On buying a pig in a poke…. the danger of the Task Force Plan

I know many people who,  although they still have reservations,  are very excited about the task force plan to possibly end the coverage gap in Tennessee as early as 2018.  I am excited but very wary.   The success of everything depends on the success of phase one with the mental health population.   I am afraid we will find we have bought a pig in a poke….. we will find we have put our faith and our hopes in something whose chance of success is extremely problematic.   And if it is not successful there will be no phase 2.  It is time for advocates to ask hard,  but necessary questions before we find out we have put our faith in something that can not deliver.

The first thing to understand is that the Task Force is doing far more than simply giving insurance to people who don’t have it.   What they are actually proposing is,  in my opinion,  one of the most far reaching mental health reforms in the history of the Tennessee mental health system…. without any input from the Department of Mental Health (at least as far as I know)  or any new funding to pull it off.

The general idea is that the expense that those with mental health issues cost the state due to chronic and extreme use of hospital emergency rooms can be drastically decreased by a combination of insurance which allows them to pay and (this is the important part) coordination of medical and behavioral needs to allow for the most effective service and best results for the people served.   There is nothing wrong with any of it but…..

That idea makes someone in a case manager type of role essential.   It also assumes that enough primary care physicians who are right now reticent about taking any new Tenncare patients because of low reimbursement can be found who are willing to serve this population and act in concert with these case managers to provide the kind of care needed.   And that doesn’t even include questions about enough mental health providers.

That case manager person does not exist in the Tennessee mental health system.   The closest thing is something called level 2 case management which serves about 50,000 people for about 30 million dollars.   All mental health providers do not provide this service.   I don’t think Tenn Care reimburses for it at a high rate.   Case managers in the existing system have case loads running from about 50 to well over 100.  Waits for services are real.   They do not provide services nearly as intensive as the task force seems to feel (correctly I think) is needed for success of their venture.   Interestingly enough level 2 case manager services for the last couple of years have been proposed by Tenn Care to be cut as being too expensive and not essential.

Without a plan by the Depth of Mental Health and Commissioner Doug Varney as to how 114,000 people can be added and a new position created to organize the services offered them can be done within whatever the financial constraints facing it phase 1 is empty words that will have a very hard time getting past legislators scrutiny. The assumption that the task force makes that assuring us they can and will do this is the same thing as a plan to do it is wrong.

It is time to ask hard questions and get real answers. Accepting this plan without careful scrutiny of its chances of success is wrong. The mental health population is the most complex and difficult population to work with and to have any faith in this proposal there needs to be a lot more meat on these bones.

It is our responsibility to the people in the gap to see as much as possible that phase 1 really does open the door to phase 2.


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