I am expressing my concerns about the proposed changes to Targeted Case Management (TCM) for individuals with SMI and SED diagnoses. As anyone who works in this field knows, case management is the cornerstone of an effective service system for individuals with behavioral healthcare needs. Having listened in on the DMAS discussion that points to the need to change how TCM is currently delivered in favor of a tiered approach that could result in some people not having case management at all is disheartening, to say the least. It also fails to give credence to the fact that many people remain stable because they have TCM services.

My first concern is the statement that CSBs are billing for services that do not meet the definition of “case management.” The notion that CSBs are billing for services that fall outside the scope of TCM is not one that is well-informed or consistently supported. What indicates this? Reviewing the CMS guidance on the Medicaid definition of case management services, I found that some states have been fraudulent in their billing of TCM services. However, the fact that all TCM services come through CSBs provides additional layers of oversight in Virginia that may not have been in place in states where this fraudulent activity was widespread. The existing TCM rates were set with the intent to provide the service as prescribed by the federal definition, so to suggest reducing the rate because CSBs are doing more than intended is an incohesive argument.

One example given is that case managers should not be providing “counseling” services. While it may be referred to as “supportive counseling,” case managers assist individuals with processing information about the services available to them. They assist with processing information so that individuals can navigate day-to-day circumstances. If this needs to be called something else so that case managers can do it without it appearing to fall outside of the scope of their duties, then, let’s call it something else. But to take that away takes away the core of what it is to be a case manager. And if case managers are doing more, it is likely because other services are so scarce and difficult to authorize/maintain that they are doing whatever they can to try to care for the individuals they support. They should not be punished for that.

My next concern is the proposal of a tiered rate based on the needs of the unique individuals. The needs of the individuals we serve are not always predictable. Having a monthly rate in place ensures that whenever an individual reaches out, the case manager is expected to respond or follow-up in a reasonable time to assist the individual. This is not something that is easily navigated in services that have time limits and set meeting times. If the need is to justify the rate, then let’s continue to discuss reasonable approaches to documentation and case load sizes; but there should be no consideration of lowering these rates for any tier when in fact, we are supplementing the existing rates with STEP-VA funds.

This brings me to my next concern which is the expectation of STEP-VA and the goal of moving toward the CCBHC model. These things are mentioned in the DMAS meetings, but the conversation is clearly at odds with the direction that CSBs have been moving toward since the advent of STEP-VA. Is it possible to work toward strengthening case management for STEP-VA while dismantling it for this approach proposed by DMAS?

To be clear, I fully support a build out of community services which have failed in the past for many reasons. In fact, the community services being proposed such as intensive in-home, therapeutic day treatment, and mental health skill-building are not new services– these services have co-existed with TCM; however, over time, the administrative burden of these services and the denial of authorizations for services that were deemed clinically necessary by licensed professionals decimated these services for many CSBs. How can we overlook that? Why not look at why these services have failed or gone underutilized in the past and correct those issues? To try to work these services back into the system by compromising the one remaining service that we have been able to provide and mandated to provide is not fair to anyone involved. To take away the one service that has been a consistent source of service and support for many people in favor of services that have been unstable over the past several years is not logical.

If the issue is the need to build out of community-based services, let’s focus on that and leave TCM intact. At a minimum, these community services should be in place and proven to be accessible to the people who need them before any changes are made to case management. This conversation has to shift to supplementing case management rather than replacing it if we are going to be able to holistically care for Virginians who depend on our behavioral healthcare system.