official behavioral health report first draft

IntroductionNo discussion about creating an effective behavioral health care system can even begin without determining what the desired end result is. Does “effective” simply mean the cheapest way to care for the mentally ill, whether that be in prisons, emergency rooms, or outpatient care? Does “effective” mean preventing people from committing crimes or suicide? Or does it mean helping people with psychiatric disabilities recover? And if that is the case, what does it even mean to “recover”? Is that just a reduction in symptoms, or something more? We at the Rio Grande Foundation believe that recovery does not just mean reducing the symptoms of mental illnesses, but improving the quality of life and functional ability of patients despite their illness. In this paper, we will define an effective system as one that helps patients achieve these goals in the most cost-efficient way possible.

Throughout the course of this paper, we seek to answer the most fundamental questions regarding the implementation of an effective behavioral health system—What goals do we eventually hope to accomplish? What principles does the system need to promote to achieve these goals? And what policies should be implemented to create a system that promotes those principles? While all of these questions require complex, multifaceted answers, we at the Rio Grande Foundation believe that the key to a successful system is to allow patients and their families the freedom to take control of their own recovery, while providing them the support of care coordinators to ensure they receive the best care possible.

Executive SummaryIn the wake of the provider shutdown, many New Mexicans finally began to realize just how broken the state’s behavioral health care system is. Unfortunately, many of these people placed the blame solely on the Martinez administration for shutting down the providers, when in reality the system had been broken long before that. In fact, the system was so backed up that people applying for developmental disability (DD) waivers is 2004 still have not received services. The behavioral health care system has failed in New Mexico, but fortunately there are many opportunities for improvement.

_______________________________________________________________________________________1 Rio Grande Foundation

by Christopher AbbottMental Health PolicyResearch Assistant

Key Points New Mexico’s

behavioral health system has been in crisis for over a decade

Provider shortage has led to long waits for treatment

Lack of incentives has led to poor quality of care

Evidence-based practices are a highly effective way to treat mental health issues

Underfunded, but money alone cannot solve the issue

Patients and

Rio Grande Foundation August 2016

PolicyPerspectiveBehavioral Health Care Policy in

New Mexico

August 2016 Behavioral Health Care Policy in New Mexico

At the most basic level, New Mexico needs to create a system that empowers patients and providers to access the care that they need, which means freeing them from an ineffective, inefficient bureaucracy, which is currently dominated by the Behavioral Health Collaborative (BHC). Fortunately, eliminating this body and returning control of behavioral health purchasing to individual agencies can help lead to a system that emphasizes recovery and early detection. However, this alone will not be enough to reform New Mexico’s behavioral health care system.

To repair New Mexico’s broken mental health care system, changes will need to be made at all levels to improve quality and access to care. For instance, the expansion of mental health courts from being pilot projects in a few counties to cover every eligible person in the state could greatly reduce the incarceration rate of the mentally ill, saving budget dollars that could be diverted to improving care for those with the most serious psychiatric conditions.

In addition to the mental health courts, there are a slew of other evidence based practices that could be promoted in New Mexico to improve results. New Mexico currently has only 15% of its funds tied to evidence based services, while states like Oregon link 70% of their behavioral health budget to evidence based practices. While quotas may not be the most effective way to promote these practices, ensuring patients and families understand the benefits of these services may expand their usage while still ensuring patients have control over their own treatment plan.

Expanding the provision of evidence based treatments in New Mexico can also partially be accomplished by making providers and behavioral health purchasing entities responsible for their results. As it currently stands, New Mexico has no performance incentives for providers, Managed Care Organizations, or the statewide entity. This is largely due to the fact that no data is being collected that reflects the effectiveness of the system. Thus, to create performance based incentives and to measure the effectiveness of specific qualities, the state must first begin recording data such as the percentage of patients who are able to effectively manage their condition(s) and reintegrate into the community.

Policies such as these will help to improve the quality of care in New Mexico; if they are combined with policies to improve the quantity of care, New Mexico may finally be able to have a functioning behavioral health system for the first time in decades.

Unfortunately, expanding access to care may prove to be even more difficult than improving its quality. Perhaps the most controversial long term effect of the controversial 2013 provider shake down is that many doctors, specialists, and other qualified providers were ultimately forced to leave a state that already struggled to meet the needs of its citizens. To make matters worse, the provider shortage is a national issue, meaning that New Mexico cannot easily find new providers from other states, and the supply shortage could lead to particularly high wages for psychiatrists and other behavioral health specialists.

Fortunately, there are other options to expand the access to healthcare in the state, starting with eliminating restrictions on telehealth services. New Mexico recently passed a bill requiring that all services that would be accepted by MCOs in person to also be accepted if it were provided via telecommunications. This is certainly a step in the right direction, and expands access to care for patients in rural areas who cannot commute to receive care in person. However, this alone does nothing to increase the size of the provider network patients have access to. Fortunately, New Mexico could allow providers who are licensed in other states to provide telehealth services to New Mexicans. Since in-person contact is not required for telehealth services, this would not have a negative impact on the quality of



services received. Additionally, having out-of-state doctors provide these services would give New Mexico’s providers more time with patients in person, allowing more patients to receive behavioral health services.

In addition to expanding telehealth, New Mexico can expand its behavioral health workforce by utilizing more care coordinators and peer support specialists, who both provide valuable service. While this is certainly not a cure all, in the short term these are the best policies available to New Mexico to improve both the quality and quantity of care for its citizens, and this crisis is far too severe to wait for the supply of providers to increase on its own.

System OverviewNew Mexico’s behavioral health care system is in a state of crisis. But this crisis is not the result of the 2013 provider “shakeup”—it goes back much further than that, to (at least) the 2004 shakeup, when the Behavioral Health Collaborative (BHC) was created.

The BHC is a governing body that consists of fifteen state agencies that have financial interests related to behavioral health care, led by the Human Services Department (HSD) which contributes 80% of the BHC budget. Other key agencies include the Departments of Health (DOH), Public Education (PED), Corrections (NMCD), and the Children, Youth, and Families Department (CYFD), which is responsible for providing behavioral health services to children.

The BHC coordinates services via six regions representing the four quadrants of the state, Bernalillo County, and Native American reservations, which are then subdivided into 18 local collaboratives (LCs). These LCs are designed to give communities ownership of local health issues and make recommendations to the BHC.4

As the regulatory body for behavioral health care in New Mexico, the BHC performs several important roles. Chief among these were setting service definitions, monitoring training, and evaluating performance.1 Additionally, the BHC is responsible for contracting with a single statewide services purchasing entity and/or Managed Care Organizations (MCOs). The Statewide entity or MCOs work as contractors to ensure providers are paid for the services they provide in accordance with the BHC’s service definitions. In New Mexico, the statewide entity was paid for services before they were delivered, which is contrary to best business practices.4 Additionally, the statewide entity was not at risk for expenditures and reimbursed providers via a fee-for-service method, and the lack of post-treatment follow ups resulted in “performance” measures that the LFC called “an open invitation for abuse and possibly fraud”.4 Together, these poor management decisions resulted in a system that provided no incentive for efficiency.

The original idea behind the BHC was a good one: It was designed to create a front-end, prevention based collaborative health care system rather than having a series of agencies using their limited resources on behavioral health care when crises emerged. So, for example, rather than having NMCD use its resources managing care for inmates with psychological disorders, who are incarcerated far too often, some of these resources could then be redirected to help people with mental illnesses receive treatment to avoid having them commit crimes in the first place. Likewise, CYFD and PED would be able to coordinate funding so students can access behavioral health care in school. Such a process would be particularly beneficial because students who are referred to treatment actually receive care

_______________________________________________________________________________________ Rio Grande Foundation 3


90% of the time when it is available in schools, compared to just 10-15% of the time when they are told to seek treatment outside of school.2 Unfortunately, this has not happened.

