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North Carolina's mental health system
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.
"All we are is the banker."
Oh. Well then... who's in charge?
Mental Health Reform
First, I would like to thank the News and Observer writing staff for following this story. As a mental health professional, I must say that it is time the problems with the Community Support definition are exposed.
I agree with some of the arguments presented by Ms. Mary Ellen Anderson. However, I disagree completely that cutting rates is a good idea. In fact, I think it would be catastrophic. Everyone would suffer including the mental health client especially.
I see these problems as a function of economic theory.
My solution arguments are as follows:
1) PUBLIC PROGRAMS FUNDED BY PUBLIC DOLLARS SHOULD BE EXECUTED BY PUBLIC PROVIDERS. Mental Health services are funded by the public through Medicaid tax dollars. However, the choice by the state to privatize services was partly done with the economic belief that a free market would enhance competition and therefore enhance efficientcy and mental health services. Neither has happened as evidenced by the failure in question. I believe this failure was due in part to the fact that mental health is NOT a consumer driven industry. Public dollars allocated to private providers leads one to ask the question: "Who is the ultimate customer?" The client or consumer? Mr. Joe or Ms. Jane Taxpayer? or how about the Medicaid system administrators since they are the ones who allocate the funding? To the client receiving services, he or she is economically indifferent to chosen providers. For example, if I don't like the taste of Big Mac burger at McDonald's, I can go across the street and spend my money on a Burger King Whopper. Even though state laws promote consumer choice and freedom, most mental health clients simply are referred to private providers upon in-take and they have no reason to question the quality of service rendered. Why? Because it is a free service to them. Medicaid recipients are not paying for their service, the taxpayer is. The old adage "its much easier to spend someone else's money than his own" rings true in this case. To the provider, these quesions are irrelevent. Providers in a free market are primarily interested in profit maximization from a business perspective. I would like to think that most providers out there have a mission to provide high quality mental health services and many of them in fact do. However, the problem is that in a business sense, the client is just a consumer and revenue is generated by Medicaid payments. Therefore, I conclude that any good or service that is publicly funded tends to breed inefficiency especially when demand exceeds the supply. Providers end up not competing for consumers but end up competing for Medicaid dollars.
2) GET RID OF ALL (OR AT LEAST MOST) OF THE BUREAUCRATIC RULES AND REGULATIONS THAT PREVENT PROVIDERS FROM GETTING PROPERLY PAID. As a case manager, I write many treatment plans. I have witnessed payback situations where providers do not get paid for services due to a treatment plan that has simple logistical errors on it (i.e. name mispelled, obvious date left out such as birthday of a client or a blank not properly filled in). The problem is that most providers have too many clients to serve and too little time to make sure that all the I's are dotted and T's are crossed. People are human and they make mistakes. In my opinion, Medicaid will try to find every little excuse not to pay for services so as to save money. Bureaucracy increases and the ultimate quality in mental health services decrease. They decrease because providers are spending too much time trying to make sure that they are following the rules to the T so as to get paid instead of "running the business and providing the service" The client therefore cannot receive the service. I have witnessed firsthand of not being able to provide a good service to a consumer because of red tape. Therefore, I think what also happens is that it is too tempting for providers to provide medically unnecessary services "in bulk" with the hopes of making more than the expected paybacks for not properly following a bureaucratic rule (a loss in this case). By no means am I implying that authorizations for services are not important but I believe that there are too many to keep track.
I like to think that I provide a good service to a client in need of such service. Therefore, I think more focus should be on consumer satisfaction who received mental health services. I believe more focus should be placed on surveys of providers completed by consumers. These surveys can be mathematically analyzed through statistical means to determine if a provider is not doing their job.
3) ANY IMPLEMENTATION OF PUBLIC POLICY IN A FREE MARKET WILL CAUSE "THE LAW OF UNINTENDED CONSEQUENCES." Simply put, any changed law that involve finances will affect the free market. Ms. Anderson suggested cutting Community Support costs. This is a bad idea because providers, as profit maximizing firms, will only try to make up the loss by increasing productivity. Remember, the price of service is fixed in this case. Productivity is billable time for services rendered. Revenue is billable hours X service rate. This in turn will cause more strain on direct clinicians resulting in higher turnover and higher costs for labor. Labor is probably the most expensive variable and fixed costs a firm incures. This in turn will cause the provider to look for new ways to make up any losses which leads to more inefficiency.
We were never asked!
A lot that is not going well in America today is the result of greedy CEOs who leave "their" company with millions stolen from the company, yet the NC legislators turned a CMH Center system, that was working well, except for turn over being high from low pay in many areas (the pay varied greatly from area to area) to greedy private interests!
