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Kudos to Ruth Sheehan of the N&O for an excellent column in Monday's paper.  For those unmoved (and I really hope very few of you are) by the plight of Phil Wiggins, the mentally ill man she has followed for several years now, read this and think about it.  Sheehan talks to the mother a bipolar disordered teen son who is at the end of her rope trying to care for her boy and protect his fellow high school students from what could happen when he is off his medicine.  Although, as the column makes clear, even on his medicine he is a challenge for his mom because of the amount of support he needs.  Not only is his medicine exorbitant, "but at 6-foot-2 and 380 pounds, he is a force unto himself."

Now, here I could go in several directions, pointing out that some of that nefarious community support we've heard so much about would obviously help someone in this boy's situation, including (gasp) a trip to the movies or a visit to a friend's house accompanied by someone trained to help a person hearing voices – even on meds – socialize normally.  Or I could go off on the system that punishes people with private insurance, or a private mental hospital that would call a mother and tell her to pick up her son or they'll take him to a homeless shelter because his paid days are up, and in spite of the fact that they must know he needs more help.  All of these nightmarish pieces of the unholy mess that is mental health reform deserve attention.  But why don't we look back (in anger, perhaps?) at what brought our society to this point. 

In the sixties, to those galvanized by the civil rights movement, deinstitutionalization seemed like the dream solution to the sometimes draconian asylums that dotted the country.  Of course, it was predicated on the availability of new drugs that were going transform mental illness into something manageable for most patients, allowing them to live and participate in the community.  To a certain extent, this happened.  But the medicines were oversold or, maybe more accurately, the amount of support these people would need was undersold.  There are some great reasons to stay on psychiatric medicine, but there are also some compelling reasons to go off them.  The side effects can be gruesome, from serious weight gain to the pointless involuntary movements of tardive dyskinesia.  Not to mention that they're expensive and can be difficult to keep up with on a daily basis, even for someone with no other problems.  So we were supposed to create a great network of services available to people on an outpatient basis that would keep them on their prescriptions and able to function.  I used to live in a densely populated, small city where it was clear to any and all how necessary such a system was, and, indeed, we had a good enough one to be referred to as "The People's Republic of __".  Now, in a city as sprawling as Raleigh, it is a lot easier to avoid some of the unpleasant facts of life, and pretend, unless you're related to them, that the mentally ill are taken care of, or someone else's responsibility, or whatever, who cares?  So when the state says we haven't got this great community care system in place (because we never really created it after all), but we can accomplish is by privatizing anything and everything, there are many, many people who think that's peachy and sufficient, not to mention (note to self) an opportunity to make a profit.  Unfortunately, the least of our brothers aren't here for their potential profit margin.  They're here to enrich, challenge, defy and improve us.  Pretty much like every child who's ever been born.  But the mentally ill need a lot of help and we need to pay for it.  Because it's right and just, and because there but for the grace of a few dopamine receptors, go any one of us.

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Stop but GoEaster Seals UCP delivered a letter to Gov. Easley this week that included a time line of events leading up to the current crisis with our mental health system. The following is a simplified version of that timeline that reveals some interesting things:

Pre-2006: Series of meetings occur that redefine what types of Community Support (CS) services will be provided and the qualifications of staff that will provide them. The state’s new definitions bundle the services together so there is no distinction between services provided by a degreed professional and a high-school graduate. Providers and advocates express concerns that this blending would lead to problems, they warned that DHHS would not be able to determine if services were being appropriately delivered.

Jan. 2006- Federal Government approves the new blended rates for Medicaid services.

Jan. 2006- Sec. Odom orders providers to implement the new blended service definitions by March 2006. 

Jan.–Mar. 2006 – Provider and case management organizations have 60 days to totally restructure and reorganize. Organizations were previously told by the Division Director that they would have 6 months to reorganize. Consumers must choose a primary provider between their current case management agency, their direct service provider or a new provider. New authorizations for service must be acquired for every consumer.

April 2006- Sec. Odom announces that all consumer authorizations will be done by one company, Value Options. Providers must transfer all their authorization requests by June 30th. There is a backlog of authorizations at the local and state level as a result of the new system.

Jul 2006- Value Options begins processing authorizations for all mental health services. Volume is more than double the amount the state forecast. Value Options is understaffed. Authorizations back up and processing difficulties result when they try to speed up case reviews. The Division Director issues a memo telling providers to serve consumes regardless of whether an authorization has been issued. Providers may give up to 28 hours of service to a consumer within 30 days while the authorizations are processed.

July-Dec. 2006 – Issues begin to arise because of delayed authorizations. Agencies can’t bill for services without the authorizations, they have cash flow problems. Value Options processes the bulk of requests with minimum changes (i.e. they rubber stamp the authorization requests).

Jan-Mar 2007- The Division of Medical Assistance completes a compliance review of 167 CS program sites (139 distinct agencies). The sites reviewed where those where Value Options has authorized high numbers of service units per customer. The review examined 10 files per program.

This timeline shows that a year ago, DHHS was telling providers to go, go, go. Change the system, blend all the services into one flat rate, reauthorize all the consumers, do it in 2 months not 6 months. Value Options was to provide a check and balance in the system but when they become hopelessly bottlenecked, DHHS signaled everyone to go ahead with services to consumers by instructing providers to authorized 28 hours of service for 30 days.

Now with mental health costs soaring, Secretary Odom is screaming stop. Without notice the rates are being slashed 33%, the hours of allowed services are being cut from 28 hours to 8 hours, and the mental health services, that the state defined as appropriate, are being presented to the public as inappropriate uses of the system.

Our mental health system has serious problems that need to be fixed. The mixed signals coming from the DHHS are part of the problem, not part of the solution. Perhaps the best solution to the crisis would be for everyone involved to proceed with caution.

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I’m pretty critical of greedy, profit-hungry corporations but this week I have to side with mental health providers who had their reimbursement rates slashed 33% by the state health and human services officials. dhhsAfter reviewing an audit, state officials decided that the $60 per hour charged by mental health providers for community support services was excessive and retroactively reduced the rate that the state will pay to $40 per hour. This was a knee-jerk reaction by state officials. Maybe the current rate is too high, maybe it is excessive in relation to the cost of providing services, maybe changes are called for but not in the manner by which they were done. As Chris Fitzsimon pointed out in his Monday column:

Even if state officials believed cutting the reimbursement rate for the services was the right thing to do, why not announce it 60 days in advance and allow public comment?  

The state’s actions last week were unfair. More importantly, they set a bad precedent for doing business with our state government. When the state acts in bad faith, service providers will do the same. Nobody wins. If privatization is going to work at all, the state and the service providers are going to have to play fair with each other.

Right now, the trust has been broken between the state, the providers and the mental health patients; it needs to be rebuilt. We could start by having an honest and public discussion about North Carolinas mental health needs and what it actually costs to provide mental health services of all types. It’s the fair thing to do.