It’s peculiar how control of important elements of our lives, and especially our health slip away from us. If “value” is defined as getting back your money’s worth, health insurance value dwindled over the years to the point that consumers were discouraged from seeking help for mental health problems. The consumer’s portion of the payment for service has grown through high deductibles, excluded treatments and medications, and other methods. The Department of Health & Human Services (HHS) is calling this “insurance company abuses”.
The new rules and regulations are giving some control back to consumers by enabling them to appeal insurance company denials to pay for service. Insurance companies use both internal and external appeals processes, and according to HHS, processes will be simplified and easier for consumers to negotiate. Chasing down satisfaction and eventual payment has traditionally been a pain, and the changes sound like a very real way consumers can experience the newly enhanced value of the health system in America.
Whether decisions to deny payment for your claim come from a person inside the health plan or an independent decision maker, you have this increased control over your ability to get treatment, especially for mental health and addictions issues. I remember being denied payment for a claim years ago, and having previously negotiated the insurance company’s appeals program and lost, I gave up, paid the bill and quit seeking treatment. That caused me grief as the problem got worse.
On a human level, who wants to spend the time and energy over fifty bucks to fight the entire insurance industry over a denied claim? At what point does it become worth the fight? As the dollar amounts that must be paid for treatment increase, the value of the appeal increases. The control we are gaining has tremendous value. Treatment can take a number of sessions, repeated assessments to measure improvement, and other services. If the insurance company is denying payment for treatment, that fifty bucks can grow into thousands, or tens of thousands if treatment is avoided.
OK, so you have a right to appeal…how do you do that?
Many states have offices (different names nationwide) to help consumers appeal claims denials, and states that don’t have such offices have access to a pile of money ($30 Million) to help establish one. This is really good news, increasing value of time spent appealing claim denials by lowering the consumer’s amount of effort to get the claim paid. These offices will share information that can help consumers convince the insurance company to pay the denied claim…and according to these new rules & regulations, the insurance company has to listen to you.
This will be a relief to anybody who has a child prone to anxiety attacks, or in the throws of a suicidal episode and an emergency visit to the hospital is needed, as well as follow up treatment. Situations like this can involve multiple care givers, and the hospital may not have a mental health department, so a referral might be needed. These complications equate to dollar signs, and when you look at your paystub and see the amount that’s taken out to cover the child, you want the healthcare value in return for that payment. If it’s not there, fight it.
You have friends in high places.Read more →
I was robbed a number of years ago, and it didn’t feel good. It was like that old game show where contestants got a free shopping spree, leaving my possessions of less worth strewn about the house, and the ones worth anything were gone within the five minute shopping spree. I felt violated…and poorer. The new healthcare world could lead to lower crime, and I’m all for that. I’d rather you didn’t have to experience that sort of violation.
Most cops who pay attention to this sort of agree that methadone clinics in the neighborhood lower crime. If people with mental illness issues are treated, there is less panhandling, self-medicating with drugs and alcohol (which leads to crime), and homelessness. If a cocaine addict in addiction treatment pays the rent instead of heading to the dealer on payday, crime has instantly dropped.
Recent healthcare legislation has made treatment is more easily available to those who need it. In a recent Forbes article, Rachel E. Barkow and David B. Edwards say that of the 20 million American substance abusers, a little over 10% are getting treatment. By improving access to treatment, assuring treatment providers are paid on par with physical health counterparts, and policing treatment quality, the country is on track to improve that ratio.
A number of years ago, I read somewhere that 85% of prisoners in the California prison system were residents either because their crime was alcohol/drug related or they were high while doing the crime. Other than offering proof that sober criminals are better criminals, this anecdotal information asserts that crime and alcohol/drug abuse are related. Making it easier to get treatment can lower crime. Currently, over 25% of the 6.5 million people on prole, probation or supervised release are using illicit drugs according to Forbes. That in itself is a crime, and sets up the neighborhood for burglaries and such.
This makes me a bit nervous. I also think that number may be a bit low, but that’s another story.
We’ve known alcohol/drug abuse and crime are related for centuries, and we’ve started doing something about it. It’s not just a few cops on the street who notice the drop in crime when treatment is available. It’s people like you and me. Reports nationwide show drops in crime with increased access to treatment. The National Treatment Improvement Evaluation Study (a big one) showed a 64% drop in arrests and a 78% drop in drug sales. Holy cow! That’s cleaning up the neighborhood!
Since the proof is so overwhelming, you’d think opposition to supporting treatment in the neighborhood would disappear. Not so. I recently wrote about the insurance empire fighting Mental Health Parity, wherein these treatment centers (which are helping to lower crime) would be paid on-par with physical health providers. It seems that no matter how good an outocme may be, there will be those whose income is affected negatively, and they will fight for the money.
