In their column in this issue of Psychiatric Services, Willging and Semansky (1) describe proposed changes to New Mexico's behavioral health care system. New Mexico's initiative is a unique approach to addressing the fragmentation of behavioral health care services and may serve as a model for addressing this issue in other states (2).
An analysis of the gap between the need for and provision of behavioral health services in New Mexico (3), completed in 2002, and the report of the President's New Freedom Commission (4), released in July 2003, identified fragmentation as one of the most critical issues facing behavioral health services in New Mexico and throughout the United States. Because multiple funding streams and multiple departments are involved, mental health and substance abuse services for children and adults are often disconnected and confusing for consumers, their families, and providers. New Mexico has duplicative administrative structures, multiple definitions for identical services, varying outcome and data requirements, confusing authorization and billing processes, inconsistent service delivery approaches, and inadequate mechanisms for quality oversight.
The New Freedom Commission called on the federal government and the states to conduct comprehensive planning to address this fragmentation. New Mexico is one of the first states to attempt such a comprehensive approach, not only to planning but to redesigning the financing and oversight of services funded, provided, or managed by 15 state departments.
New Mexico's Human Services Department contracts with three statewide Medicaid managed care organizations that serve children and adolescents and, to some extent, Medicaid-eligible adults. The Medicaid fee-for-service system has a utilization review process that is inconsistent with the processes used by the managed care organizations. Adults who are not covered by Medicaid are served through five regional care coordination organizations under contract to the Department of Health. Children and adolescents who are not eligible for Medicaid are served by providers who contract directly with the Department of Children, Youth, and Families.
Adults who have behavioral health care needs that affect their parole are served by programs funded directly by the Department of Corrections. Counties receive funding from the Department of Finance and Administration for treatment of persons who are convicted of driving while under the influence of drugs or alcohol. The Department of Transportation funds programs for prevention of driving while intoxicated. The Department of Health's office of school health works with school districts to bring health and behavioral health services to children and adolescents in schools. Vocational rehabilitation is the responsibility of the Department of Public Education, and jobs are the responsibility of the Department of Labor. Housing for persons with low incomes is addressed by the Mortgage Finance Authority, a quasi-governmental organization whose board is chaired by the Lieutenant Governor.
In September 2003 New Mexico's Governor, Bill Richardson, asked these entities and his health policy coordinator to collaborate on funding, services, and structures for state and federally funded behavioral health services in New Mexico (5). Legislation that created this Purchasing Collaborative became law in May 2004. Although the promise of this approach is clear, it is a huge undertaking to bring so many departments together to jointly procure a single statewide entity responsible for all behavioral health services and all mental health and substance abuse dollars. Achieving this goal means undoing or eliminating current administrative infrastructures at the state and regional levels, which will help reduce administrative costs.
Designing the requirements for and interdepartmental oversight of a single statewide entity and determining the appropriate role and shape of local community input and ownership are daunting tasks. Volunteer local systems of care will include providers, community health improvement councils, local councils for services for persons who drive while intoxicated, jails, schools, local elected officials, the faith community, tribal representatives, and consumers and their families. These systems will be responsible for local planning and identification of service gaps, providing input on the quality of service delivery at the local level, and creating intersystem referral and collaboration mechanisms to mirror the state collaborative effort in local communities.
Since the mid-1990s, New Mexico's history of designing and implementing major changes in the behavioral health system among departments and within the Medicaid system has been particularly troubling. Medicaid behavioral health services were carved into medical managed care organizations statewide over the objections of stakeholders. A separate regional structure for non-Medicaid services for adults was developed. Non-Medicaid services for children and adolescents and for adults leaving prisons were contracted directly without use of an intermediary. Ironically, previous decisions to integrate behavioral health and medical services within Medicaid led to increasing problems of fragmentation among behavioral health services funded by Medicaid and those funded by other sources and other agencies.
Each time systems were designed and changed, transitions were associated with confusion and start-up costs for providers as well as difficulties for consumers, consumers' families, and other systems that were required to interface with behavioral health providers and service recipients. New Mexico does not want to repeat mistakes of the past. It will be difficult to take behavioral health services out of the current Medicaid managed care organizations, in which pharmacy and transportation and care coordination services and activities are intertwined with health care services. Eliminating the regional care coordination system, developing local systems of care, selecting one statewide entity for the management of behavioral health dollars, and then making the transition to this entity will be associated with disruption. Moving contracts that have been entered into by multiple state departments to a single statewide entity will require careful consideration of the special requirements and needs of each population served. Asking local communities to organize into local systems of care that address all mental health and substance abuse prevention and treatment issues will be challenging.
