U.S. Department of Health and Human Services Office of Inspector General Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care OEI-02-17-00490 September 2019 Joanne M. Chiedi Acting Inspector General oig.hhs.gov Report in Brief U.S. Department of Health and Human Services September 2019 OEI-02-17-00490 Office of Inspector General Why OIG Did This Provider Shortages and Limited Availability of Review Behavioral Health Services in New Mexico’s Medicaid The need for behavioral health services is Managed Care particularly pronounced in New Mexico—a State What OIG Found that has among the Despite the need for behavioral health services—which Key Takeaway highest rates for suicide includes treatments and services for mental health and and deaths from substance use disorders—many counties in New Mexico have The challenges faced by New overdose in the Nation. few licensed behavioral health providers serving Medicaid Mexico—including provider The Office of Inspector managed care enrollees. These behavioral health providers shortages and limited General (OIG) received a are unevenly distributed across the State, with rural and availability of behavioral congressional request to frontier counties having fewer providers and prescribers per health services—are likely look into concerns 1,000 Medicaid managed care enrollees. Further, a significant shared by other States and about behavioral health number of New Mexico’s licensed behavioral health providers will require both State and provider shortages and do not provide services to Medicaid managed care enrollees. national attention. the availability of care In addition, most of the State’s licensed behavioral health for Medicaid managed providers serving Medicaid managed care enrollees work in behavioral health organizations care enrollees; these (BHOs), which include federally qualified health centers and community mental health centers; enrollees account for however, BHOs report challenges with finding and retaining staff, as well as ensuring most of New Mexico’s transportation for enrollees. As a result, these organizations cannot always ensure timely access Medicaid population. for enrollees seeking behavioral health services. These organizations also report difficulty arranging or making referrals for services that they do not provide largely because of the lack of How OIG Did This providers. In addition, they report challenges with continuity of care for enrollees, citing limited Review care coordination and lack of integration of primary and behavioral healthcare, provider We analyzed State shortages, and barriers to sharing health information, such as a lack of access to broadband. Medicaid managed care Nonetheless, BHOs highlight promising initiatives to increase the availability of behavioral health data on the number of services, including open-access scheduling, treatment first, care integration, and telehealth. behavioral health providers and the What OIG Recommends number of managed Although this report focuses on New Mexico, it provides insights into challenges that are likely care enrollees by shared by other States providing behavioral health services to Medicaid enrollees, especially in rural county. We also and frontier counties. In addition, because of the breadth and depth of these issues, additional conducted a survey of support at the national level is needed. Therefore, we recommend that the Centers for Medicare & selected BHOs that play Medicaid Services (CMS) identify States that have limited availability of behavioral health services a critical role in and develop strategies and share information with them to ensure that Medicaid managed care providing services to the enrollees have timely access to these services. We also recommend that the New Mexico Human State’s Medicaid Services Department expand New Mexico’s behavioral health workforce that serves Medicaid enrollees as well as to managed care enrollees. It should also improve access to services by reviewing its access to care uninsured residents. In standards and by increasing access to transportation, access to broadband, and the use of addition, we interviewed telehealth. Lastly, it should improve the effectiveness of services by increasing adoption of selected providers, State electronic health records, identifying and sharing information about strategies to improve care Medicaid agency coordination, expanding initiatives to integrate behavioral and primary healthcare, and sharing officials, and key information about open-access scheduling and the Treat First Clinical Model. Both CMS and the stakeholders. New Mexico Human Services Department concurred with our recommendations. The full report can be found at oig.hhs.gov/oei/reports/oei-02-17-00490.asp TABLE OF CONTENTS BACKGROUND 1 Methodology 5 FINDINGS Many counties have few behavioral health providers serving Medicaid managed care enrollees 6 Most behavioral health providers work in behavioral health organizations; however, these 9 organizations report challenges with finding and retaining staff Behavioral health organizations cannot always ensure timely access for enrollees seeking 10 behavioral health services Behavioral health organizations report difficulty arranging or making referrals for services that 12 they do not provide Behavioral health organizations report challenges with continuity of care, citing limited care 15 coordination, provider shortages, and barriers to sharing health information Behavioral health organizations highlight promising initiatives to increase the availability of 18 services, including open-access scheduling, treatment first, care integration, and telehealth CONCLUSION AND RECOMMENDATIONS Recommendation to the Centers for Medicare & Medicaid Services: Identify States that have limited availability of behavioral health services and develop 24 strategies and share information to ensure that Medicaid managed care enrollees have timely access to these services Recommendations to the New Mexico Human Services Department: Take steps to expand New Mexico’s overall behavioral health workforce 24 Increase behavioral health providers’ participation in Medicaid managed care 25 Review its standards governing access to care and determine whether additional standards 25 are needed for behavioral health providers Improve access to transportation for Medicaid managed care enrollees needing behavioral 25 health services Work with State partners to strengthen access to broadband in rural and frontier counties 26 Expand the use of telehealth to increase the availability of behavioral health services 26 Take steps to increase adoption of electronic health records and participation in the State 27 Health Information Exchange by behavioral health providers Identify and share information about strategies to improve care coordination 27 Expand initiatives to integrate behavioral and primary healthcare 28 Share information about open-access scheduling and the Treat First Clinical Model and 28 promote expansion AGENCY AND STATE COMMENTS AND OIG RESPONSE 29 APPENDICES A: Detailed Methodology 31 B: Number of Licensed Behavioral Health Providers That Serve Medicaid Managed Care Enrollees 34 in New Mexico C: Number of Selected Behavioral Health Organizations That Report Having Difficulty Providing 37 Timely Appointments D: Number of Selected Behavioral Health Organizations That Report Having Difficulty Arranging 38 Each Service E: Centers for Medicare & Medicaid Services Comments 40 F: New Mexico Human Services Department Comments 43 ACKNOWLEDGMENTS 47 BACKGROUND Objectives 1. To determine the number of behavioral health providers that serve New Mexico’s Medicaid managed care enrollees in each county. 2. To determine the extent to which behavioral health organizations are able to meet the needs of the State’s Medicaid managed care enrollees. 3. To identify challenges and promising initiatives for improving the availability of behavioral health services for the State’s Medicaid managed care enrollees. Research has shown that Medicaid enrollees experience a higher rate of behavioral health disorders—which include both mental health disorders and substance use disorders—than the general population.1 In spite of the importance of treating such disorders, many Medicaid enrollees encounter significant barriers when accessing behavioral health treatment. These barriers include an overall shortage of behavioral health providers in the United States, combined with a relatively small number of behavioral health providers who accept Medicaid.2 Such barriers can impede access to necessary services, resulting in untreated addiction and mental health conditions, worsening health, and increased medical costs.3 ___________________________________________________________ 1 Government Accountability Office (GAO), Medicaid Expansion: Behavioral Health Treatment Use in Selected States in 2014, (GAO-17-529), June 2017. Accessed at https://www.gao.gov/assets/690/685415.pdf on April 4, 2019. 2Substance Abuse and Mental Health Services Administration (SAMHSA), Report to Congress on the Nation’s Substance Abuse and Mental Health Workforce Issues, January 24, 2013. Accessed at https://www.cibhs.org/sites/main/files/file-attachments/samhsa_bhwork_0.pdf on April 5, 2019. See also Medicaid and CHIP Payment and Access Commission (MACPAC), Physician Acceptance of New Medicaid Patients, January 24, 2019. Accessed at https://www.macpac.gov/wp-content/uploads/2019/01/Physician-Acceptance-of-New- Medicaid-Patients.pdf on April 5, 2019. 3GAO, Medicaid Expansion: Behavioral Health Treatment Use in Selected States in 2014, June 2017. Accessed at https://www.gao.gov/assets/690/685415.pdf on April 4, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 1 OEI-02-17-00490 Improving access to behavioral healthcare is essential in New Mexico, where 56 percent of adults with mental illness do not receive treatment.4 Further, the State has among the highest rates for suicide and deaths from overdose in the Nation.5 New Mexico also ranks as one of the poorest States in the Nation, with more than half of the population either covered Behavioral health includes: by public health insurance or • promotion of emotional health, uninsured.6 • prevention of mental illnesses and In 2013, New Mexico substance use disorders, and experienced major disruptions in services, with the closure • treatment and services for mental and replacement of many of its and substance use disorders. largest behavioral health organizations (see text box below). The Office of Inspector General (OIG) received a congressional request to look into concerns about behavioral health provider shortages in Medicaid managed care. In response, OIG agreed to conduct a review to determine the number of behavioral health providers that serve the State’s Medicaid managed care enrollees and the availability of care to meet the needs of this population. OIG also agreed to look at the extent to which providers have waiting lists, the extent to which providers have difficulty making referrals, and any challenges with continuity of care. Historical perspective of behavioral health in New Mexico The behavioral health system in New Mexico experienced major disruptions in the provision of care that affected Medicaid managed care enrollees. In 2013, the New Mexico Human Services Department suspended Medicaid payments to 15 behavioral health organizations due to an accusation of fraud; these 15 organizations provided about 85 percent of all behavioral health services to enrollees. Although all of these organizations were eventually cleared of wrongdoing in subsequent years, 13 of them went out of business. These organizations were initially replaced by Arizona-based organizations; however, all but two of these replacement organizations are no longer practicing in the State. ___________________________________________________________ 4 SAMHSA, Behavioral Health Barometer: New Mexico, Volume 4: Indicators as Measure Through the 2015 National Survey on Drug Use and Health, the National Survey of Substance Abuse Treatment Services, and the Uniform Reporting System, 2017. Accessed at https://www.samhsa.gov/data/sites/default/files/NewMexico_BHBarometer_Volume_4.pdf on June 10, 2019. 