Mental health Madness in Mecklenburg county

As of this writing, I do not know of a therapist who actively accepts Medicaid insurance within the Greater - Charlotte region.

The mental health care system in North Carolina within the last few years has undergone significant changes (North Carolina Health News). How services are provided to consumers has been changing as well as the distribution of those services. North Carolina is attempting to move more towards community-based care in lieu of institutions. However, in 2012, "... North Carolina changed how it provides mental health care for those on Medicaid. The state put 11 regional organizations, called MCOs, in charge and gave them less money to work with." (WFAE);

This has mirrored the trend nationally where states have shifted cost into the community without properly funding them "... the Community Mental Health Act of 1963, promised that 1,500 small community mental health centers would be constructed—but this ideal never materialized.... "The program was never adequately funded by either the federal government or the states," Paul Appelbaum, a Columbia psychiatry professor and longtime critic of deinstitutionalization, told VICE. "Since then, a patchwork of programs has been created but never enough to meet the demand."(VICE News). It is those who need the services that suffer the most, not just the providers of the services. It has led to a reduction of the quality of care, which paradoxically, may also mean we end up paying more in the long term. 

Speaking as a therapist, the change has been slow but swift. In the beginning, most of us who have worked in the mental health system knew that things often change. I remember my co-workers joking about how every few years, things change, and we therapist just adjust. Little did we know this would be more of a sea change than just a rough wave. From ValueOptions, to MeckLink, and now Cardinal Innovations, the changes in MCOs have been swift; each having their own positives and negatives. 

With the current MCO, the regulatory burden regarding paperwork for mental health care has become excessive. This is seen as an over reaction to a relatively lax regulation process prior to the implementation of the current system. Often there were huge Medicaid overruns and payouts to providers which often lead to longer treatment of care at the higher levels; Psychiatric Residential Treatment Facilities (PRTFs), Intensive In-Home (IIH), and Day Treatment to name a few---  with little or lax regulatory oversight. In some cases, clients would stay in treatment for years, bouncing around from one provider to another with little end in sight. 

While proper documentation is important and paramount for regulatory review, the extent and amount of documentation can have adverse effects which affect the delivery of care. Often, a treatment plan or a progress note is seen as being more important than the actual providing care. A therapist bills for a 60 minute session of outpatient therapy which could easily be consumed by 10 or 15 minutes of paperwork that cannot be billed for. The higher the level of care, the more time it takes exponentially to complete paperwork.  Oftentimes documentation for these higher levels of care can easily exceed 30 minutes per one hour billed session. This leads to a prioritization of documentation over treatment care. 

This visibly takes form when an MCO or an insurance company requests from a therapist (or their organization) his or her notes and penalize that therapist or organization for an entire session(s) several months later if the documentation does not meet strict standards. The penalty cost is often the entire imbursement given for treatment. This leads to a constant fear of paying back money to the MCO or insurance company which could leave that therapist or organization in a financial hardship or bankrupt months after the treatment has been provided to the client.  This is usually due to often minor oversights in documentation, such as a missed check box or a misplaced goal that does not align with the treatment. I have known several small and large mental health organizations to simply close (or stop accepting medicaid) in the last two years due to regulatory burdens. 

This is due to prioritization of documentation, the increased amount of documentation, and the reduced compensation for treatment. Automation of therapy documentation is often seen as cheaper and sometimes more efficient than hiring Qualified Professionals (QPs) or office assistants to assist in the paperwork and is promoted by the MCOs and agencies. While efficiency and standardization are important, oftentimes what is lost is a narrative of a particular case or person. You lose something when you reduce a person to a set of check-boxes. This is not a recent occurrence to the medical field in general. Most doctors offices and nurses have been, within the last decade or two, more bound by electronic check-boxes which could constrain the diagnostic process and doctor-patient relationship. These documentations, while often easily accessible and accountable, often have hidden costs which are not easily calculated. (NY Times)  

Over-reliance on these boxes for compliance utilization could paradoxically lead to poorer outcomes of care. (IBJ) It has been shown that doctors who rely too heavily on these items during the screening and execution of care often have lower reported client satisfaction outcomes. When this occurs within the mental health system, which largely relies on a therapist/patient relationship, overall quality of care diminishes. Nicholas Carr addressed this in his book, The Glass Cage ---   ''...above all, the interposition of the computer screen between doctors and their patients. Studies have proved that checking records, possible diagnoses and drug interactions on a computer during a medical examination can interfere with what should be not only a fact-based investigation but a deeply human, partly intuitive and empathetic process. One tiny but telling detail: Handwritten records allow physicians to pick out and attend to the comments of individual colleagues. How? Penmanship. In computerized rec­ords, one font fits all." (NY Times)  

With the increased regulatory burden becoming individually and organizationally more expensive, many experienced mental health therapist are simply quitting. Therapists who have 5, 10, 15 and 20 years of experience are leaving the Medicaid provider system at dizzying numbers. Many other agencies have been heavily scrutinized and shutdown. This has led to late paychecks or sometimes nonexistent paychecks to the therapists. Private insurance companies often only cover outpatient care visits and are far from perfect (NPR); the higher levels of intensive care are usually not covered in insurance plans. Such uncertainty in the system leave many therapists to accept only self-pay clients or  completely move to other domains of care. Some therapists are leaving the field altogether. Ultimately this hurts those who are at most in need; the families of at risk youth. 

While the current phase of mental health in Mecklenburg County may only be just a phase, it may also be a red herring for things to come as these trends mirror national trends. Unless regulatory excess, improper funding of care, increased denials of repayments of care given, and an over-reliance on check-boxes are no longer seen as proper utilization review and execution of care, there will be a continued loss of experienced clinicians within the system, and a real decrease in the quality of care and outcomes for the clients involved. In the end, we end up paying more for these individuals in the criminal justice system. Most jails and prisons across the nation are quickly becoming Mental health institutions; undermining the problem we sought to solve in the first place. America's largest mental health hospital is now a jail  (The Atlantic).

Ironically,  this is where I am now working as a therapist. Either we learn to pay and invest now as a society, or we will continue to pay higher costs much later.

I strongly recommend watching VICE's recent documentary on this epidemic: