Obit calls out TennCare cuts

Parents blame Knox man's suicide on changes
Kristin M. Hall, Associated Press

Tuesday, April 12, 2011

NASHVILLE — The parents of a schizophrenic man who committed suicide published an
obituary Sunday that said they blame TennCare cuts for his death, casting attention on the impact
of reducing public-funded mental health care in Tennessee.

Francis Scott 'Scotty' Zingheim, 48, was diagnosed with paranoid schizophrenia at 15, said his
parents, Frank and Ann Zingheim of Cumberland County. He was among 170,000 adults
'disenrolled' as part of a 2005 TennCare reform, and he lost mental health services.

'Our family's sadness is compounded by the lack of effective, vital mental health treatment,' the
family wrote in the obituary, which ran Sunday in The Tennessean.

When Zingheim lost TennCare eligibility, he also lost enrollment in an intense, specialized
program for people with severe and persistent mental illness. His parents said that program had
changed his life, keeping him on his medications and out of the hospital.

'If you start falling off your regimen, then they will come out to your house and watch you take
the drugs,' Frank Zingheim said. 'It's much more than a safety net; it is a true treatment program.'

The Program of Assertive Community Treatment model is used nationwide. In Knoxville, where
Zingheim lived, Helen Ross McNabb Center is the provider.

McNabb President and CEO Andy Black would not discuss specific patients but said PACT is
reserved for the sickest people in the mental health community.

His family said in the obituary that Zingheim had to leave the program when he lost TennCare;
although Medicare paid for his medications, it wouldn't provide for the case management to
ensure he took them.

Then, 'we began the downward spiral of every six or nine months in the hospital,' Frank
Zingheim said.
PACT's purpose is to help people manage serious mental illness to the point where they can
reinter the community without relapsing and ending up in a hospital, in jail or on the streets.

'It does exactly what it was designed to do,' said Ben Harrington, executive director of the
Mental Health Association of East Tennessee.

But the intensive case management program is designed to take only about 100 people at any
given time. Harrington estimates there are more than 19,500 people in Knox County with severe
mental illness.

It's also expensive. The cost to keep one person in the program a full year is $10,000-$12,000.
But if it keeps them from relapsing, it's 'a wise investment,' Harrington said; a yearlong inpatient
stay in a psychiatric hospital is closer to $220,000.

'With treatment, a lot of people can navigate back to a level where they can … not be impaired
by their illness, and they can live and work and play like the rest of us,' Harrington said. At that
point, some can move to less intensive case management.

But not all are capable of reaching that point, he said — including some cut from TennCare who
need PACT but are no longer eligible.

TennCare Bureau spokeswoman Kelly Gunderson expressed condolences for the Zingheim

When TennCare replaced Tennessee's Medicaid program in 1994, it was an expansive plan
intended to cover all the state's uninsured and 'uninsurable' residents. Over the years, a variety of
changes — including decreased federal funding, court orders and mushrooming health care costs
— pushed former Gov. Phil Bredesen to cut nearly all adults except for pregnant women.
Gunderson said that reform 'brought adult eligibility requirements in line with traditional
Medicaid programs and brought costs under control.'

The state and some organizations created a 'mental health safety net' to help uninsured
individuals, Gunderson said, 'so they could continue to receive medications if they no longer
qualified for TennCare coverage.' She said additional services are provided through the
Department of Mental Health.

Harrington calls the safety net 'wildly successful' but said as people are dropped from TennCare,
the pool it serves becomes larger. He compared it to a rubber band, 'stretching and stretching. If
we keep adding more and more weight to it … eventually that rubber band is going to snap,
because we have not added any more funding.'

The Zingheims, who are retired, tried private case management for their son, but said it was
expensive and not as effective as PACT.
Scotty Zingheim had attempted to kill himself about a week before his death and had been
hospitalized. After he was released, his parents visited him in Knoxville. 'Everything seemed to
be normal,' Ann Zingheim said. She said that was his first suicide attempt.

On March 31, he jumped from the 12th floor of his apartment building.

The Zingheims said they wanted the obituary to be a reminder of the real effects of cuts to social
services. TennCare and other programs continue to face funding cuts as state officials try to
offset the end of $2 billion in federal stimulus funds.

Nonhospital providers, including behavioral health, are facing a 7 percent cut in TennCare
reimbursement rates that was included in last year's budget but staved off with federal funds.
That's on top of a 1.5 percent rate cut in this year's proposed budget, Gunderson said. The
lowered reimbursement rate could force providers to cut services or limit the number of
TennCare patients they'll see, Harrington said.

Black, whose center provides mental health, substance abuse treatment and social services in
Knox and 16 other East Tennessee counties, said without access to enough care, the mentally ill
end up in hospitals, jails, homeless on the streets — or in cemeteries.

