Monday, November 28, 2011

Medicaid Waiver Double Talk Straight from the Horse's Mouth : NC Mental Health Reform Was Supposed to Be About Choice (Until PBH Got Involved)

Here is my response to Betty Taylor's (Betty Taylor is the CEO and area director of CenterPoint Human Services) article re: the Medicaid Waiver which is about to sweep across NC re: trying to reduce the cost of NC Medicaid. It won't work and the reason it won't work is that it is predicated upon issues that don't have to do w/ the cost of mental health care vis a vis the quality of services-----for NC medicaid clients.

Here is the NC DHHS outline of how this wholesome waiver is gaining ground across the state:

The private health care companies will simply not offer services (hey: it looks cheaper on paper) and it will appear, in terms of accounting (REMEMBER: Lanier Cansler who heads up NC DHHS is an accountant not a mental health person) that things are improving. One of the primary tenets of NC Mental Health Reform was to offer CHOICE to clients/ consumers. And I challenge ANY mental health care company to offer high level outpatient mental health services in the homes of clients like I do. I'm not necessarily bragging about this but it does get the services to the clients and I have a zip no-show rate.

And so, what is being proposed as per this article and as re: the Medicaid Waiver, is a 'CLOSED NETWORK' which will necessarily drive the quality of care down and the cost UP. You'll have less qualified people offering less professional services and you can bet my bottom dollar it won't be in the homes of the clients.

Here is the article from the Winston Salem Journal and below that is my comment.

Betty Taylor: Waiver changes will impact consumers and providers

"....On Oct. 31, 2011, CenterPoint Human Services received approval to be a 1915(b)/(c) waiver site. As CEO of CenterPoint, the Managed Care Organization or "MCO" that will implement the waiver for Forsyth, Stokes, Davie and Rockingham counties, I want to share with you what this means for our community.

Your first question may be what is a "waiver"? The Social Security Act sets out requirements that must be satisfied before Medicaid will pay for services unless the state has federal approval to "waive" them. North Carolina received federal approval to "waive" two sections of the act in its provision of Medicaid-funded mental-health, substance-abuse and intellectual/developmental-disability services. Waiving §1915(b) allows North Carolina to implement managed-care delivery systems for these services while waiving §1915(c) allows long-term care services to be delivered in community settings instead of institutional settings.

Most of us agree that receiving care near home instead of in distant state facilities is a good thing. Unlike concerns with commercial, for-profit managed care, implementing a publicly managed care-delivery system also has benefits. Access to services is increased, quality is continually assessed and stakeholder input and education is key. It is up to the MCO in our community, CenterPoint, to assure these results. With wise management of funds, any remaining funds will be reinvested in the community to create additional services.

There are changes under the waiver that impact consumers and providers. Without a waiver, the Social Security Act requires that any "willing and able provider" be allowed to deliver and bill for Medicaid-funded services. This is called an "open network." Under waiver the MCO is not required to contract with all providers and a "closed network" can be created. The MCO is charged with analyzing local needs and designing its provider network to address those needs. In the closed network, consumers still have choice, although it is not unlimited. CenterPoint will maintain an open network in the first year of waiver operation allowing providers the opportunity to demonstrate their value in being included in the closed network in the second year.

North Carolina has toyed with expansion of waiver for several years as a way to contain Medicaid costs and to raise the bar on service quality. PBH, a MCO serving Cabarrus, Davidson, Rowan, Stanly and Union counties, launched its publicly managed waiver in 2005. The state watched closely and asked questions about outcomes, efficiencies, access to services and consumer responses. During this period, North Carolina experienced multi-million dollar Medicaid cost overruns for a service called Community Support. At the same time, PBH had no such economic issues and legislators noticed...."


(Here is my comment place in the paper):

What a lot of double talk is being foisted on the public here.

First of all, let's write in clear English and/ or use an editor at the paper please. Is the Medicaid waiver associated w/ only substance abuse and developmental disabilities ONLY? I declare: this is news to me and its a very important point I might expect that this is not MOST of the people with Severe Persistent Mental Health challenges aka Medicaid consumers.

Secondly, there is no longer, for the most part, since 1970, as associated w/ Wyatt v Stickney (see FRIDAY, NOVEMBER 18, 2011: Ricky Wyatt of Wyatt v. Stickney Passes:Wyatt v. Stickney 1970 Case Discharged Thousands of Patients to Community Mental Health: mental health care at a psychiatric hospital far removed from the residence of the citizen seeking mental health services. Outpatient Mental Health Care is where we've been heading and utilizing for the past 30 years.

