Wednesday, February 27, 2008

Diane Bauknight offers a cynic's nutshell version of the "MH reform" movement in NC

A cynic's nutshell version of the "MH reform" movement in NC:
by Diane Bauknight

The legislature stumbled across this national movement to reign in state costs for Medicaid by targeting mental health and DD. We had people come in from Michigan (Richard Visingardi) to show us the ropes of reform. He left after the die was cast, but not before double dipping salary both in Michigan and NC (being paid in both places as a full time employee.) We are use to those kinds of shenanigans in NC. It didn't even ripple the water here. Visingardi high-tailed it back to Michigan after his dastardly deed was done, and let us with the framework of our reform, based on the Michigan model. The Michigan model proved to be a colossal failure (in Michigan), but we plodded along with the plan anyway. Why should we learn from other state's mistakes?

Here is the basic idea: Medicaid is one of the fasting growing expense of states. However, the real costs behind Medicaid are end-of-life elder care, but that is too politically risky. The Mental Health "reform" movement was hatched in conservative think tanks and focused on the privatization of health care and cost-cutting measures, much as the privatization movement for prisons and other public institutions evolved.

The focus of the reform is to shifts costs from the state to other funding pools. This includes, for example:

Close the state hospitals and get the private hospitals to do the MH care. Why? the private hospitals can pull down federal $$ that the state can not access. The state can also close the buildings, which is a great expense. Problem: Private hospitals do not want to do MH care, as they make little money (or lose money) and it is labor intensive.
Build more prisons to house people with MH, while you close down MH facilities. Entire MH sections are being built in prisons to house mentally ill people. Federal funds can be used to pay for mental health wings in prisons but not in state hospitals. It is also much cheaper to lock people up than to provide long-term treatment in a hospital.
Close (public) area programs. Now the buildings are not costing the state, and the state is no longer in the business of providing care. Indigent people find it harder to receive care with the safety net gone, which (in the short term) saves the state money. Consolidate the area programs, which saves more money. Turn the LME into gate-keepers for community-based services, so they squeeze the providers and consumers even more by denying medically necessary care. Reward the LME by giving them more money if they keep costs down (reduce hospital admissions) and take money from them if they don't.
Hire a big company to deny the more expensive services, like institutional care, groups homes, etc... Pick a friend to pay the big bucks for denying care. Value Options has lots of ties to administrators in our DMH--so they were a great choice. This is a win-win for all! Our friends get to be billionaires and we can still save state $$.
Water-down services. Create new service definitions that provide fewer services, shorter duration and cloak it in the "recovery model" so that they are time-limited. Send out lots of press releases how these reduced services are actually "enhanced services." When services don't exist, confuse the public by saying that "naturally occurring" services will be identified. Don't explain that "naturally occurring" (FREE) services don't exist for most people with serious MH and DD disabilities. Save even more $$.
Dump the professionals where ever you can. They cost too much. Let them supervise a team of para-professionals that will actually work with the person receiving care. Hire high school grads and give them 20 hours of training to teach people with the most challenging mental illnesses "skills" to "recover". Send them out into the community when there is a crisis, at least on paper. You and I know that 24/7 crisis care could mean that the private provider will not respond unless the person already meets criteria for hospitalization (danger to self or others). Heck, it looks good on paper that we provide 24/7 care. If it gets that bad, call the cops. They will sit with the person in the ER for days if they have to and the best part is THE COUNTY pays the cop to supervise the person and the private hospital gets to deal with it!
Turn the psychiatrists into paper-pushers. We don't have that many psychiatrists left in NC. Lets make sure we get the biggest bang for the buck from our psychiatrists. Have the therapist tell the psychiatrist what drug to prescribe and let the psychiatrist write prescriptions! (Yes, there could be some serious side effects from the drugs, but OH WELL.)) On second thought, maybe we can get nurses to do this! Think of the savings.....
Make it really, really hard for people to figure out how to file a legal appeal. Instead, have them think the appeal goes through the LME first. If the grievance does go to court, spare no costs in fighting people who have had medically necessary care denied. We don't want to set any precedents and open the doors for people to think they can truly fight the system when their human rights and entitlements have been violated and actually win.
Understand and accept that there will be some suicides or broken lives. Hell, we can't save everyone and we have have to REIGN in those costs! Consider it collateral damage.
Hire your friends to do lots of studies to support your findings that hospitals should be closed down and community based services developed. Do this every few years so it looks like you are concerned and you are open to hearing new ideas, even if the reports continue to repeat the same "findings." Continue to close state facilities and hospitals, but don't actually develop truly comprehensive community based services, and the ones you have developed-- make sure they are weak and time-limited. For children, pretend like the services are not time-limited (so you don't violate federal law) by calling it a suggested time-frame which can be appealed if more hours are needed. (HA-HA-HA. Aren't we clever?) Make sure it is really hard for any provider to survive that delivers community-based services. That way the services will not be "over-utilized" (mental-health speak for "cost too much.")
Shift costs to the counties. Legislate that the counties provide oversight of the LME, but give them no power to truly manage a system that has no accountability. Lean on the counties to fund more mental health services. Use their police and private hospital ERS instead of creating crisis facilities.
Build a private provider network for those that can pay. Ignore the needs of those that can not (saves lots of state $$.) Keep the focus be on managing the usage (costs) of care by driving providers out of business that insist on providing the true level of care (duration, intensity) the person needs. Make the provider afraid to provide services outside of the established time-frames, regardless of what the person actually needs. Threaten audits if they do. Close down some private providers (you can do this by de-certifying, demanding paybacks, doing audits, or just declaring the provider "too hard to work with"). This will instill fear in the remaining providers. You mean "business. "
Create a wall of paperwork so that it is so difficult to deliver care that few providers can actually survive, and the system morphs into big business private providers. When providers fail, blame them for poor business management. Fewer providers are easier to manage, anyway. When private providers can not keep up with the mountains of ever-changing paperwork and fail to cross all of their T's, accuse them of fraud, or of stealing, or just being plain greedy. Then, drive them out of business by insisting on retro-active paybacks. Now we have them where we want them.
Stonewall consumers until they go away or die. And don't forget that there is plenty of room on the streets and in prisons (even though some bleeding-hearts claim that those with mental illness are flooding shelters, jails and prisons.) Remember our goal: we need to REIGN in costs.
Oh, did I mention we are 43rd in mental health spending in NC, and post-reform costs are causing Medicaid costs for treating mental illness to soar? Could the answer be for the state to recognize that the reform has failed and spend the upfront money needed to create a true continuum of care that actually might result in less need for institutionalization---when the right services are provided at the right time by the right professionals?

Right now we are putting money in a system that can not work. It is like continuing to repair a car that is on its last leg. We are being nickeled and dimed to death with no hope of ever seeing a return on the money we have spent. And, more importantly, people are suffering. Diane Bauknight

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