Medicaid Managed Care for Mental Health Services: The Survival of Safety Net Institutions in Rural Settings

Abstract

Few accounts document the rural context of mental health safety net institutions (SNIs), especially as they respond to changing public policies. Embedded in wider processes of welfare state restructuring, privatization has transformed state Medicaid systems nationwide. We carried out an ethnographic study in two rural, culturally distinct regions of New Mexico to assess the effects of Medicaid managed care (MMC) and the implications for future reform. After 160 interviews and participant observation at SNIs, we analyzed data through iterative coding procedures. SNIs responded to MMC by nonparticipation, partnering, downsizing, and tapping into alternative funding sources. Numerous barriers impaired access under MMC: service fragmentation, transportation, lack of cultural and linguistic competency, Medicaid enrollment, stigma, and immigration status. By privatizing Medicaid and contracting with for-profit managed care organizations, the state placed additional responsibilities on "disciplined" providers and clients. Managed care models might compromise the rural mental health safety net unless the serious gaps and limitations are addressed in existing services and funding.

"An Old Way to Solve an Old Problem": Provider Perspectives on Recovery-Oriented Services and Consumer Capabilities in New Mexico

“…We conducted in-depth interviews with mental health providers in New Mexico, a predominantly rural and economically-challenged state that has undergone three major shifts in the delivery of publicly funded services since 1997 (Willging, Waitzkin, and Nicdao 2008; Willging, Waitzkin, and Wagner 2005). Each shift extended the penetration of managed care within the public sector.…”

Preparing for a Public Sector Mental Health Reform in New Mexico: The Experience of Agencies Serving Adults with Serious Mental Illness

“…The 55-item survey asked about organizational characteristics, staffing patterns, administrative issues, financial issues, clinical care and perceptions of reform. This survey is one component of a 5-year, multi-method assessment that also employs ethnographic methods and secondary analysis to evaluate how reform affects access and quality of care for adults with SMI (Semansky et al, 2009; Willging, et al, 2008). …”

“…Previous studies of MMC found that agencies often increase staff time or change their service array (Beinecke et al, 1999). Implemented in 1997, New Mexico’s first major statewide reform, MMC for physical and mental health services, increased administrative costs and burdens for direct service providers (Willging et al, 2005; Willging et al, 2008). Mental health agencies added administrative staff to respond to increasing paperwork and complex authorization requirements and to communicate with multiple managed care organizations.…”

Merging Opposing Viewpoints: Analysis of the Development of a Statewide Sustainable Local Food Advisory Council in a Traditional Agricultural State

“…We developed a codebook of themes and subthemes based on the questions of interest, the questions asked during the interview, and any themes that emerged during an initial review of the transcripts. Two research staff coded each of the transcripts within Microsoft Word, then met to review the coding of each transcript and reconcile any differences (Willging, Waitzkin, & Nicdao, 2008). Research staff then reviewed the themes and subthemes to determine which were most salient.…”