Colorado, USA — On a Sunday in September, Matt Vinnola was curled up on the sidewalk in the city center, with hollow eyes like the stuffed lamb he used as a pillow.
The former honor student and youth Taekwondo champion seemed too far to drive a fly from his lips, or realized that he was peeing on concrete through his shorts. If he noticed a woman offering wet wipes or a man trying to hand him a five-dollar bill, he would not show interest.
"Tell them, tell them I don't need help, so stop it," he complained to anyone.
The voice in Winora's head yelled in a low voice. They can be so loud and stable, he thinks everyone can hear them. Chronic paranoid schizophrenia and the addiction to shooting anything he could find made the 29-year-old Denfrett stay in emergency rooms, psychiatric wards and prisons so many times that his mother stopped counting. .
One crisis after another, Janet Van Drak had to push the Denver Mental Health Center to provide care for her son instead of finding reasons to deny it. Every time the center asked him to stop treatment, Winola lost confidence in seeking help. The more confidence he lost, the harder his mother, because he was in free fall, and she alone could not catch him.
"What kind of safety net system can blow away the most difficult situations?" Van Drak once wrote in a letter to himself. "Abandoning Matt, abandoning anyone in crisis shouldn't be an option."
As part of our ongoing statewide mental health “edge” report, the Colorado News Cooperation spent six months investigating a state’s behavioral health system, which will identify some of the most vulnerable and at-risk in crisis. The Colorados turned the door away without obtaining recourse officials from the state.
We use 17 community mental health centers as the core of Colorado's safety net, and these centers generate more than $437 million in annual taxes.
We understand that Colorado is the state with the highest incidence of adult mental illness and the lowest access to care in the United States. For nearly 60 years, these centers have been granted non-competitive contracts and privileged status without meaningful supervision.
Our survey shows that despite the surge in mental health needs, these centers — most now facing labor shortages — generally treat fewer clients during the pandemic than before.
At the same time, more than half of the centers have liquid reserves of US$10 million or more. The Denver center retains more than $40 million in mobile reserves, and its customers face record long waits for care.
COLab also found that it started long before the pandemic:
The national payment system inadvertently provided these centers with an economic incentive to reduce the number of patients and charge higher fees, while also protecting them from competition.
For the same service, these centers charge taxpayers as much as 17 times that of independent Medicaid providers, but the fees on which these rates are based have little transparency.
Some centers, including those located in communities with large immigrant populations, do not have Spanish-speaking care providers.
And some centers have been paid for projects they did not provide, and state agencies have not prevented funding — and are responsible for monitoring — them.
We understand that some of these and other problematic practices stem from the long-standing pressure on the country by powerful trade associations in the center to avoid reforms to ensure greater transparency and accountability.
Even now, when the government of Governor Jared Polis prepares to set up a new cabinet-level department to implement these reforms, we find that the state government is regressing at the urging of trade organizations.
In the months before the new Behavioral Health Administration even launched in July, state officials have ruled out key ways to monitor these centers more closely. They also almost canceled the new department's top safety net priority: step in when the center failed customers like Vinnola and tried to catch them before they bottomed out.
The community mental health movement began in the 1960s when President John F. Kennedy called for the deinstitutionalization of patients with mental illness.
Private non-profit organizations have emerged near Colorado to provide mental health services—and ultimately, addiction counseling—to keep people away from hospitals and communities.
These organizations eventually became the 17 Regional Community Mental Health Centers (CMHC) that the state has relied on for more than half a century to treat Colorado people who are poor, Medicaid or underinsured and unable to pay for private treatment, and stabilize people’s lives in crisis .
Each of them is contracted to provide inpatient treatment, intensive outpatient treatment, outpatient psychiatric care, counseling, and other forms of assistance to residents of the county they are responsible for.
These centers have helped Colorado for generations, especially those with less complex mental health needs. According to national statistics, in the fiscal year ending in June, they served a total of 158,911 customers.
"Colorado is fortunate to have a system built with such a powerful CMHC network," Doyle Forrestal, chief executive of the Colorado Behavioral Healthcare Commission, the center's trading group, wrote in an email.
Nonetheless, we found a huge difference in the quality and speed of the center's services.
