share.triangle.com - North Carolina's mental health system - Comments

mental health reform

Margaret DWyer — Wed, 30 Sep 2009 04:34:00 -0400

NAMI (National Alliance for the Mentally Ill) has rated the states mental health systems. Connecticut is rated a "B". This is the highest rating, along with several other states. My daughter is a client there and treated very well. I believe they do an excellant job. Why not copy what they do?

Tiered Reimbursement System

GeoMan — Mon, 19 Jan 2009 21:44:08 -0500

I just read Lynn's most recent article about the Tiered or Step rate system. First, I applaud Lynn and all of the staff for continuing to follow up on this story. It is vitally important to have the facts about this disaster called Mental Health Reform dispensed. What is sad and interesting is that I constantly run into other Mental Health Professionals that I used to work with BEFORE MH Reform and we all shake our heads, feel absolutely powerless, and continue to provide the best service we can while voicing our opinions. It is disappointing that those of us doing front line boots on the ground work are disregarded when we are the conduit between policy and reality.

The Tiered system, once again, is an economic change that will have economic consequences. State level policy makers have not drafted change based on quality of care or drafted policies based on clinical modalities or realities. I am saying it now, and I am anticipating unforeseen consequences, but the Tiered system will only have ECONOMIC implications and not CARE improving outcomes.

What I anticipate is that since the private agencies are dollar driven, work loads will be raised to unreasonable levels. With the rates of reimbursement decreased the private agencies will push for increased "billable hours." It is simple: Squeeze the tube of toothpase at one end and it smooshes (no, not a real word) to the other end. An old army phrase is that fecal matter rolls downhill: The state tweaks rates to the private agencies and the private agencies tweak the rates for the employees. Private agencies will compensate for decreased rates by encouraging cranking out those hours. I offer the following quote from an administrator: "You do whatever you need to, just get those hours" (hint hint)

Some private agencies have quotas of 30 "billable hours" per week and some even have gone to 35 "billable hours." Now this may not sound bad, but when you factor in the requirements for compensation, otherwise known as Unfunded Mandates (ie - it is a requirement but not on the states' dime....do it to meet billing standards but take it out of your coffers) then you realize how unrealistic this is. Accounting for the drafting of PCP's (Person Centered Plans), getting authorizations, travel to and from clients' homes and meetings at the school, progress notes, supervision (both being supervised and supervising Paraprofessionals) then one recognizes the futility of having quotas. And what about training? Training is non-reimburseable. How do we continue to educate the providers when there is no money available from the state and fee-for- service forces providers to put their efforts into only billable services?

Here is the sound bite, ready?.....PRIVATIZATION WORKS ONLY WITH WIDGETS AND NOT WITH MENTAL HEALTH CARE

I have already seen quotas resulting in , oh just a weeeee bit more time added on the time sheets than what actually ocurred. I have also seen TWO and THREE clients being seen at the same time (One QP with 3 clients for one ACTUAL hour but BILLING 3 hours total, one for each client). As a Contract Therapist I have heard the complaints of clients about the doctors who have clients lined up at the door (get em in and get em out) 5 deep, waiting in the waiting room for hours. The clients say "he didn't even look at me, saw me for 10 minutes, adjusted my meds, got up and opened the door and called in the next person." The privatization model is driving this type of conduct - making mental health private clinics into mass production machines that look like something out of a Dr. Seuss book.

There is also pressure from administration to double book and triple book. Once again, if you cut rates and hurt the bottom line of the private agencies then the pressure comes down on those providing the service to produce more: "Double book em so if one doesn't show then you can slap someone in the time slot and bill for it." I RESIST THIS TYPE OF QUANTITY BASED CARE DOWN TO THE CORE!!! So the following scenario is my nightmare (PLEASE NOTE - this is sarcastic and aimed at the unrealistic pressures of the current context and is NOT a true reflection of my practice philosophy - it is fiction based on fact): "Mrs. Johnson, I am so sorry that last week you came home from work and walked in on your deceased son's body from a self inflicted gun shot wound to the head, and I'm sorry he was so depressed after being discharged from the Marines with a blown off leg that he couldn't envision a life outside of the Corps, and I am sorry that you still smell the clorox in your nose from where the Crime Scene Unit cleaned the biological matter off the wall, but my job is on the line and I have to double book clients and someone is out in the waiting room right now so I have to cut our session short. My recommendation is to go home, take your meds, watch Animal Planet when those images which are burned into your minds eye cause you distress and follow up with me next week."

