NYT: Insurance Companies Duke it Out over 80 Cents On The Dollar To Be Used Towards 'Welfare of Patients':State Legislators at Risk 4 Secret Deals

whew: leave to a Rockefeller to speak the truth:.....

BCBSNC has a 'liason' committee which 'interfaces' with the NC State Legislature. NOTE: the suffixes of said committee all indicate alliance w/ BCBSNC (see: http://madamedefarge2scutinizingbcbsnc.blogspot.com/

NYT
July 23, 2010For Insurers, Fight Is Now Over
By REED ABELSON

http://www.nytimes.com/2010/07/24/business/24insure.html

".....The legislative battle over the health care overhaul ended months ago, but it is hard to tell from the intense effort now under way by insurance companies to retool a critical provision.The law requires health insurers to spend at least 80 cents out of every dollar they collect in premiums on the welfare of patients, a critical issue for the companies’ bottom lines.....

But state regulators are only now deciding what precisely that means, as they draft the rules to enact the law. WellPoint, (gee, that's the company that just turned down some charges I sent in utilizing guidelines which Medicare adheres to but which they, as a 'pretend Medicare' company ----Medicare Advantage---dontyaknow----company---do not adhere to) which operates Blue Cross plans in more than a dozen states, wants to include the cost of verifying the credentials of doctors in its networks.

Insurance companies like Aetna argue that ferreting out fraud by identifying doctors performing unnecessary operations should count the same way as programs that keep people who have diabetes out of emergency rooms.Some insurers even insist that typical business expenses — like sales commissions for insurance agents and taxes paid on investments — should not be considered part of insurance premiums, which would make it easier for them to meet the 80-cent minimum.But consumer advocacy groups and others see the insurers’ proposals and their lobbying for a more expansive definition of what would be permitted as an effort to water down the law by including too many administrative costs under the umbrella of patient care. “A lot of what they are hoping to shift over there does not — and should not — qualify to improve an individual policyholder’s quality of care,” said Wendell Potter, a former insurance executive who now is critical of the industry and represents consumers in the discussions with state regulators.

On Tuesday, Senator John D. Rockefeller IV, Democrat of West Virginia, sent a letter to regulators expressing his concern that the insurers could have too much influence on how the regulations were being drafted. By his reckoning, insurers and their compatriots have submitted nearly 160 comment letters, totaling more than 600 pages, to the state regulators. Consumer advocates have submitted just 23, he wrote.“The health insurance lobbyists failed to beat the health care reform bill in Congress — but with billions of dollars at stake, we cannot and we should not expect them to throw up a white flag and start looking out for the livelihoods of American families,” Senator Rockefeller said in a statement. “They’re working every angle of the implementation process to shirk their obligations under the new law.”At stake, according to a report issued Thursday by Health Care for America Now, a coalition that supports the new law, is hundreds of millions of dollars when the law goes into effect next year. If the six largest for-profit insurers had had to meet the new standards last year, they would have been required to refund $1.9 billion, the coalition said.

NC's Needs Increase While Per Capita Spending Drops by 6.4%

From the desk of NC State Representative Verla Insko, of Orange County, co-chair of the Joint Legislative Oversight Committee on Mental Health Reform:

"The table shows a few interesting things over this time period:

1. The state budget has increased .4 percent ($92 million)
2. Population has grown 7.3 percent (650,000)
3. K-12 enrollment inched up 2.9 percent (41,000)
4. UNC enrollment grew 9.8 percent (20,000)
5. Community college enrollment jumped 27.7 percent (53,000)

The state is doing more with its money. Budgets are stretched, despite claims there have been no hard choices out of this legislature. Per capita spending in actual dollars (not adjusted for inflation) has fallen from $2,127 to $1,991, a decline of 6.4 percent. "

MH Reform Delayed Two Months Affects the Private Companies,not the Individual Professional Providers (Unless They Are Employed by the Private Company)

Recent article by reporter covering mental health concerns on a consistent basis:

http://www2.journalnow.com/content/2010/jul/01/010240/mental-health-reform-delayed-two-months/

".....For months, the N.C. Department of Health and Human Services stressed that only agencies certified as CABHA would provide services in five key categories as of today. Those that did not qualify, or chose not to, would have their clients involuntarily transferred to other agencies.

The categories are: case management; peer support for recovery initiatives; community support teams for adults; intensive in-home treatment for children; and day treatment for children and adults dealing with issues such as substance or sexual abuse....