Last summer, a Greeley resident with severe depression could see a psychiatrist within a few weeks of calling the center there, but people who were equally depressed in Rio Blanco or Moffat counties had to wait 9 or 11 months respectively. Get the same appointment if Mind Springs Health-the center that serves these counties-agrees to schedule one.
According to multiple sources, at least four centers are providing addiction counseling services by staff who are not qualified to provide counseling to addicts.
We talked to people who work or work in three centers that rely on clinicians who are not trained in pediatrics to prescribe medications for the children.
Customers in the four centers told us that their clinics were so slow to update prescriptions that they were slow to respond to biochemical reactions while waiting.
We found that there were no bilingual clinicians in the centers serving six communities with large immigrant populations, which left Spanish and others who could not speak English almost without care.
Annie Diaz of Cortez, as a consultant for Axis Health System, treated about 80 clients at a time-she said many people had trouble remembering their names and questions.
"In this case, I did my best, but it's not my best, and it's not good enough," she said.
Some center staff described the pressure to abandon the most difficult cases.
A former case manager in Mind Springs in Summit County said that earlier this year, administrators told her to stop treating a critically ill client because he made inappropriate racial remarks. She said she opposed it because she knew he had no other support system, but agreed because she was afraid of losing her job.
Soon after, the client ended his life.
"I blame myself for this every day," said the case manager who resigned immediately after committing suicide. Fearing that the death of her client would harm her career, she requested to remain anonymous.
Mind Springs cited privacy reasons for refusing to discuss the case.
Emma Harmon is a single mother and Medicaid recipient in Durango. When she feels very depressed, she thinks about suicide several times every hour. She said the center made her wait six weeks to make an appointment, and then waited another three weeks to meet with someone to make a treatment plan. During this time, she asked to see a psychiatrist, but was told that he was busy. Her mother took her to the hospital and was discharged from the hospital because she did not actually hurt herself.
A spokeswoman for Axis will not comment on Harmon's case.
"I was on the verge of death—so, so close to suicide, they said'you are fine' and didn't follow me up," Harmon said. "The way things seem to work out there, you actually have to commit suicide before they meet with you."
If you are experiencing a mental health crisis, please call the Colorado Crisis Hotline at 1-844-493-TALK (8255). There is no wrong reason to lend a hand.
The Center’s trade group, the Colorado Behavioral Medical Commission, negotiated on their behalf with the Colorado Department of Health Care Policy and Financing, which provided approximately two-thirds of public funding through Medicaid, and negotiated with the Behavioral Health Office, which provided approximately A complex network involving 18 national institutions and more than 75 projects maintained the third place.
Although the local area has long been concerned about their services, the state has handed over decades of automatic contract renewal to these centers.
Over the years, commissioners in most of Colorado's 64 counties have complained that if the center fails to do so, their law enforcement and public service officials will eventually deal with the mental health crisis.
Parents raised their hands at the support group meeting to describe the despair of having to send teenagers experiencing psychotic episodes across the state because there are no juvenile psychiatric beds nearby.
Some patients with major depression can only receive two to three treatments, but they will be prescribed indefinitely with little follow-up.
State mental health officials have long been aware of these and other issues.
"The center and the country have been failing people," said Robert Westwin, director of the Behavioral Health Office, which will be transformed into the Behavioral Health Administration when the new department is launched in July.
At the same time, committee members pay an average of US$66,000 per year in dues, and have been lobbying and litigating for years to limit the number of independent contractors authorized by the state to receive medical assistance in US dollars.
"These centers almost have a place in the local market and don't want to compete," said Byron Pelton, a Logan County commissioner and member of the state task force that aims to increase access to behavioral health care.
The committee also promotes the maintenance of the Medicaid reimbursement rate status enjoyed by its members in the country.
For example, the Denver Mental Health Center received $592 in Medicaid reimbursement, such as a one-hour consultation, compared to $91 for the same services paid to independent clinicians by Medicaid. The Denver Center receives $818 per hour for crisis intervention, while the cost to private providers is $47.50 per hour.
These reimbursement rates are based on a formula developed by the center’s trade group in conjunction with the state government that divides the center’s total expenses in any given year by the total number of services it provided in the previous year.
The higher the center’s expenditure and the fewer times it treats its clients, the more money it will get through Medicaid reimbursement. This method effectively motivates the center to reduce its expenditure efficiency, and restricts or even rejects customer care.
