Aug 25, 2013

No Medicaid Health Homes for Ohio

Ohio is backing off plans to add primary care clinics to its network of community mental health centers. The plan for so-called Medicaid Health Homes failed because it adds unrecoverable expense to a system where every single dollar is already tied up.

This should not come as much of a surprise for people familiar with Ohio Medicaid payment issues. I’ve served on the governing board of a neighborhood health clinic, a Federally Qualified Health Center (FQHC). Even with the enhanced payments we received under this program, we could never find a way to add mental health or addiction treatment to our standard menu of primary care services. I attended workshops and seminars to learn how to parse primary care organization billing codes, but what we found is that the system won’t support what actually works. When a person comes in for a primary care visit, the clinic can't bill for a mental health visit the same day. 

Ohio mental health organizations have a different set of technical problems. Years ago, the state obtained a federal waiver that carved out mental health from mainstream Medicaid. This made Ohio mental health and addiction services operate on a pre-allocated cost-reimbursement basis, not fee-for-service. Every dollar within an agency budget is tagged for service delivery based on service capacity estimates. The main management dynamic is utilization of the Medicaid budget allocation. Unspent dollars are reclaimed through an audit process, so there is no margin left over for success or experimentation. Because every dollar within an agency is already allocated, every new service requires new funding.

This provider funding dynamic prizes stability, not innovation. Competition is suppressed. Ohio Medicaid mental health contracts are no-bid contracts. In many communities there’s an undercurrent of cronyism. Provider executives get cozy with local politicians and mental health board members to make sure their agencies stay in the game. Agencies that provide a service at lower cost don’t win, and new providers are frozen out.

Adding primary care to mental health agencies also requires service efficiencies the population served makes difficult to sustain. Ohio Medicaid primary care is organized around fee-for-service reimbursement based on procedural billing codes. The codes provide about enough money for each encounter if the staff ratios are figured correctly, but the medical team must keep to a fast schedule, and every patient must have Medicaid or another insurance coverage. Unfortunately, people with mental illness usually take more time to serve. This makes it impossible to maintain the brisk pace that generates enough revenue to sustain the primary care effort long-term.

Link to news report:

Aug 23, 2013

Aug 20, 2013

Another celebrity lost to suicide

I learned of another celebrity who committed suicide today, a young African American man whose show I have been watching. I always wonder if a friend or co-worker or relative had an opportunity to ask the kind of questions that might have interrupted what was happening.

There is, of course no blame for the family or friends. We humans can be terrible at confronting trouble. I just came across a list the author Mary Pipher compiled of things people do to avoid dealing with the trouble that lies right in front of our face.
The Ways Humans Defend Themselves From Too Much Reality

1. We deny reality entirely.
2. We accept some aspect of reality but deny other equally critical aspects.
3. We minimize or normalize.
4. We overemphasize our lack of power.
5. We deny our emotional investment in reality.
6. We compartmentalize.
7. We feign apathy.
8. We kill the messenger.

Perhaps this actor’s trouble was just Too Much Reality for friends and family. And besides, under the best of circumstances it’s seldom easy to see suicide risk factors piling up in another person’s life. Suicide signals and the right follow-up questions are not well known.

Imagine how hard it is for a person to admit that they need help. For one thing, the person in trouble is likely to be activating the same eight pathways to reality denial as everyone around them.

And then there is the stigma  factor. Many people find mental health concerns shameful. Churches don’t handle it well. The African American community does not handle it well.
And the celebrity community?

The path to recovery is tough for anyone, let alone a person in the public eye. We pursue and persecute celebrities with problems. I watch my share of televised trials and reality TV profiles of celebrities emerging from rehab. Even the best of these shows are fully capable of treating troubled people with scorn. I can imagine the apprehension building up for a person with tough symptoms, and can sympathize with the reluctance to seek help.

I believe we need more ordinary community support for people experiencing depression and other mental health concerns. People from every walk of life have successfully confronted these problems. We do see some celebrities emerging to tell their stories. I have particular admiration for Demi Lovato and Lady Gaga, who both seem eager to be good examples for their fans and for the public at large.

But celebrity examples go only so far. Depression and disappointment are routine in our world.  We need more ordinary people to step up and reveal how they have handled their own difficulties. We don't need some sort of pageant of people with labels on their sweatshirts. We need people who are willing to hang out and say "This is what worked for me."

We also need to see more sympathy and less scorn from those who host shows highlighting celebrities with problems. There’s plenty of legitimate news value in showing How People Confront Too Much Reality and Manage to Pull Through. 


By the way, here are four questions anyone can use to check in on a person and see if they are okay. If the questions sound awkward, rephrase them so they work for you.

1. What have you accomplished since the last time we met?
2. What are you facing?
3. Who are your allies?
4. What is your plan?

If,  after hearing their answers to these questions, you feel a gut-level worry, follow up with the following four questions – the ones most likely to uncover a suicide plan. Ask these questions directly.

1. In the past few weeks, have you felt that you or your family would be better off if you were dead?
2. In the past few weeks, have you wished you were dead?
3. In the past week, have you been having thoughts about killing yourself?
4. Have you ever tried to kill yourself?

If there is a Yes answer to any of these last four questions, don't leave the person alone. Call 911 or the person's doctor, or the national suicide hotline  1-800-273-8255.