Is this type of care what Odom envisioned? Well, this is the result of the cost cart way ahead of the care horse. I've done Social Work for over 20 years and business realities are always present, but when they outweigh any evidence based clinical modalities or tacit client care then THE PROBLEM IS NOT THE SERVICE PROVIDERS BUT THE CURRENT SYSTEM DESIGN.

I strongly resent private agency administration being Draconian, saying "This is the way it is, it is the current context and you are either with us or there's the door."

So in summary, although the next great band aid (Tiered Reimbursements) is coming around the bend, I sigh and shake my head anticipating the aforementioned negative unforeseen consequences. I guess I suffer from Casandra syndrome: being able to envision dire consequences but being powerless over changing the course of events.

Once again my commendations to the News and Observer team and also to all ethical, conscientious, seasoned, dedicated clinicians out there who face another day trying to resonate our voices up to the legislature and hope that one day they will get it.

Geoffrey Zeger, ACSW, LCSW

Back to Basics

mmiller41 — Wed, 03 Dec 2008 17:55:18 -0500

Let's get back to the basics here. The essential problem is that profit driven health care simply does not work, especially in the Mental Health sector. It would simply be too embarassing for the state to admit that the underlying premise of MH reform was flawed (just like the rest of the no regulation, free-market BS that was blown up our skirts for the last 20 years) and say, "Let's go back to something like the previous system that worked".

Just like we see with the huge corporations who are raking in the taxpayer's dollar upon threat of "economic collapse", the only people who have really benefitted from the new "system" in NC are those llc's reaping the profits and untrained paraprofessionals in CS Services. Yes, there are some qualified paras in the CS arena, but they are too few and far between and those good ones are often undervalued (they also have many of the same issues w/ system that a good therapist would have) and are burned out and apathetic. Wonder why? I also new private therapist who were essentially bribed by the CS agencies. Read, "If you do this DA at this rate, we'll make sure client X comes to see you." Any ethical therapist would have to refuse, but how exactly would they report this and to whom? The CS licensing board??!

As a Master's level graduate and former LPC who gained licensure during "reform" debacle, I can share some of my experiences and observations:

1)The new system made it nearly impossible for LPC's to gain licensure, since the LCSW lobby was more powerful and set up a reimbursement structure that paid more for LCSW's. (Read: "hire only LCSW's and take more profit for provider agency".)

2) As CS became the latest doll of the debacle/system, highly skilled MH professionals were purposefully marginalized, not the crux of treament (Read: "you can pay CS less since they are paraprofessionals and do not have a Master's degree" AND "you really don't need that much training (MA) to help people with mental illness" AND "ethical treatment standards are not important at all')

3) Newly "famey" CS para's and QP's suddenly held all the power in the treament. Therapists were told to refer everyone we could to CS so the company could bill for those services. However, EVERY client I referred to CS stopped coming to regular outpatient therapy almost immediately. When CS worker was questioned, I was told such things as, "Well, I talked with the parents and they didn't think the kid needed to come to therapy and said they would pull them out totally if forced to do so. And I agree." OR "I can't get reimbursed for the time I would have to wait if I drop them off at OT, so I just won't do it. Sorry." Then when the kid was (surprise) in another crisis, they called ina panic and then dumped them back on the therapist for a quick miracle cure!! Yeah. That is what untrained paraprofessionals do, for lack of TRAINING and KNOWLEDGE. But there was no top-down support to back up OT recommendations b/c the agency directors were also untrained AND had to show a profit for the agency in order to keep their good paying jobs...hmmm. Who is to blame here??

4) By the time I left, which was right after I was forced to immediately drop 3/4 (yes) of my caseload who were IPRS clients (I refuse to call them consumers) when CPHS apparently "forgot" to track how much money was being sent out for IPRS clients and OOPS it ran out in Oct of that fiscal year, therapists were still being told to "make" 25hrs of productivity each week or risk losing their job AND YET they were losing clients to CS and being relegated to being almost solely a diagnostician (DA's). When I told the director that I could not simply "drop" these IPRS clients-that it would be dangerous and unethical-I was told, "We are a 'for-profit' agency and we do not provide any services to clients for free." What's a good therapist to do....?

5) Ethical therapeutic practice in the current system is essentially impossible. There were numerous times when I was asked to do unethical things by a supervisor or director who was either beholden to the profit-based system OR simply did not have the appropriate knowledge base to interpret, identify and remedy unethical practice and/or situations. THIS IS WHY I QUIT PRACTICING IN NC!!! This includes the order for therapists to "market" their provider's services in the community and the school system (READ: mining for Medicaid $$); not addressing concerns about the abuses inherent in the new system; forcing therapists to provide therapy "in consumer's home" (Read: working outside the office/in the community is ALWAYS best) on the sole basis of getting to the client in order to bill for services; etc.