"It's hard to imagine how this formula is in the best interests of Colorado people, especially when so many people are waiting for treatment," said Nancy Van der Mark, the former director of the Colorado Office of Behavioral Health and now a consultant.
According to a cost report submitted to the Department of Health Care Policy and Finance, Greeley’s North Mountain Behavioral Health Center and Denver Mental Health Center (MHCD) have the lowest and highest reimbursement rates of the 17 centers, respectively.
Gree charges the Medicaid program at $228 per hour for consultation, while Denver’s same service charges $592 per hour.
MHCD stated that it needs higher interest rates to fund a series of projects that the contract requires the center to provide, and to subsidize other non-profitable projects, such as food storage rooms and homeless shelters.
Forrestal, the committee's chief executive, declined multiple requests for interviews. In a series of e-mail exchanges, she stated that it is unfair to compare the reimbursement rates of these centers with those of independent Medicaid providers because the centers provide "depth and breadth" of services.
In addition, she wrote, “the funding for behavioral health is severely underfunded. If there is no (committee) effort to obtain additional funding, (the center) will not have new funding to expand services or establish new projects.”
The trade organization recently hired Laurel Karabatsos, the state’s assistant director of Medicaid, as a consultant. A few months after she left the Department of Health Care Policy and Finance (HCPF), she has been working with the state’s Assistant Director of Medicaid. The organization participates in the meeting to change the future payment method.
Karabatsos has not yet sought comment on whether the work violates the state’s revolving door ethics law prohibiting state employees from working in industries under its supervision, and HCPF believes that there is no conflict of interest.
Since Colorado implemented the Medicaid program in 2013, these centers have received more public funding, and regulators have stated that some people are wasting funds due to inefficiencies and other problematic expenditures.
According to a cost report it submitted to the state, as the basis for its reimbursement, the Aurora Mental Health Center will spend 48 cents in administrative expenses for every dollar spent on medical expenses in 2020.
This is in stark contrast to Greeley's North Range Behavioral Health-the most efficient of all centers in the state-and records show that in the same year, records show that for every dollar spent on nursing care, 8 cents was spent on administrative expenses.
Kelly Phillips-Henry, CEO of the Aurora Center, attributed her substantial increase in management costs, in part, to newer technologies, including the system needed to switch to telemedicine.
Former State Director of Public Services Reggie Bicha has long frowned at the excessive use of mental health funds for things rather than people. He specifically pointed to the hydroponic greenhouse at the Dahlia Campus Mental Health Center in Denver, which circulates water through fish tanks and garden beds.
"This is a wonderful little concept," he said. "But from an organization that keeps saying that they need more financial resources, I don't see almost that kind of creativity used to fight serious mental illness, reduce suicide rates, and keep people away from hospitals, prisons, and institutions."
The $15.6 million Dahlia campus is partly from center and private donations, but mainly through Denver Urban Renewal Authority bonds.
For the union representing the workers in the Denver Center, CEO Carl Clark earned US$819,340 in 2019 (the most recent year when the data was released), including a bonus of US$331,583, which is a pain point. This is 10 times higher than the average income of clinicians there that year. Clark defended his income, pointing out that his salary was determined by the board of directors, not by himself.
Our analysis of financial disclosure found that his average total compensation for the CEO of the Colorado Community Mental Health Center in 2019 was $301,337, which is two and a half times higher.
The audited financial report of the Denver Center also shows that it has $41 million in current assets in 2020. Clark said his board likes to keep large reserves as an "emergency fund."
Since the outbreak of the 2020 pandemic, as the pandemic-related depression and anxiety rates have soared, Denver residents have faced the longest waiting time for care in history.
Denver is not the only center that has been retained. Last year, the other nine people retained at least $10 million in liquid assets, and their waiting time was increasing, and the state fell to the lowest point in the national ranking of access to medical services.
"If CMHC is now unwilling to reinvest its reserves to expand access to care, when will it?" Van der Mark asked.
As the pandemic swept through Colorado in early 2020, these centers temporarily suspended most of their services and then switched to telemedicine. However, in the fiscal year ending in June 2020, they still managed to treat more patients than in the next fiscal year, when the number of cases across the state fell by 7,200.
