Friday, January 14, 2011

Two Models of Comparison: NC DHHS's CABHA model vs Well-trained Available and Mobile Mental Health Provider

There's a lot of talk about CABHA, the newest version of NC Mental Health Reform to be rolled out starting 1.1.2011.

Here are some comments re: CABHA from mental health advocates across NC. Secondly, I present a model which I think works superiorly to that administratively-heavy model.

HI all:

Here is Dr. Hammond, Licensed Psychologist, whom has created another model (and there are lots of Dr. Hammond's out there, perhaps------whom operate beyond the confines of CABHA).

I continue to stay outside the CABHA loop and bill directly to Medicare/ Medicaid/ 3rd parties. My license as a psychologist allows me to do this.

Moreover, best I can tell, I perform most all the duties of the CABHA: I provide high quality therapy; I wrap around to primary care physicians and specialists by phone and letter; I cross link across Departments of Social Services, physicians, attorneys, probation officers, and clients. Another name for this is case management. This is an item associated w/ CABHA services as is therapy or outpatient therapy.

You might recall that Governor Perdue was keen on case management. This is a mistake, in my estimation, as a case manager does not stay 'close', if you will, to the client, whom, I might venture to say, is empowered by being included in the process of 'getting better.' Case management is all about creating paperwork which inches its way through a system in an attempt to get things cranked. Enough already, I say.

So, contrary to case managers, I know the clients and their families very well as I see them regularly--- and in their homes.

The only thing I don't provide is intensive in home therapy; no, I'd have to say that as re: families I see, what I try to do is PREVENT things from going to that intensive level.

And I don't see state funded clients because the paperwork does not get paid for and I didn't earn a PhD in order to fill out paperwork well.

Additionally, I believe I save NC Medicaid money by keeping people out of the psychiatric hospitals due to my availability. As you might surmise, people really do not like going into a psychiatric unit and will do a lot in order to avoid having their freedom removed, even for a few days.

I'd say that the most valuable property of any mental health service is AVAILABILITY; MOBILITY is a subset of being available as many people w/ mental health issues have transportation challenges.

Moreover, I might suggest that the quality of the system can be evaluated as associated with the paperwork requirements: a lot of paperwork means, implicitly, that the system that was created is burdened by run-away administrative costs, inefficient, and commonly not helpful to the client in a timely manner.

All my model requires is that I be mobile----that I see my clients in their homes----a subset, as I stated, of availability. This works well in rural western NC and I have a zip no-show rate and command a decent salary. Additionally, the IRS provides a nice tax deduction in terms of mileage as associated with business costs impacting my salary.

Thus, to my mind, the mental health model that works for clients and assumeably practitioners, is associated with mobility and availability. This attends to the nature of mental health issues. Strike while the iron is hot in terms of issues and you can make a lot of progress in terms of clients learning how to handle their own challenges---such that they get it 'right' or at least 'better' the next time around. Thus, they are empowered and become more self sufficient and move away from spending the mental health care $$.

If CABHA is heavy w/ paperwork, it won't work; moreover I assume it appears that NC DHHS still has not figured out that paperwork has nothing to do w/ mental health care (this is probably too radical a thing to expect of such a large organization, frankly). If you are using licensed or certified or appropriately qualified providers, you can get the work done efficiently as long as you remember what their expertise is and its not in doing paperwork.

This is why we need a one-provider medical system (remember that?): because administrative work, inclusive of paperwork, weighs down the system and diminishes availability and mobility which is what must be in place re: the mental health care business.

Marsha V. Hammond, PhD, Licensed Psychologist, Asheville, NC

Here is a comment outlining an advocate's concern re: CABHA:

Lets see if I understand all the issues in this email:

1. Why was there not consumer input?

2. Who thought of CABHA?

3. Who are they accountable to?

4. Will it be another “boondoggle” as described in the email

Just my opinion …

1. There was lots of consumer input but indirectly…….community support rolled out, LME s divested and everyone had a fit because EDs filled up and state hospitals filled up. Community support agencies treated kids and Medicaid, statistically speaking and fraud was prevalent. Everyone wanted something different and things had to move quickly

2. Who thought of it? Well that is a good question. It is not rocket science…..lets see the Area Program model with limited dollars worked. You have similar safety net type models with local health departments and DSSs…..and then you had PBH that had a comprehensive provider model that seemed to work. The state could not manage a 1,000 providers billing the day lights out of Medicaid community support. So it is not a stretch or some conspiracy to say that the state leaders did not have to look far to see what direction to drive the ship in. They just had to decide on what to call it.

3. Who are CABHAs accountable for……in a non-waiver area they have many masters. They are accountable to the State, the LME and the Feds. In waiver areas it is just accountable to the LME for they control all state, local and federal dollars.

4. Will it be another mess……….well it should prove to be less of a mess at worst. But the reality is that the devil is in the details. This good idea has not gone without its glitches. For example, the large number of CABHAs has increased supply and demand on MDs and that has driven up cost beyond reimbursement rates. Then you have child and adult CABHAs. Well what means is the child CABHAs will be Medicaid funded and adult CABHAs will limit the indigent they see and treat only Medicaid when possible or they will take their Medicaid earnings to support the indigent adults. Fat chance with a private company of that happening. Just my opinion but CABHAs need to be CABHAs, not child, adult or SA. You don’t have a local DSS to have a child DSS or an Adult DSS do you? No, they have different units within the same DSS because it is cheaper, creates synergy between professionals and is less confusing to folks needing the service. So a boondoggle? I don’t know. Growing pains, yes. Step in the right direction? Yes.


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