“System stuff” is blamed for many of NM’s problems

Copyright © 2022 Albuquerque Magazine

When asked about the state’s behavioral health care problems, many pointed to Governor Susana Martinez’s 2013 review that shut down 15 providers — permanently.

But those who have been around for long enough say that by then, the system had already experienced its fair share of ups and downs – mostly downturns – riddled with tension and instability.

“We had a lot of problems before that happened,” Thomas Sims, former regional director of value options, told the newspaper.

Rodney MacNeice, executive director of government affairs at the University of New Mexico Hospital, called many of the issues “systemic things.”

“Most people don’t even know that all this stuff was going on, in the background, unless you’re doing this work,” he said.

Sims said the biggest upheaval was prompted by Medicaid’s budget overruns in the 1990s.

He said the state often goes beyond its budget and, as a potential solution, has decided to turn to several managed care companies to run the Medicaid health system.

Sims said the complexities of the system led Governor Bill Richardson to put behavioral health funding under one entity, giving value options a four-year contract in 2005.

McNease said this caused a headache for providers who had to switch to the new architecture within the value options.

At about that time, Sims said, Pamela Hyde, then the secretary of state in the Department of Human Services, was pushing to spend more on community treatment and less on middle levels of care. For example, instead of putting a Raton teen in residential treatment in Albuquerque, build an outpatient system in Raton where they can easily get services from their home.

“She was trying to do something really well and she has research behind it…I think it needs time and stability,” Sims said.

It was not done gradually, he said, in a way that gave time for those community services to build up and occurred primarily in the big cities, such as Albuquerque.

Sims said the change was “very asymmetric” and that the value choices were to put the plan into action. But McNease said these community-based providers have not been fully realized.

At the time, Sims was working at Value Options.

“Value options got off to a bad start, claims weren’t paying and things were a mess. Two years later, the situation had improved a lot. By then, state-company relations had “deteriorated.”

As a result, Sims said the state decided not to renew its contract with Value Options and awarded another entity, Optum Health, a five-year contract in 2009. He immediately said there were problems; Complaints about claims and contracting.

“What they also want are smooth transitions…every system says ‘We’re going to have a smooth transition.'” And I roll my eyes at it and say it’s impossible. “There are a lot of loopholes and things going on,” Sims said.

He said each company has different systems for claim reimbursement, contracting and insurance benefits. Each change caused turbulence and instability, allowing no kind of baseline or way to measure progress.

Then, in 2013, the Martinez administration referred 15 behavioral health providers for investigation by then-Attorney General Gary King, alleging potential fraudulent billing. McNease said the audit created more system disruption and halted Medicaid funding for providers, some of which were community-based and never recovered.

He said the state brought in providers from Arizona but they only stayed a few years, due to low repayments. In the end, the state created the first version of the Centennial Care for the Medicaid system, a system that we’ve had somewhat of since then.

In 2016, Attorney General Hector Balderas had acquitted the last 15 closed providers after he found no evidence of fraud and described the overall situation as “unfortunate”. Valderas said investigations identified $1.16 million in exaggerated bills, versus the $36 million management had initially claimed.

At the time, a spokesperson for the Department of Human Services doubled down, saying, “Balderas’ decision to allow these agencies to get rid of the smell of bad policies and the shortcomings of the people who rely on Medicaid the most.”

Sims laments the way things went in the past, but believes that all is not lost.

He said: “It is possible to change the regime and should not be hostile and political this and that.” “It really doesn’t have to be like that and I hope the country gets through a lot of that.”

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