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‘System things’ blamed for NM’s many problems

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Copyright © 2022 Albuquerque Journal

When asked about the state’s behavioral health care woes, many point to Gov. Susana Martinez’s 2013 audit that shut down 15 providers – most permanently.

But those who have been around long enough say that, by that time, the system had already seen its fair share of ups and downs – mostly downs – filled with tension and instability.

“We had a lot of problems before that happened,” Thomas Sims, former regional director of Value Options, told the Journal.

Rodney McNease, executive director of governmental affairs for University of New Mexico Hospital, called many of the issues “system things.”

“Most people just didn’t even know all these things were happening, in the background, unless you happen to be doing this work,” he said.

Sims said the biggest disruptions were spurred by Medicaid budget overruns in the 1990s.

He said the state was often going over its budget and, as a possible solution, decided to turn to several managed care companies to administer the Medicaid health system.

Sims said the system’s complexities led Gov. Bill Richardson to place behavioral health funding under one entity, giving Value Options a four-year contract in 2005.

McNease said this caused headaches for providers who had to switch over to the new construct under Value Options.

Sims said, around that time, then-Cabinet Secretary of the Human Services Department Pamela Hyde was pushing to spend more on community-based treatment and less on intermediate levels of care. For example, instead of putting a teen from Raton 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 good and she had research behind it … I think it needed time and stability,” Sims said.

He said it wasn’t done gradually in a way that gave time for those community-based services to build up and mainly happened in big cities, like Albuquerque.

Sims said the change was “very uneven” and Value Options was to put the plan in place. But McNease said those community-based providers never fully materialized.

At the time, Sims was working at Value Options.

“Value Options got off to a bad start, it was not paying claims and things were a mess. And after two years, the situation got a lot better,” he said. By then the relationships between the state and company “had deteriorated.”

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

“What they want, as well, is smooth transitions … Every system says ‘we’re going to have a seamless transition.’ And I kind of roll my eyes at that and say that’s impossible. There are too many glitches and things that happen,” Sims said.

He said each company has different systems in place for paying claims, contracting and insurance benefits. Each change brought disruption and instability, which doesn’t allow for any kind of baseline or way to measure progress.

Then, in 2013, Martinez’s administration referred 15 behavioral health providers for investigation by then Attorney General Gary King, alleging possible fraudulent billing. McNease said the audit created more system disruption and shut down Medicaid funding to the 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 reimbursement. Eventually the state created the first version of Centennial Care for the Medicaid system, which is more or less the system we’ve had ever since.

In 2016, Attorney General Hector Balderas had cleared the last of the 15 shuttered providers having found no evidence of fraud and called the overall situation “regrettable.” Balderas said the investigations identified $1.16 million in overbilling, as opposed to the $36 million the administration had initially alleged.

At the time, a spokesman for the Human Services Department doubled down, saying Balderas’ “decision to allow these agencies to get away scot-free reeks of bad politics and shortchanges the people who rely on Medicaid the most.”

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

“It is possible to change the system and it doesn’t have to be so adversarial and politically this and that,” he said. “It really doesn’t have to be and I hope the state is moving past a lot of that.”

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