Editor’s note: The Bollard has granted this writer anonymity as a whistleblower. We also decided not to identify the specific agency he worked for, because the activities described are not limited to that agency; they are systemic problems.
“Every man must decide whether he will walk in the light of creative altruism or the darkness of destructive selfishness.”
— Martin Luther King, Jr.
The ultimate goal of case management for adults with mental illness is to help them progress to the point at which they no longer need case management. The dozens of non-profit agencies in Maine that provide this service claim to be dedicated to that goal. “At the heart of our program is the belief that people dealing with mental illness can determine the course of their own lives,” reads one mission statement. The catchphrase “Helping people help themselves” shows up a lot. Agencies extoll their ability to give clients a “life of independence and greater satisfaction,” to “encourage them to take personal responsibility for their lives” and attain “self-management of their mental illness and life.”
The clients are assumed to share that goal, and nearly all of them do. Many desperately hope to rejoin society as a fully functioning citizen, someone who can make and keep appointments, do their own shopping and laundry, spend time with friends and family again. Many also express a strong desire to one day give back to the community that’s helped them in their time of need. Case managers are not psychiatrists, but their work builds the foundation of life skills clients need for their treatment to be effective.
I worked as a case manager in Portland for 18 months. During that time I came to realize, much to my disbelief, that the system acts in direct contradiction to its stated goal. Rather than encouraging independence, agencies foster dependence, because that’s what pays the bills and keeps the machine running year after year. The winners in this game are the agencies that profit under this arrangement (regardless of the organization’s official tax status). The losers are thousands of the poorest and most vulnerable people among us.
The mounting moral outrage I felt compelled me to quit my job last year. It is with much regret that I’ve written what follows, but the question Dr. King posed in the quote above must be answered, and I’ve chosen to follow the light.
Chocolate bars and schizophrenics
The first job I ever had was working as a salesman for charity. When I was a kid I sold World’s Finest Chocolate bars door to door to raise money for my school. My mother would drop me off at one end of a street and wait for me at the other. My goal was to get rid of all the bars in the cardboard box I carried, and I always achieved that goal — even if I had to eat a few along the way. It wasn’t a tough sell. The bars only cost a dollar, the money went to a good cause, and there was a $1 Pizza Hut coupon on the wrapper. But I was good at closing the deal, and it felt good to be doing something to benefit my fellow students.
As a young adult I had a successful career in sales, but I missed the satisfaction of contributing to my community, so I started a small charitable organization to support a local food bank. I subsequently earned an undergraduate degree in psychology and decided to pursue a career in social services. I was hired as a case manager for mentally ill adults soon after I moved to Portland.
In retrospect, the abundance of job opportunities in this field should have been my first warning that something was wrong with the system. Even entry-level positions in case management pay well in Maine, generally over $15 an hour, plus benefits and bonuses of up to $500 per quarter. You have to earn a certificate as a Mental Health Rehabilitation Technician/Community, but that’s not difficult — there are no tests or grades; all that’s required is attendance and a cleared check — and you can work on a provisional basis until you’re certified, which I did during the first year of my employment.
You don’t need to understand Jungian psychology to be a case manager. You have to know how to schedule an appointment and how to drive to the nearest Shaw’s. Ideally, you’ll also be adept at teaching clients how to make appointments and shop for food. But in reality, as I’ll soon explain, the better you are at that aspect of the job, the harder it will be to keep it.
The provision of case-management services to people with mental illness is a growing industry. According to the Maine chapter of the National Alliance on Mental Illness (NAMI Maine), one in four adults will experience a “mental health disorder” in any given year. In a 2010 report, NAMI Maine estimated that nearly 51,000 adults in Maine “live with serious mental illness.” Nationally, the number of adults whose mental illness qualifies them for disability benefits increased two and a half times between 1987 and 2007, according to Harvard professor and former New England Journal of Medicine editor Marcia Angell.
The case-management system serves people who can’t afford treatment and lack support (from friends, family or finances) to handle the demands of daily life while seeking or receiving treatment. Many have prior or ongoing drug problems and histories of mental, physical or sexual abuse. Many are homeless. Few have finished high school or attended college, and practically none of them have held a job for a significant length of time.
Based on what I observed during my time at the agency, I’d say there are some clients who don’t really need case management and are taking advantage of the system, but that’s a small minority of those receiving services, and money-hungry administrators practically invite this type of fraud. At the other end of the spectrum is the minority of the population whose mental illness is so persistent and severe that their chances of becoming a fully functioning member of society are nil. Those clients certainly need the assistance case managers provide, as do the majority of those in the middle, who can resume their daily lives if they get the help they need. (The program I worked for does not accept people with mental retardation, Alzheimer’s disease and other incurable conditions.)
