Should Mental Health Care go to the highest bidder?
I can remember a conversation I had a while back with a county commissioner. I was discussing an idea with him when he paused, calculated for a moment, and said “Yes. That fits into my way of thinking.” It was a while ago, so I don’t know if I have the actual words right, but it communicates the gist of what he was saying. He supports something only if it fits into his ideological framework. I appreciated his honesty, but it struck me that his methodology was…well…wrong. While the platform of an elected official may have helped them to office, it seems to me that in a democratic republic such as ours, the needs of the people should be the primary issue. This may sound naive, but the matter of governing should be an empirical matter more than an ideological one.
Far be it for me to dispute the idea that Colorado’s mental health care system is broken. I believe it is. However, the question is not whether it is broken. The question is how to fix it.
This seems to be the case in a new mental health law being considered by the Colorado legislature. According to the Fort Morgan Times, this new law strives for more transparency when it comes to taxpayer dollars, but Community mental health centers worry that it may reduce services rather than improve them. According to the Times, this new law promises to transform the mental health services making them more accountable and more efficient by bringing an end to the automatic lump sums given to the 17 regional mental health regions who are responsible for disbursing Medicaid funds to mental health clinics and practitioners. While the article deals almost exclusively with clinics, private practice providers also play an important role in managing the State’s mental health services. I know. I was one. At any rate, the State’s contention is that the present system is inadequate because “We are investing a billion dollars into behavioral health and we had many many people unable to access services in a timely fashion, or sometimes they were offered services, but it wasn’t what they needed,” Rep. Mary Young, a Greeley Democrat and one of the primary sponsors of the bill asserts. These politicians say that they have interviewed a great number of people and providers whose stories tell of a broken mental health system, one that needs fixing.
Far be it for me to dispute the idea that Colorado’s mental health care system is broken. I believe it is. However, the question is not whether it is broken. The question is how to fix it. I would also agree that many of the state-funded mental health clinics are far from adequate, but I would also add, they try to do their best with limited funds and services, especially in rural areas where I had my practice. Again, the question is not that these services are often inadequate; the question is how to make them more adept at serving the areas of which they are a part. As Governor Polis reasoned, answering these questions needs to be based upon what people say and an honest collaboration with the players in the State’s mental health services: those managing the 17 regions, mental health clinics, the many private practice providers working in the Colorado, and political leaders. Based upon the Times reporting, this seems to be the strength of the process designed by the Governor and to which lawmakers have turned for information. The system is broken, they heard, and the bill they are putting together aims to fix it by favoring people over centers and expanding services where and when needed.
A good private practice therapist does not need a lot of advertising to succeed. That normally comes from word of mouth and the referrals they receive from other practitioners. Will they have a place in Colorado’s new system? If not, mental health care will be severely truncated.
So given their collaborative efforts, what does the State think is a reasonable response to Colorado’s mental health problems? When confronted by a horribly complex issue, which this one is, lawmakers like the country commissioner I mentioned seem to default to their favorite ideological answers thereby forcing what others have said into their preconceived notions. Does this work?
Doing away with the system the State has in place now, the Times reports that they want to replace it with capitalism’s free market system. At the center of this system is a competitive structure whereby mental health care goes to the lowest bidder demonstrating the highest efficiency in treatment. On the face of things, this does not sound like a bad idea. Why should tax dollars be thrown away on services that are not needed and fund bureaucracies far too bloated? Why not shake up mental health care so that which is unnecessary and ineffective will fall out and find no place in the system? I have no fight with this, but fee market capitalism? Is this something new? How is it going to help?
A monopoly in health care or a dogmatic appeal to reduce the cost of care? Defaulting to one’s ideals can transform what is really being said.
According to proponents of this bill, it destroys a monopoly. What monopoly? The monopoly created by those managing the 17 regions, and the agencies and practitioners that do not have to compete for those dollars. According to the ideological playbook of free market capitalism, busting up these monopolies and making agencies compete with one another will go a long way in addressing the gaps and weaknesses of the Colorado mental health system. It does so by replacing the regional agencies with state agencies that assure the money is distributed statewide but only to those willing to bid for the privilege.