The inability of the Collaborative to better coordinate services has led many providers to advocate for its termination.3 Doing so has several advantages. First, it would eliminate HSD’s monopoly on the control of the behavioral health care system, allowing other agencies to operate more freely. Thus, rather than needing HSD’s representative on the BHC to approve partnerships, agencies such as CYFD and PED would be able to reach agreements independently to improve patient outcomes. Additionally, it would eliminate an additional level of bureaucracy that lacks the support of even its own member agencies, many of whom have stopped attending BHC planning meetings.4

While the BHC has hindered the operating ability of the behavioral health care system, there are several other important factors to consider as well. New Mexico simply does not have a sufficient behavioral health workforce to meet the needs of the state. This has been exacerbated by the Affordable Care Act and Medicaid expansion, which have done little to increase access to behavioral health care in the state given that the current supply of providers is unable to meet the expanded demand, resulting in long waiting lists and shorter or less frequent appointments.

New Mexico has also sought out other ways to transform its behavioral health care system. In 2012, HSD submitted an 1115 Medicaid Waiver to the Centers for Medicare and Medicaid Services (CMS) to implement Centennial Care. Additionally, in 2013, the state decided to eliminate its single Statewide purchasing entity for Medicaid and replace it with four MCOs, while maintaining its statewide entity for non-Medicaid purchases.4 As part of this transformation, the behavioral health “carve-out” was also eliminated. Theoretically, this was designed to promote an integrated behavioral and physical health system, as a single funding source made it easier for providers to be reimbursed for both physical and behavioral health services they offered. In practice, eliminating the carve-out has not been enough to achieve an integrated system.

Also in 2013, the state implemented SB 0069 with overwhelming bipartisan support. This bill required any and all services that would be accepted coverage if offered in person to also be accepted when offered as a telehealth service. As a result, health care, including mental and behavioral health care, became much more accessible to thousands of New Mexicans living in rural and frontier areas, and those with other transportation issues.

One final point worth mentioning is that New Mexico’s behavioral health crisis is not due to a lack of funding. In addition to the Medicaid expansion, non-Medicaid funding has been expanded recently while the numbers of consumers decreased. This could be expected following the Medicaid expansion, as patients previously receiving state funding transferred to Medicaid services as they became eligible. However, even using data from before the Medicaid expansion when there was a clear, demonstrated need, increased funding still did not yield increased access to services. For instance, from FY2011 to FY2012, BHSD’s non-Medicaid funding increased 10% from $54 to $59 million, while the number of patients receiving services decreased 10% over the same period.4 The causes of this vary from increased units of outpatient service to longer stays in residential and inpatient facilities with relatively few resources being directed to proven, evidence based practices. However, all of these causes can be attributed at least in part to a lack of incentives promoting efficiency within the system.



This issue is particularly severe in New Mexico, though it is an issue affecting much of the country.2 In the long run, this will be resolved by free markets increasing wages to encourage more students to enter the behavioral health care industry. However, given the amount of time it takes to become educated, trained, and certified as a licensed provider, it could take a generation for free markets to adjust to this government intervention. This has prompted many lawmakers to draft proposals to expand the workforce more quickly. These proposals have ranged from expanding the role that peer support can play in the recovery process or decreasing barriers to telehealth access, both of which allow providers more freedom to meet the demands of patients. Other bills, such as 2015 SB 154, 2007 HB 0112 and 2007 SB 0141, have sought to further intervene in free markets by funding programs at UNM and NMSU, which were not requested by the universities, to incentivize more New Mexicans to go into behavioral health care. However, both of these bills are flawed in several ways, with the most significant issue being that they still provide no incentive for these students to remain in New Mexico after they are trained.

These two issues are complementary—the state’s inability to create an effective, front-end behavioral health system results in people with psychiatric disabilities being incarcerated or warehoused on the back-end of the state’s behavioral health system, which directs resources and providers away from front-end care to prevent such issues in the future. Thus, between the ACA, Medicaid expansion, BHC, and burden of overregulation on providers, government intervention has strained the ability of New Mexico’s behavioral health care system, hurting the people that these interventions were designed to protect.

Evidence Based PracticesEvidence based practices are the golden standard of health care treatment, combining the best available evidence with clinical expertise and patient values to develop cost-effective, results-oriented treatments. Some of the most common evidence based practices in behavioral health are Wraparound Care, Intensive Outpatient Programs, Treatment Courts, Multisystemic Therapy, Functional Family Therapy, and Treatment Foster Care. The proven results of these treatments should help to better inform lawmakers about the most effective ways to spend New Mexico’s behavioral health dollars. In addition to evidence based practices, there are multiple “promising practices” that are being implemented by the state health care system. While these do not have sufficient science-based evidence to prove their efficacy, these practices are judged to be clinically sound, designed to meet the needs of consumers, and are associated with positive outcomes. These practices include Comprehensive Community Support Services (CCSS), Peer Support Services as a component of the service array, and the use of Core Service Agencies (CSAs) for care coordination. These services tend to be widely supported by providers and patients, and should not be discounted solely because of the lack of scientific research into their efficacy.

As of 2013, approximately 15% of the state’s behavioral health services budget was specifically linked to evidence based practices. This is significantly behind behavioral health leaders, such as Oregon, where 75% of the state budget for mental health care is tied to such practices.1

However, since 2011, the Legislative Finance Committee (LFC) has developed the New Mexico Results First Model to estimate the financial costs, savings, and return on investment of various policies.



Some of the most prominent evidence based and promising practices are outlined below:

Multisystemic Therapy: “Multisystemic Therapy (MST) is an intensive family- and community-based treatment program that focuses on addressing all environmental systems that impact chronic and violent juvenile offenders -- their homes and families, schools and teachers, neighborhoods and friends. MST recognizes that each system plays a critical role in a youth's world and each system requires attention when effective change is needed to improve the quality of life for youth and their families. MST works with the toughest offenders ages 12 through 17 who have a very long history of arrests.”2

While this treatment covers significantly more than just behavioral health issues, this should not be overlooked in the mental health care system when implemented in collaboration with the New Mexico Correction Department as a way to reduce crime and recidivism rates while improving care and quality of life for adolescents with behavioral health concerns.

A study by the Washington State Institute on Public Policy (WSIPP) evaluated the benefits and costs of this treatment, and found that, on average, the benefits of Multisystemic Therapy outweighs the cost by $24,751 per patient per year receiving care, providing a benefit to cost ratio of $4.36:1. Additionally, this resulted in a 98% chance of a positive net value, indicating that this evidence based practice is highly effective. 1

Functional Family Therapy: Similar to Multisystemic Therapy, Functional Family Therapy (FFT) is also a family-oriented therapeutic service. However, FFT focuses on decreasing intense negativity in the home life, addressing behaviors such as blaming, abuse, and depression by promoting family communication and conflict resolution skills. It then attempts to help the family learn to utilize community resources to prevent future relapses.3

FFT is one of the most effective Evidence-Based Practices currently available to providers. The WSIPP study that found highly effective results for Multisystemic Therapy found even more promising results for Functional Family Therapy. It found that benefits outweighed costs by $67,108 per patient per year, providing a $21.57:1 benefit to cost ratio. Further, WSIPP found a 100% measured risk, essentially guaranteeing that FFT will yield a positive net value.1

Wraparound Care: New Mexico utilizes the Milwaukee Wraparound method, one of many methods of wraparound care available in the behavioral healthcare system. This system, like most other forms of wraparound care, focuses on providing children with comprehensive, community based care. These services are individualized and planned by a collaboration of parents, teachers, providers, and other important people in the child’s life. Unlike most other services, wraparound plans are designed to be flexible, allowing students to receive care in their home or community on their schedule, rather than in offices during office hours when children and their parents are typically in school or at work.4

There is a significant body of evidence supporting the efficacy of wraparound care when properly implemented. However, randomized studies of wraparound services have found lackluster implementation fidelity and low morale for wraparound services.5,6 This has led some researchers to find that, despite providing patients with more hours of care and services, wraparound care is no more effective than the cheaper, traditional intensive case management for less-impaired youths with serious emotional disorders.6 Other research has also led to findings that wraparound care is less effective than Multisystemic Therapy.7



Thus, wraparound care should continue to be included in the behavioral health care system, particularly for severe cases of psychiatric disabilities or emotional disorders. For the cases where wraparound services are used, Wraparound Fidelity Index measurements should be utilized to ensure providers are administering the proper services, especially because many wraparound providers lack the advanced degrees that most behavioral health providers hold.5,8 Additionally, in many cases there may be alternative options that provide equally effective care while placing less strain on the overburdened system in the state.

