House of CardsTennessee's mental health care system was built on poor planning, inadequate funding, and faulty assumptions. Patients and doctors are paying the price.
by Val Pendergrast
Karen is on the verge of tears, and her voice trembles as she relates her personal history of "childhood molestation that began at age 4," and "one rape after the other." The former nurse struggles daily with multiple personalities and post-traumatic stress disorder stemming from severe abuse; she battles anorexia as well as bi-polar disorder, and at least one of her personalities is suicidal. Another personality she calls "the mutilator" is intent on self-destructive cutting and blood-letting. Hospitalized three times in the past three months, her most recent suicide attempt was yesterday, when she cut her wrist "until blood just spurted like an oil well." She didn't call anyone--she didn't want to be a bother. She'd like to feel better, but in her severely depressed state, feeling better is inconceivable.
"Nothing good's ever happened to me all my life," she says. "I feel like I'm just not worthy."
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TennCare, created by the McWherter administration in 1994, was designed as an alternative to Medicaid, the federally-funded, state-administered program that provides inexpensive health insurance coverage for the poor and otherwise uninsurable. The TennCare plan was one of the first state efforts to switch from a fee-for-service basis to a managed-care approach. The intent of managed-care was to reduce skyrocketing medical costs--a serious problem for the poor and uninsured who, for lack of access to regular and preventative health care, relied on hospital emergency rooms as their primary source of care. Unable to collect payment, and unable to absorb the costs themselves, hospitals turned to the government for relief. As health care costs soared out of control, the government, at the state level, opted to experiment with a managed-care approach. This meant that a separate entity--called a managed-care organization or MCO--would be hired to manage the state and federal dollars spent on health care. It was an ambitious undertaking, especially since no one knew what to expect. Knoxvillian Elizabeth Rukeyser, past president of the National Mental Health Association, says the state failed to do its homework.
"It's not something that's been done before, and we didn't know how to do it right," she says. And mental health care, including substance and alcohol abuse treatment, was excluded from the contract between the state and the MCOs. When the state government changed hands in 1995, Gov. Don Sundquist appointed Bob Corker as head of Finance and Administration, the department then responsible for administering TennCare. It was Corker who presented the idea of contracting, or "carving-out," mental health care to Behavioral Health Organizations, adding a middleman to function like MCOs for mental health care. Under mounting pressure to maintain the equilibrium of the state's precariously balanced budget, Corker hastily implemented the carve-out plan, effective July 1, 1996, deftly deflecting responsibility for the mentally ill--and all financial risk--onto the behavioral health organizations. Rukeyser says that when the state contracted with the BHOs, "it opted out of responsibility." "Seeing that there wasn't enough money, they opted to make the BHOs do the dirty work because politically, it wasn't a nice place to be," she says. "There was no planning. [State administrators had] no clear plan in their own minds" about how to tackle the massive undertaking. So they passed the buck. "In order to have managed care, you have to give the provider the capacity to manage care," Rukeyser says. Financially and structurally, she says, providers are incapable of fulfilling that goal under the current system. |
The $511 social security disability check she received at the first of the month is all but gone to pay bills; $6.05 went for a five-day supply of an antidepressant that has stabilized her in the past. This time, it hasn't yet been approved by the behavioral health organization, or BHO, in control of her treatment.
"Hopefully by the time those five pills are gone, I'll have the OK to get more," she says in a voice devoid of hope.
She'd like to commit herself to the hospital, but she knows from experience that a six-day stay is not long enough to make any real progress. But six days is the limit her insurance coverage--through TennCare Partners, the mental/behavioral health arm of TennCare--will allow.
"It's the only place I know to turn to. They keep me long enough to go to group [meetings] and open up [emotional] sores, then they release me," she says. "But I feel safe those six days."
For Karen and many of Tennessee's 53,000 severely and persistently mentally ill, it's just not enough. She's afraid, and her care providers are afraid for her. Since the advent of TennCare Partners last July, funds to provide adequate care for the mentally ill are in short supply. Providers--doctors, nurses, and case managers working for community mental health centers statewide--have watched helplessly as budget cuts have crippled their limited resource base. As a result, providers fear that their carefully constructed network of care and support for the mentally ill could easily come crashing down.
