Leaving aside (for the moment) the moral argument over whether people are entitled to charity or should only receive it through the voluntary kindness of others, we must examine the economic issues inherent with a centrally planned welfare state. The premier economic issue is, unsurprisingly, cost. Since the cost is not determined by the dynamic forces of supply and demand, it must be set by politicians who make appropriations for bureaucrats to administer. There is a limited amount of money and naturally what is spent on one program is not spent on another. Thus, the need to control costs is paramount. That is what this post is about.
Speaking from my experiences as a mental health case manager, the government programs that my organization (and all of those like it) rely on for almost all of their funding are Medicaid and Medicare. I was originally surprised that many of my clients had Medicare, but unbeknownst to me, a person qualifies for that program after receiving two years of SSI. Billings to these programs provides the budget for my entire organization. (It does not have a development department and neither did my last company.)
Our billing is based on the DSM, the bible of psychology. However, government insurance does not cover every diagnosis in the DSM. In fact, only five diagnoses are reimbursable for adults in case management--Major Depressive Disorder, Bipolar Disorder, Schizoaffective Disorder, Schizophrenia, and Psychotic Disorder NOS. Anyone who does not fall into those five diagnoses cannot receive mental health case management services paid for by the government. This includes people with Personality Disorders (an estimated 10.6% of the population, and I would venture an even higher percentage of people with low-income), Anxiety Disorders(an estimated 18% of the population and I would again venture a greater percentage in the population I serve), and those with the myriad other diagnoses present in the DSM. Even our women's trauma team cannot bill for services under Post-Traumatic Stress Disorder. So, diagnoses are made to fit billing rather than the person.
Within that chunk of the mental health population we can actually work with, the government applies the fee-for-service model of reimbursement (as does private insurance). A case manager can only bill for interventions designed to address functional deficits related to a client's particular diagnosis. That this conceptualization flies in the face of strengths-based social work is important, but secondary to the discussion here. Part of the difficulty I face in billing for my services is that some things I do are either not directly related to functional deficits or address practical rather than clinical problems. It's not enough to say "this needed to happen, so I did it" in your billing.
Say I bring Ralph, who is diagnosed with paranoid schizophrenia, to the social security office. I go over the goals of our visit on the car ride there (billable). I talk with him about his vocational goals, manage his mood, and engage him in conversation for the first hour we wait (billable). If in the second hour of our wait time, he were to become tired of my yammering and clam up, I can no longer bill for sitting with him. Even though if I were to get up and leave, he would never complete this appointment and might lose his income, I can no longer bill for supporting him while we wait.
In addition, one cannot bill for teaming with another service provider, coordinating care, or talking on the phone with a client. At this point, hours of work I do every day is not billable for my company and I am not reimbursed for my time. After I work with the client directly, I write up a service ticket for how long the intervention was and provide the billing code for "individual case management." I also bill for group services for the three groups I co-lead at my company.
Speaking broadly across the country services in case management are either provided by state or local governments, or more commonly, by non-profit or low-profit companies. (I work for a non-profit.) These companies are built on a relatively straightforward mathematical model. A minimum amount of billable hours is required of each case manager daily(mine is 5.5 hours) so that in the aggregate their combined billings will cover the costs of operating the company--perhaps leaving some room for reserves (depending on the quality of the company). My company genuinely needs me to meet that quota each month because it cannot support my salary without those funds. Most companies will work with a person struggling with their productivity for a period, but will let them go if they are unable to fulfill their requirements.
If this system were to operate without oversight (like the home health aide industry does), there would be rampant fraud. Simply input the correct things into the system, and out will pop money! Audits are performed yearly (I believe) by our local Department of Mental Health. I assume this is a state function in real states (I live in DC). DMH reviews a sampling of our clinical notes. Whatever percentage of that sample does not pass the inspection, Medicaid and Medicare recoup the costs. For example, if 5% of our notes are audited and we have a 40% failure rate, 2% of our total revenue is taken back by the government. The standards by which notes are graded are not published, but there are rough guidelines that my agency is attempting to implement that lead me to believe that there is some knowledge of expectations. So, my agency is graded on an unpublished rubric (or the whims of auditors, perhaps) with some guidelines that are discernible beforehand. This has left us in a pretty stable financial situation compared to other organizations.
