The second half of May and first half of June were a challenging time for us. Two elderly parents had acute medical needs at the same time in different cities. Both were hospitalized, one in a critical care unit.

During this time I found myself thinking about different aspects of the experience. For those of you who have not yet had the responsibility to care for an elderly parent, these issues might be interesting to look forward to. For those of you who are our age-mates, you will probably have additional issues to offer.

1. Medicare mostly works. (Medicare with a secondary insurance works even better.)
2. Health care workers, for the most part, really seem to care.
3. The quality of care you receive depends upon your ability to advocate for yourself…or to have surrogate advocates.
4. In the heat of the emotional moment, having siblings helps, even if they are in a different state.
5. A Health care Surrogate, an Advance Directive, or a Living Will are not optional.
6. The toll on family caregivers is huge.

1. Medicare mostly works. Medicare with a secondary insurance works better. I know doctors complain about Medicare and the amount they are reimbursed and about dealing with Medicare claims. I also know that health care services are provided without question when Medicare is the payer. In an emergency situation, not having to be concerned about the method of payment allows everyone to focus on the care of the patient. I think there is a great deal to be valued in that.

2. Health care workers, for the most part, really seem to care. Health care workers are overworked and hospitals are understaffed. Nurses and nurse technicians are responsible for so much documentation that they often feel that direct patient care gets shortchanged. In two separate hospitals in two parts of Florida, my experience was that hospital staff did an excellent job in spite of the demands on them…and that they really cared about their patients and about the job they were doing for them.

3. The quality of care you receive depends upon your ability to advocate for yourself…or to have surrogate advocates. Without a spouse and/or children or some other sort of advocate, people do not get as good care as when an advocate is present. The reasons are simple. A sick person is not in any position to ask for assistance, to question the treatment being provided, to assure the medication they have been handed is the correct one, or to guarantee that they understand the instructions they have been given.  If no one is present to say that they are hard of hearing, verbal instructions and questions may be forever lost. Even if a staff person eventually realizes they are not being heard, all of the previous interaction including important questions about history, may have been in vain. Without another person who understands how to go between the patient and the staff, a person may well get sicker because they could not ask for help or did not want to be a bother, could not question the protocols being followed and give benefit of their personal experience with previous treatment, did not recognize the medication they were given or understand the name and function of the medicine when the nurse administered it, or did not understand the follow-up instructions and the rationale for giving them.

4. In the heat of the emotional moment, having siblings helps, even if they are in a different state. Siblings are an asset when dealing with ill parents. Having others with whom to discuss the events and issues is crucial. They help generate additional questions that should be asked. They remind one another of family health history and events that can easily be forgotten. They can share the responsibility for sitting with and encouraging Mom or Dad. Having others to participate in important decisions if a parent is not capable of making those decisions for themselves is invaluable.

5. A Health care Surrogate, an Advance Directive, or a Living Will are not optional. Rightfully, hospitals and health care workers do not want to make decisions for a patient. They especially do not want to make decisions that are inconsistent with the wishes of the patient. They will strongly and clearly recommend what they see to be the best course of care and, with the patient’s permission, they will implement those recommendations up to the limits that the patient sets. If the patient has no person or document setting the limits, all care will be provided as the staff recommends and all of the care they recommend will be provided. Being clear about the limits is only fair to one’s children and essential to one’s care providers.

6. The toll on family caregivers is huge. No matter the outcome of the health care incident, the emotional and physical cost to family caregivers cannot be underestimated, especially if the other elderly parent is one of those caregivers. We most often think about the sick person and how they handled the health care event. It is important that we also think about the family members who participated in the caregiving for Mom or Dad while they were in the hospital and during the caretaking that follows.

My quick Google search for “caregiving” yielded 2,270,000 results. “Family care giving for older adults” yielded 924,000 results. Obviously, this is an area in which interest has exploded. While many of the search results are for some sort of paid service, adding the word “free” at the end still resulted in 514,000 hits. Many communities offer respite care and support groups through their local hospice agencies. Online information and organizations abound. As we baby-boomers age, I fully expect that this will become an industry in itself, with paid and volunteer and not-for-profit organizations.

In the meantime, we are very glad that our elderly parents made it through this round with the health care system. I wonder what your experiences with elder care and our health system have been. Where do you see us heading and what role do you see for behavioral health care in this elder care world?

Please share you comments below.