5New Mexico Health Care Workforce Committee, 2017 Annual Report, October 1, 2017. Accessed at http://www.hsd.state.nm.us/uploads/PressRelease/2f473c14ee 654f868b5a25b3cfd15a6d/NMHCWF_2017Report_eDist_LoRes.pdf on April 3, 2019. 6 U.S. Census Bureau, 2013–2017 American Community Survey 5-Year Estimates, Selected Economic Characteristics. Accessed at https://factfinder.census.gov/faces/ tableservices/jsf/pages/productview.xhtml?src=bkmk on June 10, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 2 OEI-02-17-00490 Medicaid managed care in New Mexico Medicaid plays a critical role in providing behavioral healthcare. Nationally, Medicaid is the single largest payor for behavioral healthcare, accounting for approximately 11 percent of all Medicaid spending.7 Most States, including New Mexico, provide a portion—if not all—of their behavioral health services through Medicaid managed care plans. These plans typically provide behavioral health services through a network of participating providers in exchange for a fixed monthly fee per enrollee (often referred to as capitation). New Mexico’s Medicaid managed care program, Centennial Care, was implemented in 2014 and requires managed care plans to cover services for physical health, behavioral health, and long-term care.8 Most (80 percent) of New Mexico’s Medicaid population is enrolled in one of New Mexico’s three managed care plans.9 These plans provide services to enrollees throughout the State, and most of the behavioral health providers that participate in Medicaid managed care participate in all of the State’s managed care plans. Federal regulations require States to develop standards for access to care that all managed care plans must meet.10 These standards are intended to ensure that each plan maintains an adequate network to provide access to covered Medicaid services.11 New Mexico’s standards for behavioral health require that appointments for non-urgent behavioral healthcare be ___________________________________________________________ 7 This analysis is based on 2009 Medicaid data. Mark et al., Insurance Financing Increased for Mental Health Conditions But Not for Substance Use Disorders 1986-2014, June 2016. Accessed at https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2016.0002 on June 10, 2019. 8 The New Mexico Human Services Department oversees the Medical Assistance Division and the Behavioral Health Services Division. The Medical Assistance Division is responsible for contracting with Medicaid managed care organizations and the Behavioral Health Services Division oversees SAMHSA-funded behavioral health block grants. 9These data were provided by the New Mexico Human Services Department. Note that the Native American population is typically exempt from the requirement to enroll in a managed care plan. See New Mexico Administrative Code (NMAC) 8.308.7.9(A). Also note that for most of the study period, there were four Medicaid managed care plans in the State. 10 42 CFR § 438.206(a). 11 42 CFR § 438.206(b)(1). Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 3 OEI-02-17-00490 available within 14 days and behavioral health outpatient appointments for urgent conditions be available within 24 hours.12 Licensed behavioral health providers Licensed behavioral health providers have a range of education and training in specialties that address substance use and mental health needs. These behavioral health providers are able to engage in a broad range of interventions, including assessment, psychotherapy, and crisis intervention services. Independently licensed providers may be directly reimbursed by Medicaid for their services. Such providers include psychiatrists, psychologists, and licensed clinical social workers.13 Certain independently licensed behavioral health professionals are also authorized to diagnose mental illness and substance use disorders, and in some cases, can prescribe medication as part of an enrollee’s treatment plan.14 The next level of licensure consists of non-independently licensed providers. These providers typically work under the supervision of an independently licensed provider and generally cannot be directly reimbursed for their services. These providers include licensed master’s level social workers, licensed mental health counselors, and licensed associate marriage and family therapists.15 Behavioral health organizations Although outpatient behavioral health services can be provided by individuals (and by individuals who form group practices), behavioral health organizations (BHOs) are core providers that play a critical role in providing ___________________________________________________________ 12 NMAC 8.308.2.12 (E), (F). The standard governing request-to-appointment time, for non- urgent behavioral healthcare, can be waived if the enrollee requests a later time. New Mexico also requires that appointments for behavioral health crisis services be available within two hours. See NMAC 8.308.2.12 (R). In addition, New Mexico requires its managed care organizations to comply with standards that address distance and travel time between enrollees and contracted providers. See NMAC 8.308.2.9 (A)(11)(c). 13 NMAC, 8.321.2.9 (H). 14New Mexico Health Care Workforce Committee, 2017 Annual Report, October 1, 2017. Accessed at http://www.hsd.state.nm.us/uploads/PressRelease/2f473c14ee654 f868b5a25b3cfd15a6d/NMHCWF_2017Report_eDist_LoRes.pdf on April 25, 2019. 15NMAC 8.321.2.9 (J). Some behavioral health services may be provided by non-licensed providers who are not able to prescribe medication and are not able to practice without supervision. These include master’s level behavioral health interns, certified peer support workers, and pre-licensure psychology post-doctorate students. New Mexico Network of Care, Behavioral Health in New Mexico: Challenges, Medicaid Contributions, New Opportunities. Accessed at http://newmexico.networkofcare.org/content/client/1446/3Centennial%20Care%20Update- Final.pdf on June 10, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 4 OEI-02-17-00490 services to the State’s Medicaid enrollees as well as to uninsured residents. BHOs include federally qualified health centers, community mental health centers, behavioral health agencies, rural health clinics, and core service agencies.16 In addition to outpatient services, a number of behavioral health services are delivered in inpatient or residential settings. These include psychiatric hospitals, residential treatment centers, as well as facilities that provide inpatient treatment for substance use disorders. Methodology We used several data sources to address the study’s objectives. We first analyzed State Medicaid managed care data to determine the number of behavioral health providers serving New Mexico’s managed care enrollees by county. We focused this part of the study on licensed behavioral health providers who render outpatient services to Medicaid managed care enrollees. Licensed behavioral health providers have the specific education and training needed to address a broad range of mental health and substance use disorders. We did not include non-licensed behavioral health workers and other physical health workers who may provide only limited behavioral health services such as diagnostic screening.17 Next, we conducted a survey of 53 selected BHOs to determine the extent to which these organizations are able to meet the needs of the State’s Medicaid managed care enrollees. In addition, we interviewed selected behavioral health providers, State Medicaid agency officials, and key stakeholders. We analyzed these data to identify challenges and promising initiatives for improving the availability of behavioral health services for Medicaid managed care enrollees. See Appendix A for the detailed methodology. Standards We conducted this study in accordance with the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. ___________________________________________________________ 16 New Mexico may designate a BHO as a core service agency if it provides and coordinates certain core services, such as psychiatric services, medication management, crisis services, and treatments that support an enrollee’s recovery goals. This study also does not include out-of-State behavioral health providers licensed by New 17 Mexico who provide services remotely. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 5 OEI-02-17-00490 FINDINGS Many counties New Mexico has about 2,700 licensed behavioral health providers that serve its Medicaid managed care enrollees. These behavioral health providers are have few distributed unevenly across the State. As a result, many counties have few behavioral health providers that serve Medicaid managed care enrollees. providers serving New Mexico has 2,665 licensed behavioral health providers that Medicaid managed serve nearly 670,000 Medicaid managed care enrollees care enrollees Licensed providers are essential to meeting the behavioral health needs of enrollees. Enrollees with serious mental illnesses or substance use disorders often require a team of providers that consist of several different types of licensed providers. These providers include prescribing providers such as psychiatrists and advance practice nurses. They also include other independently licensed providers, such as professional clinical counselors, clinical social workers, and marriage and family therapists. Additionally, there are non-independently licensed providers that include social workers, registered nurses, and substance use counselors. These providers generally cannot be directly reimbursed for their services and typically work under the supervision of an independently licensed provider. In total, New Mexico has 2,665 licensed behavioral health providers that serve its Medicaid managed care enrollees in 2017. See Exhibit 1 for more detailed information about the number of licensed providers in New Mexico. Exhibit 1: Licensed behavioral health providers in New Mexico. Source: OIG analysis of State Medicaid data, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 6 OEI-02-17-00490 Many of the State’s licensed behavioral health providers do not serve Medicaid managed care enrollees Shortages of behavioral health providers are a problem that affects behavioral healthcare for all populations, not just for its managed care enrollees.18 A study of the New Mexico healthcare workforce found that 9,528 behavioral health providers had active licenses in the State in 2016.19 The smaller number of providers that we identified—just 2,665 providers or 30 percent—indicates that many behavioral health providers in New Mexico do not provide services to Medicaid managed care enrollees. If only a small proportion of that workforce serves Medicaid enrollees, enrollees’ access to critical services can be impeded. More than half of New Mexico’s counties have fewer than 2 licensed providers per 1,000 enrollees; all of these counties are rural or frontier The 2,665 licensed behavioral health providers are distributed unevenly across the State. Notably, 19 of the State’s 33 counties have fewer than 2 licensed behavioral health providers for every 1,000 Medicaid managed care enrollees. All 19 of these counties are rural or frontier.20 This includes 13 counties that have between 1 and 2 providers per 1,000 enrollees; 3 counties that have fewer than 1 provider per 1,000 enrollees; and 3 counties that have no providers at all. In contrast, four counties—most of them urban—have much larger numbers of licensed providers per 1,000 enrollees. These 4 counties ranged from 6 to 19 providers per 1,000 enrollees. See Exhibit 2 and Appendix B for the number of licensed behavioral health providers by county. ___________________________________________________________ 18 Almost all of New Mexico’s counties have a “health professional shortage area” for mental health. For more information see Health Resources and Services Administration, Health Professional Shortage Areas Find. Accessed at https://data.hrsa.gov/tools/shortage- area/hpsa-find on May 24, 2019. 