The committee attributed this decline to what Forrestal called the “terrible behavioral health workforce crisis,” she wrote, leaving more than 1,000 vacancies among its members.
"There is simply not enough labor to meet the demand."
Union members countered that the center could retain more employees by drastically raising wages—and by using bonuses for executives like Clark to do so.
Despite the labor shortage, the committee objected to a proposal that the soon-to-be-launched Behavioral Health Administration provide “care coordination”-regional teams work with some of the most difficult clients to ensure they don’t fall out of the center’s care , Otherwise don't fall into the cracks.
The proposal is designed to help people like Winola, if they have outstanding criminal charges, outstanding performance or delusions or difficult to manage, the center will usually refuse treatment.
The trade organization tried to block the proposal, saying that these centers have coordinated care for their customers, and that the state's intervention in doing so may divert funds from their own services.
The committee has been strongly opposed to attempts to add a "no refusal, no withdrawal clause" to the center's contract for many years to prevent them from refusing to provide services for the most seriously ill customers or abandoning customers who are difficult to serve.
The council has an unlikely ally in Vincent Atchity, the president and chief executive officer of Colorado Mental Health, the state's leading advocacy group for mental health challengers.
In the working group responsible for recommending reforms, Atchity voted against making care coordination a priority for the new department because he called it "trying to appease the strongly opposed (center)." He described his vote as "more diplomatic than actual opposition."
The number of members of the working group supporting the priority of care coordination exceeds the number of non-voteers, which may be the most important aspect of the state’s emphasis on "people-oriented" reforms.
Nonetheless, a state report outlining how the new department will operate in early November did not mention the kind of hands-on care coordination approved by the working group on page 109.
Instead, it lays out a detailed plan for what officials call "nursing navigation"—a way to help the public find behavioral health providers over the phone or online.
Werthwein, who has been a strong supporter of providing care coordination until this fall, initially stated that his office intends to exclude the plan from the report because the details of how to staff and fund it "has not yet been worked out."
However, in the same interview, he called this omission a "negligence" and insisted that the new department will prioritize actual care coordination and will revise the report accordingly.
So far, the office of the so-called "nursing coordination working group" Werthwein, which came together to solve this problem, has not mentioned inter-personal care coordination plans. Instead, the team focused solely on making the national mental health care system more technically human.
At least for now, there is no important plan to realize that sometimes the center will disappoint people, and when they fail, someone should step in and prevent these people from free fall.
Werthwein's Behavioral Health Office stated that it does not know how many poor Colorado people are being served by these centers, or how many private insurance does not include mental health care. These centers allow for proportional payment.
State officials also stated that they did not know what the center would receive due to the services it did not provide.
For example, the Mental Health Center in Montrose was paid to establish a mobile crisis plan in the six counties it covers. Due to logistical reasons, the plan did not serve San Miguel County.
County Commissioner Hilary Cooper spent months trying to figure out where the funds for the project in her county went.
"They showed me a bunch of fancy budget slides and explained that for someone like (me), it was really too hierarchical and complicated to understand. In the end, I didn't get the answer." she says.
In response, Shelly Spalding, the center’s chief executive, did not specify where her organization spent the money.
"I think we are transparent," Spalding said. "But maybe others think we are not transparent enough. Maybe something is missing in the translation."
Summit County officials said they couldn't get a response from Mind Springs Health about what it should spend on the detox program, and the program closed without telling them.
They also said that despite years of suspicion, Mind Springs has never said how much public money it spent in the county—and it should—.
CEO Sharon Raggio told them and us that there is no such information because Mind Springs does not track the services or expenditures of each county, but more broadly tracks the services or expenditures of the 10 Xipo counties it is responsible for.
“When you ask about it, it’s like a ridiculous mystery,” said Sarah Wayne, Assistant Manager of Summit County, who referred to Lagio as a “liar” and Min Springs as "thug".
"The way the state contract works and the way money flows are very confusing," Wien said. "And I think community mental health centers benefit a lot from this chaos, because it makes it more difficult to hold them accountable."
These centers also benefit from their status as private 501(c)3 non-profit organizations, and unlike government agencies, they are not subject to public records laws.
The federal tax law stipulates that these centers can-and as we discovered in the report-refuse to provide information about how they use public funds, not just the few financial disclosures required by the IRS and the state.
