“PSYCHOLOGIST INVOLVEMENT WITH MEDICAID:  Servicing the Poor and Disenfranchised in New Mexico While Weathering Change” by Ricardo Gonzales, PhD

Medicaid Provider Survey Findings: In January 2010 I asked the NMPA membership to complete a Medicaid Provider survey to better understand psychologists’ involvement in this system of care.  We have attached a link to the survey results, (click on survey link).  You can access these results and their details by clicking on this link that has been set up as a Power Point presentation.   Thirty three providers responded to this survey.  At the time of the survey there were a total of 204 paid NMPA members indicating that approximately 16% of the membership completed the survey.  In general, the results indicate that 70% of the providers surveyed see 10% or less of Medicaid clients on their case load.  This percentage is considered “Typical” based on survey responses indicating that at least for the last three years (66%) of providers saw this percentage of Medicaid clients on their case load. 

Particularly noteworthy in these findings were that “inadequate pay” (56%) and payment delays prompted by administrative paperwork (52%) keep providers form seeing more Medicaid clients.  Providers saw as inherent problems in the Medicaid system the following:    1) the system does not pay adequately for psychological services (67%); 2) state contractor changes prompt numerous system changes in administrative requirements (50%); and 3) the Medicaid system poorly coordinates both the medical and psychiatric/psychological care of those with dual disorders (42%).  While 40% of those surveyed indicated they do not see Medicaid clients on their case load, these same inherent factors (noted above) contributed most to reasons for not participating in the Medicaid system. 

This article seeks to highlight the changes that the Medicaid system has gone through starting with the state’s efforts at Medicaid reform in 1997.  I hope this review provides a better understanding of the Medicaid behavioral health system as well as an understanding of its systemic problems.  My hope is that this understanding will also offer psychologists glimpses as to where their services are needed most in this system of care.  To avoid sounding too simplistic, or to avoid giving the reader the impression that the Medicaid mental health system is fraught with problems, I would recommend reading the articles in their entirety that I have attached as a link.  I briefly summarize these articles below.  They are the works of the Behavioral Health Research Center of the Southwest and Pacific Institute for Research and Evaluation.  Since the start of Medicaid Reform in 1997 the above two research groups have sought to monitor the progress of Reform.  I would consider these articles key to understanding the impact of behavioral health Medicaid Reform particularly from 2003 through 2009.   After the summaries below I offer some suggestions psychologists might consider in their approach to improving their ability to work within this system of care.     

NM Medicaid History:

Since the start of Medicaid Managed Care (MMC) in 1997 our Medicaid system (to say the least) has been in a state of flux.  Before the state instituted MMC Medicaid operated under a Fee-for-Service arrangement in which psychologists practiced independently billing the State for the Medicaid services they provided.   With the advent of MMC – Medicaid restrictions and encumbrances to the independent practice of psychology eventually led to fewer and fewer psychologist’s involvement seeing Medicaid clients.  The problems encountered by psychologists at the time of MMC, however, were pronounced, as well, among most provider groups in the state (Waitzkin, 2002). 

In 1997 three managed care companies were tasked with the administration of Medicaid mental health services in New Mexico.  Shortly after the start of MMC complaints from provider groups, agencies, psychiatric hospitals (particularly child) servicing this population, and the community at large, led to the brief closure of the State Medicaid system by CMS (the Centers for Medicare and Medicaid Services) through the involvement of the Bazelon Center for Mental Health Law.  This event centered on the concerns over psychiatric hospital closures (particularly child), closures of behavioral health programs for the poor (considered safety-net institutions in rural areas), coupled with provider groups (particularly child psychiatry/psychology) leaving the state over administrative and payment barriers.  During this time many of the most vulnerable Medicaid patient groups (particularly children, chronically mentally ill) found their way into the justice system instead of receiving appropriate behavioral health treatment.  The times in New Mexico were unsettling as well given the extremely high violence mortality death rates (Willging, et al. 2003).

