I would like to register concern for proposed changes to Targeted Case Management (TCM) for individuals with Serious Mental Illness (SMI) and Serious Emotional Disturbance (SED). I support the need to address the Commonwealth’s “legacy” (IIHS, MHSS, Psychosocial Rehab, & TDT) services, which has experienced skyrocketing expenditures over the past couple decades influenced by provider behavior and inconsistent service provision. It is important going forward to have effective controls, provider accountability and standards of care to optimize our system of care.
However, I am vehemently opposed to TCM being lumped in in order for DMAS to exercise their temporary authorization by the GA to make changes if “budget neutral”.
The absence of meaningful discussion or understanding regarding the role and benefit that TCM plays in every localities’ system of care and the anticipated consequence of such action is concerning given the speed in which DMAS’ timeline is moving. As the public comment period ends, it is not clear how the new Community Psychiatric Support and Treatment (CPST) service will be managed or delivered. The stated goal to have a final plan to overhaul “legacy” and case management services by July 2025 to accommodate a yearlong period implementation of July 2026 to exercise the authority granted by the GA is dangerously rushed.
TCM, provided only by CSBs, accountable to our local and state government, has enabled layers of oversight protecting the integrity of the service and consistently addressing system gaps for some of the Commonwealth’s most vulnerable citizens in ALL communities. It is illogical to believe there will not be substantial impact resulting from such action.
It would lessen financial resources of the CSB, who time and time again have aggressively responded to address those gaps that have resulted from previous policy decisions while simultaneously addressing other system needs and mandates. This will constrain supports available for our individual communities and the Commonwealth as CSBs serve individuals regardless of ability to pay.
If believing it will lead to a “budget neutral” solution a few things need to be considered.
First, the well-known escalating costs for the “legacy” services over the last two decades has been attributed to provider behavior and need for effective controls. During this time a growing number of providers, without a shared respect for the system, have redirected their efforts from one legacy service to another following regulatory changes being introduced. As a result, those easier to access services experienced ballooning costs without successfully achieving standards in care that were envisioned.
Secondly, any financial estimates made to address this as a “budget neutral” approach will be highly skewed as those increasing Medicaid expenditures, year after year have exceeded budgeted amounts and have been connected to reimbursement claims influenced by aforementioned provider behavior and questionable service delivery. This has impacted Virginia’s ability to apply resources to strengthen the statewide system of care as desired.
Recognize that providers that follow new rules and regulations are those who have consistently followed and demonstrated respect for the previous ones as CSBs have consistently done for over 50 years.
Thirdly, it should be noted that TCM rate increase years ago aligned to offset a significant reduction of State General Funds (SGF) to the CSBs from DBHDS in order to ensure that CSBs were capable to safely function as the community-based safety net for some of Virginia’s most vulnerable citizens. This would certainly have a great impact for the CSBs already underfunded, providing millions of dollars in uncompensated care and are actively working to address other needs and mandates, including but not limited to STEP-VA. This necessitates that the role of TCM be strengthened rather than dismantled. Such action is inconsistent with other Virginia initiatives intended to improve the Commonwealth’s Behavioral Health System.
Proposal of a tiered TCM rate based will not accurately account for or address system failures, but instead fails to recognize how pivotal the lynchpin of services has been across every system of care in Virginia. CSBs have weathered their responsibility as the community safety net during very difficult times over 50 years for our individuals, communities, and the BH System as a whole which has resulted from policy decisions, system failures and the lack of recognition for impending challenges. TCM has been integral in doing so.
Please recognize that the needs of individuals served with SMI and SED are often unpredictable and may change rapidly. TCM has assisted in maintaining stability for so many of these individuals preventing them from reentering crises and helping to mitigate them when they arise. TCM must be able to provide crisis diversion (unanticipated, unscheduled situation) that require supportive assistance whether by phone and face to face to resolve immediate problems. Attempting to create cost savings in this manner lumped in to address challenges experienced with “legacy” services is short-sited.
References that Virginia’s State Plan Amendment “may or may not be approved again” is insufficient rationale to utilize the current authorization by the GA to make change. Essentially CSBs, the community safety net would be adversely impacted as DMAS seeks a “budget neutral” solution to address challenges that have resulted from lack of accountability with legacy services spanning over several decades.
Changing the model and access for TCM without accurate information or understanding of the role played and the repercussions to the system and most importantly individuals’ whom the CSBs have served for over 50 years would be a half- hazard approach for decision makers to take with dangerous consequences to our system that cannot be unwound. From both a historical and simple mechanics perspective, this is nonsensible, impractical, inconsistent with the other BH efforts and is essentially pulling the lynchpin out of the wheels as we are moving.