Zingheim's parents requested that donations in his honor support The National Alliance on
Mental Illness in Tennessee,

News Sentinel health writer Kristi L. Nelson contributed to this report.

© 2013 Scripps Newspaper Group — Online
On Being a Doctor Annals of Internal Medicine

Time’s Up
M aggie sat staring in the exam room, remnants of the
hot Tennessee sun darkening her white blouse. I had
originally misinterpreted her blank stare as a sign of indif-
This watch was different. Not only did it have an easy-to-
read face with clear numbers and digital date readout, there
were no alarms. Every night while I sleep or work, it talks
ference. But now, after years of office visits, hospitaliza- to the atomic clock in Denver and sets itself to the exact
tions, and family strife and care, I realized that her stare time. No effort on my part. It loses 1 second every 20
was part of her way of dealing with a less-than-generous lot million years.
in life. Maggie had indirectly benefited from her diagnosis “Are you taking all your nerve pills? Do you need the
of HIV infection. She had never before received care in a one you take for sleep every night? How often do you need
comprehensive health system, but her diagnosis of HIV to take the stomach pill? I hope you’re taking all the heart
and resultant TennCare coverage allowed her to be seen pills.” Slowly the form began to fill in. She would have to
regularly by a medical provider who could address her var- rely on pharmaceutical patient assistance programs and
ious medical needs. Her shortness of breath and night samples for her psych meds; some of her cardiac meds
cough led to a cardiology evaluation and a diagnosis of would be available through a poorly funded statewide
hypertensive heart disease. Her many joint pains set us on safety net program; and her HIV meds would come from
a course that revealed her avascular necrosis of the hip. Not ADAP (AIDS Drug Assistance Program), as long as federal
surprisingly, her insulin resistance developed into diabetes funds lasted. Many meds would be changed to less expen-
and, most important, her mood swings finally culminated sive formulations.
in a serious breakdown at the clinic, after which she was “Maggie, I want you to take this list with you up front
hospitalized and received aggressive treatment for depres- and tell Yolanda at the front desk that you need to see the
sion. Through it all, Maggie amazed us with her diligence patient assistance coordinator. She’ll go over this list and
in keeping appointments, taking medications, and calling help us figure out how we can get the meds you need, and
when she needed us. Her quality of life improved signifi- then we’ll see which meds you might be able to buy.”
cantly despite her desperate home situation. Her HIV in- Buying meds would be unlikely. Maggie spent whatever
fection was the least of her problems. She remained on her leftover cash she had from her disability check bailing out
first antiretroviral regimen with undetectable viremia, her son or buying food for her grandchildren. Maybe we
while dealing with an abusive methamphetamine-driven could get some assistance from one of our slush funds—
son and his 3 hyperactive children. On this day, she had some gay bars raising money for special needs at the center.
traveled 40 miles from her small house trailer to discuss a We would patch things together somehow.
new problem. Maggie remained seated in her chair, her gaze now
“My psychiatrist says I need all my meds, but he meeting mine. “Doc, what you’re saying is I’ll be alright.
doesn’t know how I’m goin’ to get them.” That was cer- Cause the heart doctor said if I don’t take my pressure pills
tainly true. Eleven years after one of the most progressive my heart won’t be able to pump, and I’ll end up with a
managed care Medicaid programs in the country had been heart attack. I told you what the psychiatrist said. I ain’t
introduced in Tennessee, political and financial pressures missed none of my HIV meds since I started. You told me
had led the state to disenroll more than 300 000 patients. I couldn’t miss.” Her mouth remained open a little, tongue
Most patients like Maggie had become eligible because of wiping her lower lip. I could hear the other exam rooms
their “uninsurable status,” and she was likely to become 1 filling up.
of 900 patients in our clinic to lose coverage. “So, I guess it’ll be just as good as TennCare.”
“We’re setting up all kinds of programs to get you the “No, Maggie, it won’t. We’ll have to fill out a lot of
meds you need,” I said. “Some of the programs will cover forms. Some of these companies won’t approve the meds,
your HIV meds, and then there is a safety net program in and we’ll have to change them. We might have to pull you
your county to help get the other meds. What we are going off your HIV meds next year if the ADAP funds run out.
to do now is go through every med and make sure you It’s going to be a lot more complicated than it’s been. But
need it.” I pulled out our newly developed form, a “Pre- we’ll figure things out.”
scription Plan Draft,” and looked at my watch. Ten sixteen Maggie sat, staring at me. “What if I need to go back
exactly. I had just bought the watch a few weeks ago. It had in the hospital? Is my heart doctor going to still see me?”
been advertised in an airplane catalogue, and I had been on A gnawing pain in my stomach started up. “We’re
a quest for a watch I could read easily because of my newly probably going to have to handle a lot of your general
failing sight. I had tried every cheap watch available that medical problems here. Hopefully we can keep you out of
had large enough numbers, but once I brought them the hospital. We’ve done pretty well up to now.”
home, the numbers seemed to shrink and various digital The noise she made was sort of a snort. I was hoping
alarms and timers started beeping and blinking without she had found something funny in all this. It wasn’t until I
any input from me. I just wanted the time and the date. saw her first tear that I realized that Maggie was finally
© 2006 American College of Physicians 73
On Being a Doctor Time’s Up