19Note that this analysis was mandated by the State of New Mexico’s Legislature. The 9,528 providers identified in the study are the same types of providers that are included in our report. See New Mexico Health Care Workforce Committee, 2017 Annual Report, October 1, 2017. Accessed at http://www.hsd.state.nm.us/uploads/PressRelease/2f473c 14ee654f868b5a25b3cfd15a6d/NMHCWF_2017Report_eDist_LoRes.pdf on April 25, 2019. 20New Mexico designates counties as urban, rural, or frontier. Note that frontier counties have an average of 2.8 people per square mile, and rural counties have an average of 13.7 people per square mile. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 7 OEI-02-17-00490 Exhibit 2: Distribution of licensed behavioral health providers in New Mexico. Source: OIG analysis of State Medicaid data, 2019. Rural and frontier counties have disproportionately fewer licensed providers than urban counties. Only 29 percent of licensed providers are located in rural and frontier counties, even though nearly half of the State’s Medicaid managed care enrollees reside in these counties. Further, rural and frontier counties have a median of 1.8 providers and 1.5 providers per 1,000 Medicaid managed care enrollees, respectively. In contrast, urban counties have a median of 6.4 providers. See Exhibit 3. Similarly, rural and frontier counties have disproportionately fewer behavioral health prescribers. Ten frontier counties—with a total of 27,000 Medicaid managed care enrollees—have no prescribers. Further, rural and frontier counties have a median of 0.2 prescribers and 0.0 prescribers per 1,000 Medicaid managed care enrollees, while urban counties have a median of 0.7 prescribers. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 8 OEI-02-17-00490 Exhibit 3: Rural and frontier counties have a lower median number of providers and prescribers. Median Number of Median Number of Prescribing Behavioral Health Providers Behavioral Health Providers County Type per 1,000 Enrollees per 1,000 Enrollees Urban 6.4 0.7 Rural 1.8 0.2 Frontier 1.5 0.0 Source: OIG analysis of State Medicaid data, 2019. Most behavioral Sixty-two percent of the State’s licensed behavioral health providers serving Medicaid enrollees work in BHOs.21 These organizations play a unique role health providers in the State’s behavioral health system work in behavioral because they are responsible for health coordinating care and providing essential organizations; services to managed care enrollees who have serious mental illnesses, severe however, these emotional disturbances, or dependence on organizations report alcohol or drugs. BHOs are core providers challenges with typically offering behavioral health services to the State’s Medicaid enrollees as well as finding and uninsured residents.22 retaining staff Notably, 38 of the 53 selected BHOs report that they need additional staff to meet the needs of Medicaid managed care enrollees in their area. They report particularly needing prescribing providers and providers that specialize in treating substance use disorders. Of these BHOs, one in three did not have a prescriber on staff. Additionally, two in three BHOs did not have a provider specializing in substance use disorders on staff. Most of the BHOs in need of additional staff are located in rural and frontier areas. BHOs further note that staffing challenges affect enrollees with all types of diagnoses. As one BHO states, “there are far more requests for services beyond staff capacity.” BHOs also highlight challenges with finding and retaining qualified staff to meet the needs of enrollees. Several cite an overall lack of licensed providers in the State or their area to meet the demands of the population, ___________________________________________________________ 21 The remaining providers work in group or independent practices, other outpatient settings, or inpatient facilities. 22As noted earlier, BHOs include federally qualified health centers, core service agencies, community mental health centers, behavioral health agencies, and rural health clinics. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 9 OEI-02-17-00490 as well as challenges maintaining a highly trained workforce. According to several BHOs, there is an extremely limited pool of qualified candidates, and when they do find qualified candidates, it can be difficult to retain them. This challenge particularly affects rural and frontier BHOs. As one BHO explains, “It is difficult to find and hire therapists in [rural] New Mexico…it is really difficult work with a high burnout rate. Therapists from other areas, [who are not familiar with the specific needs of the community], do not last.” Behavioral health BHOs provide essential behavioral health services to Medicaid managed care enrollees. Yet, many BHOs report that Medicaid managed care organizations enrollees have difficulty accessing the full range of behavioral health cannot always services at the frequency they need. BHOs further report difficulty providing ensure timely access timely appointments for enrollees, and some BHOs for enrollees maintain wait lists for certain seeking behavioral services. Providing timely health services access to behavioral health services is important to ensuring positive health outcomes and to ensuring that patients’ behavioral health conditions do not go untreated. More than half of BHOs are not able to offer timely appointments for enrollees Most BHOs (29 of 53) report that they do not have urgent appointments available within 24 hours or routine appointments available within 14 days with providers in their BHO for Medicaid managed care enrollees. According to New Mexico’s standards, appointments for urgent conditions must be available within 24 hours and appointments for routine behavioral healthcare must be available within 14 days.23 See Appendix C for more detailed information about the number of BHOs that are not able to offer timely urgent or timely routine appointments. ___________________________________________________________ 23 NMAC 8.308.2.12 (E), (F). Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 10 OEI-02-17-00490 Notably, 23 of 53 BHOs are unable to provide urgent appointments with prescribers in their BHOs within 24 hours. Twenty of these BHOs do not have prescribers on staff.24 The other three have wait times for urgent appointments with prescribers that range from 2 days to 21 days. At the same time, four BHOs are unable to provide urgent appointments with non- prescribers in their BHO within 24 hours. For these BHOs, wait times with non-prescribers range from 2 days to 7 days. In addition, 25 of 53 BHOs are unable to provide routine appointments with prescribers in their BHOs within the 14 days as established by New Mexico’s standards. For the BHOs with prescribers on staff, wait times for routine appointments range from 20 days to 90 days. Four BHOs are unable to provide routine appointments with non-prescribers in their BHO within 14 days. For these BHOs, wait times for non-prescribers range from 30 days to 75 days. Some BHOs maintain wait lists for certain behavioral health services If the BHO is at capacity, it may have to maintain a wait list until services become available. Fourteen BHOs report having maintained a wait list in the past year for at least one of the services they provide. Most We are not supposed to have commonly, they had wait lists for a wait list, but the reality is certain outpatient services such as that at different times substance abuse treatment or providers have had to use a counseling and therapy. Four BHOs wait list because of workforce had a wait list for up to one month; an issues. additional six BHOs had a wait list for -BHO Administrator longer. BHOs report that wait lists particularly affect services for beneficiaries with autism spectrum disorder, depression, and substance use disorder. ___________________________________________________________ 24 BHOs may provide appointments by arranging services with others providers who are not on their staff. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 11 OEI-02-17-00490 BHOs report that transportation is a challenge to ensuring access to timely services A number of BHOs (9 of 53) highlight challenges with accessing nonemergency medical transportation, despite New Mexico’s requirement that its Medicaid managed care organizations provide such transportation to enrollees who need it.25 For example, one stakeholder notes that there are no nonemergency medical transportation providers in the area that offer service in the evening, making it particularly difficult for enrollees to access intensive outpatient substance abuse counseling services, which are often held in the evening. A few BHOs also note that difficulty accessing nonemergency medical transportation causes delays in care. For example, one BHOs notes, “[non-emergency medical transportation] has to be scheduled, and sometimes that takes a few days for approval. The patient is then seen a week after their initial scheduled appointment.” Behavioral health BHOs arrange services or make referrals for services that enrollees need but that BHOs do not—or currently cannot—provide. Enrollees with mental organizations report health and substance use issues need a range of services that include: difficulty arranging recovery and support services; non-intensive outpatient services; intensive or making referrals outpatient services; and inpatient and residential services. BHOs report difficulty arranging behavioral health services in each category to meet the for services that needs of Medicaid managed care enrollees. See Exhibit 4 for a description they do not provide of the different service categories and Appendix D for the number of BHOs that report having difficulty arranging each service. ___________________________________________________________ 25 New Mexico requires that Medicaid managed care organizations provide nonemergency medical transportation for enrollees who have no other means of transportation and need to get to and from medical services, including behavioral health services. NMAC 8.308.2.12 (P). New Mexico’s managed care organizations contract with providers to offer nonemergency medical transportation services to enrollees. New Mexico Human Services Department, Centennial Care Waiver Demonstration: Section 1115 Quarterly Report, March 2, 2018. Accessed at http://www.hsd.state.nm.us/uploads/files/Public%20Information /Centennial%20Care/Quarterly%20Reports/2017%20Quarterly%20Progress%20Reports/Final %20Report(2).pdf on February 15, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 12 OEI-02-17-00490 Exhibit 4: Behavioral health services includes a variety of services that are generally organized into four categories. Source: OIG analysis of State documentation on behavioral health services, 2019. BHOs most commonly (43 of 53) report having difficulty arranging recovery and support services for Medicaid managed care enrollees. BHOs explain that provider shortages make it difficult to make referrals and can result in enrollees not receiving the support and services that they need. Notably, BHOs report difficulty arranging psychosocial rehabilitation services that help enrollees develop coping strategies, as well as respite care that provides short-term relief for primary caregivers. As one BHO notes, these services are “already provided by an extremely limited number of providers, which is continually shrinking.” Most BHOs (42 of 53) also report having difficulty arranging intensive outpatient services. This includes arranging applied behavior analysis–a type of therapy that focuses on improving social skills and adaptive learning skills for enrollees with autism spectrum disorder. As one rural BHO explains, there are no providers that offer this type of therapy in the five neighboring counties, making it extremely difficult to arrange these services for enrollees. As a result, enrollees may need to travel long distances to the nearest provider. Another rural BHO adds that its nearest autism care provider is 4 hours away. Similarly, most BHOs (39 of 53) report difficulty arranging inpatient and residential services. In particular, some BHOs note that there are a lack of inpatient psychiatric facilities and detox facilities. One stakeholder notes that, as a result, “it is a long, long wait to get enrollees into inpatient Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 13 OEI-02-17-00490 psychiatric treatment, and it is even more difficult to secure inpatient psychiatric treatment for a child.” Further, these facilities may be far away. According to this stakeholder, the nearest child inpatient psychiatric treatment facility is 200 miles away. Another stakeholder notes that many of the inpatient facilities for substance use disorders “will not accept enrollees on any medication, often only accept men, and [will] not accept anyone with mental health diagnoses. This clearly leaves many enrollees without care.” Further, many BHOs (33 of 53) report having difficulty arranging non- intensive outpatient services. Nearly half have difficulty arranging medication assisted treatment to treat opioid addiction, such as buprenorphine. BHOs also attribute this difficulty to the lack of providers. As one provider notes, the number of medication assisted treatment providers in one of the larger urban areas needs to double in size in order to meet current enrollee needs. BHOs also highlight difficulty arranging day treatment—services that focus on improving functional and behavioral deficits—and note a lack of providers offering these services. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 14 OEI-02-17-00490 Behavioral health Continuity of care is particularly important for patients with behavioral health diagnoses because they may require treatment from a number of organizations report providers for extended periods of time.26 Continuity of care includes challenges with maintaining care when transferring from one setting to another, seeing the continuity of care, same provider each visit at the BHO, and exchanging health information throughout the continuum of care. BHOs report a number of concerns citing limited care about continuity of care for Medicaid managed care enrollees. coordination, provider shortages, Enrollees’ care is not always maintained during transitions, due in and barriers to part to limited coordination among providers More than half of BHOs (29 of 53) sharing health report that enrollees’ care is not always A few BHOs use warm handoffs to information maintained when they are transferred promote continuity of care from one level of care to another. Warm handoffs occur between two Breakdowns during transitions of care healthcare providers when a can cause confusion regarding patient is being transferred from treatment plans, duplicative testing, one setting to another. In addition discrepancies in medications, and to in-person communication missed appointments.27 between providers, the patient is A number of BHOs report difficulties also included in the discussion with coordinating enrollees’ care during about his or her plan of care. This transitions. One BHO notes that helps to build relationships constant provider turnover results in between care coordinators, enrollees not effectively transitioning to providers, patients, and their other care providers, causing a families and provide opportunities significant proportion of these enrollees to clarify or correct information. to leave care altogether. Another stakeholder notes that there is a lack of coordinated care for enrollees who need both mental health services and services for substance use disorders. Many of these enrollees must see multiple behavioral health providers to meet their needs, and those providers do not always coordinate patients’ care. ___________________________________________________________ 26 Institute of Medicine Committee on Crossing the Quality Chasm, Coordinating Care for Better Mental, Substance-Use, and General Health, 2006. Accessed at https://www.ncbi.nlm.nih.gov/books/NBK19833/ on March 27, 2019. See also Biringer et al., Continuity of Care as Experienced by Mental Health Service Users: A Qualitative Study, November 21, 2017. Accessed at https://bmchealthservres.biomedcentral.com /articles/10.1186/s12913-017-2719-9 on March 27, 2019. 27Although BHOs strive to provide coordinated care, some types of BHOs are required to do so. See CareLink NM, CareLink NM Health Homes: Provider Policy Manual, 2018. Accessed at https://www.hsd.state.nm.us/uploads/files/Providers/Manuals%20and%20Guides/Managed% 20Care%20Policy%20Manual/CLNM%20Pol%20Manual%2012_28_18.pdf on June 11, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 15 OEI-02-17-00490 A few BHOs also note that the lack of integration between primary and behavioral healthcare acts as a barrier to coordination efforts. Integrating primary and behavioral healthcare—which typically involves close collaboration of both physical and behavioral health providers in the same location—can be critical, since certain behavioral health disorders carry higher incidences of physical issues, including obesity, diabetes, asthma, migraines, heart disease and cancers.28 Enrollees are not always able to see the same providers, often because of a lack of providers or high turnover One-third of BHOs (17 of 53) report that enrollees cannot always see the same provider as the previous visit for the same service. Ongoing relationships with the same provider create stable conditions for enrollees; changes in providers can often create setbacks in treatment, and can sometimes give rise to anxiety, frustration, and a sense of being rejected.29 A few BHOs highlight the importance of engaging in and maintaining such relationships to improve health outcomes. As one provider Part of [ensuring continuity of notes, “enrollees are scheduled care] is you have to keep people with the same provider…which in the workforce. You can see a ensures sustained recovery.” provider more than once—that is really critical—it can be done. BHOs find that a lack of providers - Key Stakeholder limits their ability to keep enrollees with the same provider. For example, according to one BHO, “more patients are being seen in psychiatric emergency services because of the lack of community providers, resulting in continuity of care issues.” Some BHOs also state that staff turnover results in some enrollees being unable to continue with the same provider, which affects enrollees’ health outcomes. For example, a rural provider, who focuses on treatment for autism spectrum disorder, notes that turnover impacts a child’s long-term outcomes since each new provider has to build a rapport with the child and learn the child’s complex treatment plan. Enrollee health information is not always communicated because of barriers to sharing enrollee health information across providers Half of BHOs (26 of 53) report that enrollees’ health information is not always communicated in an effective and timely manner throughout their ___________________________________________________________ 28 The Colorado Health Foundation, The Colorado Blueprint for Promoting Integrated Care Sustainability, March 2012. Accessed at https://www.integration.samhsa.gov/ TCHF_IntegratedCareReport.pdf on January 8, 2019. 29 Biringer et al., Continuity of Care as Experienced by Mental Health Service Users: A Qualitative Study, November 21, 2017. Accessed at https://bmchealthservres .biomedcentral.com/articles/10.1186/s12913-017-2719-9 on March 27, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 16 OEI-02-17-00490 continuum of care. Sharing health information helps coordinate care among different providers and across different settings. It also helps providers reduce unnecessary testing, avoid medication errors, and decrease administrative costs.30 Electronic health record (EHR) systems can be a critical tool for supporting seamless and instantaneous health information exchanges across providers when those providers’ EHR systems are interoperable (able to exchange information). Many BHOs (26 of 53) use EHRs, and find that using EHRs helps them to improve services for enrollees. According to one BHO, its EHRs provide quicker access to health [EHRs] improve continuity of information and improves its care for patients with multiple ability to share records with providers, maintain updated providers and ensure continuity information, document patients’ of care. Some BHOs further note past records, and track patients’ that their EHRs enable providers recovery goals and to collaborate across behavioral interventions. health disciplines and with primary healthcare providers. - BHO Administrator Despite the advantages of EHRs, some BHOs (13 of 52) have not adopted EHRs.31 Nearly all of these BHOs are rural. Rural providers face a unique set of barriers to implementing EHRs, such as difficulty connecting to broadband service. Broadband is high-speed internet access, and is needed to support EHRs and other health information technology services such as telehealth.32 In New Mexico, only 47 percent of people in rural areas have access to advanced broadband, compared to 95 percent of people in urban areas.33 Other barriers to implementing EHRs include a lack of expertise on how to use such technology and what some BHOs perceive to be prohibitive startup costs. One stakeholder further explains, “it is difficult for provider organizations, unless they are very large and have sufficient scale, to afford the cost of an EHR.” ___________________________________________________________ 30 Office of National Coordinator for Health Information Technology (ONC), Why is health information exchange important?, March 21, 2018. Accessed at https://www.healthit.gov/faq/why-health-information-exchange-important on March 18, 2019. 