The fact is, I haven’t been robbed lately. There are a number of addictions and mental health treatment centers in the neighborhood. They are in jeopardy, however they’re solving their problems, in part due to improvements to the healthcare system. A drop in crime is a good thing.Read more →
It’s tougher today for a lawyer to get clean and sober in Louisiana.
That statement comes from a very common story in our world today, this time played out in the halls of justice. It seems this lawyer and crack cocaine user, John Clegg, lost his job over his problem with that substance: He tested positive for the drug twice after completing rehab. That’s not unusual, nothing special. People lose their jobs if they have drug problems and fail to get recovery quickly enough. What can I say, John? It takes what it takes, I hope this is your bottom and you get clean and sober.
The problem in this story was one of confidentiality. A friend of mine who works for The National Law Journal pointed out the story to me, and upon reading it, I became distressed that the Legal Assistance Program has been compromised. The court cut the legs from underneath this helping organization by saying it’s OK for a firm to report a lawyer to disciplinary authorities even if the substance abuser is trying to get help. John was enrolled in the Lawyer’s Assistance Program, had gone to rehab, and was doing the best he could and sometimes people in recovery relapse, in his case, two relapses were reported.
A person with the disease of addiction sometimes has no choice but to chase his drug. The cravings can get that bad. It’s said that alcoholism is an allergy to alcohol, accompanied by an irresistible compulsion to drink. A lot of folks in recovery and in addictions treatment feel it’s the same for drug users. They say a drug is a drug, is a drug, asserting alcohol and crack cocaine are different vehicles to get to the same place: out of the addict’s own skin.
In the old days, if you weren’t destitute, with no job, no friends and without a big pile of debt, you hadn’t hit bottom and needed to go out and use some more till you really wanted to get clean…or hit one of the other three options, jails, institutions or death. It’s not that way any more. The idea that seems to be working for some is to raise the bottom so people get clean without all that drama and tragedy and pain to self and others. That’s all well and good. In many places, the police and courts realize addiction is a disease. Treatment takes what it takes, and they’re fairly tolerant until stupidity like drunk driving or violence or endangering others enters the picture.
The court in Louisiana doesn’t seem to believe in tolerance in this case. Apparently, there’s a law that guarantees confidentiality to enrollees in the Lawyer’s Assistance Program, but it means nothing. When the firm John worked for took enough of a bath in paranoia, they decided to turn his case in to the disciplinary authorities, who ultimately suspended our friend John. The court said that was OK.
I really don’t mind that John relapsed and lost his job. It’s too bad. He’ll get another or start his own firm. What burns me up was the action that led to that. He could have been fired without being reported to disciplinary authorities and subsequently having reporters and people like me plastering his plight all over the web.
That can be bad for a career and a life.
Good luck, John.Read more →
While doctor and politician Howard Dean believes it’s better to have passed the recent healthcare bill than not, he says it’s not healthcare reform…It is coverage expansion. It’s a simple concept, really. Everybody needs to put food on the table…and preferably have a table to put it on and a place to put the table. That assumes jobs and paychecks come into the mix. By guaranteeing medical coverage, payment for healthcare becomes guaranteed, healthcare providers earn a living, and people’s health problems get attention.
With healthcare payment guarantees, mental health issues become the next topic of discussion. There is resistance to comply with recent legislation assuring health and addiction treatment services getting paid on par with physical health issues. I recently discussed the battle the insurance industry is waging to escape restructuring their business to comply with Mental Health Parity. Additionally, millions of senior citizens need treatment services not likely to be paid for by Medicare, according to Dr Dean’s interview in The National Council’s Healthcare Reform Magazine It seems that Medicare has been exempted from the reforms of the healthcare bill. It appears that insurance companies and Medicare are in the same ethical boat when it comes to mental health and addictions treatment. Everybody says they want people to be well and have better lives and nobody wants to pay for it.
The place I see ethical responsibility in action is with treatment providers.
I was talking with a friend who runs a small addiction treatment facility recently, and I was stricken with his sincerity. He wants to help addicts stay off drugs and have a good life. In my experience, that’s true throughout the business. Whether you talk with helping professionals in your local community mental health center, addiction treatment facilities or social services organizations, they want to help others.
My peers write on a personal level about coping with issues, relieving symptoms of disorders and generally improving our mental health. I believe they, and most professionals in this business are sincere. They want alleviate suffering. The ability to help is slowly being improved.