crying. “Well Doc, I guess we just have to decide which Since August 2005, over 200 000 Tennesseans have lost
one of my problems I’m going to have to die from.” their TennCare coverage.
She still had that blank stare, her tears running down
to her jaw line. Stephen Raffanti, MD, MPH
“Don’t worry, Maggie; we’ll get through this. We’ve Vanderbilt University
gotten through tougher things before.” Nashville, TN 37203.
Picking up her new paperwork, she stopped at the
door. “I don’t know how they expect us to make it.” Requests for Single Reprints: Stephen Raffanti, MD, MPH, Compre-
Then she was gone— out to the front desk, across the hensive Care Center, 345 24th Avenue North, Suite 103, Nashville, TN
hall to the patient assistance coordinator, back to the trans- 37203; e-mail,
port van, and over the rolling hills of middle Tennessee.
I looked at my watch. It was 10:48, exactly. Ann Intern Med. 2006;145:73-74.


Add favorite articles to your personal archives or retrieve collections for
the following article types at

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74 4 July 2006 Annals of Internal Medicine Volume 145 • Number 1
TennCare cuts put mentally ill at risk

Search to get full access

TennCare cuts put mentally ill at risk Published 2:41 p.m. CT March 6, 2015 | Updated 11:24 a.m. CT March 10, 2015


Dealing with racing thoughts and hearing strange
voices, Sarah Hale was lost in the rat maze of mental
Buy Photo
She was a college dropout, without a job or any hope
(Photo: George Walker IV / The
Tennessean) about the future. She couldn't even sleep.

Now — little more than a year later — the 20-year-
old woman is punching a time clock, paying taxes and focusing on personal goals. The
change didn't occur because of a new miracle drug. It happened because she took her
old medicine while working with a therapist. Matthew Ferguson, her case manager,
kept her on track.
Two players missing from
Predators' second postseason
But now she could lose that help. Once she turns 21, she falls into the adult service practice
category, which is facing budget cutbacks. 2:14

TennCare cuts would limit case management for adults to only those coming out of Ryan Ellis discusses the
hospitalization. And that service would end after three months. The cuts shave $10.5 playoff history
million in state spending, savings that mental health care experts say will be short- 0:54

"If these folks are not getting care, they will end up in the jails, they will end up in the Sen. Mark Green tapped for
Army secretary
hospitals and they will end up being homeless," said Ben Middleton, chief operating 1:04
offcer of Centerstone, which provides community-based behavioral health care.
"Without tending to their issues, they could not only be a harm to themselves but to
Alabama members speak
about Jeff Cook’s
TennCare changes cause problems for nursing homes
Parkinson’s diagnosis
The case management services save Tennessee about $86 million a year, according v
to Middleton, by keeping people out of hospitals and other crisis situations.
Alabama's Jeff Cook reveals
Originally just a proposal, the cuts for mental health case management weren't spared he has Parkinson's disease
in the budget Gov. Bill Haslam sent to the legislature. Once federal matching money is 1:34

fgured in, the cuts to this program add up to $30 million.

But Haslam is giving the program a second look.

"We'll be reaching out to a variety of stakeholders, including mental health
professionals across the state, in the coming days and weeks," said Alexia Poe, the
governor's director of communications.

Middleton said he and others had tried earlier to convince offcials not to cut the

"We can't just idly sit by and let this happen when we know the damage this will have
on the populations we are serving," Middleton said.

Hale said she has bipolar schizophrenia, a condition that got out of control when she
stopped taking a prescribed medication and started popping Xanax. The anti-anxiety
drug, which usually calms people, had the reverse effect on her. She descended into
psychotic episodes and would stay awake for three to four days at time.

"I was really angry — enraged," Hale said. "I would want to beat people up and fght,
disrespect my mama and stuff like that. It made my schizophrenia worse. The voices
were telling me to do things that would have me in jail for life. I was really, really

Woman gets TennCare help — 6 days after her death

She said her frst two meetings with Ferguson, who works for Centerstone, were a
waste of his time. But he kept at it. He made sure she made her appointments with a
therapist and had the transportation to get to them. While the therapist treated her
illness, Ferguson over the past year has helped her navigate the little and big
obstacles of life.