Unfortunately for my company, this auditing regime will not be in place for much longer. Because of the constantly worsening fiscal situation in the government, auditors need to recoup more and more of the money they have paid out without explicitly cutting anything and all under the guise of preventing waste and abuse. Within the next few years, the failure rate of billable notes will not only be applied to the sample of notes in the audit, but the agency's total billings. Using the same numbers as my previous example, 40% of our billings would be taken away by the government and we would likely be bankrupt within the month. The regime our billing model was built on will be fundamentally changed, and our organization must change with it.
A few points on note failure make this situation even more dire. The longest notes are also those most likely to fail an audit (think about my example with Ralph). So, the notes from which the agency derives the most money are also those it will likely lose in the future. To compensate for this, we are encouraged to divide up our service tickets into chunks of time, each becoming a note unto itself. Adding further to the time of writing notes, an comprehensive agency guideline has been produced to increase overall note quality. While this is actually useful in many different ways, one of its consequences is that case managers spend more uncompensated time of their workday completing notes instead of working with clients to make that productivity quota.
But what does note auditing actually measure? No auditor actually checks to see whether people are with their clients for the exact amount of time. Nor do they check whether the interventions mentioned in the note match with what actually happened. Heaven forbid if audits were intended to judge quality of services. Auditing is subject to test-effects. Learn the right way to arrange some thoughts and you can meet your productivity quota--regardless of what actually happened in real life.
This is fraud. It's one of the worst things I have encountered in my almost two years as a case manager. Most case managers know it as either "rounding up" for hours in service or as "making shit up." The better of our peers will round up to the next increment for billing, as DMH thinks everything between 8-22 minutes only counts for 15 minutes of service. The worst of them will work 5 hours a day and submit 12-hour work days that any auditor would balk at (you know, if they looked at patterns in individual case manager's notes). Just how prevalent fraud is in case management is an interesting question. I'm nervous to just talk about it here. I'm pretty sure most of my peers would rather admit drug use in a survey than fraud. It's an incredibly difficult thing to quantify. An unscientific and extremely limited guess from intuition alone would put that number at around 20% of all case management billings in my city.
Why do practitioners commit fraud? Oddly, it's not for profit. Whereas a doctor who charges for unnecessary services or pads his billing is usually looking to line his pocket, case managers are not directly reimbursed for their services. Most are salaried employees whose billings are taken by the organization as a whole. Individuals generally do it because there is simply not enough time to do all of that work. And though the hours in the day and the pay has not changed over the past few years, the requirements for billable hours has increased secondary to cost control measures from the government. As the government compensates and recoups more costs, the organizations will find ways to adapt to the new environment and inflate their costs to survive. Like the struggle of hacker vs. security professional, the dance of cost inflation and cost control will continue on in perpetuity until our social spending hurls itself over a precipice.
It is the structure of the system itself that is unsustainable. In addition to the problem of fraud, organizations rely on Medicaid and Medicare for funding, which pay the lowest rates for mental health workers (and set the floor for private insurance reimbursements). Yearly reductions in these rates are commonplace and are expected at case management agencies. Those expectations, in turn, are manipulated by the government who will often make the fiscal situation seem more dire than it actually is (20% cuts!!) so that the actual reduction (only 10%) will seem less bad (and the result of hard work by people fighting for those who help people in need!!!) Playing with expectations in this way has many effects on individual case managers:
- organizations may raise productivity requirements on case managers, further incentivizing fraud
- case managers will be less likely to provide services to clients that they cannot bill for
- they will think of clients in terms of the DSM and deficit-based model
But this policy also affects the organization as a whole. How can organization plan ahead one year, if its leaders do not know how much money they will be receiving this year? How can they open new centers, bring on-line new programs, or invest their money in (for example) recovery-based housing if its gross revenues will be reduced by as much as 20% from last year?
The answer is that they must keep more money in reserve (and away from clients) than they would have otherwise done if those figures were stable or knowable and there were less regime uncertainty. Government control of mental health funds means less investment in innovative programs or continued investment in current ones. Money that would have been spent helping clients must instead be hoarded as a bullwark against the interventions of government. Maintaining an organization under these circumstances is incredibly difficult, let alone growing or starting one. This leads to less innovation and competition among mental health agencies.
Ultimately, we have a sclerotic industry based on unsustainable math whose last consideration is for the client being served.
No comments:
Post a Comment