As reported by Open Minds and American Psychological Association Practice Organization, the lawsuit challenges the rulemaking process and has requested a temporary restraining order to stop the rulemaking process from moving forward. They argue that the Departments of Health and Human Services, Labor and Treasury overstepped their rulemaking authority in how they interpreted the statutory language and violated federal rulemaking procedure in publishing the rule as they did. While the judge denied the temporary restraining order because the law will not be enforced until July 1, 2010, the court will hear the case as presented by the parties to the action.

On May 9, 2010, the NY Times reported that insurance companies and employer groups are also objecting to the rules.

In a suit over the rules, Magellan and other companies said the concept of nonquantitative limits was “boundless and ill defined” and would reach virtually every policy and procedure used to manage mental health benefits.

As most mental health providers can readily attest, the procedures used by insurers and managed care organizations to limit costs and usage of behavioral health services have themselves been “boundless and ill defined”; after all, a treatment plan certainly could not be a valid treatment plan if it is printed on the wrong form. The MBHOs have been innovative in their development of “every policy and procedure used to manage mental health benefits.” Unfortunately, most of that management has consisted of denying or limiting the amount of service provided and placing onerous requirements on providers.

The NYTimes article states that:

One premise of the law is that mental illnesses often have a biological basis and can be treated as effectively as many physical ailments. But insurers say it is impossible to use the same techniques in managing the treatment of colon cancer and schizophrenia, or heart failure and major depression.

What do you think? Is it reasonable to assume that mental illness and addiction can be managed using the same techniques as are used to manage the treatment of cancer or heart disease?

Please share your comments below.

HITECH provides for stronger controls. It requires that the provider be able to inform the patient (upon the patient’s request for the information) about all the times that PHI has been released by the organization (disclosures), to whom it was released, and the purpose of the release. This includes release of information for operations and billing. If you send claims to an insurance carrier via a clearinghouse, you would need to be able to document every time a claim was sent and that it went to both the clearinghouse and the insurance company. If you send it to the payer directly on their web site, you would still need to be able to document every time you did that.

HHS has been gathering comments from provider organizations about the burden this will place upon them. How the rules are ultimately written remains to be seen.

At the same time, the HealthIT Policy Committee has been working on a framework for privacy and security of PHI as we move toward EMRs and the electronic exchange of identifiable personal information. An attempt is being made to come up with methods and understandings that will allow a national standard and method of exchanging PHI in spite of different laws and requirements in each of the 50 states. A Privacy and Security white paper series explores these issues.

Part of the current concern is the point in an exchange at which a specific consent should be required from a patient for release of their information. It is believed that patients feel fairly secure when provider #1 releases information to provider #2 whether the provider is a lab or another physician. Trying to determine the point at which comfort in an exchange is lost and the requirement of consent is triggered is part of the challenge. For example, if provider #1 has consent to send information to provider #2 but the only method of doing so is through a third party (like a clearinghouse or directory), does additional consent need to be obtained for that transaction? What kind of situation must exist to trigger a patient’s right to “opt out” of the electronic transaction.

These are important issues that pertain to information electronically exchanged for billing and operations as well as for treatment. Avoiding the use of an EMR will not shield you from addressing these issues if you send claims electronically. . . even at a payer’s web site. 

What do you think about protecting the PHI of the consumer of services?  What are you doing to assure that you meet the requirements of the law? Please share your thoughts and comments below.

1. The National Council Public Policy Update of April 8, 2010 pointed out an important change in timely filing requirements for Medicare claims:

Requirements of the Patient Protection and Affordable Care Act makes (sic) several changes to the Medicare timely filing requirements. Under the new law, all claims from before Jan. 1, 2010 must be filed by Dec. 31, 2010. Beginning on Jan. 1, 2010, all claims must be filed within one year after the date of service in order to be considered timely.

Sec. 6404 of the law details the requirements. This is a change from the former allowance of 3 calendar years to file a claim. Be clear about this: you now have 1 calendar year after the date of service to file a timely claim for payment for those services.  Now might be a good time to use your billing software to learn which old Medicare claims have not been paid (the claims may have been lost) and if there are any Medicare services that have not been billed. If these are not already three years old, you have only until the end of 2010 to file them, and with services that are new in 2010, you have one calendar year to file a claim for the services.

2. Seth recently posted a message on our User Group about the potential privacy and security problems that can be caused by data left on newer copiers and multifunction machines. NJAMHAA Newswire of May 3, 2010 also commented on the possibility of HIPAA violations that can result from careless use of these machines. Seth’s comments follow:

Now that you finally got all your computer hard drives encrypted and you are feeling pretty smug, here comes another headache — thousands of images containing PHI stored on a hard drive hidden inside other office machines. Take a peek at this investigative report by CBS news:

http://www.youtube.com/watch?v=6pIFUOav2xE

This is a pretty big vulnerability. If you have one of these higher end digital copiers, printers, or multifunction machines and it is stolen — or you neglect to remove or wipe the hard drive before selling or trading it in, you have a reportable security breach. Nobody would be likely to have a list of the patient documents that had been copied over the years, so you
would have to assume that EVERYONE’s protected information was at risk. That means reporting to the Feds, taking out the newspaper ad announcing your negligence, and the rest of the breach notification nightmare!