Ben Harrington, executive director of the Mental Health Association of Greater Knoxville, Inc., says the plan looked great on paper.
"We have the Cadillac of insurance plans, but the Cadillac doesn't have any wheels," he says.
"It's really impacting people that need treatment because some of those safety net programs are disappearing from the landscape."
The two BHOs selected to manage mental health care for Tennessee's "severely and persistently mentally ill," (those qualifying for care under the TennCare Partners program), Tennessee Behavioral Health and Premier, were hastily assembled to take over the state's job. Lest anyone think that the BHOs lacked the necessary credentials to qualify as professional health care managers, their bloodlines read like pedigrees, with the same requisite inbreeding. Premier, serving 59 percent of the TennCare Partners' population, began as a joint-venture between Green Spring Health Services, Inc., Foundation Health PsychCare Services, and Options Health Care, Inc.--in partnership with Columbia/HCA Healthcare Corporation. (Foundation Health PsychCare has since pulled out, leaving Premier in the lurch.) Tennessee Behavioral Health, serving the remaining 41 percent (and the majority of East Tennessee), is a conglomeration of the Fort Sanders/Covenant Health System and Merit Behavioral Care Corporation. Despite their impressive résumés, critics say the BHOs were unprepared for the task assigned.
The Partners plan was implemented in July '96 despite a warning from the federal Health Care Finance Administration (HCFA)--the agency in charge of federal health care funds--that the program appeared under-funded from the get-go. Since its inception, TennCare Partners has garnered more than its share of problems, from lack of funds to restrictive rules governing medications--resulting in a slew of grievances from patients, their families, and providers. Harrington says the state turned a deaf ear.
"Every time a concern was raised with the state, it was met with 'talk to the BHOs', or 'it's not a problem,'" he complains. One complaint frequently voiced by patients and providers is the timeliness--or lack thereof--of appointment scheduling, which frequently results in unnecessary hospitalization.
Melinda, a woman with chronic mental health problems, was dining with a friend from her support group late last August when her mood suddenly shifted from "hyper and manic" to severely depressed. Alarmed, the friend called the mobile crisis unit (a crew dispatched in emergencies by community mental health centers) and told them Melinda was considering suicide. Unable to give them a "definite answer as to whether or not I was going to kill myself," Melinda was instructed to attend a "crisis day treatment" at a local community mental health center. Expecting to see a doctor, she waited four hours before being told her appointment wasn't scheduled for 10 days.
"I told them, 'I'm in crisis now,'" she says. "So I went to a liquor store and picked up a bottle and had every one of my pills refilled."
Once again, the friend intervened and called mobile crisis, who told Melinda, "suicide is a part of life, and you have to learn to deal with it."
Stabilized now, she voices her frustration with the Partners system of care.
"They've cut out things like day treatment," she says. "I had an excellent counselor, but now she's gone. They don't pay for certain medications. I have to have a doctor send in a paper (to TennCare Partners) telling this guy that knows absolutely nothing about me that this is what I need."
Many of the providers' complaints stem from similar frustrations.
Dr. Clif Tennison, medical director of Helen Ross McNabb, says one serious problem with TennCare Partners is its formulary--the detailed set of rules that dictates what medications a doctor is allowed to prescribe for his patients. The TCP formulary, he says, is overly restrictive.
"That's a very important clinical issue," he says. In a managed-care situation where resources are rationed, it's vital for doctors to be able to make their own decisions about what medicines will work best for their patients--the goal being to quickly stabilize an individual in order to circumvent more expensive hospitalization. Instead, doctors are prescribing medications only to have their decisions challenged--and often denied--by their managed-care organization. The end result is that patients are unable to obtain the drugs their doctors have deemed most effective and frequently wind up in relapse--and in the hospital.
