Regional mental health centers are alarmed by Colorado's 232-page plan to shake up the system

By Jennifer Brown, The Colorado Sun

The signature piece of legislation to redefine Colorado's mental health system is a 232-page bill that's causing panic among community mental health centers that for decades have cared for the state's most vulnerable patients.

That's because the bill laying out the state's new Behavioral Health Administration proposes blowing up the system as they know it.

Colorado has 17 community mental health centers, each responsible for providing crisis services, ongoing therapy and help with housing to people who are low income or don't have insurance. The centers operate in 17 regions of the state under no-bid contracts with the Colorado Department of Health Care Policy and Financing, which dispenses funding through the Medicaid program. The centers receive $437 million in tax dollars per year.

Under the proposed setup, the result of Gov. Jared Polis' behavioral health task force, community mental health centers would no longer automatically get lump sums of money to operate the gamut of services. Supporters of the bill see it as ending a monopoly and a funding stream that's less than transparent, but community mental health centers say it will result in fewer services at a time when Colorado is facing a mental health crisis.

The legislation is monumental — as evidenced by the backlash — and at last lays out the details behind the governor's plan to remodel behavioral health care statewide. The new administration will have oversight of the state's mental health and substance abuse programs, now splintered among various state agencies, and must set up a grievance process for Coloradans who are unable to access care or receive care that is poor quality.

Polis' task force, including various subcommittees, listened to mental health experts as well as families who have used the system in dozens of meetings before writing the proposed policy, which received its first hearing Friday.

"We were 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," said Rep. Mary Young, a Greeley Democrat and prime sponsor of the bill along with Rep. Rod Pelton, a Republican from Cheyenne Wells. "That is my goal, that we develop a system that can meet the needs of everyone."

The plan is to create new regional entities called "behavioral health administrative service organizations," which would dole out state and grant funds to make sure regions of the state have a full array of mental health services. Those organizations would hire the mental health and substance abuse treatment clinics needed to provide the services — through contracts that require bids and are based on patient outcomes.

The proposal eliminates the definition of a community mental health center in statute, and the budgetary allocation that Colorado gives the centers. It replaces it with two new definitions: comprehensive providers, which have to provide the whole list of services, and essential providers, which can pick which mental health or substance abuse services they want to offer in a specific region.

Centers warn counties will end up with fewer services, not more

The bill's authors intend for community health centers to apply to become "comprehensive providers," requiring them to justify their costs and compete against private clinics or companies. But, so far, community mental health centers are wary.

"It fractures the system," said Dr. Carl Clark, president of the Mental Health Center of Denver. "The way it's written right now, there's actually no incentive to be a comprehensive provider."

Clark fears that providers will end up bidding on and offering only the services that make money, or at least don't put them in the hole. The services that don't get funded well, including helping people find housing or employment, will decrease, particularly in rural areas, he said.

Southeast Health Group, the mental health center for six counties on the Eastern Plains, is contracted by the state to provide services for those who can't pay, no matter how remote. One of the counties it serves, Baca, in the southeast corner of the state, has just 3,500 people. So, Clark wonders, which new mental health and substance abuse providers are going to want to set up shop in Baca County?

"You open this up, essentially to the free market, and people are going to pick and choose," he said. "I think we'll have counties that have no access to mental health services. They have the idea that if we add competition, it will improve services. I don't think we're going to compete to take care of people who are in involuntary treatment, or take care of people that are going in and out of jail, or to take care of people that don't have a place to live."

Community mental health centers have come under harsh scrutiny by mental health advocates and the media in recent months, particularly as patients' families have shared stories of their loved ones falling through the cracks. The centers have been plagued by accusations of failing to help people in crisis who later took their own lives and, in the case of Mind Springs in Grand Junction, committing prescription errors that put patients' health in danger.

Clark said much of the criticism is based on misunderstanding, particularly among lawmakers and the public. When people don't receive adequate help at a community mental health center, it's often because they aren't cooperating with treatment, he said. The centers can't force people to get care unless they're under an involuntary commitment.

"What happens when a family member doesn't want help?" he said. "It gets characterized as the 'mental health centers don't want to do their job, but if we had competition, somebody would do it.' That's a naive notion."

The no-bid, 200-page contracts the state has with its 17 community mental health centers originated decades ago as part of an effort to create a coordinated system. But that system is broken and it's time for an upgrade, said Rep. Young, who was a school psychologist and ran for office mainly because she was concerned about youth mental health.