Mental Health/ Treatment Courts: Mental Health Courts (MHCs) are a specific type of problem-solving court, functioning similarly to the much more prevalent drug courts. MHCs hear cases involving persons who have psychiatric disabilities and have been charged with a crime. However, rather than focusing on detention as a way to prevent future misconduct, MHCs attempt to deal with the crime by addressing the perpetrator’s mental health needs. One of the benefits of MHCs is that they can bring people into the behavioral health system and ensure they are receiving the care they need by requiring and incentivizing treatment, medical care, and case management. This is particularly beneficial for people who would not be in the system otherwise, often due to a lack of access.

A WSIPP study found a benefit to cost ratio of $3.69:1 for drug courts, with a 100% measured risk (effectively guaranteeing that these courts would be a more efficient use of state dollars than incarcerating persons with drug addictions in the standard justice system.1

Unfortunately, MHCs are a much newer development than drug courts, and therefore have significantly less data supporting their overall efficacy. However, several internal studies of individual MHCs strongly support their effectiveness. For example, the Bonneville County MHC in Idaho saw a 98% drop in the number of psychiatric hospitalizations and a 90% drop in incarcerations of program participants after 6 years. Graduates of the Bonneville County MHC had a recidivism rate of 24%, a number that "continues to decrease with more graduates and the increased maturity of the program".9 A Washington State MHC reported that program participants were 75% less likely to reoffend within 12 months of program completion than those who chose not to receive treatment.9 Other MHCs throughout the nation have reported similar results, including those in New Mexico.

There is also plenty of room to expand the provision of mental health court programs in New Mexico, as the five existing MHCs serve only four of the state’s thirteen judicial districts (The Metro Court overlaps with the existing Second (Bernalillo) and Thirteenth (Sandoval, Cibola, Valencia) District programs). While these are four of the most populous districts, Doña Ana County (Las Cruces) and the eight other judicial courts account for over 750,000 people, which would yield a 60% increase in MHC participation if the new courts were utilized at the same rate as the existing courts.10 Additionally, the current mental health courts are operating at only 62% capacity. However, mental health court services could be made available to more mentally ill offenders by improving the screening and referral process and expanding the types of crimes that can be referred to mental health courts. Such policies could reasonably be expected to increase the number of cases diverted to mental health courts by 25%, which would result in mental health courts operating at ~77% capacity, compared to the 62% capacity at which they are currently operating. If this occurred in addition to creating more courts, the state would double the amount of mentally ill offenders who are diverted from the traditional corrections system in New Mexico to 375 per year from the current 187. Estimating that 375 people would be able to be served by mental health courts in New Mexico is still a fairly conservative estimate given that there are roughly 1,500 people with serious mental illnesses in the state correctional system at any point in time2.



Several factors may affect this number, but throughout this paper a maximum of 375 potential patients will be used to estimate potential costs and benefits of expanding access to mental health courts throughout the state.

While the primary issues mental health courts aim to address are public safety and the patients’ well-being, their financial benefits should not be overlooked. New Mexico’s up-front incarceration costs per prisoner per year is just over $35,500, or $97.25 per day.5 This is more than seven times the cost of enrolling a mentally ill offender in a mental health treatment court program, which costs $3,700 per year, or $10 per day.7

Given the average 12-month graduation time for mental health court enrollees, this would yield a savings of nearly $32,000 for each patient diverted from traditional courts. This means that the 186 patients in the state’s five existing mental health courts save nearly $6 million per year. However, expanding the mental health court system to serve 375 people with serious mental illnesses in the state correctional system at any point in time2 across the entire state could save $6 million more per year. Furthermore, these savings would take effect in the same year that the courts are created, less the startup costs which could be subsidized by federal grants. This could then be repurposed to fund up to a 12% increase to general fund appropriations for behavioral health services, without creating any new taxes. While the state simply does not have enough of a budget to invest more in behavioral health care, policies such as these that can make a more efficient use of existing dollars can make major improvements in behavioral health care.

Even more important than the short term financial benefits of mental health courts is the impact they have on the people they serve. While there is no quantifiable data on the well-being of patients who go through the mental health courts, the frequency of how often they are re-arrested reflects how well their illnesses are being managed. This data indicates that mental health courts are highly effective in providing treatment to people with the most severe mental illnesses.

One of the best-designed academic studies into the effectiveness of mental health courts found that mentally ill offenders who were directed to traditional courts rather than mental health courts were 250% more likely to offend than their counterparts in mental health courts,4 which is consistent with data from New Mexico.3

In New Mexico, patients who graduated from their mental health court programs had a recidivism rate of 19.27%. For all program participants, including those who did not graduate from their mental health court, the recidivism rate increases slightly to 23%, which is significantly lower than NMCD’s overall re-arrest rate of 44.6%.3 However, this indicates that mentally ill offenders who are directed into the traditional court system are re-arrested nearly 60% of the time, which is consistent with other academic studies.8, 9 This is also significantly higher than the overall recidivism rate. However, this also indicates that every 100 people diverted to a mental health treatment court program will prevent 37 people from being re-arrested over the next three years. Additionally, many other patients experience a reduction in the number of crimes committed, leading to an arrest-reduction rate of 73.7% in 2015. This has several benefits, from lowering the state’s crime rate (which is the highest in the nation)5, to improving the quality of life of mental health court participants.

One statistic NMCD records specifically for mental health courts is the multiple-offense reduction (MOR) rate, which tracks the number of “crisis cyclers” being rearrested over four times per year.3 The MOR then compares the number of people considered “crisis cyclers” in the year before entering the MHC compared to the number of “crisis cyclers” the year after



their graduation. In Fiscal Year 2015, the MOR rate was 66.7%, and this has increased to 77% in 2014, indicating that mental health courts have been very effective at treating the most vulnerable offenders.3 Combined with the impressive 19% graduate recidivism rate, mental health courts reduce roughly 75% of arrests in the year following graduates’ release.3

While there is no publicly available data on the exact number of arrests before entrance into the mental health courts in New Mexico, the number of crisis cyclers is recorded, and the number of arrests for non-crisis cyclers must be between one and three. Thus, mental health courts reduce 75% of the 108-327 arrests (~218) that would be expected from patients in their first year after release, which would be approximately 160 per year. If mental health courts were expanded to serve 375 people in all areas of the state, this could prevent another 160 arrests per year

Mental health courts’ ability to reduce the recidivism rate also has the benefit of saving the state millions in law enforcement, judicial, and correctional services. While the direct savings of paying for mental health courts rather than traditional courts was discussed previously, the savings from preventing mentally ill offenders from continually cycling through the criminal justice system may be even more significant.

While data for the average sentencing length of mentally ill offenders is not available in New Mexico, a common policy is to only admit arrestees with jail sentences over 60 days into mental health courts. Thus, using 60 days as a conservative estimate for the average sentencing length would mean that preventing an additional 160 arrests per year would save the state an additional one million dollars on incarceration costs5, reduce the crime rate, and improve the quality of life for New Mexico’s most vulnerable.

