The existence of Rio Arriba County’s only state-funded mental health facility has been prolonged by at least a month at the request of a company that apparently contributed to the clinic’s downfall.
Ayudantes Inc., which provides services for patients with mental illness and substance abuse issues, won’t close its Riverside Drive location until at least the end of November, Executive Director Violanda Nunez said last week. The Española clinic had been slated to shut down Oct. 31 because of financial troubles, leaving many of its patients with a choice between driving to Ayudantes’ Santa Fe facility or going without treatment.
“All of the services will be the same,” Nunez said, adding it was still unclear how long the provider will remain in Española.
Nunez said part of the clinic’s financial problem is tied to OptumHealth New Mexico, the subsidiary of UnitedHealth that was hired earlier this year to manage the state’s $1 billion substance abuse treatment and mental health services system. The state pays OptumHealth to distribute funding to its behavioral health providers such as Ayudantes, but the state claims the company hasn’t been sending the clinics much of the money they’re owed and has already fined the company for breaking its contract.
When Ayudantes first announced it was closing in early October, Nunez cited financial problems stemming mostly from changes that went into effect when OptumHealth’s contract began July 1.
OptumHealth has come under fire from state legislators and some in the state’s behavioral health industry for failing to fully reimburse providers such as Ayudantes, putting a strain on non-profit entities that often have small cash reserves and have trouble absorbing the financial hit. Since OptumHealth took over, the state has required all behavioral health care providers to be reimbursed for individual services rather than funded in monthly allotments as they had been prior to the start of the company’s five-year contract. This change was done to make providers more accountable for the money they spend, according to the state.
Last week Nunez said she had been assured by OptumHealth the clinic would have enough money to operate at least through November.
“They have assured me that enough of my claims will be paid so that I can stay open,” Nunez said.
And although Nunez said she was reluctant to complain about the company in light of the its recent cooperative attitude, she said Ayudantes hasn’t received payments for many of the services its provided since this summer, she said.
“I know it has negatively affected providers and services,” Nunez said.
Nunez said she expected there would be a bidding process soon at which time area providers could apply to receive the state contract to provide community mental health services for Rio Arriba. She said Ayudantes would apply for that funding again, but if the provider managed to stay in Española, it would have to be a smaller operation with less staff and a smaller space.
$1.2 Million Fine
OptumHealth replaced ValueOptions, a company that had overseen the state’s behavioral health system since management of the system was privatized in 2005. But four months later, OptumHealth is apparently still having trouble filling the basic requirement of that contract: sending money to providers when they perform services such as therapy or drug rehabilitation.
The New Mexico Behavioral Health Collaborative, which oversees OptumHealth’s contract for the state, announced Oct. 29 it would impose sanctions on the company, including a fine of approximately $1.2 million, for failing to comply with that contract. In a letter to OptumHealth, the Collaborative claims the company has been late on many of its payments and improperly refused to make others.
The fine, specified in the letter as 1 percent of the value of the contract since July 1, is difficult to assess exactly because the company is paid by the number of claims providers make, Collaborative spokeswoman Betina McCracken said.
“We estimate it’s about $300,000 a month,” McCracken said.
The fine will continue to amass until OptumHealth comes into compliance, according to the letter.
The problems seem to be tied to the computer software the company uses to process claims, McCracken said. After four months, the state decided the company should have been able to fix the problem, she said.
OptumHealth released a general statement in response to the sanctions stating the company was working with the state to address its issues. OptumHealth spokesman Chris Cervini said the company would have no further comment on the sanctions.
Roque Garcia, the chief executive officer of Rio Grande Behavioral Health and Southwest Counseling Center, both in Las Cruces, said OptumHealth’s failure to pay claims is already a big issue for providers like his, and it could soon become a huge problem for patients. More than half of the claims his non-profits have made to OptumHealth have not been paid, he said.
Rio Grande Behavioral Health has been able to absorb the cost of operating by digging into its cash reserves, but Southwest Counseling has laid off 21 of its 125 employees in the past few months, Garcia said. He said patients at the facilities haven’t been hugely affected, but he said that can’t last for long. For some providers, such as Ayudantes, there’s almost no money left, he said.
“If it goes on for another couple months, if this goes on unchecked, the whole system is in danger of collapse,” Garcia said.
State Sen. Carlos Cisneros (D-Questa) said the switch to OptumHealth has clearly caused problems, but he doesn’t think the company is as “horrific” as its predecessor, ValueOptions.
Cisneros said ValueOptions frequently failed to pay providers consistently, and it made questionable decisions about which facilities to fund. OptumHealth has some of the same problems, which is discouraging, he said. During ValueOptions’ tenure, Rio Arriba lost its only medical detoxification program and Ayudantes’ methadone program in Española.
“This doesn’t seem to be improving things a whole heck of a lot,” Cisneros said.
After the state awarded the contract to OptumHealth in January, ValueOptions filed a formal protest of the decision Feb. 9. ValueOptions spokesman Lon Wagner said the state has yet to rule on the protest, and he assumes that is because ValueOptions has threatened legal action related to an unfair bidding process.
“Basically we could not file a lawsuit until they make a decision on the protest,” Wagner said.
Fee for Service
Some of issues that led to Ayudantes’ shaky finances can be directly tied to OptumHealth, but a more complex mix of problems led to the rocky situation in Española, Nunez said.
She said part of the problem is the state’s new policy that clinics be funded on a fee for service schedule. In the past Ayudantes was simply given one-twelfth of its annual allocation each month, but the non-profit now receives money only when OptumHealth determines it has provided a service, she said.
The fee for service model works in well-populated areas, but it’s much trickier to negotiate in more rural settings, she said. There are fewer patients than in urban areas and transportation issues lead to a higher number of no-shows to appointments, she said.
“If you have a limited population, the fee for service doesn’t work,” she said.
And the new payment rules also make Ayudantes more vulnerable to problems at OptumHealth. Nunez said one major issue has been that Ayudantes has never acquired a list of the services it can be reimbursed for, so the clinic’s staff has no idea which services will trigger a payment from OptumHealth.
Regardless of the cause of the problem, the consequences make one Hernandez patient nervous.
The woman said she attends psychosocial rehabilitation sessions at Ayudantes multiple times a week for Post Traumatic Stress Disorder resulting from an experience when she had been car-jacked.
“They want us to go to Santa Fe for services but most of us don’t drive,” she said.
For her, losing such an important part of her weekly routine could be devastating, she said.
“It’s a little community; it’s like a little church,” she said.