marking the largest one-year jump in its share of the economy since the government started keeping such records half a century ago.....

In the absence of change, the report raises a grim prospect for the country -- a healthcare system consuming an ever greater and potentially unsustainable share of the economy even as private health coverage lags.Last year, CMS estimated that government spending on healthcare would not overtake private spending until 2016, compared with 2011 or 2012 in the current report.....

Federal and state spending on Medicaid, the nation's primary health insurance program for low-income Americans, jumped nearly 10% in 2009, according to the report. Medicare spending, meanwhile, shot up just over 8%.....

CMS officials noted that healthcare spending has been increasing even as the number of Americans without health insurance is growing, another sign of problems with the system.....

Inefficiency is becoming a particularly acute problem for state and federal governments, which the report shows are increasingly supporting the nation's healthcare system....."

NCMJ: 'Trickle Down' Blew Past the MH Providers w/ Their Fingers in the Leaky Holes:thanks for all you do

accepted to the North Carolina Medical Journal:

on the matter of working w/ the Severely Persistently Mentally Ill vis a vis the role of the mental health provider sanguinely holding their finger in the leaking holes:

NC Med J November/December 2009, Volume 70, Number 6

Readers’ Forum

".....A bittersweet moment took place several years ago inwestern North Carolina as former director of MHDDSAS,Michael Moseley was speaking to a small audience atWestern Carolina University, describing the emperor’s newclothes in terms of how well North Carolina mental healthreform was moving along. This was the same day that thelargest private company, which insured 10,000 for mentalhealth care, was collapsing two counties over.

The chaotic churn of the disinvestment, which could havebeen anticipated but not avoided after the fact, coupledwith the refusal or inability of the LME’s utilization reviewdepartments to authorize and reimburse for mental healthcare for uninsured, state-funded clients as rendered bywilling, independent providers, has not just dissuaded me,but blocked me from working with this patient population.

One of the original tenets of North Carolina mentalhealth reform, which sits at the heart of insurance policiesassociated with choice of providers, is to support thelivelihood of the smaller providers who work outside themainstream currents.

While the Journal’s issue was devotedto blocks of providers, be they within private, for-profitcompanies, or working at free clinics, bear in mind theusefulness of providers who have their limited number offingers plugged into the holes of the dyke.

Marsha V. Hammond, PhD,Licensed Psychologist"