However, there are still some concerns regarding these policies that tend to worry lawmakers. Chief among these are concerns over a regression to 1950’s era psychiatric care caused by coercing those with behavioral health problems into treatment. However, these concerns are misguided, as MHCs are not coercive—defendants must choose to receive treatment, and the power of defense attorneys will be expanded by MHCs to prevent any coercion. In fact, defense attorneys could effectively shut down MHCs by advising clients not to accept treatment if the system collapses.9

Additionally, there are concerns that MHCs would not be needed if there were sufficient services to care for people with psychiatric disabilities before they committed crimes. This theory overlooks the fact that, in part due to the stigmatization of behavioral illnesses, and in part due to a lack of diagnoses, many people would not seek help on their own. However, if given the choice between receiving treatment and being incarcerated, many may opt to receive treatment, giving them an opportunity to begin a new chapter in their life. Regardless, there are also not sufficient resources to treat everyone at this point, so MHCs could at least direct some of those resources to the people most in need of treatment to prevent crises, which would also save money from incarcerations that could be spent on more treatment for the rest of the community.

Care Coordination: The health care system can be complex and confusing even for the most well educated patients, and ensuring patients receive consistent, quality care is crucial to reducing costs and improving results. Care coordinators (operating in Core Service Agencies) can be an invaluable tool to ensure patients receive the appropriate care to fit their needs and remain in the system as long as needed, as patients leaving the system and experiencing a crisis increases costs dramatically.10 Additionally, without care coordination, providers are



often left to direct patients to the appropriate services, reducing the amount of time they can actually spend providing services.1

While care coordination has not been proven as an evidence based practice, its positive results have prompted private Managed Care Organizations (MCOs) to adopt this practice as a cost saving measure. 10 Additionally, some evidence suggests that for less-impaired children and adolescents with serious emotional disorders, intensive care coordination can be as effective as wraparound care in ensuring that patients get the care they need.6 No similar study has been conducted involving adult patients, though it is likely that the results would be similar for this group.

Community Involvement: Given the extreme shortage of providers, there is no way that the mental health treatment crisis can be fully addressed in New Mexico without community engagement. Fortunately, there are several opportunities for people to get involved to improve the delivery of mental health resources in New Mexico.

As with all issues that involve government policy, people can get involved in crafting a solution by encouraging their elected representatives to support policies that would result in better care for New Mexico’s mentally ill population. However, there are also several ways for people to help improve care for people they interact with every day.

In any given year, 20-25% of the population has some mental illness, with 4-8% having a severe illness. Over the course of their life, this doubles to half of the entire population. Of those people who do have a mental illness, 50% see symptoms by age 14 and 75% experience symptoms by age 24.4 Unfortunately, we have a gap of 8-10 years between the onset of symptoms and the arrival of treatment.4 Fortunately, taking steps to screen people for mental health issues is very easy to do and would be a wise investment for the state.

While universal screenings for children was previously discussed as a policy proposal that could help detect mental illnesses as they start developing, rather than years later, there will likely not be any such legislation in the foreseeable future. However, there is nothing preventing people from getting screened for mental illnesses on their own, or preventing parents from having their children receive regular screenings. Having pediatricians perform this service would still be the most convenient and effective way to screen patients, but for children whose doctors will not or cannot do this, there are several other options available. For instance, websites such as Mental Health Colorado have screening tests for a variety of mental illnesses, and parents could use data from these results to determine whether or not their children need to receive additional mental health care services. Additionally, while mandatory pediatrician screenings would have resulted in nearly universal screenings, parents who encourage their children to get screened may also be more likely to actually ensure their child receives support for any illnesses they are diagnosed with, whereas universal screenings would result in many untreated diagnoses.

Additionally, throughout their lives, people with mental illnesses come across dozens of people who would be able to help them receive the services they need, if they were able to detect the signs of mental illnesses. This provides people who want to make a difference the opportunity to do so by taking training sessions from organizations like NAMI so they are able to detect symptoms of mental illnesses and help direct people to treatment services in the future. This would be particularly important for teachers, who are the most likely to be close enough to students as they begin to develop symptoms of mental illnesses. This training would also be crucial for police officers and people in the judicial system, such as defense



attorneys and judges, who would be able to recommend that mentally ill people be redirected to mental health courts when applicable.

While non-professionals cannot provide intensive therapeutic services or prescriptions, taking training classes on how to interact and support people with mental illnesses can make a major impact on the quality of life for people with mental illnesses. While caretakers and families of people living with mental illnesses certainly learn how to interact with their loved one, training can help speed up the learning curve when mental illnesses are first discovered. Additionally, learning how to interact with people with mental illnesses is crucial for law enforcement officers, as the mentally ill are particularly prone to police violence, much of which could be prevented with proper training.

One of the additional benefits of having people be trained on how to interact with people with mental illness is that it can help to address the stigma of having a psychiatric disability. This “stigma”, which could be more accurately referred to as discrimination, not only worsens the illnesses (for instance, by reinforcing people with depression’s idea that they may have something “wrong” with them”), but it is also one of the main barriers preventing people from receiving care they need. Mental Health Colorado found that 28-40% of people with mental illnesses reported that the stigma against the mentally ill was one of the factors preventing them from receiving care, either because they did not want to admit to themselves that they were “sick” or because they were concerned about how they might be treated if their boss/friends/family found out that they had a mental illness.

Comprehensive Community Support Services: CCSS is a service designed for persons with a serious mental illness who are unable to lead independent lives without frequent coaching and support due to the severity of their illness. While it lacks sufficient data to be classified as evidence based, the Centers for Medicare and Medicaid Services (CMS) has stated the CCSS is not only a beneficial service, but a necessary one.11

There are 14 services offered under CCSS in New Mexico. The primary provider is responsible for assessing which of these services are needed for each patient, and the Community Support Worker (CSW) is responsible for ensuring patients receive this care, in addition to acting as a teacher and supporter of the patients.11 In New Mexico, a CSW is paired with no more than 20 clients at a time. CCSS also includes a variety of activities intended to promote independence, such as encouraging patients to maintain basic standards of hygiene, meal preparation, money management, and how to maintain a relationship with a landlord. CSWs are also the first line of contact for patients, and are therefore responsible for monitoring the client’s symptoms and ensuring clients understand the use and effects of any medications they may take.12

Peer Support Services:

The implementation of peer support services is fairly widespread, with the most well-known example being Alcoholics Anonymous. This approach has been widely praised for being relatively effective and inexpensive. Within the behavioral health system, peer support services also have the benefit of expanding the provider workforce, which is insufficient to meet the needs of the state.

While most of the scholarly research into peer support services is methodologically flawed in some way, and therefore unable to define the service as evidence-based, the research does indicate positive results. However, the way that peer-support services are implemented does impact their effectiveness.



A SAMHSA commissioned meta-analysis of the existing literature on this topic broke peer support services down into three categories: peers added to traditional services, peers in existing clinical roles, and peers delivering structured curricula. It found that the most effective models were the peers added approach, with 8 of 13 studies finding a positive impact, and the peers delivering curricula, with 4 of 4 studies finding positive results. There was less support for peers in existing roles, for which only one of three studies found positive outcomes.13

New Mexico’s existing behavioral health system attempts to integrate peer services in a number of ways. One of these is through CCSS, by encouraging providers to use peers as CSWs.11 This approach would be classified under the peers in existing roles approach, which was deemed the least effective in an analysis of the existing literature. However, given that integrating peers into existing roles appears to at least yield some positive benefit, and doing so is virtually free (assuming the salary for peer and non-peer CSW’s is similar), this approach could still be beneficial. However, determining if adding peer services outside of the existing roles is an efficient use of resources is a question that must be answered by the state moving forward, and if so, what the service definitions will be for these peer supporters.