Despite the above noted outside efforts to correct the system, concerns about MMC persisted.  Particular concerns were aired about the financial impact of behavioral health services of three managed care companies each with varying administrative requirements and billing processes.  These administrative burdens eventually became barriers leading to payment problems which in turn contributed to high turn-over among clinicians and the closure of approximately 60 facilities during this first reform period (1997-2003).  During this time MMC did little to reduce the service barriers or to improve quality of care among ethnic groups (Willging. et al. 2004).

Aware of the problems inherent with the above Medicaid system of delivery, the State in 2003 decided to again revamp this behavioral health system.  Based on the President’s New Freedom Commission on Mental Health*, State reform architects sought to create a system based on cost effectiveness and performance, where services would be recovery oriented, consumer driven and responsive to diverse community needs (Hyde, 2004).  This system was designed with the intention of ensuring quality based services that are as well evidenced-based, and culturally competent….consistent with the “Commission’s challenge” to reduce health disparities. 

In 2003 the NM Interagency Behavioral Health Purchasing Collaborative (PC) was developed to over-see the implementation of these reform plans.  The PC (composed of 15 State agencies) sought to consolidate the State’s BH funding and to better manage these funds under a unified set of administrative practices (Willging, et al 2009).  Then in 2005 (through a competitive bidding process) the State established a contract with a single for-profit private corporation (ValueOptions) to collaborate with State officials to create the infrastructure for the proposed Medicaid system of care.  As part of this ambitious plan Local Collaboratives around the State (now 15 situated in the State’s legal districts, including Native American governments) were developed to provide advice to the PC regarding enhancement of care and quality of life for consumers and families (Kano, et al, 2009).

Research Findings:

Semansky, et al (2009) has studied the State’s adult Medicaid mental health infrastructure comparing both the urban and rural areas following Medicaid Reform beginning in 2005.  His article reports on the differences in infrastructure, financial status, availability of services and characteristics across mental health agencies.  In his article he distinguishes the differences between Community Mental Health Centers (CMHCs) and non-CMHCs, the difference between non-profit/public agencies and for-profit agencies, and differences between rural and urban agencies in the aforementioned areas.   

Semansky initially reviews literature indicating that mental health infrastructure is generally more fragile in rural than in urban areas.  This literature also indicates that non-profit agencies are more likely than for-profit agencies to employ clinicians requiring supervision, and to rely on public/indigent funding for service delivery more so than the use of Medicaid funding.  These differences noted in the literature suggest that initiatives using managed care may be more appropriate in urban than rural areas. 

His key findings included the following:  1) There were more CMHCs/non-profit agencies in rural than urban areas - the percentage of CMHCs in rural vs urban areas was (52% vs 35%), and the percentage of Non-profit agencies in rural vs urban areas was (91% vs 41%); 2) CMHCs received a significantly higher percentage of revenue both from Reform funding (Medicaid/VONM) and other Public sources than non-CMHC’s, though there were no other significant differences in the use of these revenues sources between rural/urban and non-profit/for-profit agencies;  3) CMHCs/non-profit agencies employed significantly less independently licensed clinical staff than non-CMHCs and for-profit agencies; 4) With reform,  for-profit agencies were more likely to increase clinical staff while non-profit agencies were more likely to reduce administrative staff; 5) CMHCs were more likely than other agencies to experience a declining financial situation; and finally 6) CMHCs, non-profit, and rural agencies were more likely to offer a more comprehensive array of services (critical to serving the Seriously Mentally Ill) than non-CMHCs, for-profit and urban agencies.  

Clearly the impact of these findings indicated that CMHCs/non-profit agencies employed less independently licensed clinical staff; with reform they were more likely to experience a declining financial situation and to consequently reduce administrative staff, but as well were more likely to offer a greater array of clinical services.