Her frst goal was to get off pills. Now, she's working toward building a good credit
rating so she can buy a car and move out of her mother's house into an apartment.
She wants to go back to college and has her eyes on securing a management level job
where she works, which would qualify her for tuition assistance.

But she is taking it one step at a time.

"Really, I have just been trying to get my head right before I make any more major
decisions with my life," Hale said.[4/11/2017 5:54:37 PM]
TennCare cuts put mentally ill at risk

Under the requirements for case management in TennCare's recommended budget for
2016, Hale or someone 21 and older might have fallen through the cracks.

"Somehow, Sarah was never in crisis," he said. "She never actually went to a psych
ward or anything like that. Under those criteria, she wouldn't have qualifed for help."

TennCare fres Northrop Grumman

She is one of between 40 and 45 clients Ferguson assists. Sometimes, those clients
won't take help even though he will go their homes or even to shelters when the clients
are homeless.

"Suddenly there is no one to organize appointments and transportation," Ferguson
said. "No one to help them get food or cover bills when they don't have money for
medication. You have very, very quickly down spirals. A lot of times, they end up in the
psych hospital."

He calls Hale his golden client. She said she's grateful for his patience.

"A lot of people just give up on you," Hale said. "He's really been there for me."

Reach Tom Wilemon at 615-726-5961 and on Twitter @TomWilemon .

At issue

Potential cuts to TennCare, the state's health care plan for the poor, would limit case
management for adults to only those coming out of hospitalization. The cuts shave
$10.5 million in state spending, savings that mental health care experts say will be

This story has been updated to correct the status of Sara Hale's coverage situation.
The proposed TennCare cuts to mental health case management would affect those
21 and older.

State Coverage Initiatives
TennCare Reform, One Year Later:
An Assessment of the Impact of the 2005-2006
Changes in the TennCare Program
by Ione Farrar
David Eichenthal
Benjamin Coleman
Chad Reese

June 2007

State Coverage Initiatives is a national program of
the Robert Wood Johnson Foundation administered
by AcademyHealth.
Community Research Council
Chattanooga, Tennessee
TennCare Reform, One Year Later: An Assessment of the Impact of the 2005-2006 Changes in the TennCare Program

