A lady telephoned me today. We will call her Dannae (because her name actually is Dannae, and she gave me permission to use her name). Dannae used to have a company, Three-D’s Forever, Inc. d/b/a Step Down Group Home.
Dannae used to manage a group home for mentally ill teens in the Sandhills catchment area. Sandhills Center is one of our 11 (soon to be 10) MCOs and serves 8 counties: Anson, Harnett, Hoke, Lee, Montgomery, Moore, Randolph and Richmond. The eight county catchment area has a population of approximately 556,000 individuals.
From the time Sandhills Center (Sandhills) went “live” (contract effective date December 1, 2012, and “live” effective date April 1, 2013) until the day her company closed, May 3, 2013, Dannae and Step Down had difficulty dealing with Sandhills.
Throughout January 2013, Sandhills informed Dannae that forms were missing from the application; on or about February 8, 2013, Sandhills conducted a safety, site-visit check. On or about February 17, 2013, Dannae received a letter from Sandhills saying the site visit was fine.
April 1, 2013, came and went and Step Down still did not have a contract with Sandhills. She was told by Sandhills that everything had been approved and Step Down was on the list for approval. Yet, Step Down had consumers in Sandhills catchment area with no Medicaid contract. Numerous communications went back and forth.
April 24, 2013, Sandhills contacted Step Down saying that it had been approved and a contract would follow. But still…no signed contract.
Two check periods passed with no Medicaid reimbursements paid to Step Down.
The last contact from Sandhills was April 24, 2013, saying Step Down was approved.
Step Down was forced to close its doors May 3, 2013.
May. It is mid-August.
Sadly, Dannae is now unemployed. Prior to May 3, 2013, she contributed to society. She ran a business. She helped Medicaid recipients. Now, because of Sandhills and the bumpy (to say the least) transition to Sandhills, Dannae’s company is nonexistent.
Yet, I googled Sandhills’ Medicaid providers today. An amazingly, long list of Medicaid providers is on Sandhills’ website as “Current Medicaid…Provider List.” Here is the page in which I was interested:
I know. The print is small. But click on the picture and you can enlarge it. See Three D’s Forever, Inc d/b/a Step Down?
This is a list of Medicaid providers in the Sandhills catchment area that I pulled from today, August 19, 2013. Three and 1/2 months after Step Down was forced to close, Sandhills still lists Step Down as a Medicaid provider.
Dannae told me that Medicaid recipients/guardians are still calling her for mental health care appointments because of Sandhills list of “current” providers.
Who is supervising Sandhills’ marketing of closed providers? Who is to say that Three D’s Forever, Inc. d/b.a Step Down is the only closed provider on Sandhill’s list?
Who is ensuring that Medicaid recipients have adequate access to mental health care?
Apparently not Sandhills, which, apparently, does not even know that Step Down is out of business. Surely, not the Department of Health and Human Services (DHHS), because after the MCOs went live, DHHS cannot even track mental health services. DHHS has no idea who is getting or not getting services. The providers certainly cannot ensure adequate access. Once the providers go out of business, the owners are concerned about their own monetary situations (and understandably).
This leaves the Medicaid recipients’ guardians, if applicable, who pull up the Sandhills current Medicaid provider list and start calling around. They call Step Down only to be told Step Down is closed.
How many other providers on Sandhills’ list are closed? Or no longer accepting Medicaid?
Wasn’t Sandhills contracted to manage behavioral health Medicaid care in 8 counties?
Then how can Sandhills be oblivious to the fact that a provider on its “Current Medicaid…Provider List” is closed?
As for Dannae, whether Sandhills is managing Medicaid behavioral health car within 8 counties adequately enough is a non-issue. Her company is closed.
She is just another victim of State non-oversight.
Smoke and Mirrors: ECBH Increasing Medicaid Rates (But Decreasing the Amount of Services Authorized?)
I am always amazed at magicians. David Copperfield, David Blaine…
I once saw David Copperfield live. I was convinced prior to the show that I would be able to determine how he performed the illusions. I just KNEW that I would see the strings or the trapdoor. But I did not. I was thoroughly amazed. Despite the fact that I still know that magic is not real, I was still awe-struck and entertained. Realistically, magic is just smoke and mirrors. But, dag on, those smoke and mirrors do a fantastic job. At times, while watching a magic show, I find myself actually believing in magic. That is the power of smoke and mirrors.