On this last note, I always felt that though there might be times when it is appropriate to provide services in client's homes, this should be at the discretion of the therapist, not the company they work for. On one such visit (before losing most of my caseload due to IPRS mini-debacle described above), on arrival there was a previously unknown male present in the home who I was not aware would be there prior to going, there was dog shit all over the place and nowhere to sit; and meanwhile, while I was with the client attempting to "counsel" her, the male took the daughter outside to give us privacy. Oh-I should mention the clients' ex boyfriend was in jail for abusing the daughter (she said her ex bf was innocent and "loved" the daughter) and the new "guy" was someone client had just met over the internet the week before! He was quite likely a predator. So, I may have actually been keeping the client occupied (she was apparently unconcerned that he might have any ill intent, despite known patterns) while he groomed the girl, who was already complaining to mom b/c he liked to "wrestle". Yeah. It was good to see it all, but really therapy whould have been taking place elswhere...somewhere safe. Oh-the agency director dimissed my concerns.

My sole "marketing" (shouldn't the profit driven entity have someone doing marketing for them? Oh no-that would cut into profits!!) venture took me to the last standing agency in town to provide psychopharmaceuticals to area clients. Guess what? My most actively psychotic client was in the waiting room. Since I could not acknowledge knowing her due to confidentiality rules, this chance encounter played into her paranoia and she called hours later to say she would not see me again. Ah, success! NONE of these system failures were acknowledged by the company higher-ups, who had no real training in such matters.

Lastly, b/c I really could go on for hours about why I quit this horribly foul, broken, profit driven system...those who have mental illnesses ARE NOT just like people with broken arms or hearts. Their mental faculties are typically hindered/impaired (This is often true of parents who are charged with their children's Tx decisions...often times Tx needed as a result of the parent's own MH issues that go untreated-Read: "The kid is the problem, not my poor parenting!") For example, anyone who can diagnose a mental disorder knows that there are are certain problems often shared across Dx's. For example: insomnia, confusion, self-medication, substance abuse, poor decision-making, faulty thinking, co-dependence, etc. are all COMMON symptoms of MI that hinder good decision-making...unlike those patients going in for a broken ankle.

There are also those who, as mentioned in several posts, work the system all too well. Many would see the recommended therapist then quit to switch to someone else b/c they didn't like that therapist. Often this was b/c the therapist was doing a good job and would not enable their ongoing dysfunctional behavior. The point is, in my opinion, in most cases the MI client IS NOT the best person to "choose" who they should see for treatment. That is why we have highly skilled therapists...to determine how the client can best be served and to ensure they get the right Tx-even if they don't always like it! This is especially true of certain Dx, such as PD's.

Unfortunately, untrained people are in charge from top to bottom of the current system, private businesses are raking in the money, abusing power & squeezing out the best professionals, and endangering the people who need the system to work the most-the client. CORRUPT? INEPT? Dangerous I would say.

While Iof course I am not pleased to see all the trouble in NC (I no longer live or work there-my mom sends me articles on this subject each month), I do hope that those Master's level professionals who said in response to my concerns, "Oh, I think this idea about CS being the primary treatment may be good, blah, blah." in spite of what you saw in front of your face-I hope you are feeling the hard reality unfolding. When you assume all the power (or abdicate your professional responsiblity to address what you know is wrong) and say you know how to handle it, you better be prepared to take a lot of the blame if your way fails. And fail it has!

I don't mean to pick on

Visitor — Tue, 09 Sep 2008 14:02:36 -0400

I don't mean to pick on your argument, because you are making a valid point. I just wanted to point out a minor dicrepency. The Community Support worker, or as the state calls them, Paraprofessional does none of this. The Qualified Professional, formaly known as the Case manager in the old system, submits paper work on behalf of the Person Served. Also, Intensive In Home services are seperate from community support. An assesment is done first and foremost before anything (hours) can be authorized, and this is what is so time consuming. Yes, there is a problem with the way services must be accessed, because the process is much too long. I believe the main problem is the state dropped the ball. They thought it was a good idea, and just let people run with it. No one thought to monitor or train any of the providers to make sure they were doing things correctly. And to make matters worse, they allowed people who had not experience in the field whatsoever, to start these provider agencies and bill fraudulently; all the while not knowing how to implement services correctly. For those of us who are legetimatly trying to provide a quality service for the health of others, most were treating it as a profitable get rich quick scheme; and believe me plenty of people did get rich quick. It's sad, because I understand what they were trying to do, they just didn't execute it properly.