The payment system for these professionals has appeared to be one to avoid paying for their services. Authorizations to provide services are dictated in many cases by insurance companies. For years I’ve heard many mental health and addictions providers say it’s murder trying to get insurance to pay for services that need to be delivered now. They took the attitude that when a person needs help, help them…not after treatment is approved by a bureaucrat for payment. These folks wound up providing free services in many cases…which doesn’t put food on the table. This leads to the most important point Dean made in the interview cited above.
Treatment decisions need to be in the hands of treatment professionals, not insurance bureaucrats, so this rebuilding of the system is necessary. It takes involvement and working within the system to rebuild the system. That’s happening now. The legislation I cite is the first step, a decision to assure payment for help that improves people’s lives with quality mental health and addictions treatment. My hope is that the professionals gain more control in healthcare decisions and are treated with the respect due a trained, experienced professional. As that happens, smart, caring, people with a sense of moral responsibility to help others will enter the helping professions, joining many others who are active in changing the system to enable treatment professionals to control treatment.
Active integration of moral responsibility into the business side of this business, my friends, will be true healthcare reform.Read more →
It’s no secret that Information Technology (IT) is changing the way professionals work in mental health and addictions treatment…and what’s that mean to you? For treatment professionals, information is king, the key to delivering solid help to people who need it. That information is available in existing banks of information, contributing to an effective decision support system. The systems help assure the information is used properly to diagnose and treat problems, and without the information, both from professional resources and the consumer’s personal health disclosures, systems can still lead down the road to a bad statistics and ineffective treatment.
As workflows change in provider agencies like your local CMHC or addiction treatment facility, you’ll see a lot more of your records on screen…the record is not a secret, consumers have a right to know what’s in their record. By now, consumers should be walking through assessments for a quick evaluation of problems and measuring improvement during a visit. Counselors are involving consumers in building a treatment plan on the computer screen. Progress Notes are being included as a part of a session to make sure the next steps for the consumer and professional are mutually understood.
It’s all good. It wasn’t that long ago that most consumers wouldn’t have thought to ask for access to any of this paperwork. The fact is, in that paperwork are the keys to a better life.
Throughout all this paperwork, decision support is becoming interwoven, and valuable treatment information is being presented when it’s needed most.
The Internet and a number of paid research sources available on the computer can help the professional provide a diagnosis and treatment to a problem that may otherwise be mis-diagnosed and mistreated…as many as 70 percent of mental health problems are in this category. Dennis Morrison’s article in The National Council’s magazine on Healthcare Reform brings up an interesting case of mistaken diagnosis and treatment with potentially catastrophic outcomes. His case has a happy ending, because the right information was available on the computer. This example of effective decision support shows how IT can lead to lowering the ratio of mis-diagnosed and mistreated mental health problems.
Occasionally, I still hear mental health and addictions professionals complain that they are not “computer people”. Who is? We’re all on this planet with each other.
The computer is just a machine to record and spew out data…a decision support system will hopefully assure the data that presents itself leads to happier lives for real people who are being treated, not a happier computer. Decision support systems deliver information at the right time during treatment to offer alternatives that make sense, and some that don’t. If a professional is not presented alternatives to the same old way of treating consumers, nothing changes. If nothing about treatment changes consumers don’t improve, and that abysmal figure mentioned earlier, up to 70% mistreated mental health problems, doesn’t improve.
The American Recovery & Reinvestment Act has spawned a number of ways for provider organizations to improve their IT systems. Most computer systems out there these days have some decision support alternatives available. For the ones that don’t, perhaps market pressure to provide that sort of functionality needs to be applied. The money’s available in a number of healthcare grant programs, and political pressure is coming to bear to provide more help for mental health and addictions specifically.
Some providers, like Dennis Morrison are getting the picture and moving full speed ahead. Decision support will help improve care, and Information Technology drives these improvements.Read more →
A host of business problems contribute to you being able to walk into your friendly neighborhood Community Mental Health Center (CMHC) and talk with a counselor quickly.
You may ask, “How can that be a problem?” If it happens as a course of daily business, this condition can spell financial trouble for the CMHC. David Lloyd is a consultant in the field, and in a recent article for the National Council he points out that what amounts to poor service to you can equate to big money problems for the CMHC. A key situation lies with “medication-only” patients who need medication reviews.
It turns out over one-fifth of the appointments at a sample of hundreds of CMHCs are either cancelled or “No Show”. That’s pretty high. A restaurant losing 20% of its reservations would soon close the doors.
The cancellation is something that can be dealt with handily with sufficient notice. Simply schedule another appointment to fill the staff’s time with a money-generating task. The no show is another matter. Somebody has been scheduled to do some work, and that work won’t get done and is not likely to get done. That can affect somebody’s paycheck, and the baby needs shoes.