What might this mean? Well, it seems to be agency-centered, or at least nothing was mentioned of private practice in the Times article. The thought of this has those in private practice scrambling since a loss of Medicaid funding would make a huge dent in their incomes and their ability to do business especially in underserved and low-income regions such as those in rural and inner-city areas. But I imagine it has many clinics scratching their heads wondering how they can do more with less. Some rural clinics are reeling under the pressure of having to care for Medicaid clients, some with as long as three month wait lists. How this improves things seems unclear? Some have suggested that the private sector would fill the gap by setting up private clinics that may underbid existing agencies. I am not aware of these corporate entities although they may exist. Even so, if they do exist, Mental Health Colorado CEO, Vincent Atchity thinks that such a competitive environment “solves challenges.” According to him, the threat of the private sector taking over mental health care does not present a problem. According to Atchity, “If a big business can come in and do a better job of meeting the needs of a population for health care, I’m all for it.” But if this competition opens the door to one agency while shutting the door to others, how does this help more people be served?
Such a law, threats Dr. Carl Clark, president of the mental Health Center of Denver, “fractures the system.” I wonder about this. Will competing agencies from all sectors have “trade secrets” that rather than encouraging collaboration actually work to reduce it? Health care is a collaborative process where providers of all types need to collaborate with each other to assure the best care of their patients. Mental health provides need to collaborate with health care providers so they can have a fuller picture of their client and understand more fully how to treat them. Sometimes it is necessary to consult with occupational therapists if a person’s condition is to be understood and treated. Psychiatrists and mental health professionals need to collaborate to understand whether medication is truly helping or hindering treatment. When bidding and patient outcomes are the measure, one wonders if such collaboration will be hindered, one agency wishing not to help other agencies find a competitive advantage. While most health care professionals are concerned for their patients’ well-being, administrative concerns often interfere or at the very least, create a bureaucratic quagmire of releases and “HIPPA compliant” roadblocks. Does bidding truly help this? I think the answer to that question is anything but clear.
Finally, I wonder if a private practice can hold up under the weight of this new system? A private practice is normally run by one practitioner who may have one or two interns working with them. Are such practices allowed to compete for Medicaid dollars under this new system? If not, the mental health system in Colorado will be horribly truncated. Most private practices also have waiting lists indicating the demand for their services. A good practitioner does not need a lot of advertising to succeed. That normally comes from word of mouth and the referrals they receive from other practitioners. Their reputations, rather than a competitive bidding process, assures their business success and that, it seems to me, is the real engine of mental health care excellence. People turn to those they believe can help; they don’t care about the lowest bidder. In this new system, is there still a place for private practitioners who have earned their success through their excellence of care? It is not clear that this is the case, which means that their care will not be extended to those whose needs may sometimes be the greatest and that would be a shame. I remember a radio interview I once did. The thing that drew the attention of the station was the nature of my credentials. What is someone who has your credentials doing in a rural area like this, they wondered? “I am here,” I told them, “because this is where the need is and I want to help.” I didn’t go to that area because I was the lowest bidder, and my practice didn’t grow because of that. I was there to help those in need and my practice grew because they believed I helped them. That was made possible in large part because of Medicaid. It would be a shame if good practitioners could no longer “compete” in the Medicaid system. The real losers would then be the people, the ones the new program is meant to help.
That mental health care in Colorado is broken is almost a truism. I am pleased that politicians now realize that and are looking for new ways to fix it. I also applaud the efforts of the Governor to listen to the players involved in the hopes that a solution may present itself. But in doing so, let the players speak and do not default to an ideological perspective that may hinder more than it helps. Many of us enjoy the pleasures of a capitalistic system and this system has provided a framework in which technology and scientific advancement has thrived. But the type of capitalism being considered here—free market capitalism—may not be the solution proponents of this bill believe it to be. Competition is not in itself a bad thing, but it needs to be defined in such a way that it facilitates the collaboration so important to good mental health care and opens doors to providers rather than close them. While is important to assure quality care, we do so only by closing the doors to those who are poor providers, not by closing them to any but the lowest bidder. That is a solution grounded in the default ideology of politicians not innovation growing out of the voices of those involved in and needing mental health care.