I wrote this piece in 2012 about the misuse of medicaid money to “help the Mentally Ill.” It details a 9 month journey through the borderline abuse of the disabled by private companies entrusted with the care of those who were dealing with one or more issues. I had been saved by Jesus 3 months earlier.
“It is what it is,” the mantra of burned out mental health workers across the nation, had evolved into disgust, as the best-practice model of psycho-social rehabilitation was too expensive and did not provide quite the fix that federal and state Medicaid dollars required. The pendulum signifying the evolution of quality mental health care swung so hard that the clock spilled over and the guts of the client/consumers, providers, and stakeholders writhed with no solution in sight, just money. The new state of working “smarter and not harder” had not been thought through and the victims were clients that begged for a fix, any fix. I signed up to be a candy man.
Candy man, what does that mean? How do I feel about that? Well, if it means that I would provide food off the “dollar menu,” I did. If it means I transported people to their destination of choice, I did. Co-pays, food, over-the-counters, and even smokes; you name it…I bought the candy. Does it mean I am a prostitute? No, not in my mind and not to the multitudes of the people who have to feed themselves and others by providing team based CORE/ACT services, it meant being where they were at the time they needed the help and providing anything to keep the process moving forward.
Flash-forward to three months later and the audit approaches our program. We are called in one-by-one throughout the day to discuss the quality of documentation as well the amount of our documentation. One of our best team members tells me that “you can’t bill for actual time, or you won’t be able to stay on the job.” Apparently the clip of fifty hours each week for seeing her caseload was a bit too much to provide “quality services,” according to our CEO. In this case, a maximum of thirty hours each week and a minimum of twenty was more appropriate management of provision of mental health services. Her caseload, like mine, that spanned nearly the entire south-metro Atlanta area was deemed acceptable. She normally billed 10 clients a day for an hour each, while driving an average of 15 minutes between each contact, and documentation or ‘writing notes.’
American Psyche Services (APS), which governs all Medicaid billing, gave a score of 90% on our services. These services ranged from the provision of psychotropic medication to nursing assessments that pay our company well, to peer-supports that paid the company nearly nothing. What an outstanding score for a company that backdated any document they felt important, which included treatment plans to the date of easily six months.
Three weeks into the job, I did not sleep on a Friday night after work after realizing that I could not actually do much for my clients – not with my degree, not with my knowledge, not even if I were an elected official. While taking a person to Micky D’s, I saw a man on Moreland Avenue without a bed or clothing to for the next day. The man I accompanied only worried about one thing: tomorrow. This was after spending the morning in an infested, check-grabbing rental property with pest control trucks removing bed bugs day after day, attempting to help a woman who lost her keys, ID, bank card, and as well her dignity after the binge from the night before. I lost it. I still cannot work out this day verbally without breaking down. It was the day of the dawning on this writer that we are broke and this pendulum, wherever it swings is damaging all involved. Where our broken mental health system will go, and how we will effectively help those in need in the future is a mystery and a problem too large for our system.
Confronting the client/consumers regarding the lies told proved unhelpful to my bottom line because then most likely locating that consumer again would be difficult. This wasn’t the truth in the office in my half-hour interview in which I was told there would be no sex offenders and no violent offenders. That was the easiest lie to swallow, because after making my own dish soap this so I could buy some type of food instead, I was up for most any task.
“I pay my employees very well, and I don’t have a lot of turnover,” said the offshore doctoral grad and CEO of a CORE/ACT provider that as small as it was had dealt houses, multiple imports of choice and a the need for more. My knowledge of this provider was nothing as most providers that had sprung up in the last several years had jumped on the chance for the taking.
My understanding of the truth was for the best, because one my most frequently seen consumers was the giver of four stab wounds to the face of his rival who, “was talking to my woman” as that story went. I learned too slowly that confronting self-injurious behavior such as smoking up two-dime bags of crack cocaine, while being treated for cancer may not be the best strength based intervention. Whatever I do, don’t tell the recovering addict who carried blades in her mouth in her former life, that the full package of movie channels was not a best choice option when you need to hit up churches by the handful to have food for her and her family.