"In a managed-care environment, we need to use medicines quickly upfront, instead of waiting and trying psychotherapy first," Tennison says. "Medicines have become even more important than they have been."
A second problem is that the decision-makers at the BHOs are basing their decisions to accept or deny a particular medication on inadequate information.
"The reason I know that is, they ask us, which really troubles me." Tennison frowns. "If I'm calling and trying to appeal a denial of a particular medication and they say, 'Well, why don't you send me a couple of double-blind research studies on that thing you're talking about', I'm thinking, wait a minute. If you're making decisions about which medications I can prescribe--and all the psychiatrists all across the state can prescribe to tens of thousands of people--the fact that you don't know the research literature doesn't make me feel very confident in your ability to decide which medicines to take and which medicines not to take. That's scary."
And then there's the BHO's irrational insistence that doctors prescribe older drugs as their first choice.
"[They want us to] use the older, more toxic, more poisonous medications as first-line, and use the safer drugs that are proven with higher efficacy as second- and third-line drugs," he complains. "And there's only one way to understand that: the old drugs are cheaper."
The point the managed-care organizations are missing, Tennison says, is that using safer, newer, more expensive drugs initially actually reduces costs in the long-run.
"There's good data to show that...in the long-run, you're going to spend less money because you're going to have better compliance, people won't drop out of treatment and get sick again, and you'll have fewer co-morbid exacerbations, like other illnesses," he explains.
Perhaps the biggest thorn in the providers' side, however, is the inability to do their own "gatekeeping." The role of the gatekeeper is to determine which patients get what kind of care and how much care they get. Under TennCare Partners, the gatekeeping function rests solely in the hands of the BHOs. Under this scenario, the BHOs decide which patients are sent where for treatment, while passing the financial responsibility onto the community mental health centers. This, say the centers, is the straw that's broken the camel's back.
If providers agree to assume total responsibility for a patient's care, Tennison says, they must have the ability to screen patients to determine if they need a higher level of care. That's not happening.
"We're not able to actually see the clients that are assigned to us first to see if we can do something other than have them hospitalized," Tennison complains. Without the resources to find alternatives to hospitalization, cost-cutting deteriorates into a vicious cycle. Less money, fewer staff, and more patients result in community mental health centers operating like psychiatric emergency rooms.
"When you're working in a system with inadequate resources, you don't have room to do prevention," he says.
"What's happening is that people are getting into hospitals...and out of network providers, and it's being approved elsewhere, not by the at-risk provider agency. It's called not having authority commensurate with responsibility."
Outspoken mental health advocate Andrea Eberle, an endocrinologist at UT Hospital, sums it up in other terms. The BHOs, she says, "are not managing care, they're managing money. They don't know anything about treating people. They're pencil pushers."
Allegedly under-funded and inadequately supervised by the state, BHOs under contract with TennCare Partners took their 10 percent administrative costs off the top and began to dole out the remaining millions. Using the managed-care approach, the BHOs took on the financial responsibility for things like transportation and pharmacy costs and subtracted even more from the mental health centers' cut.
Additionally, Tennessee Behavioral Health took the liberty of anticipating community mental health centers' hospitalization expenditures, then deducted the estimated costs from the centers' already thin state-provided resources. By the time the money reached providers, the remaining slices of the pie were wholly insufficient. Even by the state's account, the original $22.84 per enrollee per month dwindled to only $4 available for actual outpatient care. Struggling to provide adequate care for their clients, community mental health centers dipped into their own pockets, many depleting "rainy-day" reserves.
Nine months later, at least one community mental health center in Tennessee has closed its doors and others are feeling the pinch.
"The only winner in this [carve-out] plan is the state," says Dick Blackburn, president of the Tennessee Association for Mental Health Organizations (TAMHO). "They've limited the amount of financial exposure that they have with this. They've won in a tremendous way and everybody else has lost. The BHOs have lost, the providers have lost, and worst of all, the consumers have lost."
