Monday, February 23, 2009

Continuing day treatment and its enemies

State OMH is trying to close day centers down

The intelligentsia in the state Office of Mental Health want to do away with continuing day treatment programs and they're cutting back those budgets, but their thinking is wrong. John Allen, a division director who's supposed to look after consumer/survivor's interests for the state office, called them “smoking and rocking clubs.” That's calumny. I've been there and they don't do that and it's most disrespectful.

The day treatment center we have in Schenectady run by Ellis Hospital offers shelter, comfort and structure, one of the few places in town that welcome people coming out of a tailspin with their mental illness.

It's mistaken for the state OMH to change the rate structure and billing procedure and thereby emasculate the continuing treatment programs that have sustained our mentally ill relatives in the community for at least the past 15 years. The state office looked for a place to cut money from, got the recovery minded fundamentalists on its side, and went in with the knife.

Continuing day treatment is a licensed, authorized program of the state Office of Mental Health to give people just out of hospital or in outpatient status some structure to go about their lives with. They have hourly instruction and group therapy discussions led by social workers, They take two meals there, have help with transportation, get access to clinical services from Ellis next door. It's for people who may not be able to survive on their own without a maintenance dose of support to help them negotiate the world outside.

The bullies at OMH sweetened the pie last fall for rebellious doctors and social workers at the mental health clinics who complained loudly about their poor pay and low Medicaid and insurance rates. The clinicians got what they wanted at the expense of the day treatment folks and they made off with higher billing rates and better pay scales, as far as I can estimate.

Meanwhile, Rich Angehr, Ellis's day treatment manager, has to worry. He said the state tightened billing rates, in one respect by restructuring things—no longer letting them charge half a day for two hours' time with a client; and a full day for three hours. As a result the agency may have to take in fewer clients and cut back their hours. It could lead to layoffs if the state cuts deep enough, he pointed out.

Many clients in continuing day treatment are right out of hospital inpatient psychiatry where they went because they couldn't cope with life outside at that moment. Some of these illnesses are heavier than we can imagine, like schizophrenia. There are those with depressions so intense they're panicky, can't sleep, feel awful and have thoughts of killing themselves. So what are the state gurus up to?

Lest we forget—people who live with schizophrenia and bipolar disorder can get through life most of the time with medicine that works and community supports. Now and then, they relapse, they go back in the hospital, at their worst they don't know who they are or what they're about. How would you like to lose your identity, to wonder who you are, to know that you're not right mentally but you have to survive it all.

The hospital turns you out in a few days, gives you a ticket to see a counselor at the mental health clinic and they set you up with continuing day treatment. You find friends and people going through the same trauma and you're all working to come out of the fog. You go there three days a week typically, a few hours a day, you listen to what's going on in the groups that will help with practical situations like handling money, using the bus, getting along with people, staying off drugs, coping with trauma.

Commissioner Michael Hogan is equivocal about continuing treatment, not willing to close it down but ready to accept it doesn't fit in with the modern model. Hogan writes:“reductions in the reimbursement rate paid to providers of continuing day treatment programs will help balance the budget. While these don't mandate reductions in capacity, OMH will work with providers that wish to transition to more sustainable program models. We do not seek to dramatically reduce capacity for this program which is a dated model that, nonetheless, provides essential supervision in some communities.”

That means the future of the day treatment business is in trouble. Hogan and others want to replace it with something called PROS—personalized recovery oriented services—that flopped when proposed a few years ago. It has a short term, self help and peer oriented outlook, pulling various staff together. The idea is to handle people quickly and get them out the door. But that's where it fails to recognize reality.

Others in the reform camp talk of the desirability of “rehabilitative services to assist people in managing their own illnesses and restore functioning across a range of life domains, including independent living social and cognitive skills. More use should be made of capitation payments, case rates and other models where providers are charged with responsibility for the whole person or for all of his or her mental health care, writes the Bazelon Center in an issues paper.

Those drab-interior day treatment centers sure don't fit this vision of patients suddenly getting up out of their rocking chairs and gliding swiftly back to society. (Roy Neville)

Sunday, February 22, 2009

State hospital honchos raid patients' Social Security checks

It's illegal but they're doing it, court suit charges

Hard-pressed Governor David Patterson is looking to make up about $30 million in the coming year in a brazen grab of patients' Social Security Disability checks by state hospital directors. Courts have already ruled it's against the law for the heads of these hospitals to confiscate the patients' checks to pay their hospital charges instead of saving the money aside according to the patient's wishes.

