Monday, June 23, 2008

Smoky Mt News: MH Reform

Another bad mental health care decision

By Raymond Turpin • Guest Columnist
-Smoky Mt News

Provisionally licensed therapists are individuals who have completedtheir formal education and training, hold master's or doctoral degreesfrom accredited graduate programs, and lack only supervised hours ofpractical experience in order to qualify for their licensure exam. Foryears, they have been able to come to North Carolina and provide much-needed therapy services to Medicaid recipients while receiving adequatesupervision from licensed professionals in their respective fields.
They have helped offset ongoing, serious workforce shortages in thisstate, and their services are critical to providers statewide who aretrying to meet the mental health needs of their communities. Theiroutpatient therapy services continue to be vitally important to thesurvival of North Carolina's fragile mental health delivery system,which is still reeling after years of mismanagement by the verygovernment agencies entrusted with its care and development.
In a continuance of puzzling decisions, North Carolina's Division ofMedical Assistance has announced that beginning July 1, provisionallylicensed therapists will no longer be able to provide outpatienttherapy for Medicaid recipients unless they work for a physician,accept only mental health referrals from said physician, and deliverall services on-site where the physician practices medicine. Thephysician is responsible for supervising the therapy, but provisionallylicensed therapists must still seek supervision from approved licensedprofessionals in their field in order to accrue hours towardslicensure.
If a provisionally licensed therapist does not work directly under aphysician, they will only be allowed to provide Medicaid's "enhanced"services, which consist of the services such as Community Support thatthe state has mismanaged into a confusing, excruciating exercise ofredundant paperwork, complex authorization procedures, hours ofunbillable time, and frequent denials.
As it stands, on July 1 the vast majority of provisionally licensedtherapists will be forced by DMA to interrupt their outpatient therapywork. This decision was made over the clear objections of the mentalhealth professional organization (Professional Alliance Council) thatthe Division asks for guidance on these issues.
Since there is still a severe workforce shortage in North Carolina,particularly in the rural areas, removing these very capable and much-needed therapists will plunge the system into further crisis. Fewertherapists providing these basic outpatient services will mean moreclients deteriorating to the point of requiring more intensive enhancedservices. The fact that there are not enough licensed therapists torefer these clients to will create a situation very shortly where therewill be hundreds of mental health clients in rural Western NorthCarolina losing their outpatient therapists. This scenario will also beplayed out in rural areas statewide. How is this going to improve thedelivery of services?
Also, relegating provisionally licensed therapists to only providingenhanced services will keep many recent graduates and many veryqualified therapists from wanting to come to North Carolina. Our statealready ranks near the bottom in mental health, and this will onlysolidify our reputation as a state that is bumbling its way towardobliteration of the mental health system with management decisions thatare not progressive or even helpful.
Most importantly, perhaps, I have yet to get an answer from DMA orDHHS as to why only physicians are being anointed in the new policy,and why a licensed psychologist is not being considered qualified to dothe same. Psychologists are expected to render the same decisions aboutmedical necessity for mental health services as a physician, yet we areconsidered unqualified to participate in the new policy.
The fact that after July 1 psychologists and other approved licensedprofessionals will still be required to provide supervision accordingto our various licensing boards requirements essentially makes us sharelegal and clinical responsibility for the provisionally licensedtherapists' work. Regardless, we are barred from employing them in ouragencies where we can refer to them and provide closer supervision andtraining.
I would also like to know where all of these participating physiciansare going to come from in the rural areas. Most are up to their necksin patients and expending all of their time serving their patients'medical needs and prefer to refer out to the mental healthprofessionals in the community when a mental health issue is suspected.The vast majority of physicians are not adequately trained in mentalhealth diagnosis and treatment, yet they are the ones that DMA hasdecided are now the most appropriate to directly supervise theoutpatient therapy work of provisionally licensed therapists?
In addition, why would a practicing physician want to further riskmalpractice litigation by allowing a provisionally licensed mentalhealth therapist to bill for services through his Medicaid providernumber? The only entities that this policy change will benefit are thegigantic mental health corporations that have deep enough pockets toafford their own psychiatrists. The smaller, truly community-basedagencies will be replaced by more impersonal, profit-driven mentalhealth Wal-Marts. The irony is that this is the type of situation thatreform attempted to correct in the first place.
At this point, any mental health agency in North Carolina stillfaithfully trying to provide needed mental health services for itscommunities deserves a medal. Many providers have left the state or thefield altogether, having grown weary of the ceaseless changes andincompetent leadership. Instead of policy changes that are going tofurther destabilize and demoralize us, include us in your decisions andlet's work together to create an inclusive system that works for usall.
(Raymond Turpin, PsyD, is the president and clinical director forHaywood/Jackson County Psychological Services. He can be reached atrturpin@jcpsmail.org.)

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