Apparently all major manufacturers offer security add-ons of some sort. Now would be a good time to inventory your document devices to determine if they contain hard drives and whether you can retrofit appropriate security add-ons to avoid a potentially disastrous situation in the future.

3. The National Council on April 23 published a review of Parity Act implementation that will allow you to determine whether your insurer or the payer with which you are dealing is in compliance with the Parity Act. Is your insurer in compliance with the Parity Act? will help you ask the right questions and provides resources to help you answer the question.

4. On April 22, FierceEMR and other sources reported that hospital-based doctors are now eligible for ARRA incentive payments for meaningful use of certified EHR technology, and that a bill has been introduced by Rep. Patrick Kennedy (D-RI) and Rep. Tim Murphy (R-PA) seeking to include mental health professionals, Community Behavioral Health Organizations (CBHOs), psychiatric hospitals and chemical dependency programs in the ARRA incentives. Time will tell what will fly.

5. And finally, the Mercom Capital HIT Report of May 3 indicated that HHS is seeking comment on the anticipated impact the stricter disclosure reporting requirements included in the HITECH Act will have on providers.

To help guide the Health and Human Services Department in tightening rules for health information privacy, HHS has asked providers, payers and consumers to comment on the benefits and burdens of accounting for the disclosure of protected health information, even if the data is intended for treatment and billing purposes. The HITECH Act called for HHS to strengthen the privacy rule of the Health Insurance Portability and Accountability Act (HIPAA). With the changes, providers, plans and their business partners will have to account for disclosures of patient information contained in an electronic health record, even if the data is for healthcare provision and payment. 

HHS’ Office of Civil Rights (OCR), which oversees health information privacy, published a request for comments in the May 3 Federal Register 
“to inform our regulations under the HITECH Act,” according to the announcement. Under HIPAA, providers and plans currently do not have to report releases of protected data when the disclosures are related to patient treatment, payment and healthcare operations. HHS said in the notice that it will remove the exemption for those disclosures when it involves an electronic health record (EHR).

Needless to say, there is a great deal going on in the world of behavioral health care and health care in general. Please feel free to share news items you discover that might be useful to other readers.

Don’t forget, your comments are always welcome. Please share them below.

That resource is really just a lead-in. In case you have not already collected some of the following sources from my references to them in other articles, I am going to put them all in one place. These are newsletters and web sites that are chock full of information that can help you stay informed about changes in the health care and regulatory world.

1. My favorite by far is The National Council (NCCBH). This organization produces regular newsletters on varied topics, but I find their Public Policy Update to be an invaluable source of information on laws and regulations, policy trends and how you can address them. I have also greatly enjoyed their Webinars. Ordinarily, I would have already registered for the program coming up on Friday, May 14, What is an Accountable Care Organization and Why Should I Care? Since I will be out of town, I won’t be able to attend when it is broadcast; instead, I will watch it at a later date from the web site. The best part is that these programs are free and you do not need to be a member to participate in them. They are provided as a service to the behavioral health community.
2. Every Monday, I receive a free multi-paged newsletter from the Mercom Capital Group, LLC of Austin, TX and Bangalore, India. This newsletter pulls capsules of information from a large variety of sources providing a quick overview of events in the domain of health care technology and health care policy. If you are interested in trying it out, send your email address to Raj at HIT@mercomcapital.com. 
3. Open Minds is a longstanding and thorough source of industry information and strategy specifically for behavioral health provider organizations. While there are an abundance of workshops, webinars and premium programs, the Open Minds Circle is a free-for-the-registering newsletter from founder Monica Oss and others at Open Minds.
4. Behavioral Healthcare and Healthcare Informatics (products of the Vendome Group), the U.S. Department of Health and Human Services, and the Office of the National Coordinator for Health Information Technology all have mass quantities of information to offer you, all available online.

The amazing thing to me is that this is just a small list. If you were to add in blogs, the amount of free, high-quality information available to you on the web is overwhelming. Choose wisely…and use that free .pdf markup tool to make it easier!

Please share with the rest of our readers sources of behavioral health industry information upon which you rely. Just enter your comments in the box below.