"I find it amazing how the state does business and changes the rules on a dime," said Judy Briggs, the chief executive of Carolina Behavioral Health Alliance and a local mental-health advocate. "I cannot imagine how difficult it must be for providers. You will never accomplish efficiencies when the rules constantly change."'
_____________________________________________________________
My comment:

"Let's be clear: the 'sickest' (SPMI: Severe Persistent Mental Illness) clients are still being seen by well qualified professionals IF they have Medicare/ Medicaid/ 3rd party insurance. I bill directly to Medicare/Medicaid/ 3rd party and am always paid. I'm not going broke. However, I provide therapy services not the four services which are being covered here and which is concerned w/ the private companies which cranked up when NC mental health reform began almost 10 yrs ago now. This being said, w/ the collapse of Community Support Services, my therapy gets done, not uncommonly, while I drive the client around to get things done that CSS used to do. So, the state can pay the psychologist the fatter rate to take care of issues or pay attention to the very real needs of the clients---MANY which are associated w/ transportation issues. One of the PURPOSES of NC Mental Health Reform was to provide mental health services to those WITHOUT insurance and THAT is the service is long gone and is breaking NC Medicaid as people move onto the Medicaid roster. Marsha V. Hammond, PhD"
__________________________________________________________
So, NC Mental Health Reform, at a meta level, if you will, had, as an agenda to 'unify' mental health services but alas, the only providers who are not sucking wind and wince everytime NC DHHS takes another sharp turn on the road and runs into a ditch-----are the solo providers.

You can't work for an organization and stay alive vis a vis this NC DHHS.


__________________________________________________________

NC State Teachers and Employees Will Have No Mental Health Parity

"Letter: Private-pay psychotherapy works

http://www.reflector.com/comment/reply/40184#comment-form

Friday, July 2, 2010

The North Carolina State Health Plan for teachers and state employees has recently announced that it has opted out of parity for mental health treatment. It is truly unfortunate that mental illness is not treated by the insurance industry with the same care or respect as physical illness.

But we may take this opportunity to recall that psychotherapy has not always been about mental illness. There have historically been and continue today to be many forms of psychotherapeutic treatment that target much more broadly defined goals, such as “feeling better.” Research has repeatedly found that psychotherapy can help increase well being and enhance social functioning....."
___________________________________________________________

This is my comment to the article:

"I am flummoxed by the announcement associated with this chatty article that indicates that for state and teacher employees, there will be no mental health parity BUT this is something good to have access to. What??

This is, unfortunately, nothing new, because the NC State Legislature allowed BCBSNC to 'opt out' of mental health reform law two years ago. Besides mental health services, BCBSNC disallows or makes so difficult that you could consider it disallowed, other important services,such as screening colonoscopies for their insured over age 50.

Medicare and Medicaid will pay for mental health services and they pay adequately for this doctoral level psychologist. Indeed, in using Health & Behavior code billing, the 96152 series of the CPT codes, I am paid at 80%,which is the same level as physicians and physical health billers are paid. If I put in a 'therapy code' e.g., 90804, 90806, 90808, I will be paid the miserable 50% rate. In that Medicare is always primary and Medicaid is secondary,for dually eligible clients, even if I use those 'therapy codes' I am still paid pretty well.

If I have clients that have Medicare ONLY, because they have a few too many assets, say, like they are paying for their trailer in rural NC, then they are deemed to be too 'wealthy' to get to Medicaid and would have to go thru that dreaded 'doughnut hole' which is about $5000.00 of costs before their Medicaid can kick in.

Humana, what I call a 'pretend Medicare' company (remember: tax payers are upshoring these companies to the tune of 18% administrative rates versus less than 5% for Medicare: 'drowning government' is therefore idiocy) will pay for 90808 (70-90 min psychotherapy, which is more useful than 45 min) fairly well, fortunately.

The NC State Legislature has a 'special committee' that 'interfaces' w/ BCBSNC. The members of that committee are: Rand Tonyr@ncleg.net NC senator; Hughh@ncleg.net; Lindac@ncleg.net; Mitchells@ncleg.net; Charlied@ncleg.net; Davidh@ncleg.net; Lindag@ncleg.net; Jamesf@ncleg.net; Danielc@ncleg.net; Jerryd@ncleg.net; Beverlye@ncleg.net; England..Bobe@ncleg.net.

Moreover, if you look at the e mail address suffixes of those BCBSNC liasons---interfacing w/the above state legislators, they are BCBSNC company suffixes. Thus, the 'legislative liasons' are employees of BCBSNC and they directly tell the NC State Legislature members what to do----and they do it.

There won't be any mental health parity until the government that the private companies are trying to drown are seen to be swirling down the drain.

There won't be any reasonably obtainable screening colonoscopies until 2014, when everyone will get health insurance.

My best advice to people without health insurance,such as myself (I will not pay BCBSNC $1000/ month for three healthy family members w/a $2500 deductible) is to gather up all your medical records, look sick as a dog, get rejected by a private company, and then hike over to Medicare where you can get some REAL health insurance prior to 2014.