Smoke and mirrors do not only appear in magic. Many politicians are expert wielders of smoke and mirrors. So to are many salesmen. And, apparently, East Carolina Behavioral Health (ECBH).
An article was published on NC Health News’ website yesterday. “Medicaid LME Updates: Cumberland/Alliance to Merge, Good News from ECBH.” Article is good. Information is good. But the ECBH news, I find “smoky.”
Click here for the article by Taylor Sisk
According to the article, “ECBH will increase the rates for psychological testing by 10 percent, personal care services by 16 percent, peer support by 7 percent and facility-based crisis and detoxification services to cover the full cost of the service.”
On the surface, the increase in rates that ECBH is implementing sounds great, right? In my head, I thought, “Wow! ECBH is doing some great marketing. Providers will want to work with ECBH…”
The problem is that the “surface level” or rate increase “on its face” is never the whole story. (Which is why ECBH’s rate increase is such an amazing use of smoke and mirrors. Most people will never see past the smoke).
The MCOs are prepaid. If the MCOs’ do NOT contract with providers and NOT authorize services, profits rise.
But would an MCO REALLY deny medically necessary services, theoretically, to INCREASE profit?? You can decide.
However, one of my clients hired me because ECBH denied 100% of continuing authorizations and new referrals for ACTT services in Pitt County.
ONE HUNDRED PERCENT!
What are ACTT services?
DMA Clinical Policy 8A defines ACTT services:
“The Assertive Community Treatment Team [ACTT] is a service provided by an interdisciplinary team that ensures service availability 24 hours a day, 7 days per week and is prepared to carry out a full range of treatment functions wherever and whenever needed. A service beneficiary is referred to the Assertive Community Treatment Team service when it has been determined that his or her needs are so pervasive or unpredictable that they cannot be met effectively by any other combination of available community services. Typically this service should be targeted to the 10% of MHDDSA service beneficiaries who have serious and persistent mental illness or co-occurring disorders, dual and triply diagnosed and the most complex and expensive treatment needs.”
ACTT services are reserved for the extremely mentally ill. These are the people who need 24-hour services; recipients receiving ACTT services are people who must receive the ACTT services to function. Yet, ECBH denied 100% of my client’s new referrals and continuing authorizations. One such denial was a Medicaid recipient who had been arrested 6 times since April 2012. After the ACTT denial, the Medicaid recipient was again incarcerated, which is where the recipient is now. Another denial resulted in the Medicaid recipient being hospitalized for suicidal ideation.
For recipients already receiving ACTT services, ECBH has forced my client to “step-down” the recipients to outpatient behavioral therapy (“OBT”). Of the Medicaid recipients that ECBH has forced Petitioner to “step-down,” three recipients were immediately referred back to ACTT when the OBT providers stated that the recipients suffered too high acuity of mental health illness to manage in OBT setting. Two recipients were incarnated after discharge; the jail employees are complaining of psychiatric problems that are difficult to manage.
Back in May 2013, the local news channel in Greenville, North Carolina, aired “9 On Your Side Mental Health Town Hall exposes problems, brings you answers.” The news channel coverage demonstrates the possibility of the widespread breath of ECBH denials, in general. Maybe ECBH’s denials of medically necessary services is not limited to my client’s personal situation.
Regardless of the breadth of ECBH’s denials of medically necessary services, back in May 2013, ECBH was getting some bad marketing from the local news. So what does ECBH do? Raise reimbursement rates.
If, in fact, ECBH is denying many medically necessary Medicaid services in order to raise profit, then isn’t ECBH’s rate increase just smoke and mirrors?
Emergency rooms and jails are our mental health care providers for Medicaid recipients?
My best friend is an ER trauma nurse. She told me that a majority of patients are mentally ill. One man came in to the ER, screaming at the top of his lungs, “Get me my lilly pad!” Apparently he believed that he was a frog. While you may smile at the humorous notion of the lilly pad man, it is a sad tribute to the state of mental illness in North Carolina. Why was he not getting the care he needed?
And here I thought mental health care was so important. In light of recent events, I would venture to say that mental health is quickly becoming our nation’s most pressing issue.
First let me say, Boston…so tragic. My prayers are with all families affected by the bombing.
