Safety-Net Institutions Safety-Net Institutions Under the New Mexico Under the New Mexico

Behavioral Health Reform: A Behavioral Health Reform: A Longitudinal Ethnographic Longitudinal Ethnographic

Perspective Perspective Marnie Watson, Cathleen E. Marnie Watson, Cathleen E.

Willging, Rafael Semansky, Miria Willging, Rafael Semansky, Miria Kano, Kano,

and the NM-BASE Ethnography Teamand the NM-BASE Ethnography Team

October 14, 2009October 14, 2009

Prepared for the New Mexico Prepared for the New Mexico Legislature Health and Human Legislature Health and Human

Services Subcommittee Services Subcommittee

PurposePurpose

Provide an overview of major themes Provide an overview of major themes derived from ethnographic research derived from ethnographic research undertaken in behavioral health safety-undertaken in behavioral health safety-net institutions (SNIs) within the net institutions (SNIs) within the context of the New Mexico reform context of the New Mexico reform

A Few Words About A Few Words About LimitationsLimitations

This presentation focuses on a subset of This presentation focuses on a subset of adult-serving SNIs affected by the reform; adult-serving SNIs affected by the reform; it does not focus specifically on children’s it does not focus specifically on children’s behavioral health care behavioral health care

This work does not document the experiences This work does not document the experiences and perceptions of state policymakers, SE and perceptions of state policymakers, SE employees, and independent practitioners and employees, and independent practitioners and primary care providers who deliver a limited primary care providers who deliver a limited set of behavioral health services set of behavioral health services

The reform reflects a ten-year process; The reform reflects a ten-year process; here, we report only on select issues here, we report only on select issues affecting SNIs during the first four years affecting SNIs during the first four years of reform implementation of reform implementation

SampleSample 14 SNIs located in 3 urban and 3 rural areas, 14 SNIs located in 3 urban and 3 rural areas,

each selected for study due to their ethnic each selected for study due to their ethnic demographics; all provided services to adults demographics; all provided services to adults with serious mental illness and/or with severe with serious mental illness and/or with severe substance use disorder substance use disorder

Range of SNIs represented in the sample: Range of SNIs represented in the sample:

– Community mental health centers (6)Community mental health centers (6)

– Substance abuse treatment centers (3) Substance abuse treatment centers (3)

– Agencies specializing in outpatient services Agencies specializing in outpatient services for homeless adults with co-occurring for homeless adults with co-occurring disorders (2) disorders (2)

– Small group practices (3)Small group practices (3)

MethodsMethods

Data Collection

Phase 1Spring 2006

Phase IIFall 2007

Phase IIISpring 2009

Participant Observation

Structured Interviews

N = 189 N= 171 N = 160

Semi-Structured Interviews

N = 189 N= 171 N = 160

AnalysisAnalysis

Quantitative analysis of structured data Quantitative analysis of structured data (not reported here, but comparison of Phase (not reported here, but comparison of Phase I and Phase II data is available on request)I and Phase II data is available on request)

Line by line coding of semi-structured Line by line coding of semi-structured interview data with NVivointerview data with NVivo

Systematic review of written interview Systematic review of written interview reports, which were compiled immediately reports, which were compiled immediately after data collection after data collection

Write-up and cross-comparison of findings at Write-up and cross-comparison of findings at monthly team meetings and annual retreat monthly team meetings and annual retreat

Emergent ThemesEmergent Themes

Administrative Demands Administrative Demands

Financial Issues Financial Issues

Comprehensive Community Support Services Comprehensive Community Support Services (CCSS) Transition Issues(CCSS) Transition Issues

Fee-for-Service (FFS) Transition IssuesFee-for-Service (FFS) Transition Issues

Statewide Entity Transition Issues Statewide Entity Transition Issues

Administrative DemandsAdministrative Demands From Phase I through Phase III, SNI From Phase I through Phase III, SNI personnel consistently reported: personnel consistently reported:

– A proliferation of paperwork A proliferation of paperwork (electronic and hardcopy)(electronic and hardcopy)