It should be noted that almost all Mental Health professionals in private practice received their practical experience at the Community Mental Health Center, under the supervision of Psychiatrists and experienced psychologists (I have 30 plus years at CMHCS and other state agencies), social workers, counselors and addiction counselors. It is these experienced professionals that were never asked if the system needed changing and how or how much.
Yes, the professionals providing the services were not asked.
I have worked as a therapist and director in SC,Fla. and NC
and I can tell you the CMHC system in NC was the most effective of all three and provided the most quality services from children to the elderly and everybody in between.
The standards for licensing in NC is so rigid that many qualified and very competent Mental Health professionals were eliminated from working at MH Centers. Now there appears to be very low standards. The standard for the Community Mental Health Centers, which started in the 60tys under President Johnson, was that no one could be turned away. And no one was at the centers I was employed.
Some services were contracted out to private resources: group homes that frequently closed down after a few years because of all the crisis the private providers could not cope with and private inpatient services; etc.
If the state wants it done right, this time create a state board of consumers(includes families), MH professionals and
business professionals. Return mostly to the system (it will cost to initially repair the system) of public non-profits centers and controlled and reasonable salaries, with work goals(this already existed). Tie the system in much closer with the state health and pension system and state standards. Some services would be contracted as it is demonstrated to be appropriate.
For the last 3 decades states (Tenn.'s made a mess)have tried to fix a system that was not broken, with the myth that "private" (means private interests and not public interests is the energy source) is "cheaper". None have been changed truly because the intent was to make it better.
Who suffers from the ineffective changes? The children, families and adults, who desperately need these services.
The US military is now finally working to make sure there are services for our returning soldiers who repeatedly are called back to a wasteful(money and soldiers) war, who need emotional support and treatment that includes the need for family support and treatment. Hopefully the state of NC will not be as slow to recognize a severe need as the US government was.
Mental Health Reform
The government should start by establishing a governing agency that closely monitors providers that offer community supports. I work in the field and hear too often of abuses much like the ones reported in the recent N&O article. Definition of community support should be established and then regular audits and site visits should take place ensuring that regulations are being followed. There is a lot of abuse in the system not only by those who don't qualify but by guardians and parents who look at community supports as a baby-sitting service.
I don't think so
"Establishing another governing agency" would be a terrible idea. That's why we are in this mess.
LME's are already charged
LME's are already charged with the responsibility to monitor CS providers and audit's have come in the form of post payment reviews and service record reviews, thus all of the paybacks by providers. Standards for providers were set too low and LME's were not supported by the Division of MH/DD/SAS when withdrawals of Endorsement were needed.
Where have you been for the past 18 months?
There is a governing agency, they are called LMEs and my last check there are more than 30 of them.
Most providers who provided community support from the beginning have had the opportunity of being in:
-at least one of the three audits that occurred in Jan/Feb 07
-post payment reviews for each of the LMEs that you provided sservice in their service area in May/June 07
-AND service records reviews for each of the post payment reviews as followup Sept -Dec 07
AS WELL as at least 1-2 monitoring reviews by each local LME as the endorsement process was entirely redone during FAll of 07 and is in the process of being redone again this Summer
Where do you think the paybacks came from? one leisurely visit from medicaid or the local LME
WHAT IS HAPPENING RIGHT NOW IS A CAREFULLY ORCHESTRATED PROCESS DEVELOPED BY DMA/MEDICAID TO ENSURE THAT PRIVATE PROVIDERS ARE CRUCIFIED FOR THE COMMUNITY SUPPORT DEBACLE
It will probably take a few years but I have a strong belief that over time more of the facts will come to light in the public arena including:
- on March 20, 2006 providers were instructed to begin providing community support at the number of hours that the client had previously received CBS and Case Management combined - CBS was a highly utilized service that NEVER received the scrutiny that community support has and to this day I have not seen a comparison of what the state spent per month for CBS and Case Management combined vs. Community Support
-LMEs do not make rules or policy - they enforce them
Many LMEs throughout the state were directly asked in provider forums to inform providers of how Community Support was different from CBS and Case Management combined, how the service notes and service plans should look - most stated they could not provide that information
WHY not? Because the state had not developed or disseminated any such information
- Lack of technical assistance or training - I worked in an LME for 4 years before moving to the private sector during divetirue of publicly provided mental health services
The state always set unrealistic time lines with little to no guidance other than memos and poorly developed policies that lack the detail necessary for an LME to inform, train, and/or provide technical assistance to providers
Many LMEs refused and still do not offer technical assistance to all private providers in their network but rather larger providers who they feel are their "safety net" provider - this was the practice when I was an LME employee and it continues
WHY DO I TAKE THE TIME TO SAY ALL OF THIS????