Thirdly, re: the matter of 'open network', excuse me, but NC Mental health Reform was supposed to be about CHOICE and this provider, for one, provides services IN THE HOME of the client. So tell me, CenterPointe, that you can improve on that. I am a solo independent psychologist and I make a decent living doing just that.

Fourthly, the need for the waiver is not 'intensified.' See above.

Fifthly, (this seems silly: Point Number 5 and proceeding): show me the stats on the 'over-run' re: Medicaid services. What I suspect is being alluded to is Lanier Cansler's predecesor's 'over-run' re: the poorly planed Community Mental health Services. What i see taking place now is an appropriate use of Case Management, for the most part. This being said, most case management which is paid for by Medicaid NC/ NC DHHS is mostly paperwork and is not face to face contact hours w/ the client. That's what I DO.

Point Number 6: How nice to acknowledge the following: "Waiver changes will impact consumers and providers" (see: TUESDAY, OCTOBER 18, 2011: Piedmont Behavioral Health (smack! slurp!): How Can We Help You Out re: Collapsed New River LME (AND SHRED YOUR PUBLIC RECORDS LAWS; )

Point Number 7: my grammatically tuned ear is wincing under the statements like "...Now waiver will be in operation..."

Marsha V. Hammond, PhD, Licensed Psychologist, NC
NC Mental Health Reform blogspot since 2007:

Friday, November 18, 2011

Ricky Wyatt of Wyatt v. Stickney Passes:Wyatt v. Stickney 1970 Case Discharged Thousands of Patients to Community Mental Health

I did part of my internship at the giant Tuscaloosa, AL state hospital, sitting right next to University of Alabama. It was a grind driving from Birmingham, past the mimosas in bloom, in my loaned VA vehicle (I had no car) in order to satisfy the criteria of my clinical internship. But I saw some things there that anyone who ever worked in mental health should see and I had excellent supervision.

In 1994, when I was there, they were lobbing off part of the large main building, second only to the Pentagon in size. For, you see, there had been over 30,000 patients warehoused there. When I was there, about 1000 patients remained. That is what an impact the Wyatt v Stickney case made and it all started at Bryce Hospital in Tuscaloosa, AL.

The patients who rode in sheriffs' cars down the tree-lined boulevard, just around the corner from the Crimson Tide campus---up to the administration/ admission building, lived there and died there; they kept the gardens that fed them and occasionally ran into the medical records department and grabbed documents revealing their sordid histories while the medical records person was busy somewhere else. And then they ran like the wind, holding tight their mental health records, never to be documented as mentally ill again (as did one friend I made in Birmingham, a street singer, indicated he had done. His history included singing alongside Pete Seeger and he didn't like it one bit that Bryce State Hospital had records indicating him to have a serious mental health issue. )

As I walked the wards at Bryce Hospital, I carried around a key ring of skeleton keys that had an entire soundtrack associated with them. I used them to let myself into locked wards and behind those doors were occasionally people who would rush them, trying to get out. There was madness in their eyes. There was Haldol in their systems; there were pink rooms where they could be straight-jacketed should they get too out of control; there were restless souls padding the halls at all hours.

And one of the more interesting assignments my supervisor gave me was to simply walk around and document what I 'saw' on the wards. And what I saw, in my fly-on-the-wall position, since I was after all a person of no importance, was nursing staff sitting at the ward desks, busy as bees, working away on their paperwork, while patients mostly patient stood waiting for long periods of time for someone to look up and acknowledge their existence. Or, if you stepped behind the desk, as I could, they would be in the nurse's small lounge in the very very old buildings, drinking coffee and talking.

And at the 'meetings' prior to the dismissal of a patient being permitted to 'get out' what I remember was the fear and trepidation of the poor schmuck who was essentially being interrogated to see if they had the common sense to state that they were free of suicidal ideation or wanting to kill someone. The patient would sit on one side of the table, sweating and squirming, and the psychiatrist, psychologist, psychology intern, nurse, social worker, and any other interested or mandated professional, would sit on the other side.

