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From January 2001 NASW NEWS It became difficult to track what happened to New Mexico's mental health funds. By John V. O'Neill, MSW, NEWS Staff New Mexico could serve as a textbook example of how a state erred in creating a Medicaid managed care system for behavioral health without input from mental health advocates, consumers, providers and state departments, only to see it flounder and fail after fed-up providers and consumers organized a high-profile effort to demand a different system. The New Mexico Chapter of NASW, and especially Patrick Tyrrell, its executive director, were very involved in the actions leading up to the Health Care Financing Administration's decision in October to refuse to renew a waiver to the state, meaning a program called Salud could not continue to operate the state's Medicaid behavioral health program. According to Tyrrell and press reports, the debacle unfolded over several years. In the mid-1990s, Medicaid health costs in New Mexico, a poor state with about 30 percent of children living below the poverty level, were increasing and the state looked for ways to cut costs and maintain quality. Republican Gov. Gary Johnson was elected in 1994 and appointed a former CEO of a managed care company, Duke Rodriguez, to become secretary of human services. With extremely limited input from advocates, consumers, the state legislature and state health, mental health and children's and family departments, Rodriguez designed and pushed through his own plan, getting a waiver from the Health Care Financing Administration (HCFA). The plan combined health and mental health in an integrated model, with all mental health services to be approved by a primary care provider, a system that disturbed social workers, since it was difficult to track what happened to the state's mental health funds. The integrated model was very bureaucratic. First, three managed care organizations — Cimarron, Presbyterian and Lovelace — contracted with behavioral health organizations to provide services. Then the behavioral health companies contracted with agencies and private practitioners for actual services. "More and more funds were siphoned away before it filtered down to consumers," said Tyrrell. Problems developed quickly:
By the spring of 1999, Salud, then in operation nearly two years, caused an organized backlash. NASW, the state association for psychologists and two state organizations for psychiatrists formed a Coalition for Effective Mental Health Care. The state's largest human needs advocacy organization, the Human Needs Coordinating Council, which Tyrrell co-chairs, became active. Letters went to the state's congressional delegation, to the New Mexico Department of Human Services and to HCFA. Various reports indicated high administrative costs for Salud and validated many consumer and provider concerns. Coalition for Effective Mental Health Care members appeared before a joint legislative committee, raising awareness. Yet problems continued, and it became increasingly difficult for providers to survive. Practitioners began to leave New Mexico. In the spring of 2000, the groups stepped up advocacy and appealed to the congressional delegation, knowing that in the summer of 2000 HCFA would be in position to extend New Mexico's waiver to allow Salud to continue for two more years. Things began to move rapidly. Tyrrell called Sen. Jeff Bingaman's office, then flew to Washington to meet with him, a contact that proved crucial. Bingaman asked HCFA to conduct a site visit, and one occurred in May, although advocates didn't feel the site visit team spent much time with consumers and providers and didn't adequately document the problems with Salud. The Bazelon Center for Mental Health Law in Washington complained about low usage rates for those eligible for services. Bingaman held a hearing on shifting of costs to the criminal justice system. With the help of Bingaman and the state's congressional delegation, another HCFA site visit was arranged for September, with Tyrrell acting as coordinator in setting up the visit. On Sept. 7, a statewide "speak out" was held at the University of New Mexico, where HCFA heard compelling testimony from all those involved: advocates, practitioners, foster care providers, community-based providers, children's court judges, a group of bipartisan legislators, and others. Also, an ad hoc group then began frequent contact with the state's congressional delegation and HCFA, which was in a position to continue, modify or deny the state's request for a renewed waiver for Salud. HCFA granted the state a 90-day extension of the waiver. Then, because of the overwhelming evidence of cost shifting, lack of cost savings and deterioration of services, HCFA said the whole waiver to operate Salud would be denied unless the behavioral health portion was withdrawn. There was unanimity of the New Mexico congressional delegation, including Rep. Heather Wilson (R), former secretary of the state Department of Children, Youth and Families, that there would be no opposition if the whole state waiver were denied. With no options, the state withdrew the mental health portion of its waiver application. The state was given 90 days to convert the behavioral health portions of Salud into a fee-for-service system. NASW and its fellow advocacy organizations agreed to sit down with the state and plan a behavioral health system that controls cost, but also one that puts the needs of consumers first, one in which patients aren't dropped to a lower level of care despite professional recommendations, and one that has ongoing consumer and provider input, said Tyrrell. "It is not a time to be celebrating," said Tyrrell. "Now there is an opportunity for us, including the Department of Human Services, to come up with a good health plan for Medicaid recipients." Much of the success in banishing Salud from the state's behavioral health system "has been NASW's active involvement and leadership in these coalitions," said Tyrrell. Back to NASW NEWS Contents
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