Questions remain about who’s ultimately responsible for keeping the most vulnerable Coloradans from slipping through the cracks.
DENVER — State lawmakers in the coming weeks will determine the role of a soon-to-launch behavioral health agency and the extent to which it will reform Colorado’s tattered mental health safety net system.
A bill introduced Wednesday seeks to carve out responsibilities for the Behavioral Health Administration and for the private contractors paid hundreds of millions of federal and state tax dollars a year to provide mental health and substance abuse care statewide.
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Dr. Morgan Medlock, the crisis care psychiatrist Gov. Jared Polis hired out of Washington D.C. to lead the new cabinet-level agency set to launch in July, promised to help carry out “a complete transformation of a system that we know is failing so many of our families, friends and neighbors.”
The Colorado News Collaborative detailed those failures in an investigation published in December.
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“The people of Colorado have spoken. And they are demanding change,” Medlock said at a press conference Friday. “Today is the beginning of us delivering on that promise.”
One of the most ambitious reforms in the 232-page bill would prohibit publicly-funded mental health safety-net providers from refusing to treat clients based on their insurance status, level of aggression, involvement in the criminal justice system or the complexities of their cases. The need for that rule stems from an established pattern by some of Colorado’s 17 regional community mental health centers (CMHCs) of “firing” hard-to-treat or indigent clients, with impunity from state regulators. The centers have been paid higher rates than other providers because they have been expected to serve as caregivers of last resort.
But the bill does not clearly state that the centers would, in fact, be subject to the no-right-of-refusal rule.
“We’re seeking clearer language – much clearer – around that,” says Lauren Snyder, vice president for governmental affairs at Mental Health Colorado, the state’s leading advocacy group.
The bill also instructs the new agency to contract with regional organizations that would coordinate behavioral health care for clients with complicated needs. But the current language is vague as to whether these organizations or the existing community mental health centers would bear the responsibility of keeping the most vulnerable from falling through the cracks. It is also fuzzy on the impact these new regional organizations would have on the higher Medicaid reimbursement rates long given to the centers, which have had a virtual monopoly on safety-net care.
- Develop for the first time a set of comprehensive statewide standards for quality of care, including timeliness of service (although the specifics of those standards would be decided later).
- Ensure that regional mobile crisis teams respond to people in need within two hours. Currently, response times run from five minutes to half a day, and some teams don’t show up at all.
- Improve data collection and analysis to identify gaps in services and improve treatments and outcomes
- Reduce bureaucracy by using one “universal contract” rather than many different ones for state mental health and substance abuse care providers
- Update payment models so providers’ compensation reflects their performance and the quality of their care, and doesn’t reflect unreasonable administrative costs
- Enhance reimbursement to safety-net providers other than the CMHCs based on access to and quality of care
- Work to diversify and expand Colorado’s behavioral health workforce
By 2024, the bill seeks to make it easier for the public to file complaints about care providers. Again, the specifics of how this would work are absent. Among those missing details: whether a dedicated investigative staff would handle grievances and regularly inspect and audit state mental health contractors – including community mental health centers – for problems with quality of care, contract compliance, failure to serve indigent clients or accept sliding scale payment, and possible fraud.
With such language in the bill, enforcement would hinge on the culture Medlock or her successors create within the new agency and their willingness to insist on compliance with the new standards. Colorado’s Department of Human Services (and its Office of Behavioral Health) as well as the Department of Health Care Policy and Financing have for decades caved to pressures from community mental health centers to avoid stricter rules around transparency and accountability, and failed to enforce existing rules.
The centers’ lobbying group, the Colorado Behavioral Health Council, did not respond to an inquiry this week about its take on the bill.
Advocates for people with mental health conditions and their families generally laud the measure, but say it needs to more clearly articulate that priority for care should go to people in crisis and with chronic mental health challenges rather than to the so-called “worried well,” meaning people with less acute cases.
“We need language that says people with the more severe cases can’t be fired by a CMHC until (another provider) has agreed to work with them,” Mental Health of Colorado’s Snyder says.
The bill does not say how much the new agency will cost, nor whether it will hire more staffers beyond those who have been working in the Department of Human Services’ Office of Behavioral Health. A fiscal note is expected in the coming week.
Under the measure, Medlock must appoint 15 to 20 people to an advisory council that reflects Colorado’s demographics. More than half must have experience with behavioral health challenges personally or in their families. That structure, she said, will ensure those needing services have a better chance to be heard.
Medlock and others acknowledged what state Sen. Pete Lee, a bill sponsor, called the “fractured and disintegrated” nature of Colorado’s mental health system. But the bill is silent about the main reason for those fractures: the majority of funding for safety-net services comes from Medicaid, and that those funds have been – and will continue to be – administered by the Colorado Department of Health Care Policy and Financing, a separate agency led by a different cabinet member. The bifurcation between one agency holding the purse strings and another setting expectations for service has created an ask-your-mother-ask-your-father lack of transparency and accountability, and deep frustrations among the public.
Late last year, a staffer and a member of the state’s Joint Budget Committee questioned the need to create the new Behavioral Health Administration, saying it would only be another layer of bureaucracy.
Medlock addressed those concerns Friday by saying the bill grants her the authority to convene other agencies and cabinet members “to create a cohesive vision that makes a difference for people…”
“This is actually a totally different way of thinking for our state,” she said.
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