Saturday, July 28, 2012

Guillotine Roll Call Time: CEO of WHN LME Loses His Position Due to $3 Million Shortfall Which the Chief Financial Officer Feigned Not Knowing About

This is my reply to the good article outlining what just took place today at WHN LME regarding the replacement of the CEO, Arthur Carder, who has been in his position, if I am not mistaken, for about 12 years.  Here is that article URL:


HEAD ROLLING TIME: Ask not for Whom the Guillotine Chops

Peggy Manning: you did a good job of providing the basic information.  However, God, or the devil, is in the details.  While it is important to have included the Mercer audit which was done July 23, 2012 (wonder who tipped off that independent auditor as to why they should take a look at the WHN LME records?), its very difficult to understand even for someone who has been studying NC mental health reform for years now----and blogged about minute details.

The Director of Clinical Operations of WHN LME stated these to be the problems which caused the $3 million overspending: "(1) an encumbrance with contractual obligations inherited from former managed-care agencies Value Options and Crossroads;(2) increases in the cost for some services; (3) and the lengthy duration of some services meant to be short-term in conjunction with service stacking."

As regards No 1, for outpatient therapy, which is what this psychologist does,  'the Medicaid year' starts 1.1. (whatever year).  After 8 outpatient therapy sessions, authorization must be approved for more sessions.  Moreover, I imagine that outpatient therapy, which SHOULD be the work-horse of mental health care, devoured very little of the LME's money.

As a doctoral level psychologist, for a 45-50 minute session which is what they mostly will approve you for, I get paid about $75.  I have Medicaid clients that I see weekly (not as associated w/ WHN LME) and even at that frequency, that would be $3700/ year.  Moreover, outpatient therapy for these kinds of SPMI (Severe Persistent Mental Illness) clients would encompass psychosocial aspects which bear a closer resemblance to social work e.g., assistance w/ finding jobs, transportation, etc., that the way that one usually thinks of as therapy.

It is an unusual Medicaid patient that receives this weekly outpatient therapy.  Moreover, most patients who are disabled, have Medicare as primary, which pays significantly better than Medicaid, and Medicaid simply picks up some pocket change. Medicaid is the payer 'of last resort.'

So, when the Clinical Director is talking about 'encumbrances inherited' I have no idea what she is talking about.  WHN LME knows very well how difficult it is to obtain authorizations for any service, including the expanded services such as PSR or Psychosocial Rehabilitation.  This is a modality offered by the private companies which were created when NC started mental health reform in 2002 that includes DAILY 6 HOUR classes intended to teach social skills, etc.  Also as associated with those private companies there are therapy charges (I refer to the 'stacking' matter which the Clinical Director indicates in No 3 is sucking down the bucks), etc.

As re: No 2, I certainly have not received any pay increase from Medicaid so I don't know what that's about either.

As re: No 3, the LME authorizes the duration of services and if they believe that there should be a cut-off point, then they could have limited the services.  But then----using the example of Psychosocial Rehabilitation offered by the private companies-----it is typical for clients to stay in PSR, for instance, for months and months.

There is background information to all of this as associated with the treatment of mental health challenges: are these people to be REHABILITATED or do they have CHRONIC ILLNESSES, like diabetes or hypertension.  When it comes to the SPMI population, their trajectory follows one associated w/  a chronic illness----not something that is going to get thorough treatment, like cancer, and then go away.  Nevertheless, the entire push / thinking behind much of what NC DHHS has put forward is associated with REHABILITATION.

So, you have intensive services meant to rehabilitate someone when  in fact, the 'cure' as much as is possible, is slow, takes place over years, is dependent on variables that cannot be impacted by an intensive quick application of PSR, for instance.  People with SPMI get better over time, gradually, when they have consistent therapy, probably from the same person for a long period of time, which is someone they learn to trust, who gently and deliberately challenges them to overcome things like avoiding other people or thinking they cannot work at all or managing anxiety and depression.  Yes, the PSR provides some of the cognitive skills training in an attempt to rehabilitate the person but these are basically chronic illnesses----if a chronic illness can be termed to be something that lasts for a few years +.

Thus, the state is spending an enormous amount of money on these Expanded Services, which are gobbling up the money (the private companies are glad to take it) when the treatment is slower, persistent, deliberate, and consistent.

Basically, the model for 'the cure' vis a vis NC DHHS is all wrong.

And basically, just as with all that money 'lost' under the old Community Support Services, which was an Expanded Service, 'the cure' is a slow, deliberate, planned-out, trust-based, professionally delivered mental health service and not some intense what-to-do-with-the-mentally-ill-person-during-the day.

This matter, of course, is not untethered to the: 1. lack of jobs 2. less and less participation of, say, Vocational Rehabilitation Services which used to do 'job coaching' and obtain jobs for these kinds of people 3. lack of transportation 4. collapse of sheltered workshops where these people can learn some skills although some people call them 'sweatshops.'  And the inability to work and improve oneself is not unrelated to the fact that if someone is receiving disability payments-----and most Medicaid patients receive 'a check' which is usually around $650-850/ month, not including Food Stamps and Section 8 Housing----you cannot work/ gross more than about $750/ month or you begin to lose some of your disability check.

I can't tell you how many disabled clients I have had who have to watch like hawks how much they are getting paid lest they have to pay back some of their disability monies.  This certainly discourages them from working and work is associated with more than just earning money; it is associated with learning social ease around others, having friends, keeping a schedule, etc.

NC DHHS will NEVER fix the outflow of money for these Expanded Services, which is soaking up most of the Medicaid money, along with the LME employees who all earn 50 grand + / year w/ benefits----until they get the model right.  And the correct model associated w/ this population, which is the SPMI, Severe Persistent Mental Illness population, such as people with schizophrenia; schizoaffective disorder; Borderline Personality disorder; severe depression or bipolar disorder; and Dissociative Identity Disorder (which is present in this population more than most people think and it is associated with severe sexual/ emotional/ physical childhood abuse)----is a model associated with the treatment of a chronic illness not rehabilitation and a quick voila fix utilizing very expensive, stacked services which the private companies are only too glad to provide.

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


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