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Mental health advocates and New Mexico officials are in sharp disagreement over the success of the state’s managed care Medicaid program in providing behavioral health services.
The dispute went national March 30 when Washington, DC-based Bazelon Center for Mental Health Law issued a report stating that the behavior health component of New Mexico’s Salud! managed care program was so deficient that its Health Care Financing Administration (HCFA) waiver should not be renewed.
The center followed up with an April 24 report outlining what it said were more detailed deficiencies.
Bazelon explained that it based its evaluation on analysis of data gathered by the state. Mental health advocates in New Mexico say they have have asked to see program statistics, but state officials have been unwilling to provide data. The advocates say the Bazelon charges square with anecdotal reports they have received.
Bazelon said it reviewed a Gallup Organization survey of members and providers associated with the three contracted managed care organizations — Lovelace Health Plan, Cimmaron HMO, and Presbyterian Health Plan — and reviewed an analysis of HMO compliance with state Medicaid regulations compiled by the Independent Peer Review Organization. From its analysis, Bazelon raised five broad concerns:
1. lack of access to behavioral health services;
2. excessive administrative costs;
3. inadequate grievances/appeals/ denial of care;
4. lack of key data to monitor;
5. low Early and Periodic Screening, Diagnosis, and Treatment rates.
The Gallup poll of providers found that 56% of behavioral health specialists reported that Salud! members were worse off than they had been under the previous fee-for-service program. That’s twice as high as the report from primary care providers and all specialists. Only 6% of behavioral health specialists said Salud! members were better off now. Concerns also were raised about a growing scarcity of services, providers either withdrawing from participation in the program or actually moving from the state, and a lack of inpatient beds.
Bazelon also cited a report from the William H. Mercer auditing firm that said the state’s unusual, multitiered administrative structure involving regional entities, health plans, and subcontractors was eating up 51 cents of every dollar, only leaving 49 cents to pay for services to clients. The organization said that under fee-for-service plans, 67 cents of each dollar went to providing services.
"New Mexico is one of only two states that put all the Medicaid population in its waiver from the beginning, including those with high and special health needs," says Bazelon policy research analyst Rafael Semansky. The other state is Tennessee. "Other states tended to roll the more difficult cases in later, after the administration, provider, infrastructure, and other problems had been worked out. New Mexico moved quickly into Medicaid managed care. The issue seems to be an unusual structure with several administrative levels."
Sally Moore, project director for the New Mexico chapter of the National Alliance for the Mentally Ill (NAMI), says advocates have asked for data but have not seen any until the Bazelon report came out. "Many of the concerns Bazelon talks about are supported by anecdotal comments we’ve received," she says. "Case services are cut back when people are functioning well, and there is no offer of case management for those who are released from the hospital. If what the reports say is true, changes are needed in the program because the intent of Medicaid managed care is to help health care, not decimate it."
Ms. Moore agrees with Mr. Semansky’s analysis that part of the problem stems from the speed of the state’s implementation. "It was done very fast. All provider input was ignored. The advocates were ignored. They tried to do too much too fast without learning from the experience as they went along. New Mexico historically has had a poor mental health system, with money going to residential treatment and other tertiary care and no investment in a continuum of care. Salud! cut back on the residential services but still is not providing the continuum."
Pat Tyrell is the executive director for the National Association of Social Workers, New Mexico chapter. Mr. Tyrell’s group participates with other providers in the Coalition for Effective Mental Health Care. Each time the coalition meets, he hears stories of providers not being paid or having difficulty obtaining a higher level of treatment for individuals who need it, he adds.
"Bazelon has connected the dots for us," Mr. Tyrell says. "I’m not surprised at anything that came out. We’ve seen a reduction in services and providers choosing not to participate or leaving the state. Before Salud! there were 600 residential beds for kids. Now there are 150. It’s hard to tell whether there were too many beds before, but we know there are people complaining now that there are long delays in finding an available bed. The test is to compare the quality of mental health services today to the Jan. 1, 1997, start of the program, and all the indicators are negative. Salud! is one of the biggest state contracts ever awarded, and we can’t afford a poorly designed system that is not delivering services to clients."
State officials contacted by New Mexico media when the Bazelon report first came out expressed resentment over an out-of-state organization becoming involved and questioned the credibility of the Bazelon analysis without specifically responding to the charges.
New Mexico Human Services Department deputy secretary Barry Bitzer tells State Health Watch that the issue of overhead expense has been hard to address. Under managed care, there are costs — information and outreach brochures, educational materials, utilization review and management, and quality control oversight and reporting — that were not a significant part of the former fee-for-service program.
"At any rate, our most recent analysis demonstrates that more than 80% of funding attributable to behavioral health for the year ending June 30, 1999, entered the door at the direct service provider level," he says.
Mr. Bitzer says mistakes in the Bazelon report, such as misidentifying the plan a subcontractor works for, challenge the quality and veracity of the work as a whole. And he charges that Bazelon has failed to give the state credit for changes it has made.
"Where this Bazelon outfit has been correct, they nonetheless have been less than forthcoming. They cited a report that it was acknowledged that there were still problems collecting useful encounter data from the MCOs . . . [and] without useful encounter data, we do not believe the state can adequately monitor the Salud! program,’" he says. "But they ignored the fact that, per our response in that report, we agreed with the finding and had taken steps to alleviate the problem through the use of sanctions in the MCO contracts. In fact, now we do have encounter data that we have publicly announced are available for inspection. [Bazelon] has never come here to review, nor have they requested a copy."
Mr. Bitzer says that while he questions Bazelon’s role, "If any bona fide New Mexico advocate wants good answers, I’m always 100% accessible by phone and e-mail. I’ve published my direct dial number in Albuquerque and Santa Fe papers, and it is printed on my business card."
It’s unclear how the controversy will be resolved. Mr. Tyrell says that since the program is a major part of Gov. Gary Johnson’s privatization efforts, it is becoming a political issue that may not be resolved until there is a new administration. He also talks about using the courts to find a solution, questioning whether the program is meeting federal standards. Ms. Moore says she hopes HCFA will take a hard look at the data and the Bazelon analysis and determine where the truth lies.
She says NAMI is considering taking its concerns to the federal agency. Meanwhile, Mr. Bitzer says that he believes the state has a "constructive working relationship [with HCFA] and that we will reach a satisfactory conclusion."