“The patients could use this money when they get out—it's theirs,” said Cliff Zucker, lead attorney for Disability Advocates, Inc., the Albany law firm that has challenged this practice. The proposed law would let the hospital director collect the income from monthly SSD checks, amounting to thousands of dollars a year, as the patient's representative payee and use the money without regard for the patient's wishes.

“They can't do it—they have a fiduciary responsibility to act in the patient's interest and they're not doing it,” said Zucker. His firm followed up a 1990s lawsuit involving a Gowanda PC patient whose monthly benefits were taken by the hospital director,which violated the hospital's fiduciary duty. Zucker initiated a class action suit last year in Weaver v. State “alleging that the state Office of Mental Health has failed to comply with the ruling in the Gowanda case” known as Muller v. State of New York and with appeals court rulings upholding it.

Here's what's claimed in the lawsuit by Disability Advocates which now believes the state is retaliating against it. Zucker charges that “facility directors regularly seek appointment as patients' representative payees notwithstanding their conflict of interest; they fail to seek appointment of independent guardians to manage patient's funds which exceed $5,000; they receive funds in excess of $5,000; they use patients' Social Security income to pay hospital charges in breach of fiduciary duty; and they fail to use patients' Social Security benefits as required by state law.

“Apparently in response to the lawsuit, the proposed legislation would overrule the Muller decision and seeks to deprive hundreds or thousands of patients of the right to be reimbursed for Social Security funds unlawfully taken by OMH in the past seven years,” Zucker contends.

“The proposed law would perpetuate a great injustice. There is a desperate shortage of supported housing and community programs for persons with mental illness, including those leaving state hospitals.

“As a result, PC patients could greatly benefit from saving their Social Security benefits to use to obtain housing, food, clothing, transportation, education and other needs upon discharge. Moreover, the availability of funds for that purpose will greatly increase the likelihood of successful transition to community life.”

The money grab doesn't apply to SSI checks because they stop at the state hospital door. But the money that is being taken from Social Security Disability checks could be banked by the patient in a special needs fund and accumulate to quite a large amount, Zucker pointed out, a nest egg for when he leaves the hospital. (Roy Neville)

Tuesday, February 10, 2009

Sweet Charity--How the state's bad debt pool for hospitals doesn't work

I came across a piece in Schizophrenia Journal recently that blasted the way NY State's bad debt and charity care pool is used to bail out hospitals that don't get paid by their patients. It also accuses the hospitals of failure to use the monies properly and to take account of the money received, some $847 million in 2003.

People in the Schenectady mental health system have felt the sting of the hospitals' aggressive collection practices when someone can't pay the full amount of their hospital care. Bill collectors start dunning them on the phone, sitting on the doorstep and threatening and insisting on back payment from patients who simply don't have the means to pay.

You'd think $847 million would solve the hospitals' problems. But it doesn't. Instead they and the state have connived to fashion a secret bailout system that doesn't benefit anybody individually who has run up a bad debt with the hospital.

The journal article (Feb 2008) is based on a study by attorneys for the Legal Aid Society of New York that led to stories in the NY Times. It is damning because it says the hospitals really get a huge belt of public money each year to pay bills of the uninsured while their advocates call for more government spending to cover the same debts of some of the 3 million New Yorkers without health insurance.

It was an eye opener because I've often wondered how any stiff without insurance can pay those huge hospital bills after a costly operation or just a stay to see what's wrong that's causing pain or discomfort. It must be even worse now as the bills pile up and more people are out of work and don't have the luxury of health insurance to cover these expenses.

The article is called “The Case for Reform: How New York State's Secret Hospital Charity Care Pool Funds Fail to Help Uninsured and Underinsured New Yorkers”. It's just a rollicking good ride—about how the hospitals don't bother to account for the money they get from the state every year and don't apply it to individual cases. They just sock it away in the general fund, don't keep records, and don't consider it as money to help individual patients pay their bills, as other states do. Instead, one hospital, Our Lady of Mercy in the Bronx, which gets $6 million a year from the state for its charity pool, refused to pay the bill when a patient applied for the funds. And the state doesn't even require an accounting while forking over this largesse year to year to our bleeding hospitals.