Willging et al., (2009) and Watson, et al. (2009) completed three systematic reviews of behavioral health reform starting in the spring of 2006 (Phase I, Initial Transition) then in the fall 2007 (Phase II), and finally in the spring of 2009, see linka below.  The sample included 14 Safety-Net Institution (SNIs) in 3 urban and 3 rural areas comprising 6 Community Mental Health Centers (CMHCs), 3 substance abuse treatment centers, 2 agencies for the homeless, and 3 small group practices.  A summary of the findings below are noteworthy.    

The initial transition was seen as extremely stressful.  Safety-net institutions (SNIs) employ clinical staff most of whom have less than a graduate education (i.e., 30% some college, 16% completed college, <40% some graduate education).  These staff represented a stressed out workforce unable to keep up with clinical paperwork constraints and the challenges of patients in crisis or with complicated problems.  These SNIs were not able to fill positions or retain qualified staff or provide for appropriate supervision.  The majority of these staff had poor knowledge of Evidence Based Practices and very limited understanding of cultural competence. 

Emergent themes from all three Phases of the data analyses of reviews included the following:  1) administrative demands were significant (e.g., there was a proliferation of paperwork/electronic and hardcopy, coupled with the need for administrative staff to process paperwork and to resubmit claims, which in turn led to payment delays, higher overhead costs, and financial difficulties – 60% of agencies indicated reform had a “poor” impact on agency administrative costs; Comprehensive Community Support Services (CCSS) contributed to growth in administrative costs not offset by intended reduction in duplicative reporting requirements); 2) financial stresses abounded (e.g., financial problems were particularly pronounced in both rural and economically depressed regions leading to fewer resources/supplies, insufficient funding for cost-of-living raises, paycheck or workweek reduction, decisions not to fill vacated positions; 3) there were CCSS transition concerns (e.g., CCSS replaced case-management services but most SNIs reported problems making CCSS financially viable, SNIs lost revenue because CCSS must be provided in vivo, yet transportation time/costs for this service is not reimbursed; there were difficulties with utilization tracking requirements;  4) there were Fee-for-Service (FFS) concerns/troubles (e.g., SNIs report a hard time adjusting financially without the “1/12^th drawdown” to ensure a steady stream of funding and there were concerns that funding through FFS vary from month-to-month making it difficult to plan for the future, finally,  5) there were Statewide Entity (SE) transition difficulties, (e.g., transition was viewed by all personnel as a major stressor with resistance to reinventing the wheel, there were unanticipated cost and labor demands associated with registering clients into the new SE enrollment system, it was hard finding SE staff with appropriate knowledge/authority to respond to inquiries, problems with “face time” and “follow through by central office SE staff, and frequent SE staff turn over compromising stable working relations).

Impressions About the Medicaid System:

The above scenarios of other provider group experiences with Medicaid Reform is not all too different from the concerns that psychologists air in our survey results above.   One may be quick to respond with complaint that the SE (the State Wide Entity) which was Value- Options during the period of review (Reform 2005 – 2009) is culprit to these Reform problems.  However, one is able to gather glimpses of where these problems begin taking a closer look at the State’s history with Reform.  A good example is looking at the plight of CMHCs particularly in rural areas of New Mexico.  For example – the Health and Human Services Department licenses CHMCs.  CMHC’s are required (based on law) to provide a range of services, and yet they are allowed to hire a staffing pattern that is minimally skilled.  The state implements a Fee-for-Service plan with all agencies cutting off from these agencies what is called the “1/12^th draw-down”.  This draw-down is a percentage of Medicaid funding that historically has been used by the CMHC, and is given as an advance.  The CMHC must now function in a Fee-for-Service arrangement without this “draw-down” or a staffing pattern that can adequately bill for services. 