EXECUTIVE SUMMARY to learn about available services, while others BACKGROUND
languish and do not access available services
Once regarded as “one of the nation’s most TennCare Implements
for which they are qualified.
comprehensive efforts to cover its uninsured Unprecedented Overhaul
population,” TennCare has undergone radi- In 1994, the State of Tennessee launched
• Primary care is generally available to disen-
cal changes.1 Beginning in 2005, in an effort TennCare, extending health insurance coverage
rollees, both through emergency room visits
to control the rapidly escalating state costs to the Medicaid eligible population in the state
and Safety Net programs, especially in the
caused by the continuation of the TennCare and to individuals who were determined to be
more populated areas of the state. A survey
program in its then-current form, most of the uninsured or uninsurable. 6 Through managed
of the state’s largest hospitals found a 25.5
TennCare expansion population recipients care, TennCare was designed to both control
percent increase in use of emergency room
– about 170,000 adult residents, or approxi- costs of the Medicaid population and reduce the
services by uninsured patients in the first full
mately 3% of all Tennesseans – were removed number of uninsured.
year after implementation of the changes in
from TennCare.2 Limitations on prescrip-
TennCare. While the number of uninsured
tion benefits to five prescriptions per month In its May 1999 assessment of the impact of
patients with prior TennCare coverage is
were imposed on those adults remaining on TennCare, Azer, Gold and Schoen found that:
unknown, it is reasonable to assume that
TennCare: persons who were institutionalized
TennCare disenrollment was a significant
and persons who were receiving services in a • Enrollment of eligible residents in the optional
contributor to the increase.
Home and Community Based Services (HCBS) groups had been very limited since 1994.
waiver were exempt from benefit limits.
• Hospitals have absorbed the cost of provid-
• Participation by managed care plans remained
ing care to an increasing number of unin-
The rapid change in health insurance status strong, but there were signs of potential future
sured patients: a survey of large hospitals
for such a significant percentage of the state’s problems including financial difficulties stem-
found that the number of admitted uninsured
population was unprecedented. Many predic- ming from inadequate capitation rates and
patients had more than doubled during the
tions were made as to the economic and health multiple changes in TennCare leadership.
first year of changes. To meet patient needs
impacts of these changes to the program.
in the new payer environment, some hospi-
• The State had strengthened its administrative
tals have moved to limit emergency room
The Community Research Council structure and oversight activities.
treatment for non-emergent or non-urgent
– a Chattanooga based non-profit policy and
research organization – conducted an analysis • TennCare had improved access to health
to assess the impact of changes in the TennCare insurance.7
• In response to TennCare changes, several
program. The goal was to provide an indepen-
social service agencies have made significant
dent assessment of the economic and health By 2004, ten years after the program’s inception,
programmatic changes in an effort to better
care impacts of the TennCare changes over the Tennessee was first among all states in percent-
meet the needs of disenrollees.
first year to provide decision makers, advocates, age of population covered through Medicaid,
and citizens with the necessary information to with 22.3 percent of Tennesseans covered by
• As of May 2007, nearly 35 percent (5,685) of
make rational policy changes going forward. TennCare.8 Similar to the experiences of many
TennCare disenrollees with serious and per-
other state Medicaid programs, despite a series of
sistent mental illness (SPMI) have not regis-
Based on survey research, publicly available reform efforts, TennCare’s costs had continued
tered for Mental Health Safety Net (MHSN)
information, data collected from a sample of to spiral upward. By 2004, fully one-third of the
services for which they are eligible.3
hospitals in the state, and a series of roundtables State budget was devoted to TennCare.
conducted with current TennCare participants,
• Key indicators of the State’s economy reflect
former participants, social service workers and The fiscal pressure of increasing TennCare costs
national trends and, to date, do not reflect
health care providers from Tennessee’s fourth was particularly acute because of Tennessee’s
economic declines predicted as a result of the
largest county, we can begin to assess the early status as one of seven states that do not impose
TennCare changes.
impacts of this dramatic change in health insur- a personal income tax. Growing health care
ance coverage: costs, a stagnant national economy and a politi-
It is important to note that these findings reflect
cal culture that made it difficult to impose or
a series of snapshots at different points in time.
• Many disenrollees with multiple chronic increase taxes created a dynamic that made fur-
Recently, the State of Tennessee has begun to
health conditions have been unable to obtain ther change in TennCare inevitable.
implement Cover Tennessee, a new program
affordable health insurance.
for the uninsured that is a separate program
Further, Tennessee is one of only two states
from TennCare.4 Also, in some cases, providers
• Loss or reduction of health care coverage that do not have a permanent Medicaid
have suggested that some of the most profound
forces both disenrollees and those still on Disproportionate Share Hospital (DSH) pay-
impacts of the changes in TennCare have yet to
TennCare to make difficult medical and eco- ment. The DSH payment is made to offset some
occur. For example, it may take longer than a
nomic choices. of the costs associated with providing hospital
year for disenrollees lacking access to specialty
charity care. As a result of expanding the popu-
care or prescriptions to feel the full brunt of
• Some disenrollees are fairly successful in lation eligible for TennCare, Tennessee was no
health effects. Nevertheless, we believe that
negotiating the complicated safety net system longer eligible for DSH payments to hospitals.
these initial findings point to the need for con-
tinued monitoring.5 