So you would think with all the hoopla in the aftermath of the Boston bombing and other serious heinous acts (Connecticut) that our mental health system would be top priority.
Is there a correlation between poor mental health systems and violent crime? Yes.
Here are some studies:
- The present study of public psychiatric beds in the United States suggests that 42 of the 50 states have less than half the minimum number of beds considered to be reasonable by knowledgeable experts. In 32 of the states, the shortage is critical or severe.
- A study in Ohio compared 122 patients with schizophrenia who had committed violent acts with 111 patients with schizophrenia who had not committed such acts. The violent patients had significantly more prominent symptoms and significantly less awareness of their illness. Friedman L, Hrouda D, Noffsinger S et. al. Psychometric relationships of insight in patients with schizophrenia who commit violent acts. Schizophrenia Research 2003;60:81.
- A study of 961 young adults in New Zealand reported that individuals with schizophrenia and associated disorders were two-and-one-half times more likely than controls to have been violent in the past year. If the person was also a substance abuser, the incidence of violent behavior was even higher. Arseneault L, Moffitt TE, Caspi A et. al. Mental disorders and violence in a total birth cohort. Archives of General Psychiatry 2000;57:979–986.
- A study of 63 inpatients with schizophrenia in Spain reported that the best predictors of violent behavior were being sicker (i.e., higher scores on symptom measures) and less insight into their illness. “The single variable that best predicted violence was insight into psychotic symptoms.” Arango C, Barba AC, Gonzalez-Salvador T et. al. Violence in schizophrenic inpatients: a prospective study. Schizophrenia Bulletin 1999;25:493–503.
- A 10-year follow-up of 1,056 severely mentally ill patients discharged from mental hospitals in Sweden in 1986 reported that “of those who were 40 years old or younger at the time of discharge, nearly 40 percent had a criminal record as compared to less than 10 percent of the general public.” Furthermore, “the most frequently occurring crimes are violent crimes.” Belfrage H. A ten-year follow-up of criminality in Stockholm mental patients. British Journal of Criminology 1998;38:145–155.
- A study of 331 individuals with severe mental illness in the United States reported that 17.8 percent “had engaged in serious violent acts that involved weapons or caused injury.” It also found that “substance abuse problems, medication noncompliance, and low insight into illness operate together to increase violence risk.” Swartz MS, Swanson JW, Hiday VA et. al. Violence and severe mental illness: the effects of substance abuse and nonadherence to medication. American Journal of Psychiatry 1998;155:226–231.
What about North Carolina? Where are our mentally ill? In jails? Hospitalized? Or receiving quality mental health care.
The study “More Mentally Ill Persons are in Jails and Prisons…” states, “Using 2004–2005 data not previously published, we found that in the United States there are now more than three times more seriously mentally ill persons in jails and prisons than in hospitals. Looked at by individual states, in North Dakota there are approximately an equal number of mentally ill persons in jails and prisons compared to hospitals. By contrast, Arizona and Nevada have almost ten times more mentally ill persons in jails and prisons than in hospitals. It is thus fact, not hyperbole, that America’s jails and prisons have become our new mental hospitals.”
Having a strong, competent, and easily accessible system to serve those people suffering from mental illness is key to so many things you would want in a society: (1) those suffering from mental illnesses would receive the quality health care so needed; (2) there would be less homeless; (3) there would be less violence (see above-referenced studies).
Now, since this is a Medicaid blog, I will obviously concentrate on the Medicaid population.
So what is North Carolina doing regarding the mental health system for Medicaid recipients?
With the implementation of the Managed Care Organizations (MCOs), the hiring of Recovery Audit Contractors (RACs) and the utter lack of supervision by the Division of Medical Assistance (DMA), the Medicaid mental health system is spiraling downward.
Medicaid recipients are not receiving the care needed because of the state’s, MCOs’ and RACs’ treatment of health care providers willing to accept Medicaid.
Here are some serious and real-life examples:
1. The MCOs are denying authorizations for more expensive mental health services.
In a certain county, a certain MCO is denying all ACTT services, stating the Medicaid recipients do not meet eligibility requirements. ACTT, or Assertive Community Treatment Team services. ACTT is a 24-hour, 7 day/week service for the seriously mentally ill. Since the MCO denied ACTT services in this certain county, despite medical necessity, 2 discharged ACTT recipients have committed crimes and become incarcerated. One discharged recipient attempted suicide. Two in jail; one in a hospital. Thank you, new mental health care providers.