31For information on nationwide BHO adoption of health information technology, see National Council for Community Behavioral Healthcare, HIT Adoption and Readiness for Meaningful Use in Community Behavioral Health, June 2012. Accessed at https://www.thenationalcouncil.org/wp-content/uploads/2012/10/HIT-Survey-Full-Report.pdf on May 3, 2019. 32ONC, Federal Health IT Strategic Plan: 2015-2020. Accessed at https://www.healthit .gov/sites/default/files/9-5-federalhealthitstratplanfinal_0.pdf on May 3, 2019. 33 Federal Communications Commission, 2018 Communications Marketplace Report: Broadband Deployment Appendices, December 31, 2017. Accessed at https://docs.fcc.gov/public/attachments/FCC-18-181A9.pdf on March 21, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 17 OEI-02-17-00490 Other BHOs note that the lack of interoperability between their EHR systems and other providers’ systems presents problems. Interoperability allows unrelated records systems to exchange electronic health information. As one BHO explains, not enough providers in the area can accept and share information with other providers’ EHR systems. Such barriers to interoperability can constrain BHOs’ ability to share health information and coordinate care among different providers and across different settings. Several BHOs also note difficulty with getting enrollee health information from certain types of providers. New Mexico operates a health information exchange (HIE)—a platform through which participating providers can share health information. The HIE has the potential to enable providers to share information about enrollees’ demographics, diagnoses, medications, encounter history, procedures, and even clinical notes. However, there are only a small number of behavioral health providers that participate in the State’s HIE. While the HIE is available to all providers, as one stakeholder notes, providers without EHRs are unable to participate in the HIE. Behavioral health Although BHOs report a number of challenges with the availability of behavioral health services, they also cite a number of promising initiatives. organizations BHOs have adopted these initiatives to varying degrees. These initiatives highlight promising increase the availability of services by improving access to providers, better initiatives to coordinating enrollee care, and expanding the use of technology to deliver increase the services. availability of Exhibit 5: Initiatives to increase the availability of behavioral health services, including services. open-access scheduling, treatment first, care integration, and telehealth Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 18 OEI-02-17-00490 Many BHOs find that open-access scheduling improves the availability of services Many BHOs (34 of 53) have implemented open-access scheduling or walk- in availability. Open-access—also known as advanced access and same-day scheduling—is a method of scheduling in which patients can receive an appointment on the day they call. Rather than booking each provider’s full block of time weeks or even months in advance, this We can see 90 model leaves part of the day open for unscheduled percent of our visits. Another part of the schedule is booked only clients within 24 with clinically necessary follow-up visits and hours of placing a appointments for patients who chose not to come on call. the day they called. BHOs implement open-access - BHO Administrator scheduling in a variety of ways. For example, one BHO reserves a few same-day appointments throughout the week, whereas another reserves one day per week for same-day appointments. All 34 BHOs that have implemented this type of scheduling report that it has improved the availability of services for managed care enrollees. These BHOs commonly note that such initiatives immediately address crisis situations, with one BHO noting that “anything urgent or emergency can be seen immediately, or on the same day.” Several BHOs further note that these initiatives can potentially decrease the need for higher levels of care or hospitalization, as well as improve enrollee health outcomes. Another BHO notes that open-access not only increases access to services, it also decreases the number of no-show appointments. The Treat First Clinical Model allows faster access to services About half of the BHOs (25 of 53) have adopted the clinical model referred to as Treat First. Developed for New Mexico in March 2016, Treat First is designed to improve access to care by prioritizing treatment and reducing State assessment requirements.34 Previously, the State required that the results of a comprehensive assessment and treatment plan for each new patient be submitted within 30 days of the first visit, emphasizing the assessment over treatment. Treat First allows for up to four encounters with a provisional diagnosis without a comprehensive assessment and treatment plan. Almost all BHOs that have adopted this model of care (21 of 25 BHOs) report that it has improved the availability of services for managed care enrollees. According to one BHO, Treat First enrollees have easier and more immediate access to services, leading to increased patient satisfaction and ___________________________________________________________ 34 Medical Assistance Division, Letter of Direction #57: “Treat First” Model Extension, August 25, 2016. Accessed at https://www.hsd.state.nm.us/uploads/FileLinks/c06b4701fbc8 4ea3938e646301d8c950/LOD_%2357___Treat_First_Model_Extension___08.25.2016.pdf on June 10, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 19 OEI-02-17-00490 better rapport with the clinicians as well as reduced paperwork and less staff burnout among providers. In addition, stakeholders report that Treat First has resulted in a decrease in the number of enrollees that are no-shows for the next scheduled appointment, which they attribute to being able to begin treatment during the enrollee’s first visit. CareLink Health Homes Program helps to integrate physical and behavioral healthcare In total, eight BHOs participate in New Mexico’s CareLink Health Homes Program, which is an integrated healthcare service program.35 The program provides a monthly capitated payment per eligible enrollee to each participating BHO. Each BHO agrees to serve as a health home and is responsible for providing and coordinating the physical and behavioral healthcare for the enrollee. The health home is also required to provide additional services, including comprehensive care management and referrals to community and social support services. Each health home must also measure and report on specific quality indicators. According to one BHO that currently participates in CareLink, it is “better able to connect enrollees with services outside their agency and address conditions causing hospitalization.” Other BHOs add that coordination of care between behavioral health and primary care is improved by more frequent contact between enrollees and providers. This coordination increases access to services and improves medication compliance, which can improve overall health outcomes. Many BHOs find that telehealth improves availability of services Telehealth uses internet and communications technologies such as videoconferencing, chat, and text messaging, to provide health information and treatments in real time. Thirty BHOs report having We would not be able to implemented telehealth in serve 90% of the families some way. Several BHOs we currently serve without report using telehealth for telehealth. assessments, and many BHOs - BHO Administrator report also providing . medication management and psychiatric services through telehealth. All 30 BHOs note that implementing telehealth has improved the availability of services for Medicaid managed care enrollees. According to one BHO that implemented telepsychiatry, this ___________________________________________________________ 35 Four additional BHOs that are not in our sample also participate in CareLink. CareLink is for Medicaid behavioral health beneficiaries with a primary condition of Serious Mental Illness and/or Severe Emotional Disturbance. See New Mexico Human Services Department, CareLink NM Health Homes. Accessed at http://www.hsd.state.nm.us/health-homes.aspx on April 5, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 20 OEI-02-17-00490 initiative increases its ability to offer more stable outpatient Project ECHO: Extension for medication management because Community Healthcare Outcomes of an increased pool of qualified In addition to providing services to staff.36 Another BHO highlights enrollees, telehealth can also be the value of using telehealth for used to train and supervise assessments, noting that it “has providers. New Mexico’s Project opened up time for our therapists ECHO uses teleconferencing to to provide more time for increase the availability of specialty individual therapy and group care in behavioral health. The therapy, reducing wait times and model links specialist teams with increasing access to services.” behavioral health providers in the Telehealth can offer particular community. Behavioral health benefits for enrollees located in providers become part of a learning remote locations. According to community, where they receive one BHO, its telehealth initiative mentoring and feedback from has allowed it to spend less time specialists. This model is now used and resources recruiting local in both urban and rural areas, and providers in rural and frontier includes training on how to treat clinic sites, allowing for better both mental and substance use continuity of care and increased disorders. access to psychiatric and counseling services. One provider adds that “telehealth has been critical in establishing care for families in rural and underserved areas.” At the same time, several BHOs note the limitations of telehealth. First, enrollees sometimes have limited receptiveness to telehealth. As one stakeholder points out, some enrollees do not feel comfortable with sharing their problems openly through technology. Second, many rural and frontier areas have limited broadband connectivity. As one BHO explains, the internet service for enrollees that live in remote areas is sometimes not capable of sustaining a good connection for telehealth. Another provider further comments: “Telehealth has improved access tremendously. However, many communities in need of services either do not have internet access in their rural area or cannot afford to pay for the service.” Research indicates that internet access remains a challenge to rural telehealth; as mentioned earlier, rural areas in New Mexico have less ___________________________________________________________ 36 New Mexico is one of nine States as of 2017 where medical boards issue telehealth-specific licenses or certificates that allow out-of-State providers to furnish telehealth services in a State that they are not located. See University of Michigan: Behavioral Health Workforce Research Center, The Use of Telehealth Within Behavioral Health Settings: Utilization, Opportunities, and Challenges, March 2018. Accessed at http://www.behavioralhealth workforce.org/wp-content/uploads/2018/05/Telehealth-Full-Paper_5.17.18-clean.pdf on April 3, 2018. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 21 OEI-02-17-00490 access to broadband—a factor that limits the types of telehealth services available to them via a home internet connection. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 22 OEI-02-17-00490 CONCLUSION AND RECOMMENDATIONS Concerns exist about the availability of behavioral health services—which includes treatments and services for mental health and substance use disorders—for enrollees in Medicaid managed care. The need for such services is particularly pronounced in New Mexico—a State that has among the highest rates for suicide and deaths from overdose in the Nation. Many counties in New Mexico have few licensed behavioral health providers serving Medicaid managed care enrollees. These behavioral health providers are unevenly distributed across the State, with rural and frontier counties having disproportionately fewer providers and prescribers. Notably, only 29 percent of the State’s licensed providers are in rural and frontier counties, despite nearly half of the State’s Medicaid managed care enrollees residing in these counties. Further, a significant number of New Mexico’s licensed behavioral health providers do not provide services to Medicaid managed care enrollees. Additionally, most of the State’s licensed behavioral health providers work in BHOs—which include federally qualified health centers and community mental health centers; however, BHOs report challenges with finding and retaining staff, as well as ensuring transportation for enrollees. As a result, these organizations cannot always ensure timely access for enrollees seeking behavioral health services. These organizations also report difficulty arranging or making referrals for services that they do not—or currently cannot—provide. In addition, they report challenges with continuity of care for enrollees, citing limited care coordination, provider shortages, and barriers to sharing health information. Nonetheless, BHOs highlight promising initiatives that increase the availability of behavioral health services for Medicaid managed care enrollees, including open-access scheduling, treatment first, care integration, and telehealth. These initiatives increase the availability of behavioral health services by improving access to providers, coordinating enrollee care, and expanding the use of technology. In addition, New Mexico recently announced its intention to raise certain provider payment rates.37 Although this report focuses on New Mexico, it provides insights into challenges that are likely shared by other States providing behavioral health services to Medicaid enrollees, especially in rural and frontier counties. These challenges—including provider shortages and limited availability of behavioral health—require attention not only at the State level, but at the ___________________________________________________________ 37 New Mexico Human Services Department. Accessed at https://www.hsd.state.nm.us/ uploads/PressRelease/2f473c14ee654f868b5a25b3cfd15a6d/FY20_RateIncrease_PubNotice_FI NAL.pdf on July 3, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 23 OEI-02-17-00490 national level as well. These challenges are particularly heightened as Medicaid agencies continue to be on the front lines of fighting opioid abuse and in ensuring that appropriate behavioral health services are available. On the basis of the findings of this report, we recommend that the Centers for Medicare & Medicaid Services (CMS): Identify States that have limited availability of behavioral health services and develop strategies and share information to ensure that Medicaid managed care enrollees have timely access to these services CMS should identify States—in addition to New Mexico—that have limited availability of behavioral health services for Medicaid managed care enrollees. CMS should work with these States to develop strategies to ensure that enrollees have timely access to behavioral health services. CMS should particularly focus on these challenges in rural and frontier areas. CMS should build on its existing efforts to provide technical assistance and share best practices and lessons learned from States’ experiences. As a part of its efforts, CMS should work to ensure that States are monitoring the numbers and locations of behavioral health providers and that States are identifying any barriers that impede access to behavioral healthcare. For example, CMS could encourage States to monitor whether there are shortages of specific types of behavioral health providers, such as substance use counselors or psychiatrists. To encourage information sharing, CMS could identify any promising practices that other States have developed. CMS could then share this information with States—such as through case studies, tool kits, and other methods. We also recommend that the New Mexico Human Services Department: Expand New Mexico’s behavioral health workforce that serves Medicaid managed care enrollees Having a sufficient number of behavioral health providers that serve Medicaid managed care enrollees in New Mexico is essential to improving the availability of services to this population. To achieve this, the New Mexico Human Services Department should:  Take steps to expand New Mexico’s overall behavioral health workforce. To address workforce shortages of behavioral health providers, New Mexico should implement initiatives to recruit and retain additional behavioral health providers. For example, New Mexico could look to other States’ initiatives, including internship opportunities in behavioral health fields and market to both in-State and out-of-State candidates. New Mexico could also encourage non-licensed providers to pursue licensure. New Mexico should particularly target these Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 24 OEI-02-17-00490 efforts towards developing its behavioral health workforce in rural and frontier counties.  Increase behavioral health providers’ participation in Medicaid managed care. A significant number of New Mexico’s licensed behavioral health providers do not provide services to Medicaid managed care enrollees. New Mexico should develop initiatives to encourage more of its existing behavioral health workforce to serve Medicaid managed care enrollees. Such initiatives could include initiatives implemented by other States, such as periodic reviews of licensure requirements and reimbursement rates, direct outreach to providers, and simplification of administrative requirements. Improve access to behavioral health services Improving access to services is another essential element for bolstering services for Medicaid managed care enrollees. To achieve this, the New Mexico Human Services Department should:  Review its standards governing access to care and determine whether additional standards are needed for behavioral health providers. New Mexico should determine whether its managed care organizations are meeting the existing State standards that apply to behavioral health providers. It should also evaluate whether any changes to its existing standards are needed in order to better meet the behavioral health needs of their Medicaid managed care enrollees.  Improve access to transportation for Medicaid managed care enrollees needing behavioral health services. Transportation to medical care is essential for Medicaid managed care enrollees who have limited means of transport to and from needed behavioral health services. New Mexico should first take steps to determine if managed care organizations are meeting their contractual obligations and to identify any challenges with nonemergency medical transportation. It should then work with its managed care organizations to develop initiatives to provide improved nonemergency medical transportation to enrollees. It should identify these initiatives and effective practices by reviewing the approaches taken by other States to improve the availability of Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 25 OEI-02-17-00490 transportation services.38 These initiatives should include working with the managed care organizations to review their networks of nonemergency medical transportation providers and looking for ways to expand the number of providers, such as coordinating with local organizations.  Work with State partners to strengthen access to high- speed, reliable, and secure communications technologies in rural and frontier counties. High-speed, reliable, and secure communications technology is needed for healthcare providers and enrollees to benefit from EHRs and other health information technology services such as telehealth. A lack of access to connectivity with sufficient bandwidth speeds—such as broadband connectivity—remains a significant barrier faced by rural providers. New Mexico should strengthen broadband access, particularly in rural and frontier counties. New Mexico should work with other State partners to look for opportunities to attract additional broadband service providers to communities that are currently without access to broadband. New Mexico should also pursue additional funding opportunities for broadband-related projects, including Federal programs that can fund projects related to broadband planning, public access, digital literacy, and deployment.39  Expand the use of telehealth to increase the availability of behavioral health services. BHOs note that telehealth has improved the availability of services for Medicaid managed care enrollees, particularly those in rural and frontier areas. New Mexico should expand the use of telehealth, as appropriate, to further increase the availability of services, particularly in rural and frontier areas. To do this, the State should encourage adoption of telehealth, expand participation in Project Echo, and ___________________________________________________________ 38 CMS and the National Academies of Sciences, Engineering, and Medicine provide effective practices used by other States to address transportation issues. See National Academies of Sciences, Engineering, and Medicine, Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination, October 22, 2018. Accessed at https://www.nap.edu/download/25184 on February 25, 2019; CMS, Medicaid State Plan Amendments. Accessed at https://www.medicaid.gov/state-resource- center/medicaid-state-plan-amendments/index.html on February 26, 2019; and, GAO, Nonemergency Medical Transportation: Updated Medicaid Guidance Could Help States, GAO- 16-238, February 2, 2016. Accessed at https://www.gao.gov/assets/680/674934.pdf on February 7, 2019. 