Nor are the hospitals gracious about the charity care fund and the way they go about collecting bills from those who don't pay. “Advocates are confronted with increased demands for help from patients who face overwhelming medical bills, aggressive collection agencies and limited awareness of relief,” the authors state.

This hits especially hard on mental patients whose illness typically waxes and wanes and causes some rehospitalization now and then. Some have no coverage while others depend on subsidized insurance like Medicaid or Fidelis Care, not private insurance unless it's on their parents' account. But these don't pay for everything—there are copays and deductibles and some patients are disallowed. There simply isn't a way for a chronically ill or disabled person to pay a back bill in the tens of thousands of dollars--unless the hospital applies its losses to that patient with the charity care money.

And in New York they don't do this, evidently in contradiction of the law. The bad debt pool is paid into by third party payers (insurance companies but not Medicare) and the money is collected by the hospitals on the basis of size and location in the state. Hospitals get their allocations under the current version of the Health Care Reform Act (HCRA law). There is also Public Health law section 2807-k that sets out the rates for an indigent care pool for the hospitals which limits their charges to non-paying patients to their actual cost for services.

Instead, the report finds, “hospitals in NY have been artificially inflating the rates to these patients, the least likely to afford them. Because there is virtually no government monitoring of the hospitals' reported bad debt pool submissions, it is unknown whether the hospitals follow state guidelines and reduce their charge rate to cost.”

And what the hospitals do is charge the full rate for individual patients who don't have insurance. As the report indicates, “unlike some neighboring states, New York requires virtually no accountability for the millions of dollars allocated for bad debt and charity care funds, ignores the need for a standardized application and eligibility system and notification to low income New Yorkers on how to access this money; and fails to regulate hospital charge rates for uninsured and underinsured low income families or to set reasonable standards for billing and collection practices.”

The persistent mystique of the charity fund in New York is baffling. The authors recommend an overhaul to see that there is a standard application and reporting by the hospitals, annual monitoring and audits by the state, and an end to the overcharging and denial of benefits to individual patients. Too many patients have found themselves in a quandary over their debt, dunned by bill collectors and denied credit by loan agencies because of the way the system works now. (Roy Neville)

Hogan's Heroes

NYS Commissioner Michael Hogan initials his transformation of the mental health system

This is about our local Niskayuna product, the present NY State Commissioner of Mental Health Michael Hogan, PhD, who came to the job two years ago flying in on his coat tails as director of mental health in Ohio (henceforth considered progressive) and as chair of the prestigious President's New Freedom Commission on Mental Health in 2002-03.

Let's see how the commish is doing these days now that he's put his transformation spin on the NY mental health system to the joint legislative committees in Albany. It comes at a bad time--just when the state's economy has accelerated its nosedive.

Former NY State Governor Eliot Spitzer paid a big bill for this star player just as George Steinbrenner was handing out money to the top Yankee prospects that winter and spring. Hogan was quickly confirmed by the Legislature in March 2007.

Hogan soon made an impact in the crusty Office of Mental Health in Albany. As some of us remember, he brought fresh views about mental health—he was open to change, smart, a listener, a doer. He started to appear around the state at regional forums to gauge what his constituents wanted —mental health consumers and their parents, professionals and business people whom he was calling “stakeholders” and some of whom we called “the grassroots.”

He endeared himself to us when we learned he had a family member with mental illness himself, and he grew up in Alplaus and went to Niskayuna High School. From there he went to Cornell and Brockport State U and then Syracuse U for his doctorate. While he served as Connecticut and Ohio commissioner he won distinguished awards from NAMI and the state Governor's Association, he authored untold papers and articles and finally came to his appointment as head of the New Freedom Commission in Washington.

He's a modern Renaissance man, you might say, capable of seeing the big picture in a world of high technology and master planning, while showing that empathy so important in dealing with something as fleshy and uncompromising as mental illness

The commissioner really believes that recovery from severe mental illnesses like schizophrenia and bipolar disorder is possible, that lives can be restored. Rehabilitation is the key and people can get well faster through combinations of short term intensive treatment and self-help and peer-led supports after a relapse. He's still for doctors and medicine but he'd shift the focus of care over to the patients and more choice of treatment if he could.

From the First Plan Onward

When he arrived in Albany in January 2007, Hogan brought with him a comprehensive state mental health plan he developed for Ohio. One wouldn't have to look far to find the similarities between it and the updated NY State plans issued since his takeover. Hogan is a progressive decentralist who wants to make mental health services local, close to home, more productive and less expensive and he's now going front with these views.

