The Nation's Voice on Mental Illness
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Grading the States 2006: Tennessee - Narrative
Drastic cuts to Tennessee's Medicaid Program, TennCare, have dominated the public mental health landscape for the past year. These cuts to TennCare have caused people with severe mental illnesses to run up against sharp limitations in the treatment and services they can receive.
Since 1996, TennCare has provided services to Medicaid- and non-Medicaid-eligible individuals who are uninsured or considered uninsurable. TennCare Partners is the mental health component of TennCare. Faced with a significant budget deficit, Governor Phil Bredesen initiated reforms in 2005 that resulted in the elimination of 191,000 adults from TennCare rolls, with restrictions on coverage for an additional 396,000 persons. The legislature created a safety net for people with serious mental illnesses, so that they at least could receive basic medications and services. The Department of Mental Health and Developmental Disabilities (DMHDD) has worked diligently with providers and advocates to register adults with serious mental illness in the safety net as they were disenrolled from TennCare. However, the safety net service array and medication restrictions are limited, with the result that many individuals are left with inadequate treatment.
One bitter pill for TennCare beneficiaries is a limit of five prescriptions per month. Arbitrary limits hurt most those individuals with the most serious health problems or disabilities. People with mental illnesses often take medications for other medical problems such as hypertension, diabetes, or heart disease. Forcing doctors and consumers to choose between medications for schizophrenia and medications for other serious conditions represents malpractice by policymakers.
Another restriction that confounds logic and fairness is TennCare's new "preferred" drug list which limits the medications that can be prescribed to beneficiaries who in the future may be diagnosed with mental illnesses. Individuals with schizophrenia, bipolar disorder, or other serious mental illnesses will be required to begin treatment with low-cost "preferred" drugs. Between different patients, "preferred" drugs may not offer the same rate or degree of effectiveness, or absence of side effects. If they don't work, physicians and consumers will be required to jump through procedural hoops to get authorization for a "non-preferred" alternative - resulting in delays which from the outset may be life-threatening. In most cases, there are no generic substitutes for psychiatric medications.
Experts who reviewed the 2005 drug formulary provisions strongly agreed that they were wrong-headed and dangerous. The TennCare Pharmacy Advisory Committee voted unanimously against the restrictions, but the governor ignored them. The sole psychiatrist on the committee, who resigned, warned: "I can't imagine a worse thing to do to mentally ill patients."
A major concern on the horizon is the apparent intention to transition to a carve-in model for TennCare behavioral health services. The mental health community has voiced strong opposition to a carve-in, fearing erosion of already inadequate behavioral health funds, additional costs of administration, and lack of service flexibility for implementing recovery and rehabilitation services. Despite this opposition, the state appears to be moving ahead with a Request for Proposals to implement the carve-in.
Trauma caused by TennCare changes was intensified with the rocky launch of the Medicare Pharmacy benefit. Even when they are listed on the rolls, low income consumers were subject to procedural barriers such as prior authorization or premium payment. One family member said, "We are tired, confused, and scared. For the past six months we have been knocking on every door. We have gotten red tape and run-around at every turn."
Sadly, the TennCare restructuring has cast a pall over what was once considered a good mental healthcare system moving in the right direction.
Tennessee has been a national leader in supportive housing. In 2000, the Department of Mental Health and Developmental Disabilities (DMHDD) established a "Creating Homes Initiative"(CHI), a partnership with local communities to provide housing options for people with serious mental illnesses. Employing seven regional facilitators throughout the state, CHI has been the catalyst for the creation or improvement of nearly 4,300 housing units.
CHI is an outstanding model that has put Tennessee near the top of states providing supported housing. It has been so successful that it spawned a "Creating Jobs Initiative" to increase employment opportunities for people with mental illnesses.
The Memphis Police Crisis Intervention Team (CIT) program has achieved national renown as a model program. Johnson County in East Tennessee recently established a second CIT program, and the state would do well to promote further replications. Tennessee has one mental health court in Davidson County (Nashville) and should establish more. Currently, there are 19 criminal justice liaison projects covering 24 of the state's 95 counties, aimed at improving coordination between the mental health and criminal justice systems - including the promotion of jail diversion.
Implementation of evidence-based practices (EBPs) in Tennessee has been slow but steady. Foundation Associates operates programs in Memphis and Nashville for co-occurring mental illnesses and substance abuse that are regarded as national models of excellence. Unfortunately, ACT programs exist only in those two cities. For a state the size of Tennessee, that is not nearly enough.
Tennessee has 49 consumer-run peer centers that implement peer recovery programs and co-occurring disorder support groups. In 1999, Tennessee was one of the first states in the nation to implement a statewide suicide prevention network, responding to the Surgeon General's Call to Action to Prevent Suicide. Unfortunately, as funding becomes more limited, maintenance and expansion of these forward-thinking initiatives is at risk.
Access to inpatient psychiatric treatment until recently was not a major problem, because of a federal waiver allowing the state to use Medicaid for hospitalizations. The waiver expired in 2004, however, and because of a general policy shift, the federal government will not renew it. Concerns now exist that there no longer will be enough psychiatric beds in the state for those who need them.
One Tennessee advocate has likened the state mental healthcare system today to "a grocery store full of food, but the people who need the food are locked out." The state has the knowledge base and national models of evidence-based practices that under different circumstances would make it a leader in setting a pace for national transformation. Unfortunately, TennCare cuts have made treatment and services inaccessible to many who need them.
At best, the 2005 cuts were shortsighted - "penny wise and pound foolish." Experience has shown that limiting access to care for people with serious mentalillnesses only increases costs in other sectors of the community - such as emergency rooms, police operations, homeless shelters, and correctional facilities, not to mention losses in economic productivity.
Unless misguided decisions are reversed and new financial strategies adopted, Tennessee will be considered a tragedy, rather than a state of national promise.