Why, you might even be able to get a colonoscopy which could detect colon cancer, associated w/the second most common cancer death. As it is, I would have to drive 3 hours to get to a BCBSNC gastroenterologist to have a colonoscopy that they would pay for, with me paying the specialist fee of $30.

Everyone of those BCBSNC liasons should be made to hold onto a Fleet's enema for 3 hours as just payment for what they help create every working day."

Appalachian Counseling Services Contract is Good for One Year Only for Largest LME in NC: Government 'Drowning'' Leads to Revolving Door Services

....on drowning the government (so we can have revolving door services: gee, such an improvement, particularly when it comes to relationships that are in place for years at a time for people with mental health challenges):

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

"Grover Glenn Norquist (born October 19, 1956) is president of anti-tax advocacy group Americans for Tax Reform. Norquist is a member of the board of directors of the National Rifle Association[8] and the American Conservative Union.[9]........Norquist favors dramatically reducing the size of the government.[11] He has been noted for his widely quoted quip: "I don't want to abolish government. I simply want to reduce it to the size where I can drag it into the bathroom and drown it in the bathtub."[26]
_________________________________________________________________
So, as per the bidding process document obtained from SMC LME administration, the contract is good for one year only (perhaps this is state mandated).

This means that next year, the next provider company could outbid Appalachian Counseling, thus destabilizing the mental health services again: more revolving doors (I guess when you 'drown'government, the next level of hell is the revolving door level).

The information regarding the pdf proposal is available from SMC LME (828 586 5501) and this is its title: REQUEST FOR PROPOSAL Array of Services: Mobile Crisis Management, Walk-in/PsychiatricCenters, and Facility-Based Crisis Seven county service area of Cherokee, Clay, Graham, Haywood, Jackson, Macon,and Swain Counties.

It states: "The proposed contract term for this service will be from July 1, 2010 (or effective upon contract execution date, whichever is later) through June 30, 2011 and renewable for additional terms up to one year."

Marsha V. Hammond, PhD

SMC LME Divests all Clinical Services to Appalachian Counseling While Meridian Glowers in the Corner: Revolving Door Mental Health Services R Us

You can make your own comment at the Asheville Citizen Times:

http://www.citizen-times.com/article/20100701/LIVING/307010029

Mental health providers change in far west WNC
BY NANCI BOMPEY • JULY 1, 2010

drhammond wrote:

"With the complete divestment of Smoky Mountain Center (SMC) LME of clinical services, is fully realized the original intention of NC Mental Health Reform as re: western NC. Government has effectively been ‘drowned.’ Oh, I forgot: consumer 'choice' was at the top of the original ‘want it’ list (got dumped years ago).

Doug Trantham, the excellent Director of Clinical Services while at SMC LME, as well as all the nurse practitioners & psychiatrists at The Balsam Center, are now employees of Appalachian Counseling: a revolving door. My clients had to sign waivers to have paperwork transferred from one pile to the other pile.

As was predicted, the bigger fish, in this case Appalachian Counseling, have simply outbid and (temporarily?) swallowed the smaller fish. Chaos reigns and capitalism, in an industry full of non-insured citizens, succeeds (?!). Soon, someone will outbid them & paperwork will again transfer.

Marsha V. Hammond, PhD http://madame-defarge.blogspot.com/ "
_________________________________________________________
The article:

"....
Jim Pitts, president of the local and state chapters of the National Alliance for Mental Illness, said Smoky had a good reputation and hopes the services it provided will continue.

“I'd say patients and the public ought to be concerned when there is no public provider,” he said. “The private providers do well under the state regulations … but without the regulations they will drop services that aren't paying for themselves.”

The move from Smoky to Appalachian and Haywood Regional is in line with the state's newest regulations that seek to have mental health services provided by fewer, larger providers, said Brian Ingraham, CEO of Smoky Mountain Center.

“We understand that this is going to be a long-term relationship and a commitment to sustain these services,” Ingraham said. “We are not going to let it fail.”
________________________________________________________________

My additional comment to the article at the Citizen Times:

"And so how is Mr. Ingram of SMC LME going to keep other businesses from under-bidding Appalachian Counseling? That would be called favoritism, wouldn't it? And since we're adhering to a capitalistic model where 'efficiency' and 'cost' trumps all else, that would call for a lawsuit associated w/ anti-trust violation issues. The agency that is now handling The Balsam Center simply outbid the other company, which was Meridian, which spun out of the administration of Smoky Mountain Center 10 years ago: another revolving door.

Best I can tell, whomever sits in the driver's seat simply glad-handed better than the other guys. God knows what 'glad-handing' is associated with (makes me want to pull the sheet over my head). Mental Health consumers and providers would do well do look at the bidding process which allowed Appalachian Counseling to trump Meridian. A FOIA request is on its way. Marsha V. Hammond, PhD NC Mental Health Reform : http://www.blogger.com/"