Areas for ImprovementThe good news about New Mexico’s broken system is that it can only improve. A complete system overhaul has the potential to make the behavioral health system in New Mexico one of the best in the country, and if it doesn’t work, we will still remain right at the bottom of the pack. Fortunately, New Mexico does not need a complete overhaul, as certain components of its system are working well, such as the 18 local collaboratives in the state, which give communities ownership of their system, and help to express their needs to the state’s MCO’s. However, it still does need some bold reforms to address the flaws of the behavioral healthcare system.

Improve Outcome Data Collection & Performance Measures: Without post-treatment follow ups with patients, no behavioral health system will be able to accurately identify its effectiveness or weaknesses. This leaves lawmakers in a bind when trying to identify the best ways to spend the state’s limited healthcare dollars. Without this data, administrative officials are essentially forced to guess how to best spend their money based on studies from other states, which is useful but far from perfect. Additionally, this lack of outcome results contributes to creating a system that invites fraud, waste, and abuse.

Outcome Data Does Not Need to be gathered in-person: Ideally this data would be obtained by in-person follow ups between providers and patients, which not only allows providers the opportunity to gather outcome result data, but also to evaluate if the patient needs additional treatment. However, given the overburdened workforce in New Mexico, providers’ time may be better spent with new patients rather than “checking in” on previous patients, which is perhaps why outcome data is rarely gathered in New Mexico. Thus, performance evaluations can be gathered via online forms or over the phone by the patient’s care coordinator. Based on these results, the provider can then quickly determine if additional services are needed for the patient. While still not perfect, this would be the most efficient option for New Mexico in the short term, and would certainly be more effective than



the current performance evaluations, which measure the amount of people receiving follow-up treatments with no account of the number who require such care.1

Create Performance Measures that Reflect the System’s Goals: As of 2013, the report card also measures the number of individuals receiving care through the statewide entity/ MCOs, but the only behavioral health measure related to performance and results is the number of suicides by youths being served by the state health care system.1

There are several issues with this being the only results based performance indicator for the behavioral health system in the state. The first is that this does not include a majority of the population that receives behavioral health care (i.e. everyone that is not 15-19 years old). Given that this is the age when most patients switch from receiving youth services to adult services, this may not even be a representative sample of either population.

This measure is also fundamentally flawed due to the small population of patients committing suicide in any given year. For example, in FY11 and FY12, no suicides by 15-19 year old patients were reported, and the FY 2013 target was 3 (despite being a major increase over the previous two years). However, even a single suicide can reflect a huge change in this performance measure, and with values this small, chance has a major impact on the data, making it essentially useless as an evaluation tool.

Another issue with this measure is that it does not monitor the quality of life of patients who do not commit suicide, or any changes in the severity of their psychiatric disabilities. Additionally, this measure does not include patients waiting to receive services, and since it is measured in absolute terms rather than relative terms, it creates a perverse incentive for MCOs to keep patients out of the system, as MCOs are not responsible for patients on waiting lists.

There are, however, many other measures which could be used to better measure the effectiveness of the system. For example, the current BHC report card tracks the percent of people receiving substance abuse treatment who demonstrate improvement on the addiction severity index (ASI) in the drug and alcohol domains. A similar system could be implemented for the behavioral health care system by having patients fill out evaluation surveys when they first received treatment, and again after they were done receiving services. These surveys could be very simple, such as those offered by Mental Health Colorado, making them quick and accessible while still producing valuable information about patient outcomes for providers and legislators.

Additional measures which could be used are hospital readmission rates within 7, 30, and 90 days after discharge and inpatient utilization rates (per 1,000 members), which could be benchmarked to other states.3 New Mexico could also track psychiatric ER visits by current and former patients, which have spiked recently, as these are a costly, ineffective way to treat patients, and reflect a poor front-end behavioral health care system.

These are just a few possible indicators that could be used to measure the effectiveness of the behavioral health care system. However, regardless of which specific indicators New Mexico decides to use, collecting some sort of outcome data to measure the system’s performance should be a top priority for lawmakers to ensure that the state’s limited resources are being spent in the most efficient way possible.


http://www.mentalhealthcolorado.org/screenings/


Incentivize Outcomes: While improving the quality of data gathered certainly helps to evaluate the effectiveness of the system, these numbers should not only be used to evaluate the system, but to improve it. One of the benefits of gathering good performance measures is that they make it possible to create a system that incentivizes results.

Prioritize Evidence Based Practices: As discussed previously, evidence based practices are scientifically proven methods that allow states to get the best value for their behavioral health care dollars. Due to the substantial body of research supporting these methods, the state has a vested interest in encouraging these practices as a way to use its behavioral health dollars in the most efficient way possible. There are, however, a few options for how to prioritize evidence based practices. Currently in New Mexico, 15% of the state’s budget is earmarked for evidence based practices. This pales in comparison to states like Oregon, where 75% of the behavioral health care funds are specifically linked to evidence based practices. However, earmarks may not be the most effective way to promote the efficient use of the healthcare dollars.

The primary issue with legislators earmarking significant portions of the state budget is that they are not typically the providers, and creating too many regulations that take away useful treatment options for providers could lead to unintended consequences and restrict access to care. However, if New Mexico instead creates a system that incentivizes results, it should naturally lead to an increase in the provision of evidence-based practices. If this does not happen, earmarking funding may become a more necessary option in the future, but for now, New Mexico should focus on ensuring providers’ incentives are based on their patients’ results, rather than the quantity of services performed.

Per-Member Per-Month Funding: One policy that has been particularly effective for Colorado to encourage innovative behavioral health solutions is its per-member per-month funding policy. This policy pays a certain fee for each patient to every health district (which is equivalent to New Mexico’s 6 BHC Regions) at the beginning of each month. Then, each region has an incentive to ensure their health dollars are being spent in the best way possible to provide high quality care to everyone, rather than incentivizing providers to simply charge the most expensive services available. However, the more important benefit of this policy is that it gives each region significantly more flexibility to spend money in the most efficient way possible without being tied down by the state bureaucracy. This flexibility is central to Colorado’s successful State Innovation Model (SIM), and has been credited for creating conditions that allow for successful partnerships between schools and providers.4

The primary concern with this policy is that it requires prepaying MCOs and the SE for services not yet rendered. However, even under the current fee-for-service model, this is still being done, which defies best purchasing practices without yielding any significant benefit. Thus, while this proposal itself would not create incentives for MCOs to run an efficient system, the flexibility it creates is invaluable to the system, and it can be supplemented by other policies that require MCOs and the SE to run an efficient system.

Incentivize MCOs to be responsible for effective results: Under the current system, MCOs and OptumHealth are not at risk for expenditures, and therefore have no incentive to promote cost-efficiency and value-based purchasing. Additionally, OptumHealth utilization analyses do not identify reasons for change between years, making it difficult to track the impact of specific policies and the changing demands for various services. OptumHealth also fails to target and analyze the effectiveness of specific services in its utilization analyses, despite also being contractually obligated for this oversight. However, the current contract



with OptumHealth lacks explicit direction for how this oversight is to be implemented.1 Thus, when the next SE contact is completed, this should be clarified and enforced to ensure that utilization analyses are better able to provide lawmakers with the information they need to create a cost-efficient system.

Additionally, OptumHealth and the four MCOs currently have no incentives or disincentives for operating an effective program.1 Thus, once performance measures are improved to better reflect the quality of the behavioral health system (as discussed previously), Optum Health and the MCOs should be given contractual incentives for performing well on those measures. These incentives could even be value neutral, basing each MCO’s on their performance relative to the other MCOs, rather than on an absolute scale. That way, if these reforms lead to all four MCOs improving their results, only those that improve the most will be rewarded, and the state still creates incentives without increasing its expenditures.

Prioritize Prevention & Early Detection: In any given year, 20-25% of the population has some mental illness, with 4-8% having a severe illness. Over the course of their life, this doubles to half of the entire population. Of those people who do have a mental illness, 50% see symptoms by age 14 and 75% experience symptoms by age 24.4 Unfortunately, we have a gap of 8-10 years between the onset of symptoms and the arrival of treatment.4 Fortunately, taking steps to screen people for mental health issues is very easy to do and would be a wise investment for the state.

