xxAACP Newsletter, Volume 11,
Number 1, Winter 1997
Regional Reports
TENNESSEE: TennCare Update
We are six months into the behavioral healthcare carve-out ("TennCare Partners"), in which two statewide BHOs (behavioral healthcare organizations) manage the care for the 11 MCOs (managed care organizations), and the whole thing is falling apart. Grossly underfunded, poorly managed, shamefully designed, TennCare Partners is dismantling the MH system and replacing it with nothing.
I would cry "help" but there is none. Even Tennesses AMI is co-opted; their latest statewide mailout included a survey that asked for feedback about TennCare from families, stating that TennCare -is having "difficulties, " but also that TAMI is committed to TennCare Partners' success. Only the Mental Health Associations and providers are vocal.
Newspapers across the state are carrying reports that "TennCare Program Leaves Poor Without Mental Health Care" (Johnson City Press , for example). CMHCs have downsized by cutting the "fat" left over from the Medicaid days (we were really rolling then, right?) in 1994, then cutting unnecessary subdermal and connective tissue in the several major cuts of 1995. Now in 1996, we first slashed into the periostium in July, and now into the marrow in December. This last cut is almost more than one can bear. We are very seriously considering the point of which the psychiatrists will have to stand and say that this cannot be sustained. We are quickly sinking far below the standard of care. Providers have cut program after program (day treatments, therapeutic nurseries, psychotherapy services, continuous treatment teams, and on and on), have reduced staff by some 35-40%, and have continued to accept record numbers of new patients. This has occurred with the least amount of staff ever, the least amount of money ever, and ever descending credentials of staff who take on front-line screening responsibilities.
For example, my "team", now numbering 5 (myself, a nurse, and three bachelor's level community service workers), has assigned to it some 600-700 patients. REcently we laid off seven more case managers. The tears and anger are getting old. And as these "kids" (case managers) walk out with their pink slips, they thank me for teaching them and tell me about their worries about their patients. It is almost too much at times.
There is no capital to begin innovative services opr to develop alternatives to hospitalization. The BHOs continue to increase our "withhold" because of the unanticipated (to them) cost of inpatient and pharmaceutical sercies to the SPMI, SED, and dually diagnosed disabled population. They give us smaller and smaller portions of an already inadequate capitation, so we can do less, so hospitalizations and suffering and suicide and homelessness and incarceration and needlessly repeated crisis will surely ensure. We have seen this already.
I read with some chagrin the occasional comments taht suggest we must accept, or even embrace, managed care initiatives in public sector mental health. I just want to say that we must reman wary. We must stand for quallity care. Things are not OK. Thing, indeed, can go awry. Come to Tennesses and see what this has done to my work - thirteen years of building and developing, and now fragmented, dissolving. Our current strategy is to do wjat we can to restructure (endlessly, it seems), to develop partnerships for survival, to do less for more people, to redefine our mission and core service competencies with each additional devastating cutback, and to hang on until the pendulum swings back. Our hope is that this is, after all, an essentially centrist society, and that these losses will eventually be redressed.
IOWA: Managed Mental Health Care in the Iowa Public Sector
Managed mental health care for Iowa's Medicaid population has been in place under contract to Merit Behavioral Care Corporation of Iowa (MBCI) Since March 1, 1996. Called "MHAP" (or "Mental Health Access Plan), the Council on Human Services recently recommended that DHS extend its contract with MBCI for this program through February 28, 1998.
Hoping that managed care would serve as an organizing principle for counties to enhance the effectiveness and efficiency of their mental health, mental retardation, and developmental disabilities service systems, the state legislature has passed legislation (Senate File 69) requiring counties to develop County Management Plans. Guiding principles of the plan were to be "choice", "empowerment", and "community". Counties could either contract with a private managed care company to manage all or part of the county's system or were to develop their own service management plan. A State-County Management Committee was established to develop administrative rules; plans were to be submitted by April 1, 1996. County management plans are required to have a single point of entry process for accessing county funding for services by an administrative gatekeeper called the "central point of coordination", or CPC. To date, county management plans for mental health service funding provided by 98 of Iowa's 99 counties have been approved. Only one county elected to contrace with the state Medicaid contractor (MBCI). The motivation for this initiative was to enhance state-county collaboration and to provide tax relief to the counties by increasing the state's share of funding for MH/MR/DD. The state intends to eventually assume 50% of counties' base year (FY94) expenditures according to a property tax relief appropriation, that being one third according to each of the 1) county share of the state population; 2) county share of state total taxable property valuation and 3) county share of FY94 MH/MR/DD expenditures.
Significant potential for cost-shifting between the counties and the Medicaid contractor for funding of community support services has been introduced by the existing structure of the Medicaid state-wide carve-out program. Whether or not the state-county management plan intitiative will provide service consistency across the state and be effective in mitigating the effects of cost shifting will be an important observation to document in the upcoming year.
Barbara M. Rohland, MD
Back to Winter 1997 Table of Contents