This blog originally founded by Blogger who holds a theological degree and a doctorate in Counseling Psychology. Taught Psychology for 32 years and is now Professor Emeritus. Is a board-certified psychologist and was awarded the Lifetime Achievement Award in his profession. Ministered as a chaplain, and pastored Baptist and Episcopal churches. Publications cover the integration of psychology and theology. Served in the Army, the Merchant Marines and the Peace Corps.

Saturday, October 8, 2011

What the H... is going on in Mental Health?

Mental health reform:  The committee which Virginia Foxx was on, reformed the disability system in North Carolina.  Services were transferred from government agencies to private companies.  Government agencies
oversee the monies.  Private agencies provide the care.  The model goes all the way down to the local systems.  A government-like agency was set up called the Local Management Entity (“LME”).  They in turn would contract with the private companies for services.

For me as a conservative, the reform was a dream come true–the best from the political left and the best from the political right.  The reform met government’s interests in overseeing tax payer money.  The privates are incentivized to produce.  It was a perfect system except as always “the best laid schemes of mice and men often go astray.”

Why Reform?  Before looking at why reform has not worked as hoped, let me give a little background.  Why reform the system in the first place?  Many scandals had been brewing at the time.  Systems were going bankrupt.  Medicaid money was being misspent.  Some administrators came close to being “perpwalked”.   These were the big items that grabbed the legislators’ attention and the appointment of a reform committee.

More problems under the radar:  However, there was more going on which was out of sight.  The country was waking up to the realization that public institutions don’t work.  The mental health system was a poster child.   There are no incentives built in.  Providers were paid whether they saw one patient a day or only a few.  As I have written elsewhere, the brain disordered population are not great for keeping appointments.  Actually, it was even  advantageous to have no-shows.  That was catch up time for paper work.

As I traveled around the state visiting many of the centers, what I found were professionals seeing few people.  At the same time, huge waiting times were growing, which were then used as pretense for needing more funds.

Another under the radar problem that surfaced was that the public providers were not conscientious in fee collecting.  After all, they were service minded  people and many were even uncomfortable in charging people for their help–an occupational hazard.  

The timing of the reform could not have been better.  In Washington, the advocates for the mentally ill were convincing the Medicaid officials that what the government was paying for were the wrong things.  The patients themselves were being listened to and Medicaid was reforming its funding system to more effective interventions. 

Thus, good reforms were taking place throughout the system.  Under the new system, instead of the patient having to follow the money, the money follows the patient.  Like any other person in the community they are able to choose their own providers.  If they don’t like one, they can shop for another.  No more “Big Nurse.”  Best of all, they no longer have to suffer the stigma of a public mental health center.

Another way the money followed them was that helpers are assigned to find them wherever they are, build rapport, see that they are O. K. and taking their meds.  Their case worker can even do tasks like convince someone to hire them, including promising to cover for the patient if he or she is off their meds and doesn’t come to work that day.  These and other services, the patients through their advocacy groups, obtained for themselves.

What broke down?  Now we come to why the system is not working as it was envisioned.  Of course the most obvious is that the recession hit.  But beyond that, from my point of view, the buck as always, finally stops at the oversight agencies.  As said earlier, it was envisioned that the government agency (LME) would monitor the privates.  The state Health and Human Services would monitor the LME’s.  Oversight has obviously been the big breakdown.

Also as one of our readers, Oatz points out, providers are not administrators.  Unfortunately, when the LME’s were formed, many of them hired from their own provider staff.  This was diametrically opposed to the important purpose of getting  providers away from administration.

One of my early observations in talking to LME staff, in addition to the obvious, some of them actually had a hidden agenda to see the system fail.  When reform was forced upon them, locals to the bureaucrats in Raleigh, raged against the new system. 

Their halcyon days would never be again.

1 comment:

NewGuy said...

For those following this story, here is a good article from the Wilkes Journal Patriot!