Mary Pipher (2013). The Green Boar: Reviving Ourselves in Our Capsized Culture.
Screening for teen suicide: The four questions to ask at risk youth. (n.d.). Retrieved August 20, 2013, from

Aug 13, 2013

Our Grand Inquisitor says you can’t have treatment

Are states using targeted auditing to disrupt mental health services?

New Mexico used a recent audit to completely de-fund 15 mental health providers serving the bulk of the state’s publicly funded mental health care. Some 30,000 individuals have had their care interrupted. A number of for-profit and nonprofit providers are closing because they cannot maintain operations while fighting the proposed findings.

Although the state’s actions are authorized by law, they were not mandatory.

There’s no public access to the allegations within the audits. The audit findings are secret.

Similar events are playing out in North Carolina. According to newspaper reports, a 2012 Public Consulting Group audit that cost North Carolina $3.2 million found that North Carolina had overpaid behavioral health providers by $38.5 million, but the state found that less than 10% of the amount in question could be recovered.

Some coverage of this trend:
Administration at odds with state auditor over mental health fraud claims

Fraud probe update: CMS defends New Mexico's defunding amid questions about audit findings

NC Medicaid: Are New Mexico and NC Medicaid Providers Fraternal Twins? At Least, When It Comes to PCG!

Even New Mexico Identifies PCG Audits as “Unreliable!”

Big names in health care audit released

Aug 3, 2013

Sorry, Brian Williams, “disgusting horrific criminal” didn’t make the DSM-5

If every grieving widow has a place in the DSM-5, why not Ariel Castro?

I saw some of Castro’s remarks at his sentencing. He seemed completely disconnected from the standard world. His behavior was out of bounds, abnormal, inexcusable and, to use a word favored by some within mental health advocacy community, he appears to have anosognosia of the criminal type. If madness has a spectrum, Castro has a place within it.

I’m glad to see some awkwardness around labeling Castro. It gives us an opportunity to consider the negative effects of labeling anyone as anything.


The picture below is by Malaika Puffer, from her blog "Sort of just a person"

Even well-intentioned diagnostic labeling can hurt.

Aug 1, 2013

Is it Kendra’s Law, or better care, that helps people get better?

I recognize there is a place within our society for very limited, highly regulated use of mandated mental health treatment. On the other hand, I have difficulty supporting the rhetoric of involuntary treatment advocacy. Too often, what I hear or read combines a wishful longing for a quick fix with a desire to control “those people.”

The emotional content around involuntary treatment is downright raw. Advocates speak eloquently about tragedies that occur when systems fail to act. But if humanity’s history of abuse of people with mental illness isn’t reason enough for caution, there is no shortage of counter-testimonials about how forced treatment can be horrific, whether it happens within or outside of a hospital.

Fortunately, with sympathy and support within our families and throughout our communities, it's possible to create a mental health environment that virtually eliminates the need to choose between tragedy or torture. Most people come to terms with the mental health situation they are facing, learn what works for them, and do okay, especially when they commit to a recovery process, get the right treatment and have the support of friends and family. Our communities do need complete multilevel treatment and support systems that deliver the right sort of care when needed. If there is too much risk or a person is unsafe, there should be a means of supporting safety, but that can happen at home as well as in institutions. Only a tiny proportion of the population with mental health concerns ever reaches the point where involuntary care becomes an appropriate option. When appropriate, the process around involuntary treatment should be prompt, responsive, flexible, respectful and humane. People involved should still have opportunities to make choices as the process plays out.

I did read with interest last week’s New York Times story about Kendra’s Law, the involuntary outpatient treatment statute in New York. Is the law as effective as the article stated? Today I received a copy of a letter from the New York Association of Psychiatric Rehabilitation Services, commenting on flaws in the research. Here’s the letter I received.
NYAPRS Note: Following is a larger version of a letter submitted to the New York Times following its publishing an article last Tuesday about a new study that suggested that Kendra’s Law mandated mental health treatment order were directly responsible for improved outcomes and reduced costs. While we believe the researchers have once again presented a flawed study that fails to scientifically prove their point, the Times piece has now spread across the country.

Kendra’s Law Study is Bad Science, Poor Example for States

Re: “Program Compelling Outpatient Treatment for Mental Illness Is Working, Study Says” July 30, 2013

The new study that claims that Kendra's Law mental health treatment orders are responsible for improved outcomes and reduced costs makes unproven and irresponsible claims that have unfortunately been blessed by the Times.

There’s plenty of research to show that people who get more and better services do better. But these researchers continue to produce claims, now and in 2009, that mandated treatment orders by themselves play a key role in improving outcomes, without scientific head to head proof.

In comparing treatment given to those with and without court orders, the study fails to ensure that both groups got the same level of improved care, instead comparing apples to oranges.

For example, Kendra’s Law patients got priority access to a significantly higher level of service than those in the voluntary group.

Further, the sample size and the details provided for the group receiving improved voluntary care is scant, resembling an afterthought.

In contrast, a 1999 Bellevue study that ensured that voluntary and mandated groups got the identical level of services found “no statistically significant differences” on “all major outcomes measures” and concluded that “the package of enhanced services” caused the improvements, not the court orders.

New York’s Medicaid Redesign plan to overhaul our entire and reward better results and decreased costs is a better example for other states to follow, one that is already showing impressive results in voluntarily engaging at risk individuals and providing strong follow up.
Harvey Rosenthal
Member, New York’s Medicaid Redesign Team
Executive Director, New York Association of Psychiatric Rehabilitation Services