The number of private, non-profit agencies providing this type of case management in Maine has also significantly increased in recent years. That has compelled these organizations to compete with one another for clients, and this competition encourages corrupt and unethical practices.
Agencies aggressively recruit new clients with methods that smack of salesmanship. So-called “intake coordinators” are known to troll for new clients at places where people in crisis congregate, like soup kitchens and shelters for the homeless and victims of domestic abuse. They commonly try to poach clients from other agencies by offering more services than the client may need.
I once met with one of my agency’s clients in a women’s shelter. During a conversation about obstacles to self-reliance, she asked me what “other” services I provided. Puzzled, I asked her what she meant. She told me an intake coordinator working for another agency said that agency would give her rides wherever and whenever she desired.
I was incensed. There I was, trying to encourage my client’s independence, and another agency was offering her free shuttle service. Ill people faced with a choice between an agency promising instant gratification and one that expects clients to work toward goals can hardly be blamed for choosing the former. (The client ultimately decided to stay with my agency, but the case manager who took over for me told me she chauffeurs this client whenever she can, to accrue what we called “easy hours.”)
Aggressive recruitment practices are coupled with remarkably lax admission standards. Agencies have lists of providers that will give even the most stable person a diagnosis for an illness listed on Axis 1 of the Diagnostic and Statistical Manual of Mental Disorders: mood disorders, phobias, ADHD, PTSD. Most agencies also have a licensed clinical social worker (LCSW) on staff who can provide the professional diagnosis necessary to receive case management. Very few clients are referred to agencies by the state. Most are recruited or are referred by shelter employees, and people can self-refer simply by walking into the office and scheduling an evaluation with an intake coordinator.
I recall hearing comments at the office like, “Just give them a PTSD diagnosis — it’s very difficult to prove” and “Autism is not qualified for case management; give them anxiety disorder.” My agency was not the proverbial bad apple spoiling the bunch. Other case managers I met had their own examples of, shall we say, highly flexible admission standards.
“Bill heavily” and “rake in” hours
Agencies have two main sources of revenue: payments from MaineCare (our state’s version of Medicaid) and a smaller pool of grant money agencies receive from the state to provide services to non-MaineCare clients. Administrators pressure case managers to maximize both income streams.
Agencies closely monitor the expenditure of grant money to ensure it’s all spent before the next fiscal year begins. They do this because if the agency does not spend all the grant money, there’s a good chance they’ll get less of it the next year. As the e-mail below, from my former agency, shows, the emphasis is on spending all the money available, not spending it responsibly.
Date: June 11, 2015 at 10:24:00 AM EDT
Subject: grant money surplus
We’ve underspent our grant money for the year. We’re going to have some left over at the end of the fiscal year (end of June) which means that extra will go back to the state. So for those of you with grant funded (non-mecare clients) you can feel free to provide a lot of assistance to them and bill heavily through the end of this month. But only through the end of June.
The amount of assistance clients get is determined by the agencies’ fiscal wants, not their clients’ needs. That is fundamentally wrong, but especially so in the field of case management, where providing extra (and often unwanted) attention to a client can hinder their progress toward self-reliance.
MaineCare payments to providers are made based on billable hours. Billable hours are measured in quarter-hour increments, and it’s common practice to round up to the nearest quarter-hour to maximize billable time. I once overheard a supervisor tell a case manager who was struggling to get enough hours, “If I work one minute past the hour, I round to the next quarter-hour.”
This sort of number-fudging — though it’s pervasive and, in aggregate, can amount to significant fraud — is relatively harmless to clients. Far more troubling and damaging are the practices employed to ensure case managers meet their requirements for billable hours every week.
The margins these non-profit agencies make on billable hours would be the envy of any for-profit enterprise. MaineCare currently pays agencies $82.44 per hour for services provided under what’s known as Section 17 of the program. As I noted earlier, the case managers are paid about $15 an hour, so the “profit” margin on billable hours typically approaches 70 percent.
There’s intense pressure on case managers to meet their goal for billable hours — generally at least 24 hours every week. Case managers who don’t meet that goal face disciplinary action, including termination. Here’s a typical e-mail I received on this subject:
Date: September 22, 2015 at 9:14:35 AM EDT
Subject: billable hours
In reviewing our team’s productivity so far this fiscal year, the majority of you have been under for several weeks (and some of you for months). This cannot continue and have our program be viable. Unfortunately, this is verging on corrective action for some of you.
To avoid corrective action, I need you all to be making your hours regularly. I’ll be checking in with you in supervisions regarding this.
On the other hand, case managers who exceed their weekly goals are awarded quarterly bonuses from the agency:
Date: December 12, 2014 at 9:14:53 AM EST
Subject: individual incentive
Just an update on the upcoming deadlines for the individual incentive this quarter:
The quarter ends December 31st. Since meeting or surpassing your billable hours for the incentive is calculated based on your total hours for the quarter, you still have two and have weeks to rake in some hours if you want to make the incentive.