Pediatrician Screenings: Two proposals would be particularly effective at screening and providing services to young patients with mental illnesses. The first would be to have pediatricians screen children during their annual check-ups, which are required for attendance at public schools and most private schools. This would ensure nearly universal screening for children, and could cut the wait time between the onset of symptoms and the arrival of treatment from ten years to less than one. There is, however, one major issue with this policy, which is that it does not ensure that patients with mental illnesses will actually receive care after their diagnosis. Given the stigma against mental illnesses, some children may attempt to hide their diagnosis, and those who do not may still struggle to access care due to its financial burden, particularly if they are uninsured or do not know that mental health services are covered under the ACA.

In-School Care: Data suggest that this theory is correct; only 10-15% of children that they were referred to mental health services outside of school actually received care.4 However, the second aspect of this proposal would be to also integrate physiatrists or other mental health care providers directly into the schools. When care is readily available in schools, students in need actually end up receiving care 90% of the time. This has also been suggested by families of children with behavioral health concerns, as schools are on the front lines of this matter and are the first state agency capable of finding mental health concerns and referring students to treatment.

To do this, some system would need to be in place to coordinate between schools and the health care system. Fortunately, this should not be difficult to arrange. High Schools (and maybe some Middle Schools) could contract with behavioral health providers who focus on children to have the on-site in the schools. The providers could have the state pay for any services they provide to Medicaid/ public insurance patients, as they would normally, and then also accept private insurance for other patients to ensure they could serve all students in the school.



If in-school therapy services were combined with basic detection training for teachers, the number of students whose illnesses are diagnosed and treated could greatly increase, improving their quality of life and potentially preventing more serious issues later in their lives.

Additionally, for innovative programs such as this, federal funds would likely be available to create a pilot program, which could result in significant savings for the program’s first few years. However, the state should only apply for a grant to implement the program if it plans to continue the programs after the federal funding expires.

Prioritize Recovery: Any taxpayer funded initiatives in behavioral health should focus on recovery-oriented care, which has the most potential to improve the long term health of people receiving services. From 2011 to 2012, Psychiatric ER visits increased from less than 150 to over 1,100, which indicates an inefficient system that does not emphasize recovery.1

Focusing on helping people learn to lead fulfilling, self-directed lives is not only the most efficient use of taxpayer dollars, but is also the only ethical, humane way to treat people with psychiatric disabilities. One area where New Mexico has been effective is in providing recovery support services to patients with substance abuse disorders. These recovery support services are wide-ranging, and help to reintegrate patients into their community in a productive, meaningful way. Recovery services include social supports such as child care, employment services, housing, peer coaching, and drug-free social activities.1 These services are invaluable for preventing remission and avoiding a system that warehouses patients rather than treating them. Such a system would be beneficial for behavioral health treatment as well, and many of the same social support services could also be used for behavioral health patients.

NMCD Partnership: One potential area to ensure the most vulnerable people with mental illnesses receive care is in New Mexico’s corrections system. Diverting mentally ill persons from prisons to rehabilitation centers via mental health courts should be the first priority here, as it vastly improves care for these patients. However, there is another reason to prevent the mass incarceration of people with psychiatric disabilities, which is the cost they place on New Mexico’s government. Patients’ Medicaid payments are suspended while they are in prison, transferring the cost of treatment from the federal government to the state, and these dollars could be spent much more efficiently elsewhere. Thus, ensuring that the federal government pays for treatment rather than having the state ay for incarceration would result in better outcomes and be fiscally responsible.

However, for patients who do end up in the state prisons, New Mexico has another opportunity to ensure that they receive care upon their release. Since many mentally ill patients either had their Medicaid payments suspended while in prison or otherwise qualify for Medicaid after their incarceration, NMCD could assist these patients in filling out paperwork to (re)apply for their Medicaid benefits and put them in contact with a care coordinator before their release to ensure they are able to make a smooth recovery into the outside world. Realistically, the only major concern with this policy would be the cost. However, this should not be much of a deterrent, as training NMCD employees to file Medicaid applications would be fairly simple, and it would typically take 30 minutes to an hour for each patient that they assist before their release. Additionally, helping people with psychiatric disabilities may also improve the state budget by preventing incarceration costs in the future. However, since New Mexico’s state budget is set annually, long-term savings



may be of little comfort to legislators facing election every other year. Fortunately, lowering the recidivism rate for mentally ill prisoners may be able to improve the budget in the same year as well. For the general prison population, New Mexico’s 2015 recidivism rate was 47% over three years.5 However, extrapolating data from Colorado shows that 80% of convicted prisoners with a serious mental illness are re-incarcerated within just 12 months. While these data do not include the length of re-incarceration, the average cost per prisoner is $2,500 per month,6 which adds up quickly given that the vast majority of prisoners with serious mental illnesses re-offend within a year. Thus, making every effort to rehabilitate these prisoners before they reoffend would not only be the most ethical choice, but would also be fiscally responsible and help to reduce crime.

Create a Sustainable System: One of the most effective ways to ensure patients never recover from their illnesses is to eliminate their care in the middle of treatment. Unfortunately, when New Mexico applies for federal grants without a plan to continue the programs after federal funding expires, this is exactly what happens.

That does not mean that New Mexico should stop applying for federal funding for new, innovative programs it implements. Rather, it means that the state should determine which programs it wants to implement in the long run, and apply for funding to subsidize those instead of implementing whatever it can receive federal funding for. These grants are designed to help states expand their system, not to be a rotating wheel of auxiliary services which are only available for the life of the federal grant before being replaced by another grant for a different service. While these federal grants do help the state reduce costs in the short term by deferring costs to the federal government, they are not conducive to a recovery-oriented system. Given that New Mexico’s biggest issue is a lack of providers, not the cost of paying them, the state’s top priority should be creating a system that emphasizes recovery. Thus, before the state applies for federal grant funding, it should ensure there is maintenance of effort and a contingency plan in place for after the funding expires. This sentiment has also been echoed by the Legislative Finance Committee and the Independent Peer Review required by the Substance Abuse Prevention and Treatment Block Grant.1

Eliminate the BHC: The original purpose of the BHC was to combine funding streams from each state agency that invested in behavioral health, federal grants, and Medicaid to create an integrated behavioral health care system. Unfortunately, providers, patients, and even the LFC admit that this has not happened.1,7 That is not to say that the BHC was inherently a bad idea; Creating an integrated system could be very beneficial for the state. However, if the Collaborative has not achieved its mission in over a decade, it is clearly not effective at creating such a system. Additionally, many providers believe that the BHC was controlled almost exclusively by the BHSD, eliminating other agencies’ control over their own funding.7 This is also reflected by diminished attendance of member organizations at BHC meetings, as organizations who feel that they have no control have no reason to attend.1 This prevents organizations from being able to effectively plan how to use their joint funding, negating the primary purpose of the BHC.

The BHC does have a few other responsibilities as well, though these could easily be transferred if the BHC were eliminated, or given to a taskforce similar to the BHC that lacks control of the state funding. For instance, service definitions could revert to being made by HSD and CYFD, or by a small task force representing HSD, CYFD, and DOH, rather than having the same BHC representatives who handle the budget also handle service definitions. Perhaps the BHC has centralized behavioral health purchasing power to reduce rates, though



the LFC found that the BHC is still overpaying for many services.1 Thus, as far as braiding funds into a cheaper, streamlined, more effective system goes, the BHC has failed its mission.

An associated body that may still be able to continue other aspects of the BHC is the Behavioral Health Planning Council. The BHPC is an advisory body of 79 members appointed by the governor representing state agencies, providers, consumers, and families. By incorporating voices from all sides of the system, the council is able to report to lawmakers on the ability of the system to meet the demands of patients, and to make suggestions to create a more comprehensive system of care.