Mental Health Reform

stevejohnson008 — Mon, 25 Aug 2008 06:09:41 -0400

The government should take responsible to undertake the mental effected people so as give them a new future. Also the patients should check up regularly and consult the doctors for treatment. There should be a bill where mental health reforms will get some fund from the government every year.

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steve

Rhode Island Drug Addiction

Improve mental health system

samflutch — Wed, 20 Aug 2008 12:57:32 -0400

First we must have mental health parity. Mental health must be covered as other illnesses are. A broken brain must be respected as a broken heart, kidney, thyroid, liver or any other vital organ. Mental illness is not a character flaw, but a set of known behaviors which are expression of disease just as shortness of breath, irregular heart beat, low insuline or thyroid hormones and on and on. Once we have parity the landscape for treatment will begin to change.
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samflutch

North Carolina Drug Treatment

Health Insurance

California health insurance — Fri, 01 Aug 2008 02:43:07 -0400

No one is in charge. Ultimately we are each in charge of ourselves only. There is no actual hierarchy of authority, there is only acceptance or non-acceptance of the idea-symbols of others.

Mindboggling

Visitor — Thu, 31 Jul 2008 06:39:35 -0400

Well.... as a therapist and previous consumer, who dug himself out of years of depresssion and suicide to become a therapist with 6+ years of experience, I WOULD never trust the old as well as theimproved version of mental health here or in several states. Until recently, I took joy in the fact that I trully helped some of my client's despite Community Support Services, crooked providers, and practically non-existent access to psychiatrists(even though my companies had them on staff. I have finally had enough of this ludicrous system led by morons who have no training in mental health (and not even remotely licensed any sense) who run the show (guess what a paraprofessional with a hs diploma at one point in time was making more money than I was as a Masters level clinician). I gave the most recent provider I worked for the proverbial finger and am no longer employed because I can abide by a system that prizes money over people and ethics (I guess I will go back to being a crazy, indigent lunatic). I would fully endorse the idea of collaboratives between mental health clinicians and primary care physicians for more of a one stop shop approach in the community but I do not think pediatricians and family care physicians want to be roped into this mess. In reality, in the current climate, I cannot foresee any way that I could go into private practice/start my own mental health company because of the rediculous state waffling on requirements and because of the cutthroat nature of other providers in my area, SO I guess I will have to join the exodus of other licensed mental health practicioners (therapists, psychologists, and psychiatrists)leaving the state for good!

Health Reform

mack — Tue, 29 Jul 2008 07:15:22 -0400

Are you have better Health. Health reform brings together all the major changes needed to create an NHS that always puts patients first.The Government is developing a national strategy to shape support for carers. "In the previous post, I looked at ten of the most common myths that get bandied about whenever Americans drag Canada into their ongoing discussions about healthcare.

mack

Addiction Recovery Wyoming

Mental health

xss500 — Sat, 26 Jul 2008 05:33:59 -0400

It is very important for patients to consult doctors and avoid self medication.

Addiction Recovery West Virginia

Mental health

xss500 — Sat, 26 Jul 2008 05:29:27 -0400

It is a very good website because it is very informative for users and viewers................................ Addiction Recovery West Virginia

Mental Health

ascent04 — Sat, 26 Jul 2008 05:01:51 -0400

Mental health problem is a serious problem in whole world. Day in end out, lot of peoples is suffering on this mental stage. Therefore, government has to take some serious steps to solve these mental health problems like established mental hospitals and centers.

Ricky

http://www.addictionrecovery.net/west-virginia

Re : North Carolina's mental health system

Garrett — Fri, 25 Jul 2008 07:04:03 -0400

Why do the Mental Health professionals receive experience at their community? Why do the Mental Health services are funded by the public? Is it necessary? Provide more information.
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Garrett

Addiction Recovery Vermont

I am new visitor to this

blessy — Wed, 23 Jul 2008 07:35:29 -0400

I am new visitor to this site. I like this site. I really agreed to mental health reform. It gives good information to our society. Every one have a mistake in fat someone are mentally mistaken. After the good treatment they will come to the previous stage. I think society is the main thing for mental depression. Our government conducts any public programs for the reformation of mentally depressed persons.

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Bless

Addiction Recovery South Carolina

North Carolina's mental health system

roger fritz — Tue, 22 Jul 2008 11:53:23 -0400

I completely agree with Mental Health services in North Carolina. Presents of any facility is always batter then none.
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roger
Addiction Recovery South Carolina

North Carolina's mental health system

mwilliam — Tue, 19 Feb 2008 16:23:12 -0500

What do you think should be done to fix the mental health system in North Carolina? We'd like to publish some of your ideas in the News & Observer.

What do you think should be done to fix the mental health system in North Carolina? We'd like to publish some of your ideas in…