It’s like any profession that survives through billable hours…like lawyers. That professional time is being paid for, and in order to keep the doors open, the staff member’s direct work with consumers needs to generate cash. Whether the consumer is on a sliding fee scale and paying the bill, or an insurance company, Medicare, or Medicaid are being billed, work needs to get done in order for the CMHC to get paid.
Cancellations and no shows slashing income can really cramp an organization’s style.
Agencies are taking a number of actions that can affect the consumer. People who are stable, happy and healthy with medications controlling their disorder are less likely to show up for a counseling session, simply because they feel fine.
Looking forward, these medication-only patients are likely to be connected with a nurse instead of a counselor, in order to free that counselor up for scheduling to see somebody who needs therapy. That may be bad news for “walk-in” business, requiring a longer wait to see a counselor, and that’s another problem being dealt with to be included in a future discussion.
This is a common sense solution, addressing a medication issue with a medication professional and making sure therapists help folks who are not feeling fine. In the process, nurses get to do their job and the CMHC benefits in two ways: The therapist’s time is paid because they’re doing the job they want to do, and the nurse is taking care of a consumer that’s been rightly directed to them, which is another billable service.
I love a win-win scenario.Read more →
Is it possible our local neighborhood insurance professional wants to discriminate against our neighborhood mental health professional? In high school (about a hundred years ago, it seems), I recognized that the insurance industry had possibly the strongest, best organized lobbying effort in the country. In that industry’s defense, a regulated industry needs friends in high places, or a lot of employees and executives would not be able to pay the bills, send the kids to college and generally live the American dream.
On the other hand, the push-pull of our system encourages the search for loopholes whenever a law is passed that is intended to better the lives of folks needing help. A few laws have come to the books lately, and one under attack by the insurance industry is the Wellstone/Domenici Act of October, 2008, “Mental Health Parity”.
Mental Health Parity is meant to assure that people working in mental health and addictions treatment get paid on a like-basis as physical health services. Traditionally, mental health practitioners have had a tough time getting services authorized and paid by insurance companies, and some avoid dealing with insurance altogether. This hurts the practitioner who needs to make a living, and the consumer who needs help with mental health issues. Higher insurance co-pays and deductibles for mental health services and limits on services were common prior to mental health parity. This law just came into full effect recently.
With billions of dollars at stake, the fight is on. The National Council says lobbyists working on behalf of the insurance industry are undermining Mental Health Parity.
The essence of the issue is discrimination, not just against mental health professionals, but against consumers who need help with mental health and addictions issues. A licensed mental health practitioner, a psychologist or psychiatrist puts a significant chunk of change into their education in order to engage in a profession of helping people. If I want to help people and have a choice to spend what could be eight years or more of my life pursuing the education to do that, I might swing toward physical health if the paycheck were to be significantly bigger. The dollar bill could rule my decision, even if I am better suited and my passion is directed toward mental health and addictions treatment. Under circumstances like this, consumers lose.
Lines are being drawn over this issue on Capitol Hill and people are choosing sides: the insurance empire, or the people who help folks with mental health or addictions disorders. We don’t have to choose a side or do anything…but we could. I recently cited a New York Times article on this subject, in which the insurance industry’s side of the story was made clear. The following day, an interesting letter to the editor was published. The National Council’s Chief Executive, Linda Rosenberg weighed in with a very important fact: suicides and incarcerations were the out come of some denials for access to mental health and addictions treatment.Read more →
In today’s world, $500,000 isn’t a lot of money. It was, however enough to drastically change Ron Hunsicker’s life. The National Association of Addiction Treatment Providers (NAATP) disclosed Hunsicker’s 5-year misappropriation of funds to members at their annual conference in June. He was the CEO of that organization for many years, and quite effective and well respected in the industry…until this revelation. Behavioral Health Online shared the answer to the root question, “What did Ron do?”
It sounds like Hunsicker fell into a very human pattern of racking up expenses on the company credit card that were later deemed “personal” by the Pennsylvania DA’s office. After five years, it looks like a significant contribution to the executive’s paycheck. It’s a picture of human frailty aggravated by a lack of controls. Nobody was auditing expenses, like any corporation or even small companies I have worked for.
My friends in recovery would say one of Ron’s defects of character came out to play. And who knows, Ron may have felt perfectly justified in using the credit card after the first decision to use the card for a questionable purchase.
That decision and all the following decisions lost him his job and regular paycheck.
It’s a testimony for honesty in expense reporting when spending other people’s money.Read more →