The decision to renew has usually been an easy one for me to make even though I do not practice and have no plan to return to work as a psychologist. I have a strong identification as a psychologist. I knew since early high school that I wanted a Ph.D. in clinical psychology; I always wanted to practice independently.

Even when we decided to relocate to central Florida and I took the opportunity to close my practice and work with SOS full time, I never considered dropping my license. After all, we have always told you that we provide software by psychologists for psychologists (and all other behavioral health providers). And anyway, who knows what time and politics will bring!

Usually my reading is a way to meet my CEU requirements and keep up with the clinical side of psychology. This year I was surprised; two of the articles I read this weekend were actually quite interesting to me; they were articles on personal or life coaching and Positive Psychology. Both of these areas have roots in the personal growth and Humanistic Psychology movements of the 1970′s, but are 21st century, mainstream ways of implementing growth-oriented interventions.

As the healthcare arena changes over the course of the next few years, it is highly likely that some organizations will seek to provide pure healthcare services. Others will choose to diversify their services in a variety of ways…and even to provide their services in unique fashion. Open Minds recently discussed both telehealth delivery of services and the use of virtual reality interventions to treat certain problems.

What new kinds of therapy has your organization considered? Do you continue to provide the same services you have always performed, or are you on the lookout for ways to diversify? What criteria do you use to decide if a particular service or technique should be added to your bag of tricks?

Please share your comments. We would love to know how you expand the services your organization provides. Just enter your comment in the box below. If you do not see a box, click on the title of the article and scroll down to the comment box. Thanks for reading!

The biggest difficulty Spring provides for me is that it is hard for me to stay task-focused. This has been the case since I was a child. I just don’t much feel like being indoors, so working on indoor responsibilities comes much harder. As an adult, work is no exception. It is hard for me to focus on tasks that need to be accomplished. I would much rather be playing….or at least doing different work.

As a result of this year’s Spring fever, it was not difficult to decide that the celebration of Synergistic Office Solutions‘ 25th anniversary should happen at home rather than in a restaurant. It may cost me a bit more work, but it is not my usual work. I get to have a party instead of focusing on the changes I need to make to our web site or some other such task.

Yes, our software company has now been around for 25 years. Seth started doing consulting to other psychologists in 1985. Our billing software for mental health and medical practitioners followed in the next year. Florida psychologists were our first customers, but we started selling nationally in 1988 or 1989. Our electronic clinical record product was released in 1990. We made the transition from full-time practice of psychology to full-time software business in 1992-1993. Sometimes I am sure we jumped from the frying pan into the fire!

The primary benefit of the change from providing services to mental health clients to providing products and services to mental health providers has been that we have met so many wonderful folks who embody in their work their mission to care for others. Behavioral health providers and service organizations are the BEST! We are grateful for the opportunity we have had over the past 25 years to work with so many talented and caring people. Thanks to each and every one of you!

As you can see, my Spring Fever is so bad this year that I could not even write a blog article that would have the usual links to information you could use. It contains nothing about behavioral health electronic medical records or HIPAA or HITECH. Oh well, maybe next week will allow a return to those serious issues.

How do you respond to the appearance of Spring? Are you one of those wonderfully responsible people who can just put your head down and keep on taking care of business? Will you share with me how you do that? Or maybe you are just like me and want to have a party!

Please enter your comment in the box at the bottom of this article. If you don’t see one, double click on the title of the article, then scroll down to the box to make your comment.

We have been using a hosted PBX-style telephone system (Onebox) for the last couple of years. This service gives us the general functionality of a PBX system without the cost. We have extension numbers for each phone. We have automated attendants with different messages at different times of the day and night, as well as for Technical Support vs. Sales and Customer Service. We have multiple voicemail boxes at which customers can leave messages. We told the company what we wanted. They set it up for us. We use it.

Our one frustration has been the length of time needed to transfer a call from one person to another within our organization. It takes so long customers sometimes hang up. And sometimes transferring just does not work at all.

In 2009 and 2010 we have been cost saving fanatics. Since long distance telephone calls and numerous telephone lines are among our biggest expenses, we began to research options other than land lines and long distance contracts. About a year ago, we started using Voice over Internet Protocol (VOIP) telephone service through T-Mobile for our outgoing technical support calls. It has mostly done the job at a fraction of the cost of long distance service, so this month Seth started to research moving our entire telephone system to a hosted VOIP solution. After a couple of days of intense research, he decided that we should try Vocalocity, a company that focuses on small businesses.