To accomplish all this, New Mexico will proceed in phases. Planning and transition will take place before July 1, 2005. Phase One will encompass the one-year period beginning July 1, 2005, when the statewide entity begins operating. The goals for Phase One are to achieve continuing transition and to ensure that services are delivered, providers are paid, and required data are collected while system changes for Phase Two are being planned for. Phase Two will take place over a two-year period and will involve work on service and system changes and on improving results in consumer and family outcomes and system performance. Phase Three will be a time during which the system is mature, performance and outcome expectations are being met, and the state can concentrate on improving quality and increasing resources.
A significant transition planning process has begun, which will include activities before and during Phase One to ensure that issues pertaining to the consumer, the consumer's family, the provider, and staff are addressed. This transition process will allow New Mexico to both plan changes and make adjustments over time (6).
As the process began, the most immediate issue was to determine the structure by which multiple state agencies would work together and how these agencies would jointly procure one statewide entity to administer and manage a single coordinated system of behavioral health care. An interdepartmental staff work group led by New Mexico's Department of Human Services began meeting weekly and produced a concept paper for review and comment by the public (7). Governor Richardson named a behavioral health manager to coordinate this interdepartmental process (8).
The Purchasing Collaborative met for the first time on June 11, 2004. The meeting was co-chaired by the secretaries of the Department of Health and the Human Services Department. During that meeting, the Collaborative approved a memorandum of understanding governing how it will operate and make decisions. A single boilerplate legal contract for the statewide entity has been drafted, as has an implementation plan that will form the basis of a Request for Proposals, which was made available for public comment in July 2004. The final Request for Proposals will be released no later than the fall of 2004 so that the successful applicant can be selected and begin transitions in early 2005 to coincide with the new Medicaid managed care organization contracts that must be in place by July 1, 2005.
Early in the process, a group of advisors representing consumers, their families, advocates, providers, primary care physicians, tribes, and other stakeholders was selected to help the staff work group develop the ideas for the public concept paper (7). Staff conducted several public forums and established a Web site (www.state.nm.us/hsd/bhdwg) and an e-mail address (firstname.lastname@example.org) to facilitate public comment on the process and on written materials as they are developed. The Collaborative meetings themselves are open to the public, and the agenda for each meeting will include time for public comment. In addition, the new law created a single behavioral health planning council to advise the Collaborative and provide the framework for any advisory process pertaining to mental health or substance abuse issues in the state. A significant number of interested stakeholders have taken advantage of these input mechanisms.
In addition to the timing of the planning process, Willging and Semansky (1) have identified the nature of the contract with the statewide entity, the comprehensiveness of the benefit package, program evaluation activities, and safety net infrastructure as issues that must be addressed. All these issues are being considered as the design process unfolds (7). Because the statewide entity's contract will involve different kinds of funding mechanisms, different financial mechanisms will be used, including at-risk capitation funding, program funding, and possibly service units or population-based funding.
Changing the model of purchasing services will not make up for an inadequate benefit package, add new money to an underfunded system, or ensure that evidence-based practices are used by behavioral health practitioners. However, the process has already helped agencies identify areas in which funds could be used differently to maximize limited resources as well as opportunities for joint funding proposals to increase available resources for planning, services, and evaluation.
Structural reforms change the nature of the system but do not necessarily change the kinds of services delivered or the amount of funding available. These variables must be addressed regardless of the structure for financing and managing services. We believe that a single integrated system, working toward common goals and outcomes, will serve as a stronger base for advocating for additional resources and a more adequate benefit package in the years to come. We also believe that a streamlined structure will provide the environment in which evidence-based practices and consumer- and family-driven services can flourish, be nurtured, and thrive. This structure will form the groundwork for the recovery and resilience we are seeking for persons with serious mental illness, emotional disturbance, or addictive disorders and for their families.
Ms. Hyde is secretary of the Human Services Department for the State of New Mexico, P.O. Box 2348, Santa Fe, New Mexico 87504-2348 (e-mail, email@example.com). Howard H. Goldman, M.D., Ph.D., is editor of this column.