There are many sides to each story however the state dept of health and human services is covering their behinds first hence the audits, post payment reviews, service records reviews,astronomical paybacks, constant reformulation of policies that require each LME to review, rereview, and rereview their private provider network
The solution is for the Dept of Health and HUman REsources to begin the hard work of training a workforce that can properly deliver enhanced benefit services "in the spirit that they intend for them to be delivered".
Private providers are struggling to properly train their staff - the market has flooded with "consultants" and "trainers" who all claim to have the "inside line" to a DHHS employee who has told them how community support should be provided correclty to avoid paybacks
LMEs are paid with state dollars to provide this technical support but they ARE NOT so providers are paying exorbitant amounts to these snake oil salesmen (and women) who are just out to make a quick buck - I keep wondering when will DHHS wake up and realize that this is the root cause of the problem - training and skill level of mental health providers - this is a problem that can be addressed immediately through state mandated training (and I don't mean the current requirements to listen to someone read the service definition to you for 6 hours - although they are creative in making their power points all look different)
THERE IS NO FORMALIZED OR STRUCTURED TRAINING PROGRAM FOR MENTAL HEALTH TECHNICIANS/PARAPROFESSIONALS WHO PROVIDE THE BULK OF ALL MENTAL HEALTH SERVICES NOT JUST COMMUNITY SUPPORT
Ultimately if the provider base is trained and credentialed to provide services by the state as nurses aides are the quality of the service that is provided will drastically improve and will gain greater consistency throughout the state (BUT the question is does DHHS want to help providers improve OR are we moving back towards the old Area Program model which wasted its share of money as well)
Why should the state pay to train private for-profits?
Why do you think the state should pay to train private for-profit providers' staff? They don't pay to train the workers at corporations in town - or fast food places --
why should more tax money go to pay for a service that you should know how to do if you have the gall to say you are going into business to do? See the problem with that?
REad carefully...
I NEVER said the state should PAY for training. I said they should DEVELOP training. The community college system does an excellent job of training nurses aides and so on because there is a defined curriculum for them and it is understood what their role will be in the workplace..a paraprofessional. I am suggesting that there be training available so individuals can attend a 2 year program at a community college to become "certified" to hold a paraprofessional position and so on for each other competency level. This is already in place for licensed professionals. Why not all the others. This is not a matter of who pays for what and believe me the state DOES NOT CURRENTLY pay for the training that private providers require for their staff. The providers pay for them. My issue is that the trainers themselves are in many cases NOT QUALIFIED to train paraprofessionals or any other worker in this field. MY focus is on having a well trained workforce that CAN provide quality care because they have attained the skill level through a defined curriculum (education) and experience (internships, practicums, whatever) to so.
Mental Health reform
Many Thanks for the series of articles on Mental Health reform ( and previos articles by lynn Bonner and Ruth Shehan). Maybe someone will now sit up and listen. That's been a major problem throughout Reform. No one was willing to listen to the County agencies that previously ran the programs.It difficul for me to hear a Division employee say "in hindsight" since they were told repeatedly that combining case management and para professional services was a bad idea. For a future article go to the Division and poll staff as to when they last provided services to a client. If they had invited a couple of experienced techs from Dix to tour the new facility every quarter they would not have the design problems they have know.
My first recommendation:Include people who actually do the work ( and are not making a profit doing so) in the decision making.
Second: Cutting rates, changine authorization etc for Community Support will not fix it. The definition has to go. We have to go back to having case management as a separate service and it needs to be provided by local government program staff and not private for profit agencies. The case manager has primary responsibility for the development of the service plan ( what the client needs) and implementation of the plan ( what the client gets). In 1981 the State settled on a lawsuit "Willie M vs Jim Hunt". The provision of Case Management was the major cornerstone of the settlement
Third: you mention that several services such as intensive in-home are dsigned to keep people out of the hosptial. Acutally they are not. In order to keep people out of the hospital you have to have intensive srevices that can be accessed and implemented quickly. in order to implement in-home services you first access Community Support which may take a couple of weeks. If the client does not have a recent clinical assessment the Community Support worker arranges for an assessment.The community support professional calls a meeting to develop a Person Centered Plan.This may also take a couple of weeks.The CS worker then submits the Plan, along with other required paperwork to ValueOptions for authorization which will take a couple of more weeks.If authorized, a referral is made for the service. 1-3 agencies may be involved in this process.Im the meantime, the client has gone in and out of the hosptial and services are still not in place! The process has got to be streamlined for crisis diversion plans. This process is not only impacting hospitals, it is impacting juvenile detention centers and jails.
Again, thank you for your assitance and attention. The stories of clients not getting services, not getting services in a timely manner or getting inadequate or disrupted services are endless.... talk to local ( non-administrative) staff.