Another example is the move to Comprehensive Community Support Services (CCSS – the state calls bundled services to promote independent living), eliminating case-management as a billable Medicaid service.  Case-management services for many years were considered a key function of CMHCs.   However, the move to CCSS involved little training.  60% of CCSS services must be provided in the home, and yet the state does not pay for travel/time getting to these points of contact.  Early on in the CCSS program, providers billed for this service.  Apparently now because of excessive billing the state has implemented prior authorizations and retrospective reviews of these services (just five months after this CCSS implementation).  Probably most glaring of State’s mistakes involves awarding the four-year behavioral health contract (though a competitive bidding process) to OptumHealth in July 2009, but then rescinding the contact in November 2009, over billing and payment problems with OptumHealth.     

Willging, et al. (2010) in a very recent article highlights “systemic failures that have affected the State’s attempt to move ahead with Reform.”  The 1^st of these, “System complexity and implementation” focuses on the failures of the PC (the Interagency Behavioral Health Purchasing Collaborative/PC) to effectively reign in all 15 agencies as well as to involve providers/clients before the change process.  While this is considered a top-down model it is contrary to the PC plans to first involve the community.   The 2^nd, “ Insufficient information technology systems,” faults the State for the on-going problems in this area … most glaring involving those with OptumHealth (OH), but also faults the State for not knowing in advance that the IT system created by ValueOptions (VO), which was developed by them and became fully functioning after two years,  is “proprietary” (owned by VO).  The 3^rd, “Lack of evaluation and accountability,” centers on the PC not instituting an early warning system to rapidly identify delivery system problems – thus creating a scenario where the State and managed care contractors are not open and responsive to complaints from providers, clients, or advocates regarding reforms negative impact on service delivery infrastructure.  Finally the 4^th, “Inadequate attention to the rural safety net,” considers the state’s standard approach to program implementation despite the numerous disadvantages that providers/agencies face in rural/frontier environments when compared with urban environments.

These reviews give some food for thought as to why psychologists doing Medicaid/and or refusing to do Medicaid struggle with their involvement in this system of care.  The State’s plan in 2003 (with the creation of the New Mexico Interagency Behavioral Health Purchasing Collaborative/PC) was to develop a system based on cost effectiveness and performance, by which services provided would be recovery oriented, consumer driven and responsive to diverse community needs, as well as being evidence-based and culturally competent.  The research reviews by the Willging group at BHRCS point to serious limitations in the progress of implementing these State plans.  Clearly the issue of economics has taken precedence in these plans, without State sensitivity to the financial impact of these changes on agencies that deliver BH services, failing further to market forces to improve behavioral health access by easing service billing restrictions/requirements that impact on agencies financially (particularly in rural areas), failing as well to garner the input of consumers and providers in these change plans.   

Recommendations:

1) “Weathering Change” as the title of our article indicates sometimes requires the need for involvement.  In this instance I believe that advocating for the needs of our organization is clearly important.  This is particularly so when working within a behavioral health care context.  With the passage of Health Care Reform the numbers that will qualify for Medicaid will soar to include those in the 133% - 400% poverty range.  The health care reform movement in our country has been one of economics.  If the State’s plan is also one of economics (our article at least suggests this) – then advocacy efforts are key.  Advocacy efforts would seek not only prevent further reductions in current payment schedules but also seek to improve payment schedules, as well as improve upon the payment road blocks noted in our survey that are so often encountered by providers working in this environment.

As part of this plan we invite you to join us in advocating for psychological services.  Our plan entails on-going consultations with the PC (the State’s Interagency Behavioral Health Purchasing Collaborative) as well as the legislative branch of the State.

2) Our survey identified Primary-care service settings (both for adults and children) as the most suitable Medicaid work environments (based on our training, system locale and ease).  The laws governing Health Care reform require the integration of psychological services in these environments.  Our survey indicates, however, that few psychologists work in these environments.  Advocacy efforts like those noted above with the PC and legislative bodies would include support for the provision of these services, and the establishment of regulations for these provisions. 

Another form of advocacy might simply involve “knocking on the doors” of these Primary-care setting and selling yourself as a psychologist for work. Our survey indicated that psychologists were not aware that these environments are any different from other behavioral health agencies.  Consequently one may not have considered these as viable employment settings. 

