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September 1, 2007
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Questioning a ‘rosy’ view of New Mexico's system

The article “A New System for New Mexico” in the June issue provided a general overview of changes under way in New Mexico's behavioral healthcare system. The “Braided Funding” system, developed during many years of planning by a broad cross-section of stakeholders, has indeed combined a bewildering array of funding streams into a single source that metes out reimbursement for virtually all publicly funded behavioral health services.

Perhaps due to their distance from the front lines of the system in transformation, the authors (the CEO and a marketing specialist at ValueOptions) presented a rather one-sided view of the process. Since the innovative aspects of the process have drawn national attention, it is fair and appropriate that additional perspectives be presented.

For example, the authors' anecdote about the child referred by ValueOptions to additional services to complement individual therapy rings quite true. In another case, an adolescent girl presented herself to a residential treatment center (RTC) and reported suicidal feelings. The service provider, after conducting an assessment that confirmed suicidal risk, requested approval for residential admission. Yet ValueOptions denied the request.

The girl ended up acting on her feelings by taking an overdose of medication. Fortunately, the attempt at ending her life was unsuccessful, and she was admitted to a different facility for acute psychiatric care—more intensive (and expensive) than she had originally requested. Meanwhile, the RTC had appealed ValueOptions' denial of services. Even after the suicide attempt, ValueOptions upheld its original denial.

The article cites numerous opportunities for public input into the multilevel structure of the Behavioral Health Purchasing Collaborative. However, participants have many questions about the practical effectiveness of that dialogue. For example, the sequence of events described above occurred in context of a precipitous change in ValueOptions' practices for approving RTC care. The unilateral change surprised clients and providers, despite the many forums in which ValueOptions' representatives participated.

Furthermore, the Collaborative's monthly meetings are held in the state capitol—an inconvenient location for nearly eve-rybody—and generally allow only 15 to 30 minutes of public comment near the end of a three- or four-hour agenda. Public comments and recommendations are received politely but without reply by Collaborative members, and there has been scant evidence of substantive response as a reward for a daylong trek to the center of power. Similarly, members of Local Collaboratives frequently express frustration that they feel their voices are not heard at the level at which major decisions are made.

The article omits mention of ValueOptions' January proposal to slash funding of community-based services not covered by Medicaid. The Collaborative endorsed the proposal, but a subsequent lawsuit resulted in the restoration of those services pending resolution of related legal issues. (Legal action is still pending as of this writing. The lawsuit was filed by an attorney who is a member of the Steering Committee of the Local Collaborative of which I am a member; however, neither I nor the Local Collaborative is a party to the suit.).

The “simplified” billing system has been plagued by a series of glitches that has resulted in payment delays of up to six months or more. The deadly combination of reduced approvals and delayed payments has been cited as a major reason why some of the state's most respected providers have gone out of business or closed services.

ValueOptions does indeed provide care coordinators to assist clients with navigating the system, but their value is somewhat limited when the services themselves are shrinking. Cost-containment—a subtext of every conversation—remains elusive. A $15 million appropriation by the state legislature in February—designed to offset ValueOptions' January cuts—was followed by the Collaborative's approval of a 3% increase in administrative costs and profit for ValueOptions.

In summary, the jury is still out regarding New Mexico's bold experiment. While high-level discussions weigh ideas on one hand and budgets on the other, families and communities continue to struggle with the devastating effects of mental illness and substance abuse. According to the National Alliance on Mental Illness, New Mexico spends less per capita on behavioral health than any other state. Clients who rely on behavioral health services as a lifeline—and those of us who look those clients in the eye and deliver the news about denied services—may have a difficult time sharing the rosy view painted by ValueOptions.

Richard Malcolm, LISW