Her local regional mental health center, North Range Behavioral Health based in Greeley, is a "shining light" among mental health centers in Colorado, but isn't reaching everyone, Young said. The systemic changes now under consideration are big enough that it isn't surprising that mental health centers are balking, she said.

"Now we are getting into the hard work of the implementation stage and really designing a system to meet the needs across this state," she said. "That obviously is providing the challenge of change."

"Competition is how we solve challenges"

The relationship between community mental health centers and some advocates is frayed after months of scrutiny about the centers' lack of financial transparency and complaints from the public. Sheriffs, county commissioners and other local officials are complaining they don't know how the tax money they pay to local mental health centers is spent.

Mental Health Colorado has taken the side of patients who are "plummeting right through the frayed gap in the safety net," CEO Vincent Atchity said.

"We have been closely aligned for many years with the community mental health centers," he said. "That's why there is some tension presently. It's not personal. To any objective observer, the way this is structured is nonsensical. It's not a private business. This is our money. This is the people's money, and it's there to create access to care for people who need that public support."

Without competition, Colorado is not encouraging "any brillant efforts that are fresh and new," he said.

"Competition is how we solve challenges," Atchity said. Without it, "you are stifling innovation. What we need is a field that is open to people who say, 'We are going to try, try again with these people, the ones who don't want help.'"

The way he sees it, community mental health centers would keep their same mission, working alongside new providers willing to serve the uninsured or people on Medicaid. "I just don't really understand the concern," he said. "One concern I heard is, 'What if a big private entity comes in and outcompetes us?' 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."

Atchity praised the Mental Health Center of Denver for its partnership with Denver police in responding to crisis calls and its apartment building for people with mental illness who were formerly homeless. But he pointed out that even with all of its outreach programs, "they are still obviously not netting everybody."

Will rural counties "lose out?"

Dr. Elizabeth Hickman, who runs the community mental health center for 10 counties in the northeastern Colorado, is responsible for an area that is 17,647 square miles. Centennial Mental Health, based in Sterling, serves from 5,000 to 6,000 patients each year through a patchwork of walk-in clinics and mobile crisis units. The area has no in-patient services, either for psychiatric crisis or detox, so the center's crisis transportation program drives patients to Greeley, Fort Collins or "where you can find a bed," she said.

"As the bill is currently written, it eliminates community mental health centers in statute," she said. "That is a mistake."

"We are embedded in our communities," she said. "We have a feeling of responsibility for our counties. If there is a disaster that strikes in the county, we are going to be there."

Even if the state's community mental health centers become "comprehensive providers," as outlined in the legislation, that would not ensure the same level of responsibility for a region, Hickman said.

Gaps in services would widen, she predicted, because there are hardly any other behavioral health providers in the region. Two of the 10 counties in her region have no private behavioral provider at all, Hickman said, and of those that do, some don't take Medicaid or allow low-income patients to pay on a sliding scale.

"The counties with lesser populations will lose out," she said.

Hickman said she's also concerned about the bill's "high vision" that everyone should have care available where they live. It's not that she disagrees with the sentiment, just that it's not reality, based on current funding. "It's written as if whatever behavioral health needs I might have, where I live, whatever my degree of resources, I have a right to a full continuum of care," she said. "Our current safety-net system is not funded to be an entitlement for the entire state's behavioral health needs."

But Rep. Young and Rep. Pelton said that, through data collection, transparent contracts and reducing "bureaucratic bloat," they expect to find ways to increase efficiency in the mental health system.

"We didn't previously know where the gaps were," Young said.

Dr. Morgan Medlock, who was appointed by Polis two months ago to head the new Behavioral Health Administration, said she's aware of the concerns of the community mental health centers and hinted that they should stop resisting change. The plan is to keep the centers operating but add new competition, and a broader expanse of services, across the state, she said.

She urged community health centers to "move into the future" and participate in the state's overhaul of mental health care, which she hopes to build into a more collaborative system in which people, even in rural areas, would receive therapy and substance abuse treatment at the same clinics.

"Providers who are ready to move into the future with us are invited and will be engaged to work together on a plan so that we keep doors open across the state," she said. "We don't want to result in a service collapse because of some misunderstanding about policy or the impact of policy. It is not our goal just to see doors close. That would not be doing the business of Coloradans."

The legislation passed its first hearing, in the House behavioral health committee, 10-1. "This is my why for running for office," said an emotional committee chair, Rep. Dafna Michaelson Jenet. "And I'm a little verklempt."