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Land of (dis)enchantment

September 20, 2013
by Dennis Grantham, Editor-In-Chief
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New Mexico state flag

Amid my efforts to learn more about the unfolding situation in New Mexico, where a Medicaid freeze was imposed in late June due to “credible allegations of fraud” against a range of major behavioral health providers in the state, I came across a comment from a mental health professional.  Amid the upset, confusion, outrage, and applause that exploded in the wake of the freeze, this professional recommended the following:

“Let’s reserve judgment and self-righteous indignation … until the facts are known.

I wouldn’t be the first, or even the thousandth, to say that there are a lot of questions about how and why New Mexico’s Human Services Department initiated and handled this funding crisis. Though the overall number of providers involved is relatively small — 15 — the scope of the freeze was stunning, since these providers served more than 85 percent of the state’s 30,000 seriously mentally ill people. It’s a crisis that certainly disrupted and may yet decimate behavioral health services in that state.

In a story like this one, there is plenty to hear from those who believe that something is terribly wrong. First, of course, is the state’s HSD, which defends the freeze decision based on its findings of “credible allegations of fraud” and maintains that its actions are entirely “by the book.”  But there are many others as well:  

  • The 30,000 people battling serious mental illness whose services were disrupted.  
  • The CEOs, providers, and managers of the defunded agencies who in a number of cases were forcibly separated their life’s work.  
  • Those who worry about the ramifications of the freeze, a “transition” process that is forcing the restructuring of about a dozen of the 15 providers under state-appointed transition managers.
  • Those who fear the destruction of statewide culture of collaboration that, through years of effort, linked the state, behavioral health providers, and consumer-driven collaboratives in an energetic service transformation program.

The fact that all of these things are occurring without an official finding of provider fraud — according to a provision of the Affordable Care Act — is what seems most terribly wrong. How could this happen to 15 organizations at once?  What does this mean for us?  That’s what we’ve got to know.  For this reason, our coverage focuses on the clash of legal interpretations over the payment provisions of the Affordable Care Act and how these interpretations might shape the outcome of this story and more to come.  

Meanwhile, the larger questions of the story remain unanswered:  Will the “credible allegations of fraud” held by New Mexico will add up to the real thing? Did leaders we know, work with, or advocate with commit fraud or ask others to do so? Do states really have the power to halt your organization’s funding without notice and legally put CEOs or other agency leaders on the street?

New Mexico officials point to the law, point to their findings, and state a confident “Yes.” And, until all the facts of the case are known, that opinion is the only fact that matters.