2. The RACs are causing quality health care providers who have never committed fraud to have their Medicaid contracts terminated based on paperwork nit-picking and causing Medicaid recipients to lose their provider.
One such provider serves teen-age boys suffering mental illnesses with violent tendencies. With its Medicaid contract terminated and the inability to pay its staff, those boys may soon be homeless and on their own. The consequences could be catastrophic. Jails and hospitals, I am sure.
What is DMA doing about the MCOs denying medically necessary services and the RACs terminating health care providers needlessly and erroneously?
DMA states that MCOs and RACs are independent contractors; therefore, DMA cannot supervise the MCOs and RACs. I say, “Hog-wash.” DMA cannot divorce itself the duties of managing Medicaid.
But, regardless, stop pointing fingers. Who cares if its DMA’s fault that the teenage boys receiving residential Medicaid services will be homeless because the RACs erroneously and without due process terminated the provider’s contract? Just fix it. Period.
Stop the jails and emergency rooms from becoming North Carolina’s mental health care providers!
NC residents who live in Medicaid-funded group homes suffer mental illnesses or developmental disabilities. Group homes allow the residents a home-like atmosphere and 24/7 health care and personal care services, such as help with toileting, bathing, and eating.
The federal government informed NC that the state was using the wrong eligibility criteria for Medicaid recipients receiving personal care. Personal care services (PCS) is a paraprofessional service that covers the services of an aide in the recipient’s private residence or group home to assist with the recipient’s personal care needs that are directly linked to a medical condition.
To fix the eligibility problem pointed out by the feds, the General Assembly set up a $39.7 million fund to pay for adult care homes, but group homes were unintentionally excluded. If the legislators did not use the word “only” in the legislation, most likely, group homes would have been covered. But in “only” covering adult care homes, group homes were excluded.
The result of the General Assembly’s oversight is that approximately 1400 people may be homeless starting January 1, 2013.
Despite an outcry from the General Assembly for Purdue to call a special session, Purdue refused. Instead, last week, Purdue announced that she was moving $1 million dollars within the Department of Health and Human Services to pay for group homes through January 2013. This allows the group home residents one extra month before Medicaid funding is gone.
The General Assembly organizes January 9th, but is not scheduled to conduct business until January 30, 2013….the day Medicaid funding will cease for the group homes.
Literally THOUSANDS of mentally disabled, NC Medicaid recipients may be on the streets of NC come January 1, 2013. Perdue claims that her last act as governor will be to prevent this to happen. But can she? No. Not alone.
Due to recently passed federal legislation, The Center for Medicare and Medicaid Services told North Carolina last year that personal care services (such as assistance with daily ADL‘s like eating, bathing, and toileting) must be reimbursed at the same rate for Medicaid patients who live in private homes and for those in group homes. It is estimated that the change in the reimbursement rate would cause $414 million less payments to group homes caring for Medicaid recipients suffering from mental illness. The result of this massive cut in Medicaid payments to group homes will cause most group homes in North Carolina to go bankrupt, resulting in all the Medicaid recipients residing at the group home to be put out on the street.
Group homes must abide by extremely stringent state and federal laws to keep their doors open. Therefore, group homes are exceedingly expensive to run. Not to mention that group homes must have 24-hour, 365 days/year employees. The cost to run a group home is staggeringly higher to run than a private home. It is illogical why the government would pay a private home and a commercial group home the same Medicaid rate. In a private home, the people live at the home; therefore private homes do not need to pay for numerous employees to work 24-hour, 365 days/year. Yet, due to federal legislation, Medicaid will reimburse group homes the same as private homes.
Can we stop this tomfoolery? It is up to the state legislators. While they relax for Christmas vacation, come New Year‘s approximately 20,000 adult Medicaid recipients may be on the street. While legislators sip hot toddies with a roof over their heads, 20,000 will be freezing in the middle of winter, homeless, during one of the coldest months of the year. Action is needed. State legislators have advised Perdue to fund these group homes will alternative funding. However, Perdue has stated this is impossible due to the language of statutes. What is needed? A special session! Make the legislators come back for a special session. If the legislators get to ring in the New Year with a roof over their heads, don’t the residents of North Carolina’s group homes deserve the same?