Outsourcing Responsibility: Behavioral Health Care Services

This chapter looks at the behavioral healthcare crisis in New Mexico, and how systematic failure,  top down healthcare reform, and corporate profit, culminated in the use of FEDERAL FRAUD PROTECTION (in the patient protection clause in ACA) to CURTAIL availability of and access to services.

• these actions have adversely affected groups of citizens who do not have access to the social capitol and political clout to advance meaningful change in how their services are structured, financed, or delivered.
• New Mexico has one of the worst behavioral health systems in the countries with the highest levels of addiction and untreated mental health issues
• 87% of services were offered by the nonprofit sector (before they were forced to close because they were accused of fraud and could not afford to fight the audits)

Total bureaucratization, transparency, and "Truthiness"

• Premised on the adoption of neoliberal ideology and marketization of healthcare
• Assumption: Health care costs are the result of inefficient government management
• Solution: Privatization
• dismantling of social welfare programs- gives people choices!
• marketization- partnership between government and profit-driven private entities
• accompanied by new standards of management and accounting, and technologies of supervision = "total bureaucratization" (David Graeber)
• ultimate goal is to extract profits from the social programs
• audit system devised to promote accountability
• nonprofit system in NM was deemed nontransparent and corrupt (although they were cleared of all charges-damage was already done)
• accusations become shrouded in an aura of "truthiness"- where absent evidence we still feel that it is true in our gut-the appearance of truthfulness.
• 1997- NM institutes MANAGED CARE for behavioral and mental health services
• address public sector accountability and decrease costs
• in practice, diverted funds from care to corporate administration and created financial hardship for providers
• more than 60 programs closed reducing services dramatically
• specialty clinics stopped accepting medicaid patients
• 2005- "Transformation" reforms led to the contracting with the for profit ValueOptions a behavioral health subsidiary of United Healthcare, Inc. (headed by a former governor)
• subject to recurring implementation problems and although they were implemented because of the need for transparency and accountability, they never produced data (either) that showed their performance (which was dismal)
• frequent billing and coverage changes
• higher overhead and labor cost for providers
• long waits for reimbursement and survival dependent of unaccounted "prepayments" which were later subject to "reconciliations" costing providers even more
• created an adverse relationship with service providers
• sold as "modernizing behavioral healthcare"- providers accused of not adjusting and being greedy
• 2014- together, called CENTENNIAL CARE

Fraud and Transparency Under Centennial Care

• 5 months prior to enacting CC, the HSD accused 20 nonprofit organizations of fraud. 
• New govt. rules required that "credible allegations" mandated the halting of payments by OptumHealth 
• meanwhile they made a 3$ contract (in secret) with PCG to conduct audits on the nonprofits - agreeing that any violations founds would send those monies to OptumHealth (profit)
• Accused nonprofits of mishandling services (like failure to provide hospitalization) for services they didn't even provide-- even though previous audits had given all the nonprofits high marks
• ACA had empowered the state agencies to aggressively crack down on fraud and waste, and although they were offered a half dozen other alternatives to halting payments, they didn't take advantage of them
• implement other remedies to protect medicaid funds
• allow the organizations to provide written evidence to the contrary
• allow some services that are not deemed compromised to continue
• conclude that the payment suspension is not in the best interest of medicaid
• OptumHealth portrayed as the hero- rooting out fraud and providing modern services
• Choices
• shut down their nonprofits
• allow 5 other for profit companies already selected from AZ to take over their facilities, internal operations, and clinical care. (most took the hostile takeover option)
• 2016- All accused nonprofits were exonerated after it was shown that 35,000 patients had lost care, resulting in increased rates of suicide and incarceration, and homelessness. 
• also uncovering of fraud and corruption, political payoffs by journalists
• Of the cleared, most were already out of business
• 2018- When money was no longer available, 4 of the 5 Arizona companies pulled out of the state, creating a huge service gap
• Optumhealth was accused of fraud (and falsifying fraud claims of others to benefit) but was continually paid by the state during this time
• OptumHealth covered up false medicaid claims to get larger reimbursements.

New Mexico still has the worst behavioral health system in the country.