– An increase in administrative staff to An increase in administrative staff to process paperworkprocess paperwork

– An increase in work to resubmit claims, An increase in work to resubmit claims, which led to payment delayswhich led to payment delays

These demands led to higher overhead These demands led to higher overhead costs and financial difficulties for the costs and financial difficulties for the majority of SNIsmajority of SNIs

Administrative DemandsAdministrative Demands Most SNI concerns focused on issues of Most SNI concerns focused on issues of accessibility: accessibility:

– Finding Statewide Entity (SE) staff with Finding Statewide Entity (SE) staff with appropriate knowledge and authority to respond appropriate knowledge and authority to respond to inquiries regarding administrative matters to inquiries regarding administrative matters

– Reported lack of “face time” with Reported lack of “face time” with andand “follow “follow through” by central office SE staff through” by central office SE staff

– Turnover within original SE compromised the Turnover within original SE compromised the formation of stable working relationships with formation of stable working relationships with key administrative personnel at all SNIskey administrative personnel at all SNIs

– While particularly acute during Phases I and While particularly acute during Phases I and II, concerns lingered in many SNIs in all II, concerns lingered in many SNIs in all phasesphases

Comparison with Survey Comparison with Survey ResultsResults

Two statewide telephone surveys with Two statewide telephone surveys with provider agencies serving adults with provider agencies serving adults with serious mental illness serious mental illness

Initial survey focused on 2005, Year I of Initial survey focused on 2005, Year I of reform; the second survey focused on 2008, reform; the second survey focused on 2008, Year III of reform Year III of reform

The surveys covered administrative issues, The surveys covered administrative issues, finances, and perceptions of reformfinances, and perceptions of reform

High response rates: 66 of 74 in 2005 High response rates: 66 of 74 in 2005 (89%) and 62 of 78 (79%) in 2008(89%) and 62 of 78 (79%) in 2008

Comparison with Survey Comparison with Survey ResultsResults

Here, we present responses to the question, Here, we present responses to the question, “How well has ValueOptions“How well has ValueOptions®® achieved the goal achieved the goal of reducing administrative costs for of reducing administrative costs for agencies?”agencies?”

– Thirty-seven percent of agencies reported Thirty-seven percent of agencies reported that the reform had a “fair” or “good” that the reform had a “fair” or “good” impact on reducing agency administrative impact on reducing agency administrative costs in 2008 compared with 25% in 2005costs in 2008 compared with 25% in 2005

– However, the dominant response for 60% of However, the dominant response for 60% of agencies continued to be that the reform agencies continued to be that the reform had a “poor” impact on agency had a “poor” impact on agency administrative costsadministrative costs

Comparison with Survey Comparison with Survey ResultsResults

Responses to other survey questions Responses to other survey questions suggest that adherence to shifting intake suggest that adherence to shifting intake and billing procedures and delivery of a and billing procedures and delivery of a new bundled service (CCSS) contributed to new bundled service (CCSS) contributed to the growth in administrative costs the growth in administrative costs

The increased costs were not offset by an The increased costs were not offset by an intended reduction of duplicative intended reduction of duplicative reporting requirements in publicly-funded reporting requirements in publicly-funded programsprograms

Survey findings correlate well with Survey findings correlate well with ethnographic dataethnographic data

Financial IssuesFinancial Issues

In general, financial problems for the In general, financial problems for the majority of SNIs increased from Phase I majority of SNIs increased from Phase I through Phase III through Phase III

Financial problems were particularly Financial problems were particularly pronounced for agencies in both rural and pronounced for agencies in both rural and economically-depressed regions, and were economically-depressed regions, and were exacerbated by the recession exacerbated by the recession

Working relationships between SNI Working relationships between SNI leadership, the state, and the SE appeared leadership, the state, and the SE appeared to be strained in those agencies to be strained in those agencies experiencing acute financial problemsexperiencing acute financial problems

Financial IssuesFinancial Issues Employee concerns regarding financial viability Employee concerns regarding financial viability (and thus job security) intensified in Phase II and (and thus job security) intensified in Phase II and continued throughout Phase III. Concerns fueled by:continued throughout Phase III. Concerns fueled by:

