Medicaid Managed Care for Mental Health Services: The Survival of Safety Net Institutions in Rural Settings (2008) (original) (raw)
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Medicaid managed care for mental health services in a rural state
Journal of Health Care for the …, 2005
State governments throughout the country increasingly have turned to managed care for their Medicaid programs, including mental health services. We used ethnographic methods and a review of legal documents and state monitoring data to examine the impact of Medicaid reform on mental health services in New Mexico, a rural state. New Mexico implemented Medicaid managed care for both physical and mental health services in 1997. The reform led to administrative burdens, payment problems, and stress and high turnover among providers. Restrictions on inpatient and residential treatment exacerbated access problems for Medicaid recipients. These facts indicate that in rural, medically underserved states, the advantages of managed care for cost control, access, and quality assurance may be diminished. Responding to the crisis in mental health services, the federal government terminated New Mexico's program but later reversed its decision after political changes at the national level. This contradictory response suggests that the federal government's oversight role warrants careful scrutiny by advocacy groups at the local and state levels.
Power, blame, and accountability: Medicaid managed care for mental health services in New Mexico
Medical anthropology quarterly, 2005
I examine the provision of mental health services to Medicaid recipients in New Mexico to illustrate how managed care accountability models subvert the allocation of responsibility for delivering, monitoring, and improving care for the poor. The downward transfer of responsibility is a phenomenon emergent in this hierarchically organized system. I offer three examples to clarify the implications of accountability discourse. First, I problematize the public-private "partnership" between the state and its managed care contractors to illuminate the complexities of exacting state oversight in a medically underserved, rural setting. Second, I discuss the strategic deployment of accountability discourse by members of this partnership to limit use of expensive services by Medicaid recipients. Third, I focus on transportation for Medicaid recipients to show how market triumphalism drives patient care decisions. Providers and patients with the least amount of formal authority and p...
Psychiatric services (Washington, D.C.), 2014
Gubernatorial administrations in New Mexico have initiated four overhauls of the publicly funded behavioral health care system over the past two decades. The most recent effort, Centennial Care, was implemented under a Section 1115 Medicaid waiver in January 2014. The authors describe Centennial Care, which closely resembles the now defunct restructuring of the public system that introduced Medicaid managed behavioral health care to the state in 1997. They also note disruptions in services to clients and hardships for providers, described locally as a "behavioral health crisis," that resulted from actions taken in 2013 by the current gubernatorial administration to force the takeover of 15 nonprofit service delivery agencies by five Arizona companies. These actions led to an onsite investigation by the Centers for Medicare and Medicaid Services.
American Journal of Public Health, 2002
PUBLIC HEALTH MATTERS Objectives. This project used a long-term, multi-method approach to study the impact of Medicaid managed care. Methods. Survey techniques measured impacts on individuals, and ethnographic methods assessed effects on safety-net providers in New Mexico. Results. After the first year of Medicaid managed care, uninsured adults reported less access and use (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.34, 0.64) and worse barriers to care (OR = 6.60; 95% CI = 3.95, 11.54) than adults in other insurance categories. Medicaid children experienced greater access and use (OR = 2.11; 95% CI = 1.21, 3.72) and greater communication and satisfaction (OR = 3.64; 95% CI = 1.13, 12.54) than children in other insurance categories; uninsured children encountered greater barriers to care (OR = 6.29; 95% CI = 1.58, 42.21).There were no consistent changes in the major outcome variables over the period of transition to Medicaid managed care. Safetynet institutions experienced marked increases in workload and financial stress, especially in rural areas. Availability of mental health services declined sharply. Providers worked to buffer the impact of Medicaid managed care for patients. Conclusions. In its first year, Medicaid managed care exerted major effects on safety-net providers but relatively few measurable effects on individuals. This reform did not address the problems of the uninsured.