Serious concerns indeed. The report notes that "it appears no Partners participants are financially sustainable at current funding levels." There's more. Among HCFA's other findings: Access to mental health and substance abuse services has been impaired; quality of care issues must be addressed; the TCP program "may" be under-funded; appropriate data to assess the program is unavailable or nonexistent; contract provisions (between the state and the BHOs) are not being met; and the state's policing of BHOs is wholly inadequate.
Finally, the state's proposed Jan. 1, 1998, carve-in--the plan to push responsibility for mental health care back onto TennCare's MCOs and eliminate the BHOs--"will not be approved by HCFA until the state demonstrates that it can effectively administer the current mental health program." HCFA's recommendation is that the state "postpone its plans to return to the carve-in model until...the end of 1998." Without HCFA's approval, the proposal is dead in the water.
Despite the HCFA report, Menke and beleaguered acting commissioner of mental health Ben Dishman maintained their stance as late as March 21 that HCFA issued "no mandates of any kind to us." Though written in "bold and mandatory terms," the HCFA documents, Menke said, "were for discussion purposes only."
"We left [Washington] with the proposition that we would in fact develop a plan of action that we have begun already," Menke told mental health advocates in the March 21 meeting at the Nashville Department of Mental Health. HCFA's "concerns," she said, "were in four major areas: contract monitoring, funding, quality assurance, and data." But, Menke says, "We don't have enough of the last item to tell enough about the other three."
Not surprisingly, Menke isn't keen on pointing fingers.
"I am not interested, I am not interested at all in this process at trying to determine whether we need to point fingers other than to try to assess what the problems are," she says. "There's enough blame to go around."
With HCFA's "concerns" and its recommendation that the carve-in be postponed until the end of 1998, what is the state's justification for returning to the carve-in model, and why the push to carve-in a full year ahead of HCFA's schedule? State officials offer no evidence to explain why the carve-in would be beneficial; all they will say is that the carve-out was designed to be temporary all along.
"It was never intended as anything but a limited carve-out," Dishman says.
Ken Badal, president of Helen Ross McNabb, says a possible benefit of the carve-in would be centralization of services, but in the face of the program's current instability, he worries that mental health care will get lost in the shuffle.
"The upside would be that there wouldn't be as much ping-ponging between general health care providers and mental health care providers. But I'm concerned that solving ping-ponging would create greater problems in terms of mental health getting its fair share."
Elizabeth Rukeyser, past president of the National Mental Health Association, says the state is stalling for time and looking for a way to deflect the heated criticism bombarding it from all sides.
"[Officials are looking] to save face at the moment," Rukeyser says. "I think they probably haven't understood what all this means." Blackburn's opinion is much the same.
"The program as such, as a defined entity, would disappear and they wouldn't have to stand up in front of public entities and defend it."
He is stunned by the state's insistence that the carve-in will take place in January.
"That timetable was just staggering to me--that there was any plan to adhere to any time line. They haven't learned anything. The priority ought to be on solving the problems. Forget about a time line."
Beyond vague assertions that a "level of stability" will "absolutely" be established in the Partners program on or before January 1, Menke appears uncertain at best as to what the criteria is for establishing stability.
"That's an interesting question and I can't answer it for you," she says. "I think that is as candid and full a disclosure as I can provide."
Dishman says the plan is to take the BHO contracts and combine them with the MCO contracts--a task much easier said than done.
At its April 10 meeting with providers, advocates, and consumers in Knoxville, Dishman and representatives of the two BHOs said they are arranging "follow-up meetings" to receive input from mental health professionals to assist them in "looking at contract alternatives," but "we've not set dates for them."
The one thing that is clear is that the program needs money to survive in the interim. Emergency funds--$8.3 million--have been diverted from TennCare to TennCare Partners, under pressure from Donna Shalala, secretary of the Department of Health and Human Services. With the re-opening of TennCare enrollment for children, state-generated funds will increase. And while the state still has a couple of days (30 days from March 17) to render its progress report to HCFA, actual progress is difficult to measure. But unless the state and BHOs can answer the hard questions coming from HCFA, providers, advocates, and consumers, they're in for a long, hot summer.