– Availability of fewer resources and supplies Availability of fewer resources and supplies

– Insufficient funding for annual cost-of-living Insufficient funding for annual cost-of-living raisesraises

– Paycheck or workweek reductionPaycheck or workweek reduction

– Personal loan to cover payrollPersonal loan to cover payroll

– Decision not to recruit for or fill vacated Decision not to recruit for or fill vacated positions positions

– Transition stress (i.e., to CCSS, FFS, and new Transition stress (i.e., to CCSS, FFS, and new SE) SE)

Financial IssuesFinancial Issues

In several SNIs, leadership during Phase In several SNIs, leadership during Phase II and III increasingly emphasized II and III increasingly emphasized provider productivity quotas to ensure provider productivity quotas to ensure billable hours, resulting in: billable hours, resulting in:

– Decreased time to devote to collective Decreased time to devote to collective activities that can build camaraderie activities that can build camaraderie (e.g., staffing, in-service training, (e.g., staffing, in-service training, holiday parties) holiday parties)

– Increased individual stress and burnout Increased individual stress and burnout

– Decreased overall employee moraleDecreased overall employee morale

CCSS Transition IssuesCCSS Transition Issues Replaced conventional case management; largely Replaced conventional case management; largely available for highest-needs consumersavailable for highest-needs consumers

A large part of CCSS must be provided A large part of CCSS must be provided in vivoin vivo

Transportation time/costs are not reimbursed***Transportation time/costs are not reimbursed***

Rural SNIs report lost revenue, as CCSS workers Rural SNIs report lost revenue, as CCSS workers travel to remote locations to meet with clientstravel to remote locations to meet with clients

Difficulties with utilization tracking Difficulties with utilization tracking requirementsrequirements

Most SNIs report problems making CCSS a Most SNIs report problems making CCSS a financially viable pursuit financially viable pursuit

FFS Transition IssuesFFS Transition Issues Despite a year-long effort on the part of Despite a year-long effort on the part of the state and the SE to prepare SNIs the state and the SE to prepare SNIs traditionally reliant on 1/12 drawdown for traditionally reliant on 1/12 drawdown for the transition to a FFS system, many SNIs the transition to a FFS system, many SNIs still report a hard time adjusting to FFSstill report a hard time adjusting to FFS

They claim that the 1/12 drawdown ensured a They claim that the 1/12 drawdown ensured a steady stream of funding, so they could plan steady stream of funding, so they could plan for the futurefor the future

They contend that funding through FFS can They contend that funding through FFS can vary considerably from month to month, which vary considerably from month to month, which can make it difficult to plan for the futurecan make it difficult to plan for the future

Statewide Entity Transition Statewide Entity Transition IssuesIssues

Latest transition viewed as a major Latest transition viewed as a major stressor by personnel in all SNIsstressor by personnel in all SNIs

Resistance to “reinventing the wheel” Resistance to “reinventing the wheel”

Unanticipated cost and labor demands Unanticipated cost and labor demands associated with registering clients into associated with registering clients into the new SE’s enrollment systemthe new SE’s enrollment system

Other Pertinent FindingsOther Pertinent Findings

SNIs, particularly those in urban areas, SNIs, particularly those in urban areas, have been able to bring up new services have been able to bring up new services under the reform (e.g., Mobile Crisis Units, under the reform (e.g., Mobile Crisis Units, Assertive Community Treatment) Assertive Community Treatment)

SNI personnel appreciate the increased SNI personnel appreciate the increased access to training and continuing education access to training and continuing education under the reform under the reform

SNI personnel are beginning to embrace the SNI personnel are beginning to embrace the notion of “recovery” among persons with notion of “recovery” among persons with serious mental illness, and are reorienting serious mental illness, and are reorienting their services to align with recovery models their services to align with recovery models versus the traditional medical model versus the traditional medical model

Other Pertinent FindingsOther Pertinent Findings

Peer providers positions are becoming Peer providers positions are becoming increasingly common within SNIs, increasingly common within SNIs, particularly in Phase III particularly in Phase III