In 2004, Tennessee Governor Phil Bredesen pro- Concurrently, while changes to TennCare were designated for Tennessee’s 23 federally quali-
posed a series of reforms designed to reduce cost being implemented, the state also launched a fied heath centers (FQHCs) and FQHC look-
and avoid any enrollment reductions. However, $140 million Health Care Safety Net program alikes as well as to 64 faith-based, commu-
the original design hinged on obtaining relief designed to reduce the impact of changes to nity-based, and rural health centers who serve
from consent decrees in effect as a result of the TennCare disenrollees. This initiative included a the uninsured. Awards of similar amounts
Tennessee Justice Center’s (TJC’s) litigation. series of programs: for 2007 were announced in February.
In January 2005, when negotiations with the
Tennessee Justice Center failed to produce a cost • RxOutreach provides disenrollees some • Several programs were implemented as part
saving resolution, Governor Bredesen proposed 55 generic drugs free of charge. The of the MHSN to provide essential mental
sweeping changes to the program. RxOutreach formulary includes medica- health services to those persons who were
tions to treat some of the most common disenrolled from TennCare and were identi-
• The revised proposal called for eliminat- diagnoses, including diabetes, hypertension, fied as SPMI. The Department was appro-
ing all benefits for 25 percent of TennCare lipidemia, depression, anxiety, allergic rhinitis, priated $11.5 million to cover core, vital men-
enrollees not eligible for the core Medicaid bacterial infections, and reflux disorders. In tal health services that people with serious
program that is, uninsured and uninsurable addition, diabetic disenrollees were eligible mental illness must retain to continue leading
adults. The 323,000 enrollees who would for insulin and diabetic supplies, with a $5 functional, productive lives.
have been terminated from the program co-pay for diabetic supplies, until June 30th.
included 121,000 otherwise uninsured adults, All disenrollees received a drug discount card, Persons who are registered into the MHSN are
97,000 non-pregnant adults in the medically which provided discounts up to 10 percent eligible to receive mental health services such
needy spend down category, 67,000 uninsur- for brand and 50 percent for generic pre- as assessment, evaluation, diagnostic, and thera-
able adults, and 38,000 individuals eligible for scription medications, and information about peutic sessions; case management; psychiatric
both Medicaid and Medicare (dual enrolled).9 pharmaceutical patient assistance programs medication management; lab work related to
and a toll-free number for assistance with the medication management; and pharmacy assis-
• The revised proposal called for a significant application processes. Individuals with a diag- tance and coordination.
reduction in benefits for individuals continu- nosis of severe and persistent mental illness
ing to receive TennCare benefits. Physician (SPMI) enrolled in the Mental Health Safety Impact of TennCare Changes
visits would have been limited to twelve Net (MHSN) are also eligible for a variety of There was much speculation about how the
annually; covered inpatient care limited to 20 assessment and case management services overhaul of TennCare would affect the health
days per year; a limit of 8 outpatient visits per and had access to one atypical anti-psychotic care sector and the state’s economy. Anecdotal
year; lab work and x-rays limited to ten times medicine and one mood stabilizer, subject to evidence suggested that TennCare beneficiaries
per year; and pharmacy benefits limited to 4 a $5 co-pay. Originally scheduled to expire uncertain of their future benefits increased
scripts per month. on June 30, 2006, this benefit was extended their utilization before changes took effect.
until the end of 2006. A replacement pro- There was also great concern regarding disen-
Tennessee was granted a waiver amendment on gram was competitively bid and implemented rollees’ ability to obtain other health coverage.
March 24, 2005, to end coverage of adults in January 1, 2007, expanding the list of gener- Likewise, the loss of or reductions in prescrip-
the expanded eligibility categories. However, ics to over 200 drugs and retaining the SPMI tion coverage was expected to negatively impact
changes to the program implemented in July and diabetic assistance. those affected.
2005 differed from the revised proposal.
• Several programs were implemented as part Some predicted that the changes would have a
The State did not go forward with the elimi- of the Safety Net program to assist TennCare significant negative effect on the state’s overall
nation of coverage for 97,000 residents in disenrollees with specialized needs, such as economy. Tennessee hospitals faced the pos-
the medically needy spend down category. those with whole organ transplants, hemo- sibility of reduced credit ratings and increased
The reason for this was a Memorandum of philia, those on dialysis, and those needing borrowing costs. On the other hand, state
Understanding agreed to by the state and plain- cancer treatments. officials projected substantial budgetary relief,
tiffs-intervenors in the Grier lawsuit regarding predicting that 2005-2006 TennCare spending
steps the state would take if relief were granted • The Health Care Safety Net also focused on would account for approximately one-fourth of
in Grier. Benefits were terminated for the increasing access to primary care throughout state tax revenue, as compared to one-third of
170,000 enrollees in the uninsured and uninsur- the state. Forty-seven rural county health revenue in 2004.
able expansion groups. While dual enrollees departments added or expanded available
were also dropped from TennCare, these indi- primary health care services, with sliding scale The Community Research Council conducted
viduals would continue to have Medicare cover- fees based on income. an “on the ground” assessment of the impact of
age – losing prescription coverage until imple- TennCare changes. The goal was to provide an
mentation of Medicare Part D in January 2006. • In addition to state-sponsored programs, independent assessment of the economic and
For those non-institutionalized adults remaining a number of community and faith-based health care impacts of the TennCare changes
on TennCare, the number of covered prescrip- organizations provide assistance, although over the first year to provide decision makers,
tions per month was increased to five, with a programs are concentrated in metropolitan advocates, and citizens with the necessary infor-
maximum of two brand name drugs.10 Non- areas. Many of these organizations received mation to make rational policy changes going
pharmacy limits were postponed indefinitely. State Health Care Safety Net grants. In 2006, forward.
over $12 million in Safety Net funds were

TennCare Reform, One Year Later: An Assessment of the Impact of the 2005-2006 Changes in the TennCare Program

