The motive for mental health agencies to keep clients depending on them

This month’s issue of The Bollard features a first-person account of fraud and malpractice inside the case management system for adults with mental illness. The whistleblower — whom I granted anonymity for several reasons, including his own complicity in the fraud he described — worked for a non-profit social-service agency in Portland for a year and a half before he resigned in disillusionment and disgust several months ago.

Shortly before that issue went to press, the Maine Department of Health and Human Services announced its intention to substantially limit the types of patients who can receive case management through what’s known as Section 17 of the MaineCare program, and to significantly cut reimbursement rates to agencies, which had been receiving over $80 per “billable hour” of service provided.

That announcement set in motion the now familiar pattern of political argument that ensues when state officials cut services to the needy. Patients and caregivers packed the State House to protest the cuts, while DHHS officials defended their decision by saying it focuses scarce resources on those most in need of assistance.

As our cover story (“The Case Management Trap”) reveals, both sides of this debate have valid points, but both are overlooking a fundamental flaw in the way the system is structured. Agencies have a strong financial incentive to keep the clients in their care dependent upon the services case managers provide. Although these agencies claim their goal is to help clients regain their independence, in practice case managers are often pressured to keep clients reliant upon them, lest the agency lose those lucrative billable hours and the case managers lose their jobs.

The state is correct in its assertion that case management is being provided to some people whose illness does not warrant that level of care. In an effort to reap more billable hours, the intake coordinators at some agencies will sign up almost anyone who can be said to be suffering from one of the less severe types of mental illness, like anxiety and other mood disorders.

But in the whistleblower’s experience, only a small minority of clients are gaming (or being gamed by) the system in this way. The new DHHS rules limit the provision of case management under MaineCare Section 17 to people with schizophrenia or schizoaffective disorder, though clients with other illnesses may qualify for a waiver if they meet certain conditions. State officials have not provided medical evidence to justify such a strict limit, which is typical of the LePage administration’s slash-and-burn approach to health care.

The mental health awareness ribbon. Nathan Daviss via Flickr. Available through Creative Commons License.

The mental health awareness ribbon. Nathan Daviss via Flickr. Available through Creative Commons License.

The agencies deserve some blame for spending MaineCare money irresponsibly, but the much larger problem is the way they manage the vast majority of clients who do have serious mental illnesses and could regain control of their lives if they were encouraged and supported to do so.

The whistleblower reports that case managers are pressured by agency administrators to meet weekly goals for billable hours, not to help clients meet their goals — like being able to shop for groceries on their own or making and keeping medical appointments. Administrators overload case managers with more clients than they could possibly help in any given week (typically about two dozen) because it’s not uncommon for clients to cancel appointments with case managers, which makes it hard for managers to meet their billable-hour quota.

The most damning revelation in the whistleblower’s account is the way case managers are encouraged to cast clients in “the worst light” when submitting paperwork to justify providing another 90 days’ worth of care. The state contracts with a company called APS Healthcare to review those 90-day “progress” reports and determine whether another three months of case management is warranted. According to DHHS, these agency requests are denied in only about 1 percent of cases.

An agency administrator I spoke with cited that figure as proof the agencies are doing an effective job helping their clients. To me, that figure indicates the opposite. Clients who receive case management for years are failing to make sufficient progress toward their goals. Effective state oversight would determine why the agencies are failing to help their clients leave the system, not rubber-stamp another three months’ worth of service based on reports written by managers who have financial and professional incentives to mischaracterize their clients’ progress.

Real reform must shift the incentive from keeping clients in the system to helping them graduate from it. That may be impossible in a system that pays private “nonprofits” princely sums to deliver state-funded services. If we had leadership in Augusta that we could trust, I’d suggest that DHHS hire case managers and provide these services directly, at a substantial savings to taxpayers (case managers make about $15 an hour). But the state’s latest slash-and-burn dictum proves that would be unwise. Best to wait until a new regime is sworn in come 2019.

Chris Busby

About Chris Busby

Chris Busby is editor and publisher of The Bollard, a monthly magazine about Portland. He writes a weekly column for the BDN.