39For a list of Federal funding sources, including grants funded by the United States Department of Health and Human Services, see the Federal Communications Commission, Funding Broadband-Enabled Health Care. Accessed at https://www.fcc.gov/general/funding- broadband-enabled-health-care on May 6, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 26 OEI-02-17-00490 strengthen access to broadband to expand telehealth accessibility. Improve the effectiveness of behavioral health services Another key element of strengthening services for Medicaid managed care enrollees is to improve their effectiveness. To achieve this, the New Mexico Human Services Department should:  Take steps to increase adoption of electronic health records (EHRs) and participation in the State Health Information Exchange (HIE) by behavioral health providers. BHOs report that EHRs improve care for enrollees and enable providers to collaborate across behavioral health settings and with primary healthcare providers. EHRs also allow providers to easily access patient information and in some cases to share that information with other providers. EHRs are also needed to participate in the State’s HIE, which can provide information about enrollees’ diagnoses, medications, procedures, and—in some cases—clinical notes. Some providers face challenges in adopting EHRs and participating in the State HIE including the prohibitive cost of many EHR systems and limited expertise on how to use such technology. To address these challenges, New Mexico should work with providers in accessing assistance and resources that support behavioral health providers’ adoption and use of EHRs and encourage participation in the State’s HIE.40  Identify and share information about strategies to improve care coordination. Coordination among behavioral health and other providers is especially important since certain behavioral disorders carry higher incidences of chronic physical illnesses. BHOs report some challenges with finding providers and coordinating among providers, particularly when enrollees are transferred from one level of care to another. New Mexico should identify and share information on strategies for improved care coordination among behavioral health and other providers. For example, New Mexico should review other States’ strategies to promote coordinated care across various ___________________________________________________________ 40 An example of a resource that may be helpful is the Regional Extension Centers, which provide on-the-ground technical assistance for individual and small provider practices that lack resources to adopt and maintain EHRs. Services include health information technology education and training, vendor selection consultation, and partnering with the State health information exchange. For more information, see ONC, Regional Extension Centers (RECs), November 7, 2018. Accessed at https://www.healthit.gov/topic/regional-extension-centers- recs on March 7, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 27 OEI-02-17-00490 settings. New Mexico should facilitate information sharing among its providers—through the development of case studies, tool kits, and other methods—to encourage providers to use these strategies.  Expand initiatives to integrate behavioral and primary healthcare. BHOs report that the increased integration between behavioral and primary healthcare can improve patient outcomes. For example, CareLink health homes is New Mexico’s integrated care model. The goal of this model is to enhance the integration of behavioral and primary healthcare as well as other services. New Mexico should assess the implementation of CareLink health homes and the value of integrating care. On the basis of the results, it should refine and expand this model or consider other models of integrated care, if appropriate.  Share information about open-access scheduling and the Treat First Clinical Model and promote expansion. BHOs report that open-access scheduling and the Treat First Clinical Model help increase the availability of behavioral health services for Medicaid managed care enrollees. New Mexico should share information with the BHOs that do not use these tools about the benefits identified by the BHOs that do use them. New Mexico could also convene forums for BHOs to share strategies and technical assistance for successful implementation of these tools. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 28 OEI-02-17-00490 AGENCY AND STATE COMMENTS AND OIG RESPONSE Both CMS and the New Mexico Human Services Department (the State) concurred with our recommendations. We made one recommendation to CMS and 10 recommendations to the State. CMS concurred with our recommendation to identify States that have limited availability of behavioral health services and develop strategies and share information. CMS stated that it will work with States that identify themselves as having behavioral health shortages and States that have managed care plans that do not meet the State defined standards of network adequacy. CMS stated that it will provide technical assistance to those States by developing strategies and sharing information to ensure that Medicaid managed care enrollees have timely access to behavioral health services. The State concurred with our 10 recommendations that seek to expand the State’s behavioral health workforce, improve access to behavioral health services, and improve the effectiveness of behavioral health services. In response to the two recommendations that seek to expand the State’s behavioral health workforce, the State noted that it plans to, among other things, use Federal grants to increase behavioral health services provided in rural and frontier counties, while also implementing a Graduate Medical Education program for providers. The State also implemented an increase of Medicaid rates for behavioral health providers and will continue to meet with the Regulation and Licensing Department to discuss the streamlining of licensing requirements and implementation of reciprocity for out-of-state providers who move to New Mexico. In response to the four recommendations that seek to improve access to behavioral health services, the State noted that it is in the process of promulgating a new rule for behavioral health. It also stated that it plans to provide additional non-emergency medical transportation for the justice- involved population upon their release. To strengthen access to communication technologies, it stated that it plans to pursue additional funding for broadband coverage and work with other State agencies to endorse increased funding for broadband efforts. It also stated that it will continue working with the State telehealth network to expand telehealth coverage. In response to the four recommendations that seek to improve the effectiveness of behavioral health services, the State plans to explore funding for connectivity and data transmission to increase behavioral health Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 29 OEI-02-17-00490 provider data sharing. It also noted that it is currently in discussions with the State’s HIE to include behavioral health providers on the HIE. The State also noted that it recently expanded the number of health homes to better integrate behavioral and primary healthcare. Finally, the State added that it plans to collaborate with the New Mexico Behavioral Health Provider Association to increase the number of providers who are trained in the Treat First model. We appreciate CMS’s and the State’s steps to address these important issues. OIG urges both CMS and the State to continue their work in this area to ensure timely access to behavioral health services for Medicaid managed care enrollees. For the full text of CMS’s comments, see Appendix E. For the full text of the New Mexico Human Services Department’s comments, see Appendix F. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 30 OEI-02-17-00490 APPENDIX A: Detailed Methodology We based this study on analyses of Medicaid managed care data from the State and on survey data from selected BHOs. We also conducted interviews with selected behavioral health providers, State Medicaid agency officials, and key stakeholders. State Medicaid managed care data We requested data from the State Medicaid Agency to determine the number and type of licensed behavioral health providers that serve the State’s managed care enrollees. Using these data, we developed a list of all unique providers listed on at least one behavioral health claim during the period of January 1, 2017, through December 31, 2017. For each of these providers, we requested information about their behavioral health specialty, their current enrollment status (i.e., “active”), and the primary county in which they provide services—and whether that county was urban, rural, or frontier.41 We also requested information about the organizations where each of the providers work. We then identified all unique active licensed behavioral health providers in the State, by county.42 We included providers in the following three categories: 43  Independently licensed, prescribing behavioral health providers consist of psychiatrists (MD or DO with a psychiatric specialty), advanced practice nurses (i.e., clinical nurse specialists or clinical nurse practitioners with a psychiatric specialty), and licensed clinical psychologists (Ph.D., Psy.D. or Ed.D.) certified for prescribing.  Independently licensed, non-prescribing behavioral health providers consist of licensed clinical psychologists (Ph.D., Psy.D. or Ed.D.) not certified for prescribing, licensed independent or clinical social workers (LISW or LCSW), licensed professional clinical mental health counselors (LPCC), licensed professional mental health counselors ___________________________________________________________ 41 Note that providers may practice at multiple locations, including locations outside of their primary service county. Further, we based our analysis on New Mexico’s designation of urban, rural, and frontier counties. Note that frontier counties have an average of 2.8 people per square mile, and rural counties have an average of 13.7 people per square mile. 42 This analysis does not include out-of-State providers. 43In addition to the types of providers listed above, the State licenses other behavioral health providers, such as certified alcohol and drug abuse counselors (CADAC) and licensed physician assistants (PA) with a psychiatric specialty. Note that if types of behavioral health providers are not included in the bullets above, there were no providers of these types in the 2017 data. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 31 OEI-02-17-00490 (LPC), licensed marriage and family therapists (LMFT), licensed professional art therapists (LPAT), and licensed alcohol and drug abuse counselors (LADAC).  Non-independently licensed behavioral health providers consist of licensed masters of social work (LMSW), licensed baccalaureates of social work (LBSW), licensed mental health counselors (LMHC), licensed associate marriage and family therapists (LAMFT), licensed substance abuse associates (LSAA), and registered nurses (RN) with a with a psychiatric specialty. We also requested the total number of Medicaid managed care enrollees by county in 2017. Using these data, we determined the ratio of providers per 1,000 Medicaid managed care enrollees for each county. We also calculated the median ratio of providers and prescribers per 1,000 Medicaid managed care enrollees for urban, rural, and frontier counties. Finally, we identified the number of licensed behavioral health providers that work in BHOs. Using the State data, we identified 351 BHOs that provide services to Medicaid managed care enrollees. These included all BHOs that provided outpatient behavioral health services to Medicaid managed care enrollees from January 1, 2017, through December 31, 2017. Survey of behavioral health organizations We selected a purposive sample of BHOs to survey. We included all BHOs designated as core service agencies because they are primary sources for comprehensive medical and support services for many Medicaid managed care enrollees in New Mexico. We then selected up to two additional BHOs with the largest behavioral health expenditures in each county to ensure geographic representation.44 Finally, we included any additional BHOs that billed for more than $1 million in 2017. In total, we selected 78 BHOs throughout the State. Next, we conducted a survey of each of the selected BHOs. Our questions focused on the availability of behavioral health services for Medicaid managed care enrollees. We asked about the availability of both urgent and routine appointments for enrollees seeking services at the BHO from both prescribing and non-prescribing providers. We also asked about the extent to which BHOs maintain wait lists. Additionally, we asked about the extent to which they have difficulty arranging services that they do not or currently cannot provide. We also asked about any challenges with ensuring continuity of care, including maintaining care when transferring from one setting to another, seeing the same provider each visit, and exchanging health information throughout the continuum of care. Lastly, we asked about challenges and promising initiatives for improving the ___________________________________________________________ 44 Five counties only had one BHO, and one county did not have a BHO. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 32 OEI-02-17-00490 availability of behavioral health services. We conducted the survey from August through November 2018. We received responses from a total of 53 BHOs in 27 of the 32 counties in New Mexico with a BHO. Of these BHOs, 16 were in urban counties, 20 were in rural counties, and 17 were in frontier counties.45 Interviews with selected providers, State Medicaid officials and key stakeholders We conducted interviews with selected providers from the BHOs, officials from the State’s Medicaid managed care program, and key stakeholders.46 We asked the behavioral health providers about their experience working with Medicaid managed care enrollees and the availability of behavioral health services. We conducted structured interviews with State Medicaid officials responsible for behavioral health services in the State and specific initiatives such as the Treat First Clinical Model. Lastly, we conducted structured interviews with key stakeholders, including representatives from the Local Collaborative Alliance New Mexico, a group of organizations that support community participation in behavioral health services. We focused our questions on the availability of behavioral health services for Medicaid managed care enrollees and on challenges and opportunities for improving the availability of behavioral health services in the State. ___________________________________________________________ 45 The 53 BHOs received more than $61 million in Medicaid managed care behavioral health expenditures in 2017. This amounts to 50 percent of the expenditures received by all BHOs in that year. 46We asked each BHO to identify at least one provider who had the most experience working with Medicaid managed care enrollees. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 33 OEI-02-17-00490 APPENDIX B: Number of Licensed Behavioral Health Providers That Serve Medicaid Managed Care Enrollees in New Mexico Exhibit B-1: Number of licensed behavioral health providers, by provider type, 2017 Total Urban Rural Frontier Independently Licensed Prescribing Behavioral Health 328 227 69% 83 25% 18 6% Providers Psychiatrists 202 151 75% 40 20% 11 5% Advanced Practice Nurses* 94 52 55% 38 40% 4 4% Prescribing Psychologists 32 24 75% 5 16% 3 9% Independently Licensed Non- Prescribing Behavioral Health 1,872 1,346 72% 449 24% 77 4% Providers Counselors and Therapists 976 682 70% 255 26% 39 4% Social Workers 584 426 73% 131 22% 27 5% Psychologists, Non-Prescribing 274 220 80% 45 16% 9 3% Substance Use Counselors 38 18 47% 18 47% 2 5% Non-Independently Licensed 465 325 70% 115 25% 25 5% Behavioral Health Providers Counselors and Therapists 250 184 74% 58 23% 8 3% Social Workers 198 131 66% 51 26% 16 8% Registered Nurses 13 9 69% 4 31% 0 0% Substance Use Counselors 4 1 25% 2 50% 1 25% Total 2,665 1,898 71% 647 24% 120 5% * Includes certified nurse practitioners with a psychiatric specialty and certified nurse specialists with a psychiatric specialty. Rows may not total 100 percent due to rounding. Source: OIG analysis of State Medicaid data, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 34 OEI-02-17-00490 Exhibit B-2: Number of licensed behavioral health providers, by county, 2017 Total Independently Independently Non- Licensed Medicaid Total Licensed, Licensed, Non- Independently Providers County Type Managed Licensed Prescribing Prescribing Licensed per 1,000 Care Providers Providers Providers Providers Enrollees Enrollees* Bernalillo Urban 187,932 149 911 230 1,290 6.9 Catron Frontier 654 - 1 - 1 1.5 Chaves Rural 25,574 3 22 8 33 1.3 Cibola Frontier 7,353 2 7 2 11 1.5 Colfax Frontier 4,448 - 4 2 6 1.3 Curry Rural 16,123 2 37 14 53 3.3 De Baca Frontier 902 - - - - - Dona Ana Urban 92,905 48 157 46 251 2.7 Eddy Rural 18,215 7 14 5 26 1.4 Grant Rural 9,472 3 33 5 41 4.3 Guadalupe Frontier 1,910 - 3 - 3 1.6 Harding Frontier 67 - - - - - Hidalgo Frontier 1,677 1 1 2 4 2.4 Lea Rural 24,730 4 14 7 25 1.0 Lincoln Frontier 6,117 - 8 - 8 1.3 Los Urban 775 1 11 3 15 19.4 Alamos Luna Rural 13,544 2 6 3 11 0.8 Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 35 OEI-02-17-00490 Exhibit B-2: Number of licensed behavioral health providers, by county, 2017 (continued) Total Independently Independently Non- Licensed Medicaid Total Licensed, Licensed, Non- Independently Providers County Type Managed Licensed Prescribing Prescribing Licensed per 1,000 Care Providers Providers Providers Providers Enrollees Enrollees* McKinley Rural 17,377 10 17 3 30 1.7 Mora Frontier 1,295 - 4 - 4 3.1 Otero Rural 16,798 13 32 4 49 2.9 Quay Frontier 3,513 - 4 2 6 1.7 Rio Arriba Rural 17,449 2 21 9 32 1.8 Roosevelt Rural 6,444 1 6 - 7 1.1 San Juan Rural 32,683 16 45 9 70 2.1 San Frontier 11,315 12 25 16 53 4.7 Miguel Sandoval Rural 33,006 15 111 33 159 4.8 Santa Fe Urban 56,777 29 267 46 342 6.0 Sierra Frontier 6,435 2 10 1 13 2.0 Socorro Frontier 6,414 1 3 - 4 0.6 Taos Rural 12,064 4 64 12 80 6.6 Torrance Frontier 7,986 - 7 - 7 0.9 Union Frontier 576 - - - - - Valencia Rural 26,852 1 27 3 31 1.2 Total 669,705* 328 1,872 465 2,665 4.0 * This includes an additional 323 enrollees in which the county was unknown. Source: OIG analysis of State Medicaid data, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 36 OEI-02-17-00490 APPENDIX C: Number of Selected Behavioral Health Organizations That Report Having Difficulty Providing Timely Appointments Urgent Appointments Number of BHOs Percentage of BHOs With a prescriber in their BHO Within 24 Hours 30 56.6% After 24 Hours 23 43.4% With a non-prescriber in their BHO Within 24 Hours 49 92.5% After 24 Hours* 4 7.5% Routine Appointments Number of BHOs Percentage of BHOs With a prescriber in their BHO Within 14 Days 28 52.8% After 14 Days 25 47.2% With a non-prescriber in their BHO Within 14 Days 49 92.5% After 14 Days** 4 7.5% * Three of the four BHOs are unable to provide urgent appointments with prescribers and non-prescribers in their BHOs within 24 hours. ** All four BHOs are unable to provide routine appointments with prescribers and non-prescribers in their BHOs within 14 days. Source: OIG analysis of BHO survey data, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 37 OEI-02-17-00490 Appendix D: Number of Selected Behavioral Health Organizations That Report Having Difficulty Arranging Each Service Number of BHOs Percentage of BHOs Recovery and Support Services Behavioral Health Respite Care 27 50.9% Family Support Services 22 41.5% Psychosocial Rehabilitation Services 22 41.5% Supportive Housing Pre-Tenancy and Tenancy Services 22 41.5% Behavior Management Skills Development Services 17 32.1% Comprehensive Community Support Services (CCSS) 15 28.3% Non-Intensive Outpatient Services Day Treatment 24 45.3% Medication Assisted Treatment (MAT): Buprenorphine 24 45.3% Treatment for Opioid Use Disorder Screening, Brief Intervention & Referral to Treatment (SBIRT) 16 30.2% Crisis Intervention Services 12 22.6% Behavioral Health Professional Services for Screenings, 4 7.5% Evaluations, Assessments and Therapy Intensive Outpatient Services Opioid Treatment Program (OTP) 22 41.5% Applied Behavior Analysis (ABA) 28 52.8% Intensive Outpatient Program for Substance Use Disorders or 21 39.6% Mental Health Conditions (IOP) Cognitive Enhancement Therapy (CET) 20 37.7% Assertive Community Treatment Services 19 35.8% Multi-Systemic Therapy (MST) 17 32.1% Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 38 OEI-02-17-00490 Number of BHOs Percentage of BHOs Inpatient and Residential Services Accredited/ Non-accredited Residential Treatment Center 30 56.6% (ARTC, RTC) or Group Home Institution for Mental Diseases (IMD) 30 56.6% Treatment Foster Care I and II 18 34.0% Source: OIG analysis of BHO survey data, 2019. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 39 OEI-02-17-00490 APPENDIX E: Centers for Medicare & Medicaid Services Comments Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 40 OEI-02-17-00490 Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 41 OEI-02-17-00490 Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 42 OEI-02-17-00490 APPENDIX F: New Mexico Human Services Department Comments Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 43 OEI-02-17-00490 Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 44 OEI-02-17-00490 Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 45 OEI-02-17-00490 Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 46 OEI-02-17-00490 ACKNOWLEDGMENTS Vincent Greiber served as the team leader for this study. Others in the Office of Evaluation and Inspections who conducted the study include Grant Conway. Office of Evaluation and Inspections staff who provided support include Clarence Arnold and Kevin Manley. We would also like to acknowledge the contributions of other Office of Inspector General staff, including Marissa Baron and Jessica Swanstrom. This report was prepared under the direction of Jodi Nudelman, Regional Inspector General for Evaluation and Inspections in the New York regional office, and Nancy Harrison and Meridith Seife, Deputy Regional Inspectors General. To obtain additional information concerning this report or to obtain copies, contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov. Provider Shortages and Limited Availability of Behavioral Health Services in New Mexico’s Medicaid Managed Care 47 OEI-02-17-00490 ABOUT THE OFFICE OF INSPECTOR GENERAL The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of beneficiaries served by those programs. This statutory mission is carried out through a nationwide network of audits, investigations, and inspections conducted by the following operating components: Office of Audit The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with its own audit resources or by overseeing audit Services work done by others. Audits examine the performance of HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are intended to provide independent assessments of HHS programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. Office of Evaluation The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable and Inspections information on significant issues. These evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI reports also present practical recommendations for improving program operations. Office of The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, Investigations operations, and beneficiaries. With investigators working in all 50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the Department of Justice and other Federal, State, and local law enforcement authorities. The investigative efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties. Office of Counsel to The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering advice and opinions on HHS programs and the Inspector operations and providing all legal support for OIG’s internal operations. General OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including False Claims Act, program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other guidance to the healthcare industry concerning the anti-kickback statute and other OIG enforcement authorities.