Two different methods were employed Table 1: Adult Risk Factor Comparison Before Reform TennCare versus Total Under Age 65
to assess impact. Risk Factor (self-reported) Have TennCare Total Under Age 65
Fair or poor health 38.0 % 13.7 %
• A series of roundtable discussions with Diabetes 18.5 % 7.2 %
Chattanooga area health care and social Asthma 19.5 % 8.1 %
service providers to discuss the impacts Smoke 46.3 % 17.7 %
of changes on their organizations and on
Source: 2004 Hamilton County Behavioral Risk Factor Surveillance Survey
their patient population.11 CRC also con-
ducted roundtable discussions with TennCare national average of about $354. Two partici- But other disenrollees indicated that they did
recipients and former recipients to discuss pants had briefly enrolled in low cost policies not want to apply for disability or other social
the result of the loss of or reductions in only to learn that none of their medications assistance programs, indicating that they wanted
TennCare coverage. In all, more than 98 were covered. to continue working and remain as self-reliant
individuals participated in a series of 7 round- as possible.
tables over a 10-month period. Medical and social service provider roundtable
participants reported that the overwhelm- 2. Loss or reduction of health care
• An assessment of critical indicators to deter- ing majority of their disenrolled patients or coverage forces both those still in
mine impact on the health care system and clients remain uninsured. 67,000 disenrollees TennCare and disenrollees to make
the State’s economy. were – by definition – uninsurable and too difficult medical and economic choices.
sick to otherwise qualify for health insurance.
MAJOR FINDINGS However, providers also noted that some dis- For those former and current recipients who
1. Many disenrollees with multiple enrollees had access to employer sponsored have not been able to meet their needs through
chronic health conditions have been health plans, but chose to enroll in Tenncare for the state’s Safety Net initiative and other pro-
unable to obtain affordable health its superior prescription coverage. It should be grams, there are a series of challenging choices
insurance. noted that TennCare had crowd-out provisions related to health care and personal finance that
in place to prevent individuals with employer- must be addressed.
According to the feedback from roundtable sponsored insurance from enrolling in the
participants and a series of indicators many program. Although the number of individuals For example, a small percentage of TennCare
of those disenrolled from TennCare have not on TennCare that had access to employer spon- recipients take more than five prescription drugs
obtained health insurance and have joined the sored insurance cannot be quantified, it does and seem to be struggling to manage their medi-
ranks of the uninsured. raise concern regarding the amount of crowd- cations. While they may have worked out a strat-
out that may have occurred with the generous egy for getting by with five medications for their
For example, in Hamilton County, the decline coverage provided by the TennCare program. chronic illnesses, any new acute medical problem
in TennCare enrollment coincided with an can throw that equation out of balance.14
increase in the percentage of the uninsured We know that TennCare recipients in Hamilton
adult population. A 2006 quality of life survey County were less likely to be in good or excel- Many individuals with multiple health condi-
of Hamilton County adults found that 20 per- lent health (see Table 1). Although comparable tions are forced to choose which conditions
cent of Hamilton County adults were uninsured national data are unavailable, studies demonstrate to treat. One strategy has been to treat the
for at least some time during the previous that lower socioeconomic status is associated conditions with the most immediate results,
twelve months. Of that population, 18% of with poor health and higher prevalence of behav- while other conditions go untreated. This may
the uninsured respondents indicated that they ioral risk factors.13 Most TennCare and former have serious future consequences; for example,
were uninsured because they lost TennCare.12 TennCare roundtable participants reported mul- untreated hypertension, a condition that usually
By comparison, the Hamilton County 2004 tiple serious health problems. Some of the most has no symptoms, can lead to stroke.
Behavioral Risk Factor Surveillance Survey frequently mentioned health conditions included
(BRFSS) found that 13 percent of all adults diabetes, hypertension, emphysema, heart failure, Patients may ration their medications by tak-
were uninsured at some time during the prior and other heart conditions -- it was not unusual ing every other dose, or may go without some
twelve months. for one participant to have all of these conditions. medications. Some reported sharing medicine
with friends or relatives. Others chose between
Roundtable participants reported that pri- According to provider roundtable participants, medication and other necessities like rent, utili-
vate insurance was unavailable, unaffordable, some disenrollees are applying for disability, ties, and food. Some social assistance agencies
or inadequate. Health insurance companies which if and when granted, would qualify noted that they have had more requests for
were legally obligated to offer health insur- them for TennCare. However, it takes several assistance with rent, utilities, and food from
ance to individuals who were on TennCare months, and in some cases years, to obtain dis- those paying for medicine that was once pro-
for 18 months or more because of the Health ability benefits, during which time the applicant vided by TennCare.
Insurance Portability and Accountability Act has no health care coverage and no guarantee
(HIPAA). Roundtable participants reported of qualifying for benefits. Moreover, provider Prescription limits have been particularly chal-
quoted monthly premiums for single cover- roundtable participants believed that many of lenging for mental health patients. Many mental
age ranging from $75 to over $1,200, with the those intending to apply for disability were not health patients have had to change a medication
average premium at $475, as compared to the actually disabled. regimen which has helped stabilize their illness. 