And the final paperwork deadline is January 15th – all paperwork due through December 31st must be submitted to [redacted] by the end of January 15th.
Here again, the inducement to “rake in” billable hours reflects the agency’s greed, not its clients’ needs.
The case managers’ need to maintain billable hours encourages practices and relationships that undermine the goal of helping clients regain their independence. Agencies provide transportation to medical appointments, grocery stores and food pantries, but will also give clients a lift for personal errands and social calls, like trips to the mall or runs to the corner store for beer and cigarettes. I once brought a client to two different supermarkets on a quest to find their favorite foods. Then we went to buy a flat-screen TV, which I helped the client set up in his apartment. The four billable hours I spent doing this netted my agency over $300.
As the relationship between the case manager and client grows, it easily becomes more personal than professional. Talks during weekly coffee meetings drift into subjects like sports, pop culture, politics and weekend plans. Substantive discussion of mental-health challenges becomes almost an afterthought, but this is all billable time.
Clients, who often have few connections beyond the homeless and illegal-drug scenes, now have a respectable friend and confidant in the case manager. But, unbeknownst to the client, the case manager’s friendship is motivated by money. Chances are that phone call or visit late on a Friday afternoon was made not to check in with the client before the weekend, but because the case manager is a quarter-hour short of their weekly goal and their paycheck’s in jeopardy. (By the way, phone calls to clients do not technically qualify as billable time — only in-person meetings do — but my colleagues and I routinely reported phone conversations as though they were face-to-face visits when documenting billable hours. I once wrote that a client “failed to make eye contact” during one such telephonic “visit,” just to give myself a chuckle.)
I’m not saying case managers never sincerely care about their clients, or that it’s wrong to take a personal interest in a client’s well-being. But I am pointing out that these personal relationships can be counterproductive for clients, nearly all of whom are ignorant of the financial pressures that prompt and shape these interactions.
Clients who now have a personal chauffer and secretary easily become overly dependent on the case manager. Soon they have no idea when their medical appointments are, or how they ever went grocery shopping alone. It’s not uncommon for a therapist or other health professional to ignore the client and turn to the case manager at the end of a session to schedule the next appointment. I personally experienced this many times. A provider once spent the last 10 minutes of my client’s appointment venting to me about their professional problems. “Hey, over here,” my client said at one point. “It’s kinda my time.” The provider just kept complaining.
The discharge criteria case managers must set often include statements like, “Client must schedule and attend provider appointments independently.” That looks good on paper, but in practice clients are seldom pushed to meet that goal. Instead, the case manager “advocates” for all their needs. This degrades clients’ self-esteem and can worsen their mental illness, sometimes with tragic results.
Agencies employ a number of tactics and tricks to help case managers meet targets for billable hours. One is to assign them more clients than the employee can possibly handle in a five-day workweek — typically more than 20 at a time. This is done because clients frequently cancel appointments with providers or case managers. Cancellations may not be indicative of a problem — sometimes they just don’t want to see you that week — but they create problems for case managers desperate to meet the mark.
If the case manager’s weekly goal is 24 billable hours (which is low by industry standards), that means the manager must make, on average, 16 appointments that last an hour and a half each. That’s an impossible task if you have a typical caseload of 25 clients and every client has an appointment. But if the case manager has only 16 clients and even one cancels, the manager must scramble to make up that time or face the consequences. It doesn’t matter which client gets the extra attention, or even if they need it. What matters is the agency gets paid. Overloading case managers with clients serves the agency’s interests, not those of the people in their care.
Date: August 4, 2015 at 9:26:05 AM EDT
Subject: need a response
It looks like some of you haven’t been making your hours lately. That being said, I need you to all email me when you get this and let me know if you have room for more clients. Thanks.
I picked up other tricks of the trade and got very clever at the game. One practice, promoted by the supervisors, was to schedule meetings and appointments at places close to where other clients lived, whenever possible. That way, if the client cancels, you can pick up billable time nearby — “Oh, hey, I was just in the area, so I thought I’d stop by and see how you’re doing today.”
Local businesses often donate gift cards to mental-health agencies. When a new hire told me she was having trouble convincing her clients to see her, I told her to offer them a gift card and a ride to spend it. “This’ll guarantee at least two hours of billable time and ensure the client will see you in the coming weeks,” I told her, “because they may think you have another gift card for them.”
I am ashamed to admit that I succumbed to the pressures of being successful in this field. I feared that I would fail in my newly chosen career if I didn’t adopt the habits of my colleagues and meet my supervisors’ expectations. There’s no avoiding the truth: We were preying on the weak.
But wait, it gets worse.
The worst light
If you get 24 hours of billable time, that leaves 16 hours in the workweek to spend on inter-office meetings and paperwork. The paperwork part is crucial, because it’s by filing reports that you make sure your clients will continue providing billable hours.