His ideas are revealed most recently in his testimony to the joint legislative committees in Albany last month. Here are what you might call “Hogan's Heroes” in the recent go-around with the legislative members, an exposition of what's needed to transform the system of mental health care in New York State into something much better:

He speaks of “good care,” exemplified by what enables people to “live, learn, work and participate fully in one's community.” To do this he would change the funding streams to include more than “medically necessary” services, include job services under Medicaid and self help and peer support under insurance; and broaden the safety net of services for both the seriously and less seriously ill.

He'd expand Medicaid coverage to include a home and community waiver so adults with mental illness can get services in the home that keeps them out of a hospital. He'd put supportive and rehabilitative services under Medicaid and make Medicaid rules more consonant with the other programs.

He wants to reform mental health care by restructuring mental health clinics. He'd remove regulatory barriers to clinic expansion and change the “COPS” supplemental rate (once an incentive to get clinics to enrich services).. Workers there have long griped about poor pay and it's led to high job turnover. While his proposal is to increase clinic rates it would be offset by less funding for continuing treatment programs, not Hogan favorites.

He'd go from there to a future reimbursement policy that “requires health payers to pay for discreet services, rather than the current OMH approach that involves the same payment approach for a doctor's visit as one to a therapist, and the same payment for a complex evaluation session as for a routine visit.” This is called Ambulatory Patient Groups or APGs and it's the new wave although it sounds like old fashioned common sense.

Hogan asks reform of psychiatric inpatient care, too. He told the legislators that “access to acute inpatient care is hard to achieve. Problems in finding housing while someone is awaiting discharge is a leading cause of long stays. Access problems mean that many psychiatric patients are stuck in crowded emergency rooms.” But he doesn't offer anything solid to tackle these issues.

Psychiatric emergency room care is especially costly and ineffective, he continued. “A few individuals overuse the ER and acute inpatient treatment because their ongoing treatment is not adequate.” He said he would look to alternative care to untangle this.

There are more items among “Hogan's heroes”, but we'll just cite two more examples. Hogan claims the state OMH hospitals, like CDPC, are becoming more productive, admitting more patients--and that may mean shorter stays, for better or worse. And the hospitals are finding useful ways for the campuses to supplement community services.

To halt the fragmentation of care in community mental health he said he'd work more closely with other agencies. “This problem is prominent for individuals who have multiple long term or chronic illnesses, including people with serious mental illness, he said. Their health has been compromised by their illness, smoking, obesity and poor lifestyle.

He also wants to expand housing through “joint development of mixed use housing” and would support converting some group homes to permanent supportive apartments, projects high on the agendas of non-profit housing providers.

Trouble ahead

But like the housing proposals, where's the money to pay for this? Projects planned to combine community residence-supported apartment models are frozen. Trouble is, these are tough times. When you change the existing order you create waves. People don't like to be laid off, others suffer when programs are cut, hospitals don't want to receive less money, nursing homes need money, too, and you can't throw the whole system out of balance by holding onto the state hospital system and knocking out basic community services like continuing treatment, in my opinion.

When we were promised 1,000 supported apartments and millions of dollars in new construction for congregate housing early last year it's a shame to find the building projects are on hold. There's no evidence of any new mental health housing in Schenectady. It's not the commissioner's fault but surely the housing is more important than talking about agency coordination and data collection, more studies and more monitoring.

Neither is it Hogan's fault that the state OMH hospital system, the biggest in the nation with 4,000 beds in 17 adult hospitals, plus six childrens' hospitals and three forensic facilities, monopolizes the state mental health budget. He can't close a single building—only the legislature can do this, and it simply crimps resources that might be used for community mental health.

And Medicaid is a bigger problem than even he lays out. Health Department runs Medicaid, which pays most of the bills for mental health and has unbelievably bad rules that don't fit the circumstances the consumers and workers find themselves in. The contracts don't allow for growth and change that are needed.

He also has to face growing disgruntlement about ineffective mental health programs, sometimes voiced in the legislature. No matter what is tried, the lawmakers say, there isn't a payoff, there isn't any sure way of curing someone's sickness or relieving his aberrant behavior or getting him back to work. With every part of state government expected to take a hit over the budget, the governor and the legislature are ready to slash the roughly $3.5 billion state mental health budget, too.

While we wish the commissioner well, it looks like his “heroes” are in trouble. (Roy Neville)