Cuts target services to mentally ill

Feb. 11--With a little help, Jeremiah Williams can live in an apartment, work and ride the bus to appointments -- even though the people he sometimes hears talking to him aren't really there.

At 33, Williams has learned ways to manage the paranoid schizophrenia and attention-deficit hyperactivity disorder he was diagnosed with at age 14, along with ways to tell when the medication isn't working.

Williams said he's tried more than 30 medications and has more than 10 psychiatric hospital stays (and a few jail stints) in his past. What stands between him and that outcome now is vigilance -- and his case manager, Michael Brasuell.

Brasuell, Helen Ross McNabb Center's adult intensive case management team leader, keeps a close check on Williams, watching for any sign of a mental-health crisis. He phones and visits frequently. He drives Williams to therapy and medical appointments, gets his medications filled and delivers them to him.

Before getting help from McNabb Center and Brasuell, "I wouldn't even leave the house," Williams said. "I might not show up for an appointment -- if I even had an appointment."

But in July, if proposed budget cuts take effect, Williams risks losing that help.

In the state's 2015-2016 budget, the Bureau of TennCare plans to cut Level 2 case management services. Level 2 case managers serve adults with chronic mental illnesses who are living in the community, not in institutions, but need help getting services and staying stable.

"That care is the glue in the system," said Jerry Vagnier, president and CEO of McNabb Center.

TennCare doesn't plan to cut Level 2 case management altogether but to limit it to three months after a "crisis," such as a stay at a psychiatric facility. After three months, the patient's managed-care organization would "assess the member's case to determine if additional case management is necessary," said TennCare spokeswoman Kelly Gunderson.

Tentatively, when the change takes effect in July, insurers will assess people who now have Level 2 case managers to determine whether they "meet medical necessity for receiving the service for longer than three months." Gunderson said Level 1 case management, for the most severe psychiatric cases, won't be affected.

TennCare estimates enough clients will no longer qualify that the state will save $30 million-- the biggest single reduction in TennCare's budget. Advocates estimate as many as 50,000 adults with serious and persistent mental illness receive Level 2 case management.

But the cost is likely to show up elsewhere, Vagnier said, when some of those people lose the case managers who are helping keep them stable -- and end up jailed or hospitalized instead.

In 2012, TennCare deemed Level 2 case management "necessary to coordinate an optimum lifestyle for the targeted consumers" by helping them make it to appointments and comply with therapies.

Before, many of those clients would have gone to Lakeshore Regional Mental Health Institute, which closed in 2012, said Ben Harrington, executive director of the Mental Health Association of Greater Knoxville.

"The typical person engaging in (Level 2 case management), at the outset, they've not necessarily been treatment-compliant," usually by skipping therapy or not taking their medications, Harrington said. "They had been using these highest-costing units of service because they've been sicker. Once in Level 2 case management, they improve significantly, and their reliance on inpatient care, emergency-room use or no-showing at appointments plummets."

JoAnn Shults, 66, saw that firsthand with her "charming, smart," 46-year-old brother. Diagnosed as bipolar, he abused drugs and alcohol to cope, she said, had lost his job and marriage and was unable to function. His siblings were at wits' end when they called a mental-health provider that served the small East Tennessee town where they live.

Four years later, her brother lives alone in an apartment a little more than a mile from her, Shults said. He's able to use public transportation to go to appointments, shopping and out to eat. He hasn't been hospitalized, he's not abusing drugs, and she doesn't worry about what will happen to him once she's no longer around to take care of him.

But "if he didn't have this help, he would either be in a funeral home or a jail," she said.

If TennCare cuts case management, "these patients might require a higher level of care," said Jim Vandersteeg, executive vice president of hospital operations for Covenant Health.

That could stress the capacity of Covenant-owned Peninsula and two other area psychiatric hospitals that provide inpatient care to TennCare clients.

The loss also might strain local hospital emergency rooms, where patients in crisis often are held until a psych bed is available.

In Knox County, Covenant's downtown Fort Sanders Regional Medical Center and Tennova's Physicians Regional Medical Center in North Knoxville traditionally have gotten the bulk of those cases.

"We worry that without (case management), these patients will likely end up in our emergency room, and then we will begin the cycle again of having to try to find an appropriate environment for their care," said Jerry Askew, Tennova's vice president of external relations. "Providing care in the ER is the most expensive form of medicine. With proper case management, many of these patients can lead productive lives in the community."

TennCare proposed a 10 percent increase in the rates it pays providers for outpatient treatment services, "to help the transition," Gunderson said. "We believe this will incentivize proper use of services for this population, which saves the state money ... and will lead to more members receiving the right service, at the right time, and in the right place."

But Vagnier, who employs more than 50 Level 2 case managers, said the cut is "undoing a system of care that's taken a long time to establish" and was designed to fill gaps left by Lakeshore's closing.

Tennessee now spends 5 percent of its Medicaid funds on mental health, he said, lower than the national average of 6.5 percent.

"It just defies all logic, when other states are increasing their benefits," he said. "I don't believe they're acting on data."

"It's like having a patient with a bad kidney and saying, 'OK, we're going to pay for dialysis, but only for a few months.' Nobody in their right mind would say that's a good course of medical treatment. That's what this feels like to us."

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