Clients and families (whom we are also Clients and families (whom we are also interviewing over the three phases) are interviewing over the three phases) are generally happy with the services they generally happy with the services they are receiving at the majority of the are receiving at the majority of the SNIs SNIs

RecommendationsRecommendations

Augment support for rural SNIs, or those that Augment support for rural SNIs, or those that lack reserves, to help them weather transitions lack reserves, to help them weather transitions more successfully (particularly those more successfully (particularly those transitioning to FFS)transitioning to FFS)

Ensure that the new SE does not repeat missteps Ensure that the new SE does not repeat missteps of previous SE (e.g., lack of consistent of previous SE (e.g., lack of consistent responses to SNIs from central office; responses to SNIs from central office; insufficient IT system to handle claims during insufficient IT system to handle claims during start-up period; returned claims for unclear start-up period; returned claims for unclear reasons and associated payment delays) reasons and associated payment delays)

RecommendationsRecommendations

Although communication channels between Although communication channels between the SNIs, the state, and the SE have the SNIs, the state, and the SE have improved since Phases I and II, we improved since Phases I and II, we recommend a continuation of efforts in recommend a continuation of efforts in this direction this direction

– During our last “check in” with During our last “check in” with participating SNIs, we encountered participating SNIs, we encountered administrators, providers, and staff administrators, providers, and staff who felt confused and uncertain about who felt confused and uncertain about changeschanges

RecommendationsRecommendations Rein in costly paperwork and reporting Rein in costly paperwork and reporting requirements that contribute to overhead requirements that contribute to overhead expensesexpenses

– Create workgroup of key stakeholders Create workgroup of key stakeholders to study paperwork/administrative to study paperwork/administrative burden issuesburden issues

– Review enrollment forms to ensure that Review enrollment forms to ensure that all requested information is necessary all requested information is necessary (or educate providers about why this (or educate providers about why this information is needed) information is needed)

RecommendationsRecommendations Further evaluate the impacts of implementing Further evaluate the impacts of implementing CCSS in place of conventional case management CCSS in place of conventional case management on SNIs and the clients they serveon SNIs and the clients they serve

Continue to work with SNIs to improve their Continue to work with SNIs to improve their ability to track authorization/utilization of ability to track authorization/utilization of servicesservices

Continue to cultivate the positive aspects of Continue to cultivate the positive aspects of reform (e.g., new programming; greater access reform (e.g., new programming; greater access to training; increased presence of peer to training; increased presence of peer providers; overall transition to recovery-providers; overall transition to recovery-oriented delivery system) oriented delivery system)

Acknowledgements Acknowledgements

The work was supported by grants from the:The work was supported by grants from the:

– National Institute of Mental Health (R01-MH-National Institute of Mental Health (R01-MH-076084) 076084)

– Substance Abuse and Mental Health Services Substance Abuse and Mental Health Services AdministrationAdministration

Special thanks to the NM-BASE ethnographic Special thanks to the NM-BASE ethnographic team, including Caroline Bonham, Shannon team, including Caroline Bonham, Shannon Fluder, Elizabeth EnglandKennedy, Elizabeth Fluder, Elizabeth EnglandKennedy, Elizabeth Lilliott, Gwen Saul, Paula Seanez, Jill Lilliott, Gwen Saul, Paula Seanez, Jill Reichman, and to our research participantsReichman, and to our research participants

For Further Information:For Further Information:

Cathleen E. Willging, PhD Cathleen E. Willging, PhD

Behavioral Health Research Center of the Behavioral Health Research Center of the Southwest, A Center of Pacific Institute Southwest, A Center of Pacific Institute for Research and Evaluation for Research and Evaluation

612 Encino Place, NE 612 Encino Place, NE

Albuquerque, NM 87102Albuquerque, NM 87102

E-mail: E-mail: cwillging@bhrcs.org

Phone: 505-765-2328Phone: 505-765-2328

Website: Website: www.pire.org or or www.bhrcs.org