Expand Workforce: Perhaps the most damaging long term effect of the 2013 behavioral health crisis is the flood of providers that were forced to leave an already overburdened system. Some of these providers may be able to be persuaded to return to New Mexico in the future. However, between the exacerbated provider shortage and the Medicaid expansion which has expanded demand, something must be done to expand the provider workforce.

The unfortunate twist to this issue is that it is not limited to New Mexico: Provider shortages exist across the entire country, particularly in the Western states. Colorado has become so desperate that they have even hired two full time recruiters to find providers throughout the country willing to relocate to their state.4 While this may not be the most efficient way to spend New Mexico’s behavioral health budget, there are certainly some polices that should be enacted to expand the provider workforce in New Mexico.

Do not attempt to distort the markets: A variety of options to expand the provider health force have been offered in New Mexico as well. Some of these, such as 2015 SB 154, 2007 HB 0112 and 2007 SB 0141, have sought to further intervene in free markets by earmarking unsolicited funding at the state’s universities to encourage students to pursue a career in behavioral health. However, these bills are fundamentally flawed, as they provide no incentive for students to remain in New Mexico after they graduate. While some of these graduates would certainly choose to remain in their home state for a while, without any incentives for them to remain, this is at best a risky investment using dollars that could be spent much more efficiently and at worst a waste of money.

Hire more non-provider staff: An opportunity the state does have to easily expand its provider workforce is with non-professional providers. For instance, rather than attempting to intervene in the markets in a way that is doomed to fail, the state could hire more care coordinators and peer support specialists to provide auxiliary services to ensure its psychologists and other medical providers have more time with patients.

Expand Access to Telehealth: Additionally, the state can significantly expand its provider workforce by making telehealth services more accessible. There are two major benefits to this. First, for people in rural and frontier areas, telehealth may be the only way they can access behavioral health services, so ensuring this is possible should be a top priority, particularly for legislators from rural districts. Additionally, telehealth services can be performed by providers outside of the state, creating a much wider array of possible providers, and giving extra time to New Mexican providers to spend with other clients in person.

There are typically three concerns raised regarding telehealth services: The first is skepticism regarding fraud, particularly if the provider and patient never meet in person,



which would be common if telehealth providers were located out of state. However, this would be no different than for people who have no way to get to their provider if they are in state, and eliminating their access to care is simply unacceptable. Thus, a policy that can be adapted to resolve both of these issues would be either having the patient come to meet with a care coordinator in person to, or even having the care coordinator drive to meet the patient at their residence if needed. This would not only make telehealth services more accessible for hundreds of New Mexicans and expand the provider workforce, but it would also help in-state psychiatrists and medical providers use their time to focus on providing care, rather than filling out unnecessary paperwork.

The second concern regards licensing for out of state providers offering telehealth services for New Mexicans. As most out of state providers would not be licensed in New Mexico, there are a couple of screening options available. The most lenient would be to maintain full faith and confidence in the licensing requirements of other states, and approve any telehealth providers who are licensed to practice elsewhere in the country. This would ensure an easy transition for people moving to New Mexico, who could keep the old doctors, at least until they find a new one in state. The ease of licensing would also yield the greatest workforce expansion. The strictest option would be to require all out-of-state providers who wish to provide telehealth services in New Mexico to become certified in New Mexico, with no exceptions. The benefit of this is, of course, uniform licensing requirements, but it may deter many providers from offering telehealth services to New Mexicans. This is also the system that is currently in place in New Mexico, since 2013 SB69 passed, requiring that all telehealth services be covered if they would also be covered in person. While this bill was certainly a step in the right direction, as it expands access to in-state providers, it does not do enough to expand the provider workforce in one of the easiest ways possible.

For lawmakers willing to compromise on licensing requirements, there is a happy medium. State health officials from BHSD, CYFD, or the BHC (if it remains intact) could first examine other states’ certification procedures and determine if they are up to New Mexico’s standards. Then providers in approved states could automatically be approved as telehealth providers when they applied. Providers in other states could then be required to become licensed in New Mexico (or another approved state) in order to practice telehealth services. This would still deter some providers from practicing telehealth services, but it would result in the greatest workforce expansion while eliminating any concerns about licensing procedures for out of state providers.

The final concern that is typically raised when discussing out-of-state telehealth services is a hesitation to spend state dollars out of New Mexico. There is, in fact, some validity in thinking that sending money out of the state will be detrimental to the economy, as those dollars no longer cycle back through. However, the multiplier effect of money at the state level is much less significant than at the national level, so any potential losses of spending a fraction of the state’s healthcare dollars out-of-state would be far outweighed by the benefits for those in New Mexico’s mental health care system.

Areas for Further Research While there are several policy changes that should be made immediately, additional tweaks will be needed down the road. However, determining what adjustments need to be made will require accurately assessing the shortcomings of the system. Thus, there will be several areas that will still need to be further researched to better inform policy makers of the changes that they will need to make.



Cost per Consumer Variance: Between regions, there are significant differences in the current cost per consumer. For instance, Comprehensive Community Support Services (CCSS) cost nearly $1,200 per consumer in Region 3 (Bernalillo County), while Regions 1 and 2 (Northern New Mexico) cost just over $400.1 This can largely be attributed to the number of units of service per consumer, which was 17.1 in Region 3, and just 7.2 in Region 1.1 There are several possible explanations for this variation: The average severity of illness, the consumers’ willingness to receive therapeutic services, billing practices, and under or overutilization.1 This could also be caused by a fundamental difference in how providers view “recovery” across regions, as some may decide to stop services when symptoms improve, rather than continuing to address the illness itself.Accounting Issues: In Fiscal Year 2012, over one million dollars were spent on “uncategorized” services. While this is still a relatively small percentage of the state’s $424 million mental health budget, categorizing this money more effectively could help lawmakers more accurately analyze the needs of the system. This is also augmented by hundreds of “Letters of Direction” from the BHC, which can be issued to excuse a provider’s inability to properly submit claims, or to make purchases which would require requests for proposal if the system were managed directly by the state. In addition to the cost of issuing letter for end of year purchases, these letters also make it more difficult to track spending within the behavioral health care system.

ConclusionUltimately, New Mexico has a few tough choices to make to repair its behavioral health system. Certainly the provider shortage and lack of funding are crippling the system’s ability to meet the needs of all of its patients, but the state cannot spend its way out of this crisis, particularly given the low oil prices and poor economy in New Mexico. Thus, to meet the needs of the state, New Mexico must reinvent its behavioral healthcare system to use its limited resources in a much more efficient manner.

The one thing that people on both sides of the aisle should be able to agree on is that the system currently in place is not working, and some new ideas are needed to revamp the broken system. While the policies included in this paper are not an exhaustive list of positive policy changes, each of them represents a step in the right direction to create a system that empowers patients and their families to receive the care they need. Ultimately, empowering patients, freeing providers from overregulation, and holdings MCOs accountable this is what New Mexico’s behavioral health system needs to achieve, as the last 12 years have shown that we cannot regulate our way to an effective system.

While there are dozens of other important issues slowly being addressed in New Mexico, repairing the behavioral health system needs to happen now. With most changes, there is a risk of the issue becoming worse before it improves, but when patients are going untreated or being sent through a rotating carousel of providers and services, positive changes to the behavioral health system are worth the risk. But while lawmakers are gridlocked by partisanship, patients are stuck waiting to receive the care they need. And unfortunately, in far too many cases, that has forced people to leave the state, or continue to suffer. Twelve years is too long to wait for care, and too long to wait for meaningful legislation to be passed. So, for the sake of the thousands of New Mexicans unable to receive care in the state’s current behavioral health care system, legislators need to overcome partisan gridlock to empower these patients to seek out the care they need now.