During weekly meetings with supervisors, case managers were told to “present the clients in the worst light.” That phrase was repeated so often at my job that it felt like a mission statement, and my fellow case managers and I followed the directive as if the fraud it implied were business as usual.
Each week, case managers are required to write what are called “notes”: a paragraph that describes how time was spent with the client and what progress, if any, they made toward their goals. Every 90 days, case managers have to produce a synopsis of those weekly notes, called a Continuing Stay Review (CSR). The CSRs are sent to APS Healthcare, a private company that has a contract with the Maine Department of Health and Human Services (DHHS) to determine how long clients should receive case management.
The need to submit a CSR that’ll guarantee another 90 days’ worth of MaineCare payments will bring out the creative writing skills in anyone. So case managers find ways to spin their clients’ behavior just like politicians spin facts into half-truths and lies:
- When a client changes topics more than once during a conversation, the case manager reports they have “racing thoughts.”
- A client’s comment that they wish they had more friends is evidence of “lack of social supports.”
- If the client didn’t speak during an appointment with a provider — because the case manager was doing all the “advocating” — that’s proof of an “inability to independently attend appointments.”
- When the client describes how excited they were to have reunited with an old friend, the case manager nods and smiles, thinking, “manic episode” and “barriers to meeting goals due to unhealthy social relationships.”
- The client says they haven’t left their apartment in two days due to a big blizzard. The case manager’s notes report “seclusion” and “bouts of depression possibly leading to suicidal ideation.”
- Did the client try to speak out against a provider’s recommendation and become angry when their protest was ignored? Bingo! That’s the cincher: “aggression towards providers.” Consider that CSR approved.
Any mention that the discontinuation of case management could put the client, or society at large, in danger is a foolproof way to keep the billable hours coming. And if the client, having become totally dependent on the case manager, grows so despondent that they slip into crisis, the bonanza of billable hours that follows could trigger a quarterly bonus.
Colleagues told me that APS stands for Automated Payment Services. That’s not true — APS is just APS — but this old joke may as well be the reality. In the most recent fiscal year, APS denied CSRs in only 1 percent of the cases it monitors. It’s like a rubber stamp that leaves an almost imperceptible smudge. I got the impression that APS employees were as overwhelmed and stressed by their workload as case managers are. It was useless to argue with them, but sweet talk (or mention that a client could be dangerous) usually worked.
During the year and a half I worked as a case manager, I saw clients come into the office every day seeking peace of mind, seeking help in their struggle to rebuild their lives, seeking hope in a world that fears and shuns them because of an illness beyond their control. I developed treatment plans for them that most people without a mental illness could not achieve. I set discharge dates years into the future. I pretended to be their “friend” even when my visits were solely motivated by my own fear of being fired. After our meetings, I mischaracterized their behavior to keep them trapped in the system.
Clients came to me seeking a bridge to better days, and I ever so slyly signed them up for a lifetime commitment. I can’t forget the defeated faces of clients I worked with who’d been receiving case management for over 10 years, 15 years, or longer. Sadly, this is not uncommon. Colleagues who worked for other agencies told me stories of clients who’d been in the system for over 20 years. Some case managers end up providing case management to their longtime clients’ children, as well — cyclical repression in action.
I was successful, I was salesman of the year, but I was never proud of myself. When the guilt got too great, I quit, but even that was not enough to quiet my conscience. I had to speak out about what I’d seen and advocate for reform.
Shortly before this story went to press, the state announced new rules that would limit this type of case management to clients with schizophrenia and cut the reimbursement rate to agencies by about 30 percent. Clients with other mental illnesses would need a waiver from a health-care provider to receive or keep services, and former colleagues told me their agencies are already scrambling to identify which clients may qualify.
That’s not the kind of “reform” I have in mind. All the talk in Augusta is about individuals abusing the system. That’s exactly backward: the system is abusing people in need.
Effective state oversight is crucial. That means independent, in-person assessment of clients’ progress toward meeting discharge criteria. It’s not sufficient to rely on the reports of agencies that have a financial interest in maintaining their caseload. Strong oversight could also identify the relatively few clients who are taking advantage of the system and dissuade agencies from signing up anyone who walks through the door, freeing up resources for those truly in need.
Limiting case management to schizophrenics is not a solution. The state has provided no clinical justification for that change, and my experience has shown me that people suffering from other mental illnesses can benefit from case management. Reducing the reimbursement rate will also do nothing to reduce the types of fraud I witnessed. To the contrary, it may encourage those questionable practices as agencies feel the fiscal pinch.
A more fundamental change is necessary. Agencies and their case managers must be incentivized to help clients meet their goals and leave their care with the life skills they need to rejoin society as contributing members of our communities. Only then will the agencies finally live up to their lofty mission statements.