Psychiatric Services, 2003
The extensive literature on Medicaid gives scant attention to the role of public input in state officials' decisions to include vulnerable populations in Medicaid managed care programs. Evaluations of public health initiatives suggest that community input can be vital to a program's effectiveness and success (1). Section 1915(b) waivers allow states to require that Medicaid recipients enroll in capitated managed care programs. Under the Balanced Budget Act of 1997, states seeking to enroll vulnerable populations, including seriously mentally ill individuals, must obtain waivers. National advocacy groups support this requirement, because it ensures federal scrutiny of managed care systems originally designed for healthier clienteles (2). Thirty-five states currently operate 77 1915(b) waivers (3), which must be approved by the Centers for Medicare and Medicaid Services (CMS) and renewed at two-year intervals. Federal regulations do not specify how consumers of mental health services, patient advocates, and providers are to be involved in the development, evaluation, and renewal of waiver programs (4). Each state determines the extent of public involvement in these three areas. Involvement can take several forms, such as including community stakeholders in advisory bodies, soliciting their concerns in public forums, and incorporating their comments in waiver proposals. Nevertheless, public participation in the design and renewal of waiver programs may not be systematic or ongoing (5). Several barriers inhibit sustained involvement of community stakeholders in system-level oversight roles, including lack of training, technical support, and compensation.
Medicaid Managed Behavioral Health in Rural Areas
Journal of Rural Health, 2003
Abstract: As of 2000, 21 states had implemented Medicaid managed behavioral health (MMBH) programs for a significant portion of their rural population. It is not clear how MMBH programs may work in rural areas since they are primarily designed to control mental health utilization. In rural areas the challenge is often to enhance service delivery, not to reduce it. MMBH programs may also affect important features of rural delivery systems, including access to care and coordination of primary care and specialty mental health providers. This article describes the implementation of MMBH programs in rural areas based on an inventory of states implementing MMBH programs in rural counties conducted between June 1999 and June 2000. The experience of MMBH programs in rural areas is also described based on case studies conducted in six states. All 21 states included the general Medicaid population (Temporary Assistance for Needy Families); 17 states included special Medicaid populations (adults with serious and persistent mental illness and children with serious emotional disturbances). Slightly less than half the states integrated (carved-in) behavioral health with physical health services in serving the general Medicaid population; only one state integrated these services for the special Medicaid population. Access to mental health care in rural areas had generally not been restricted. MMBH had little impact on the linkage between primary care and mental health. Local Managed Behavioral Health Organizations, formed by public sector entities and providers, played an increasingly important role in the evolution of MMBH.
Psychiatric Services, 2003
The extensive literature on Medicaid gives scant attention to the role of public input in state officials' decisions to include vulnerable populations in Medicaid managed care programs. Evaluations of public health initiatives suggest that community input can be vital to a program's effectiveness and success (1). Section 1915(b) waivers allow states to require that Medicaid recipients enroll in capitated managed care programs. Under the Balanced Budget Act of 1997, states seeking to enroll vulnerable populations, including seriously mentally ill individuals, must obtain waivers. National advocacy groups support this requirement, because it ensures federal scrutiny of managed care systems originally designed for healthier clienteles (2). Thirty-five states currently operate 77 1915(b) waivers (3), which must be approved by the Centers for Medicare and Medicaid Services (CMS) and renewed at two-year intervals. Federal regulations do not specify how consumers of mental health services, patient advocates, and providers are to be involved in the development, evaluation, and renewal of waiver programs (4). Each state determines the extent of public involvement in these three areas. Involvement can take several forms, such as including community stakeholders in advisory bodies, soliciting their concerns in public forums, and incorporating their comments in waiver proposals. Nevertheless, public participation in the design and renewal of waiver programs may not be systematic or ongoing (5). Several barriers inhibit sustained involvement of community stakeholders in system-level oversight roles, including lack of training, technical support, and compensation.
Characterization of Rural Mental Health Service Systems
Journal of Rural Health, 1999
Abstract: This paper explores two mental health systems in rural North Carolina that provide services to people with severe mental disorders. Recent findings show rural people with mental disorders receive less mental health care than their urban counterparts. This study asks whether rural service systems differ from urban systems in the way that their services are coordinated and structured. A popular conception is that public mental health systems in the United States are uncoordinated with many services provided outside the mental health sector. Rural service providers are seen as even more dependent on non specialized mental health providers than their urban counterparts. While many rural service barriers are attributed to the rural environment, little is known about rural service systems and how their organization might contribute to or negate barriers to care. Social network methods were used in this study to compare two rural with four urban systems of care. Findings confirm that mental health systems fit the de facto hypothesis, but that rural systems differ in ways not anticipated by the hypothesis. Rather than being more dependent on non mental health agencies, rural mental health agencies are more interdependent.