Then Manon, our lead technical support staff person, left for vacation and my headache began. You see, Seth assists with doing tech support when one of our primary staffers is out. That meant the VOIP project was handed over to me…and oh what a mistake that was….because, remember, I am technologically impaired. Much of my other work has been on hold while I tried to make this work.

Seth had begun to set up our Auto Attendants, but they were not working properly. He emailed our phone system flow chart to a support representative at Vocalocity so they would know what we wanted to accomplish. Then, I needed to work with the support representative to make it happen. Over the course of three days, an excellent representative named Nathaniel worked with me to make changes in the setup of our account. It was much more complicated than either Seth or I realized. There were some things that had to be initiated on their end to accomplish our goals; they were not end user configurable. Finally, on Monday we tested all the work Nathaniel had done and the system appears to do what we want it to in the way we want. It even lets us transfer calls from one extension to another without a long wait time.

Today I called our telephone service provider and had our main line forwarded to the number assigned to us by Vocalocity. Tomorrow I expect to start receiving calls on the new system. We will let you know the outcome.

The moral of this story is this: using new technology may be just the way to save your organization lots of money; however, have your most tech-savvy person work to accomplish the goal. Giving the task to a less-than-patient person who just wants the darned thing to work is not the most effective way to adopt the new technology….no matter how cool the technology is.

What technology implementation stories do you have to share? Has your experience taught you some things about how to most effectively adopt new technology in your organization?

Just enter your comment in the box at the bottom of the page. If you don’t see a box, double click on the title of the article then scroll back down to the box to enter your comment. Please share your experience. I must get better at this!

In the past week or two I have seen many questions about what the effects of this legislation will be. Behavioral health provider organizations are especially concerned about what the effects will be on mental health and addiction service funding.

One of the most useful resources I have come across was forwarded to the Florida Psychological Association member listserv by Dr. Bob Porter. The Bazelon Center for Mental Health Law has done an excellent job of summarizing the law and its impact on coverage for mental health services. While it will take years for all of the provisions of the new law to be implemented, a Congressional document summarizes some of the immediate effects.

In the private insurance sector, generic requirements of the law have particular impact for those with mental illnesses. In the past, such diagnoses have routinely triggered pre-existing condition clauses in policies. Within the first 6 months, the new law prohibits this discrimination.

1. No discrimination against children with pre-existing conditions.
2. No rescissions based on developing an illness.
3. No lifetime limits on coverage.
4. Tightly regulated annual limits on coverage.

In addition, for those who are currently uninsured, the law mandates:

1. Immediate help for those with pre-existing conditions (an interim high-risk pool).
2. Extending coverage for young people up to their 26th birthday through parents’ insurance.

Since so many who have been diagnosed with mental illnesses or with substance abuse issues have been denied coverage or have had coverage revoked or have reached the limits of their benefits, we should see immediate increased access to behavioral health and addiction services. The ability for parents to keep young adults on their insurance plans until they are 26 years old will assist some of the young people who experience late adolescent onset of serious mental illness or substance abuse conditions. This will allow a period during which their parents will be more able to facilitate transition to some other form of insurance coverage.

The National Council for Community Behavioral Healthcare, the trade association of behavioral health community service providers, hosted a webinar on healthcare reform and its impacts, Healthcare Reform: What Happens Next? Additionally, their Public Policy Update for April 1 gives links to resources as well as information about moving forward from here.

I attended the Council’s webinar this week and was struck by a couple of things. Because the Council primarily represents organizations that provide services in the public sector, their information is generally focused in this direction. For me, there were three take-aways from this session, and they were not all for public sector providers:

1. The Council believes Fee for Service will probably go away in the long run, to be replaced by Case Rates with a Bonus for improvement of the consumer.
2. Behavioral health providers need to position themselves for the long term. Integrated care is likely to be the way of the future and it is best to start to get positioned for that now.
3. Private practices can be competitors in the new system; however, those with deep pockets who can manage the whole range of healthcare services will be better positioned to compete.

Community Behavioral Health Organizations (CHBOs) have been working on these steps for the past couple of years and there will be pilot programs using CBHOs together with Federally Qualified Health Programs to start to provide integrated care. Unless private behavioral health practitioners also start to position themselves to play in the Integrated Care setting, they are likely to get left behind.

Even the American Psychological Association’s advocacy efforts focus on the assurance that mental health services will be part of integrated care. This sounds very much like an integration of mental health services into such settings to me.

What do you think about how the new health care reform law will affect behavioral health services? Do you foresee changes in how care is provided? What changes are you willing to make in your organization in order to assure participation in a reformed health care system? Please enter your comment below. If you don’t see the comment box, just click on the title of the article and then enter you comment at the bottom.