3) The research I have reviewed above indicates that Safety-net Institutions are staffed with minimally skilled providers.  The State’s goal with these institutions/agencies is to deliver evidence-based practices that are culturally competent.  Advocacy efforts would include the need for supervision and consultation by psychologists in these environments given that psychologists are best skilled for these tasks.

As noted above – selling yourself (individually) as a psychologist to work in these environments would be just as effective.  Our consultations with PE and legislative branches will include these recommendations.

4) Finally, the key to above advocacy efforts may lie in the supports you can muster at the Local Collaborative level.  The Local Collaboratives (in your district) meet regularly to find ways to address service provision through a variety of venues.  They are supposed to be the PC key to creating initiatives and change at a local level.  Getting involved in your local collaborative to support their endeavors and to sell your skills as a psychologist is an important approach to helping others become more aware of the importance of psychological services.

REFERENCES (with attachments):

Kano, M., Willging, C., Rylko-Bauer, B., 2009. “Community Participation in New Mexico’s Behavioral Health Care Reform.” Medical Anthropology Quarterly. 23(3): 277-297.  ..…….. Click Kano.  

Semansky, R., Hodgkin, D., Willging, C., 2009. “Preparing for a Public Mental Health Reform in New Mexico: The Experience of Agencies in a Rural State.” Behavioral Health Research Center of the Southwest, Albuquerque, NM. NIMH Grant # R01 MH76084 (Correspondence concerning this article should be addressed to R.Semansky, MPP, MA, Albuquerque, New Mexico 505-244-3408, email rsemansky@bhrcs.org).  ……..Click Semansky, Semansky Tables.

Watson, M., Willging, C., Semansky, R., Kano, M., 2009. “Safety-net Institutions Under the New Mexico Behavioral Health Reform: A Longitudinal Ethnographic Perspective.  Prepared for the NM Legislature, Health and Human Services Subcommittee. Behavioral Health Research Center of the Southwest, Albuquerque, New Mexico (Correspondence Concerning this presentation should be addressed to C. Willging, Ph.D., Albuquerque, NM 505-765-2328, email cwillging@bhrcs.org).  …………Click Watson.

Willging, C., Waitzkin, H., Lamphere, L., 2009. “Transforming Administrative and Clinical Practice in a Public Behavioral Health System: An Ethnographic Assessment of the Context of Change.” Journal of Health Care for the Poor and Underserved. 20: 866-883.  ……….Click Willging.

Willging, C., Semansky, R., 2010. “States That Fail to Learn from The Past Repeat It: The New Mexico Behavioral Health Reform.”  Submitted to Psychiatric Services, February 2010. ………….Click Willging2.  

Willging, C., Semansky, R., Waitzkin, H., 2003. “Medicaid Managed Care Waiver: Organizing Input From Mental Health Consumers and Advocates. Psychiatric Services. 54(3): 289-291.  …………Click Willging3. 

REFERENCES:

Hyde, P.S., 2004. “State Mental Health Policy: A Unique Approach To Designing A Comprehensive Behavioral Health System in New Mexico.”  Psychiatric Services. 55(9): 983-985.

The President’s New Freedom Commission on Mental Health.  Achieving the Promise; Transforming Mental Health Care In America. Rockville, MD: Department of Health and Human Services, 2003.

Willging, C., Waitzkin, H., Nicdao, E., 2008. “Medicaid Managed Care for Mental Health Services: The Survival of Safety-net Institutions in Rural Settings.” Quarterly Health Research. 18(9): 1231-1246.

Waitkzin, H., Williams, R., Bock, J., 2002. “Safety-net Institutions Buffer the Impacts of Medicaid Managed Care: A Multi-Method Assessment in a Rural State.” American Journal of Public Health. 92(4): 598-610. 

Willging, C., Semansky, R., 2004. “Another Chance to Do It Right:  Redesigning Public Behavioral Health Care in New Mexico. ” Psychiatric Services. 55: 974-976.