All people who have been involuntarily committed or convinced to stay for any period of time on a mental ward have learned what to say in order to escape. Anyone who has some modicum of mental health is ready to bolt within a week regardless of how helpful the psych unit has been. Being locked up is like being in jail. After all, it is frequently the sheriff that drags you onto the unit.

I have a client who has repeatedly run from the police or sheriff trying to drag her into a mental health ward because she could not wear her belly-ring or keep her wedding band. There are no cell phones there because you could use the wire to hang yourself. And indeed I have had clients who have needed to sleep in the hallways due to their own fears that they might strangle themselves with their sleep apnea equipment.

I have a client who stated that she was buggered by the orderlies, late at night, as she lie in her Thorazine haze. Her husband noticed the evidence when she returned home. And from that time on, she swore she would never return to that public mental health hospital in Morganton, NC and indeed she ran into the woods behind her home and dislocated her shoulder when a mental health worker sent out the sheriff again, years down the road.

And so, Ricky Wyatt, who has just passed, is today listed in the NYT on the Op-Ed pages as "appreciated" and this is what it says, in part:

".....The journey was Wyatt v. Stickney, the federal class-action lawsuit filed in 1970 against an Alabama state hospital and later expanded to other facilities. It was the first and most consequential of the legal challenges to the abuse and neglect that had doomed hundreds of thousands of patients to hellish lives in public psychiatric hospitals. It threw open the doors to treatment and to new homes in the community and, for the first time, established standards of adequate care and patients’ rights to receive it.

The ruling was made by an extraordinary federal judge, Frank Johnson Jr., a central figure in earlier desegregation rulings in the South. It was filed on behalf of thousands of Alabamans; Mr. Wyatt agreed to be its face. He had been placed as a teenager in the Bryce State Hospital in Tuscaloosa, where he was abused and drugged for no better reason than he was prone to troublemaking and in the care of an aunt who wanted to get rid of him. Back then, people could be locked up involuntarily, simply on a relative’s say-so.

The Wyatt standards led to civil rights and freedom for countless patients. But the follow-up was imperfect; many patients who were released with inadequate treatment and community support merely traded one form of warehousing for another — in prisons and on the streets. But no one who knew the pre-Wyatt world would want to return to it...."

Wednesday, November 02, 2011

20% of the Homeless are Former Veterans (Try Telling this to Tricare, Veterans' Insurer, With Whom Mental Health Professionals Cannot Engage)

"Highlights from the Nov. 1 commissioners meeting: Tough times for veterans

....Kevin Turner, supervisor of Buncombe County Veterans Services, updated commissioners on the problems facing veterans and the work of the department.

According to Turner's presentation:

• In 2010, roughly 21,390 vets lived in Buncombe County. Only five counties in N.C. had more vets living there.

• The U.S. Department of Veterans Affairs spent more than $136 million in Buncombe County – more than in all but six other counties in the state.

• About 1,000 WWII vets die around the country every day.

• An average of 18 vets commit suicide every day. The rate of suicide among vets is over twice the rate of the rest of the population.

• 8 percent of the population are veterans, but 20 percent of the homeless population are veterans.• Over 300,000 vets who served in Iraq and Afghanistan are estimated to suffer from mental health conditions; the lifetime treatment of those veterans is estimated to cost at least $660 billion (more than the direct costs of both wars combined).

• Some estimate that up to 35 percent of the 2 million vets who served in Iraq and Afghanistan over the last decade could suffer from Post Traumatic Stress Disorder......"


If we wanted to effect the homeless population significantly and diminish human suffering in general, we would provide mental health treatment to veterans suffering w/ PTSD. The treatment for PTSD is Exposure Therapy/ Desensitization. This is very well established now .

However, trying to get on the panel, as a provider, associated w/ Tricare, the primary insurer for veterans, is next to impossible.

I've tried several times, in a concerted manner, to get on the panel of Tricare (I am a Medicare/ Medicaid/ Humana, etc., provider.) You send in the paperwork, something happens to it, then you get busy w/ the taking care of clients which leads to being paid-----months go by---you never hear anything----and then you have to start hammering on that system again. Its ridiculous. Haywood county, next to Buncombe, has more veterans than any other county in NC.

Here is my comment to the above recent overview in the Mountain XPress re: this veterans matter:

"Psychologists provide mental health care to veterans. Exposure therapy/ desensitization is the treatment approved for treatment of PTSD, be they survivors of sexual/ physical/ emotional abuse or vets exposed to trauma. It takes a well trained mental health provider to enact this service. Indeed, the largest psychologist doctoral level internships in the US are associated w/ the VA System.