Make no mistake I had what some might call unhealthy love for my caseload. Seeing a woman on the day before thanksgiving reunite with her daughter in a manner that gave her the choice between rehabilitation, school, career, family and the “stem” in her face indirectly forcing her to further days and months spent in an infested home, a home that bred insects, and vermin who lined up at your door on the first, when the money came, to keep you there until something changed. Assisting with choice and self-determination, to understand supports that existed if they wanted them gave me meaning to my days. Giving a man yarn to make my wife and I scarfs so that I could score a scarf, he could “turn a hobby into a business” and feel meaningful, while he with the knowledge that I believed in him. That helped, it would mean something if they had hope.
This job also allowed me to offer words of faith and compassion while at the same providing me with adrenaline that cannot be matched by most mental heath jobs. Knowledge that being a memory to your family and not there to hold and attempt to provide was in the back of my mind, from time-to-time. I carried no weapons, just a head that was on a spindle. Faith was the one thing that was the through line of these person’s lives. Faith is free, and it provides freedom. Freedom to believe there is a being, which, unlike no one else offers eternal hope.
Was the job a banquet of services, ill gained or otherwise for all involved? At times it was, though I still didn’t eat well. Units kept food on the table. Units are the name of a fifteen-minute service that is billed for the level of billing based on your credentials. Some at our company, not agency, were very, very adept at seeing the least amount of people for the time that would garner billing for ‘a family intervention.’ In this manner a licensed master’s level professional could see two or more people for as long as needed if connected to the initial consumer. As well if you see a client for as many units as you state, factually or not, you can turn a buck in this feast on the Medicaid based dollars that an American taxpayer provides. It’s simple, the more you document, on the honor system, with nearly no need to provide proof of the length of the actual time spent with the consumer, the more money you could make. If you didn’t steal time, you were broke.
Gas costs money, providing assistance through my self-stated enabling of the person to feel human costs money. Taxes cost money, and you better stay sharp about the most intelligent way to navigate the city, system and conscious if you want to stay in the game for long. Three months in, I began looking for work elsewhere.
The goal of the services especially the ACT team was to decrease the hospital visits and jail for those with as severe and persistent mental health illness in the state of Georgia as well as nationally. Nationally one in five Americans have dealt with the effects of a diagnosis of a Mental Health. During the year of 2008, 140,000 persons living in Fulton County had a mental health diagnosis. The mentally ill population in Georgia prison’s system grew by nearly 3,000 between the years of 2001 to 2007. Georgia State Hospitals served two and a half more people each year than any other state in 2008. After 130 deaths in GA state hospitals the Department of Justice stepped in to stop the madness that had put Georgia at least a decade behind the rest of the nation in mental health.
In 2010 the settlement between the Dept. of Justice and the State of GA put many new supports in place and put Georgia on a five year plan to add more intensive services, more housing and many more ACT teams to engage the consumer on their terms and turf. The teams would have a dedicated psychiatrist, nurse, team leaders, therapists and other paraprofessionals. The goal was to meet more of the population in the community. This was more helpful to the many than the fewer who were able to attend the more intense psycho-social rehabilitation programs that functioned as a place for those with a mental health diagnosis to garner skills, meals, and education while gaining access to therapy. Simply put, serve the many in the community, rather serving fewer in an office building. While some provisions as outlined in the settlement are doing well as they are complying with the 2010 settlement, the formation of enough ACT teams as settled on by the Department of Justice, is not on pace at this time.