AppendixASI: Addiction Severity Index—common measure of the severity of drug or alcohol addiction, used as a performance measure in the state’s substance abuse recovery system

BHC: Behavioral Health Collaborative—organization chaired by HSD consisting of nine state agencies with a financial interest in behavioral health treatment. Responsible for contracting SE and MCOs for behavioral health purchasing, and for setting service definitions

BHPC: Behavioral Health Planning Council—group of 79 community members representing patients, families, providers, and state agencies responsible for providing feedback and suggestions to the BHC

CCSS: Comprehensive Community Support Services—Promising practice designed for people with serious mental illnesses who are unable to lead independent lives without frequent coaching and support due to the severity of their illness

Collaborative: Behavioral Health Collaborative (see also: BHC)

CSA: Core Service Agency—Often the first point of contact for patients, CSAs are responsible for care coordination, and may provide services directly as well if they are able

CSW: Community Support Worker—CSWs are responsible for ensuring patients receive appropriate care, and are teachers and supporters of the patients

CYFD: New Mexico Children, Youth, and Families Department—Member of BHC; responsible for behavioral health for children

DOH: New Mexico Department of Health

FFT: Functional Family Therapy—Evidence based practice that provides therapy to the family unit as a whole to decrease intense negativity, such as blaming, at home

HSD: New Mexico Human Services Department—Chair of BHC, responsible for most behavioral health issues

LC: Local Collaborative. New Mexico has 18 of these corresponding to the 13 judicial districts as well as five representing Native American reservations to provide local ownership of health issues.

LFC: New Mexico Legislative Finance Committee

MCO: Managed Care Organization—BHC contracts four MCOs to provide physical and behavioral health services to Medicaid enrollees (SE handles non-Medicaid funds)

MHC: Mental Health Court—Promising practice which operates much like a drug court to redirect mentally ill offenders to from prisons to ensure they receive care

MST: Multisystemic Therapy—Similar to FFT, MST is an evidence based treatment that focuses not only on providing therapeutic services to the patient, but also to ensuring that they have a supportive core environment of family and teachers

NMCD: New Mexico Corrections Department

PED: New Mexico Public Education Department



SAMHSA: Substance Abuse and Mental Health Services Administration—Federal agency responsible for the provision of mental health resources, which provides over $11 million annually to New Mexico in mental health block grants

SE: Statewide Entity—Responsible for purchasing behavioral health services.

From 2004-2008, this was Value-Options NM, and has been OptumHealth NM since then. Was initially responsible for all purchasing, but is now only responsible for non-Medicaid funds (Medicaid has been transferred to MCOs)

WSIPP: Washington State Institute on Public Policy


Behavioral Health Care Policy in New Mexico August 2016

SourcesSystem Overview

1) “Behavioral Health Collaborative.” New Mexico Behavioral Health Collaborative. n.d. Web. 1 July 2016. Link

2) Romanoff, Andrew. “"Behavioral Health: The Benefits of Early Intervention and the Costs of Inaction." Bernalillo County, City of Albuquerque, United Way of Central New Mexico, Greater Albuquerque Chamber of Commerce, and the UNM Department of Psychiatry and Behavioral Sciences. University of New Mexico. Albuquerque, NM. 23 June 2016. Lecture.

3) Archer, Nancy Jo. Personal Interview. 23 May 2016.

4) Report to the Legislative Finance Committee. “Cost and Outcomes of Selected Behavioral Health Grants and Spending.” New Mexico Human Services Department. Report 13-04. 16 May 2013. Link

Evidence Based Practices


2) “Multisystemic Therapy.” MST Services. Multisystemic Therapy Institute. 2015. Web. 27 June 2016. Link

3) “Clinical Model.” Functional Family Therapy. 2016. Web. 27 June 2016. Link

4) “Where We Stand: Wraparound Services.” Bazelon. Bazelon Center for Mental Health Law. n.d. Web. 27 June 2016. Link

5) Kernan, Joan B. "Measuring Wraparound Fidelity to Make Quality Improvements." Community Mental Health Journal. 50.8 (2011): 903-908. Web. Link

6) Bruns, Eric J., et al. "Effectiveness of Wraparound Versus Case Management for Children and Adolescents: Results of a Randomized Study." Administration and Policy in Mental Health and Mental Health Services Research 42.3 (2015): 309-322. Web. Link

7) Faw Stambaugh, Leyla, et al. "Outcomes From Wraparound and Multisystemic Therapy in a Center for Mental Health Services System-of-Care Demonstration Site." Journal of Emotional and Behavioral Disorders, 15.3 (2007): 143-155. Web. Link

8) Bruns, Eric J., Christine M. Walrath, and Angela K. Sheehan. "Who Administers Wraparound? An Examination of the Training, Beliefs, and Implementation Supports for Wraparound Providers." Journal of Emotional and Behavioral Disorders. 15.3 (2007): 156-168. Web. Link


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http://www.bazelon.org/Where-We-Stand/Success-for-All-Children/Mental-Health-Services-for-Children/Wraparound-Services-.aspx

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http://www.bhc.state.nm.us/

Date Title

9) Cummings, John E. "The cost of crazy: how therapeutic jurisprudence and mental health courts lower incarceration costs, reduce recidivism, and improve public safety." Loyola Law Review 56.1 (2010): 279+. Web. 27 June 2016. Link


11) New Mexico. Behavioral Health Collaborative. “Transforming the Behavioral Health Care System into an Integrated System of Care Built on Principles of Recovery and Resiliency.” Provider Training Lecture. n.d. Web. 27 June 2016. Link

12) McCray, Cassandra A. “The Quality Review: Comprehensive Community Support.” Pee Dee Mental Health Center. State of South Carolina. Mar. 2009. PDF. Web. 27 June 2016. Link

13) Chinman, Matthew et. al. “Peer Support Services for Individuals with Serious Mental Illnesses: Assessing the Evidence.” Assessing the Evidence Base Series. Psychiatric Services 65.4 (2014): 429-441. Web. 29 June 2016. Link

Areas for Improvement


2) “Screenings.” Mental Health Colorado. July 2016. Web. 6 July 2016. Link

3) Health Services Advisory Group. Report to the Colorado Department of Health Care Policy & Financing. “FY 2015–2016 Validation of Performance Measures for Behavioral Healthcare, Inc.” Colorado Medicaid Community Mental Health Services Program. April 2015. Link

4) Romanoff, Andrew. “"Behavioral Health: The Benefits of Early Intervention and the Costs of Inaction." Bernalillo County, City of Albuquerque, United Way of Central New Mexico, Greater Albuquerque Chamber of Commerce, and the UNM Department of Psychiatry and Behavioral Sciences. University of New Mexico. Albuquerque, NM. 23 June 2016. Lecture.

5) New Mexico Corrections Department. “Quarter 4 Fiscal Year 2015 Report Card.” New Mexico Legislature. Web. 25 July 2016. Link

6) United States Prison Bureau. “Annual Determination of Average Cost of Incarceration [2014].” Office of the Federal Register. 9 Mar. 2015. Web. 25 July 2016. Link


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https://www.federalregister.gov/articles/2015/03/09/2015-05437/annual-determination-of-average-cost-of-incarceration

https://www.nmlegis.gov/handouts/CCJ%20092215%20Item%207%20NMCD%20Q4%20FY15%20Report%20Card.pdf

https://www.colorado.gov/pacific/sites/default/files/Behavioral%20HealthCare%20Inc%20Performance%20Measure%20Validation%202016.pdf

http://www.mentalhealthcolorado.org/screenings/


http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201300244#_i15

http://www.state.sc.us/dmh/peedee/quality_review/2009_mar.pdf

http://www.bhc.state.nm.us/pdf/mtg/CCSS_Training.pdf

http://go.galegroup.com.proxyau.wrlc.org/ps/i.do?p=LT&u=wash11212&id=GALE%7CA245953096&v=2.1&it=r&sid=summon&userGroup=wash11212&authCount=1

official behavioral health report first draft

Documents