Outpatient mental health care is provided, for the most part, by the insurer, Tricare. Trying to get onto the panel of Tricare, in order to work w/ veterans in western NC, is next to impossible even for a licensed doctoral level psychologist. They do not respond to queries; you get re-routed to various parts of the federal insurance system; endless e mails and queries go nowhere.

If the feds want the vets to receive efficient, quality mental health care for PTSD, then Tricare needs to become a functional entity, like Medicare.

Its sordid and frankly un-American to have former veterans as 20% of the homeless population.

Get it together, Tricare, and stop making it impossible for professionals to work w/ veterans trying to recover from serving the country.

Marsha V. Hammond, PhD, NC Lic Psychologist

Tuesday, November 01, 2011

Republican Dominated NC State Legislature Has Created ONE BILLION $$ Cut To NC Medicaid Services

I saw a sign last week in Waynesville NC tauting the following:

"Stop the spending! Elect Fiscal Conservatives!"

Excuse me, but this has already happened, friend. What might be appropriate is an anarchist comment spray-painted over that tacky sign on Main Street.

Here is the what the Republican led NC State Legislature has done as outlined by Chris Fiztsimmons of NC Policy Watch:

Fitzsimon: GOP dodging budget blame

"You have to give Republican legislative leaders credit for one thing. They are getting better at avoiding the blame they deserve for the disastrous budget decisions they made this summer. And the Democrats are making it easier for them to get away with it.....

....The Republicans’ priority this year was to cut taxes no matter what, not keep teachers in the classroom or provide help for laid off workers or protect vital services to the most vulnerable people in the state.

That meant massive budget cuts in almost every state program. But the legislators didn’t want people to blame them for the services they were losing, so they wrote a budget full of smoke and mirrors to make it unclear who was behind the painful decisions.

Nowhere was that more true than in Medicaid. The budget slashed state funding for the program by more than $350 million this year, which translates to an actual cut of more than a billion dollars when you take into account that every state dollar is matched 2 to 1 by the federal government.

Thursday, HHS Deputy Secretary Michael Watson told lawmakers that Medicaid was facing a projected shortfall of $139 million, which had to be one of the least surprising revelations made at the General Assembly in quite a while.

Some of the Medicaid changes made in the budget have not yet been approved by the federal government, just as state officials predicted. The savings from Community Care of North Carolina, a successful managed care Medicaid program, are also falling well short of the Republicans wildly rosy predictions.

Watson told lawmakers the shortfall could mean an 18 percent reduction in rate Medicaid pays medical providers and acknowledged in response to a question that many adult mental health services could end.

The federal government is unlikely to approve the rate reduction, so that would mean slashing even more services for seniors and people with disabilities.

N.C. Rep. Nelson Dollar said budget writers had to deal with one-time payments and refunds in Medicaid because of bad decisions made by Democrats in previous years. In essence, it is all the Democrats fault.

True or not, building those payments and refunds into the budget is hardly justification for counting on savings that you know will never materialize.

Dollar and N.C. Sen. Pete Brunstetter both then repeated the misleading claims they made during the budget debate, that the expected savings were reasonable and they would work with HHS officials to find them.

Neither Dollar nor Brunstetter mentioned the doubly counted cut in the inflationary increase. It’s harder to blame that on somebody else.

Brunstetter said there was some “unfortunate finger pointing” going on about the Medicaid shortfall, apparently referring to comments by Perdue administration officials pointing out the absurdity in the Republicans’ claims.

But the problem wasn’t that finger pointing was going on, the problem was that not enough fingers were being pointed. Watson, the HHS official making the Medicaid presentation, missed several opportunities to make things clear for legislators and the media on hand.

And only Senator Minority Leader Martin Nesbitt asked any tough questions in the face of the Republicans blame-and-mislead dance.

The bottom line is that Republicans passed a budget that will force state officials to cut off vital services to seniors and people with disabilities. And they knew they were doing it.

The public deserves to hear that truth. Perdue and her administration need to plainly speak it.

Chris Fitzsimon is the founder and director of N.C. Policy Watch, a progressive public policy think tank that is a special project of the N.C. Justice Center."