In the past five years, voters in several counties, including Summit, have passed tax measures to cover the cost of mental health services they claim are not available from these centers.
One of them is Eagle County, which is the first time in the 60-year history of Colorado’s safety net system that it has broken away from its center, Mind Springs, to create its own safety net system-officials there said the system will do something to its residents. A more positive response. Eagle County will be the only center in the state that will not join a trade organization.
The county government has been urging the state government to reform Colorado’s safety net system for years so that taxpayers don’t have to pay double fees for services. According to a state report released in November, they supported the establishment of the Behavioral Health Administration, which aims to allow the county government and the public to "better understand the funds flowing into the community and the results of these investments."
Despite this, many county officials worry that the new department will not be able to monitor the center closely enough because it still cannot control their Medicaid contracts. This responsibility will remain in a separate Department of Health Care Policy and Finance (HCPF).
"If there is no agency that is really responsible for these parts, we worry that there will be no real supervision, and we will only see a repeat of what we have now," said Gini Pingenot of the Colorado County Corporation, which is a county government consortium.
The county government specifically urges state audit centers to conduct financial and performance audits to ensure that they comply with contractual requirements and will not be double-paid by multiple state agencies and projects that provide funding for them.
The new department has no plans to do so, although state officials insist that they will prioritize making these centers more transparent and accountable.
The former state director of public services, Bicha, pointed out that for a long time, trade organizations have been exerting "huge political pressure" to ask them not to monitor the center so closely.
"The council has tremendous influence," he said.
Before seeking and obtaining legislators’ approval for the establishment of the new department, the State Behavioral Health Task Force heard testimony from more than 200 Colorado people across the state who testified about their hopes—and desperate need—from the state’s mental health reforms.
Matt Winola's mother is one of them.
At that time, her son was imprisoned in 2019 and waited for a capacity assessment after eight involuntary hospitalizations in a year. She said that the Denver car salesperson came as "Matt's mother, advocate and spokesperson."
Janet Van der Laak wants to know why she can make appointments for her husband as a regular doctor, but cannot make appointments for her adult son at the Denver Mental Health Center. It doesn’t always know that he is sick.
She wants to know what a family like her should do when the center asks a loved one to stop treatment.
She wondered how these centers would deal with hundreds of millions of dollars in taxes if they did not treat seriously ill patients like her son.
"MHCD gave up him....... How do you give up a severely disabled person? How do you refuse others to provide such services?" Van Drak asked the working group. "We left out the huge vulnerable population that we didn't have treatment."
The Denver Clark Mental Health Center stated that privacy laws prohibit him from discussing Vinnola's case.
"Will things fall? They might be dropped," he said, adding that if clients don't seek care for themselves, the center "needs to focus on those who want treatment."
Five months after Van Drak testified, one of her eldest son Aaron Ruiz ended his life in March 2020.
Relatives said that the family was not aware of Ruiz’s mental health challenges. Since he showed symptoms of paranoid schizophrenia, he has been concerned about Vinola’s mental health for 10 years.
Five months later, Van Drak committed suicide. She was 49 years old at the time.
For more than a year, the only real voice that Vinnola can hear is no more, hijito, let's help you. Since the suicide of his brother and mother took place in his home, his weight has been plummeting. Last fall and winter, he spent a long time in prison. Now for about seven months, he has been living on the street without taking medicine or getting treatment.
When we talked to them last time, his father and stepfather had lost his track.
When time permits, his father will look for Van Draque’s sons who put mental health first, including her own. He searched the homeless camp in Denver, where there were many people who also needed a safety net, but he learned that they could not count on a safety net.
He drove past the apartment where Van Drak used to live. Neighbors there sometimes find Vinora trapped outside, sleeping on the sidewalk in front, waiting for her to return.
You can contact Susan Greene at firstname.lastname@example.org. Freelance journalist LJ Dawson contributed to this report.
This survey is part of the Colorado Press Cooperation’s ongoing "On Edge" series on Colorado’s mental health, which unites more than 160 communities and news media like ours to ensure that all Colorados are provided with high quality News. The title of the series reflects a country with the highest rate of adult mental illness and the lowest access to care, and that the state government is on the verge of either reversing its behavioral healthcare system or simply reorganizing a bureaucracy that also failed. Many Colorado people.
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