Examine the possibilities for misuse of Medicaid dollars not by the consumer or even provider of ACT services. If given the chance federal money will be spent on transporting those who are don’t need transportation, electric wheelchairs for those who are mobile and able, and paying a corporation to fund those who “can’t pay the fines” to administer probation. More people go on probation in county courts than those who pay the fine given by a landslide. If you think that SSI and other entitlement checks aren’t paying off smaller government agencies though this manner, you’d be wrong.
Without the ability to keep up with the state that is on the ‘grift.’ If someone can take, when given the option, we will take hand over fist, even if you have your license on the line. Amazing to me was the times I’ve heard over the last 10 years what a provider would not do based on the fear of a license being revoked as opposed to what one must do because their license was on the line. Have I rounded up instead of down on my notes, yes I have. Though for me writing good notes was never hard, writing a good note isn’t hard when you’ve actually performed the intervention.
The ability to meet the consumer where they were was not always the easy part. I’d start my day on the top-end of I-285, make a 35 mile trip to College Park. From there my next stop could be Edgewood, Gresham Park, Redan, or Westside among other neighborhoods. 100 miles a day; “I got that, all day.” It’s easy, you do the miles, swallow your pride, put yourself in homes and neighborhoods, not where you don’t feel safe, but neighborhoods where you know you aren’t safe. You answer your phone; you give your mobile number to your clients, try to set boundaries, or you don’t get paid.
While setting a boundary don’t fool yourself into thinking you have an intervention that’ll change the abuse of substance, the drinking of a “little wine, couple beers, and a some gin,” while being a Type 1 diabetes patient. Don’t confront a young man on about truth that he two weeks earlier conceived twin boys with his teenage girlfriend because the condoms you gave him broke. Don’t confront the behavior shrouded in falsehoods, because he needs the lies as much as he needs the behavior.
I taught skills, I encouraged behaviors, I provided positive feedback, and I made an excellent judge of hygiene, affect while performing motivational interviewing. Did I believe in it, yes I did. Do I believe that many of these client/consumers wanted success as in a relationship, a job, a car, and any sense of normalcy that could be worked for? Yes I do. They want the ability to socialize without the substance, they want to earn a paycheck and not blow it on a couple bags and liquor. They want to not suffer from hallucinations too real to touch, even though they might not admit to having them most of the time. However, all the while settling for less than mediocrity your whole life may be all that most know, and when someone attempts to pull the rug of complacency from them and introduce change it is too much. As well they have to battle new receptors in their brain that only want their drug of choice, the brain doesn’t want a job, and a friend, the brain needs a hit.
If helping the few with a lot of services, which leaves others revisiting hospitals and Georgia’s prison system, while juxtaposing those in ACT/Core services who don’t make progress, then what is next? When we will be able to have an understanding the best way to reach those mentally ill adults that actually rehabilitates them? I have no idea, but I want you to know it is possible. We can lead the broken to the water’s edge, and help them bathe. We can, but given the choice, do we? The question stands for those moving paper from the inbox to the outbox. It is our problem, the times when we as a society move our unsightly, ugly truths to a neighborhood located where we once lived? Those days are dramatically creeping to the present.
You see I’m broken, and I have been dealing with my own mental health diagnosis since 1989. I made it, somewhat. I self-medicated for many years. I’m very blessed in that I was expected to perform, go to college, get married, and eventually have a family. I am a Certified Peer Specialist, and we are to be present on all ACT/Core teams. CPS team members provide services all over Georgia and the United States. Our ability to be taken seriously as a meaningful member of the team varies from program to program, while the smart money uses us to complete a normal load as much as possible.
My days of using my illness as a crutch ended years ago, but for the people who have not experienced a forgiving yet accountable life, their illness is no crutch. Mental illness is a significant disability that needs attention and assistance like those with other disabilities were afforded long ago. Realizing that mental illness cannot be assisted as in the case with hearing or vision impairments, those with mental illness will die more than 24 years faster than those without a diagnosis according to the surgeon general. Unless we do something more aggressive the problem will only get worse. This reality is coming to your neighborhood, count on it.