TennCare recipients are not eligible for pre-
Table 2: Geographic Distribution of 2006 Primary Care Expansion Endowment Grants:
scription assistance programs (PAPs), which Faith Based, Community-Based, and Rural Providers
are designed for people with no prescription
Health Region Total # Grants Grant Total Percent of Funds
coverage. One community health clinic official
reported that it is often easier to treat a patient Metros      
with no coverage than one with TennCare, as Shelby 11 $1,680,000 27.7 %
patients with no coverage has access to a wider Davidson 9 $1,393,125 23.0 %
variety of drugs through PAPs. Knox 4 $471,875 7.8 %
Hamilton 1 $62,500 1.0 %
On the other hand, restrictions on prescrip- Sullivan 1 $37,500 0.6 %
tion drugs have led some patients to be more  
proactive with their health care. According Rural Regions
to medical providers, patients are more likely West TN 13 $710,000 11.7%
to question the necessity of some prescription East TN 7 $442,656 7.3%
medications and are beginning to ask for less South Central 6 $440,625 7.3%
expensive drugs. Some have decided to make Upper Cumberland 6 $398,125 6.6%
lifestyle changes. One roundtable participant, a
Mid-Cumberland 2 $230,000 3.8%
diabetic, lost 20 pounds after losing TennCare
Northeast 3 $161,875 2.7%
coverage and now has better blood sugar con-
trol and lower blood pressure. Health care
providers report that a few of their patients
have made similar changes, however, they stress Table 3: Chattanooga Area Community Health Clinics Patient Payer Sources
the overwhelming majority have not adopted Before and After TennCare Reform
healthier habits. Medicaid/
Total Patient Uninsured $$
Clinic Volume Volume Un-reimbursed
3. After initial confusion, some dis- Reporting Period Volume
Group percent percent Care percent
enrollees are now fairly successful in Change Change
navigating the complicated safety net Change
system, while others are not able to
1* FY 2005-2006 -16.4 % 78.6 % -41.6 % 4.7 %
access available services for which
they are qualified. Calendar Yr 2004-
2 9.0 % 11.8 % -21.6 % NA
A significant amount of confusion accompanied Calendar Yr 2004-
3 9.3 % 16.6 % -2.3 % 2.9 %
the implementation of TennCare reform. The 2005
major changes announced in January 2005 were Jan-July 2005 &
implemented in August 2005. Up to, and even 3 2.9 % 15.0 % -8.1 % NA
after, the changes were implemented, elements * Clinic Group 1 closed one of its 3 clinics in this time period, primarily due to ongoing building maintenance problems.
of the reform seemed to change almost daily. Sources: Chattanooga/Hamilton County Health Department, Southside/Dodson Avenue Community Health Centers,
Staying abreast of policy changes was frustrating Memorial Primary Care Clinics.

for social service providers, especially during the
first few months of the changes. While some cases are more extreme than others, various health-based non-profit organizations
many roundtable participants reported that they outside of Tennessee. Other disenrollees were
Provider roundtable participants described the had been dropped in the midst of treatment for less successful. Often, this was the result of not
frustration of trying to help clients navigate a very serious medical conditions. knowing what services were available to them,
new system which they didn’t understand them- especially during the first few months after dis-
selves. This may have contributed to the confu- Both service providers and TennCare recipi- enrollment.
sion and apprehensions of those most directly ents were confused as to the criteria for losing
affected by the policy changes. They believed TennCare. Many did not understand how they Some disenrollees were successful at navigating
that a more gradual phase in of program chang- could lose their coverage while they were so the Health Care Safety Net program to get their
es could have made for a smoother transition. sick. Several disenrolled roundtable participants medications. Through various PAPs and Safety
indicated they were on disability and did not Net prescription programs, they have been able
Despite significant media coverage, many dis- understand why they were disenrolled. to obtain most of their required medications.
enrollees were unaware of the program changes The MHSN consumers also benefited from
until they either received notification that they A number of disenrollees reported that they having a pharmacy assistance coordinator avail-
had been dropped or were denied medical ser- had succeeded in accessing care, but that the able through all of the MHSN providers. The
vices. Several roundtable participants indicated effort had become almost a full-time job. One most successful disenrollees were proactive and
that the state had done a poor job of notifying roundtable participant assembled a reference had the capacity, patience, and the support of
them of dropping and/or reinstating coverage.15 book of services she has accessed or tried to friends or family to negotiate the complicated
access. Her network includes assistance from patchwork system of assistance.

TennCare Reform, One Year Later: An Assessment of the Impact of the 2005-2006 Changes in the TennCare Program

But some patients found that using the State
Table 4: Changes in ED Use by Payer
Safety Net formulary required them to change
Number of Visits Percent Difference
the medicines they had been taking. In some
FY 2004 FY 2005 FY 2006 2004-2005 2005-2006
cases, the formulary drugs were less effective.
Others indicated that the formulary met few or Uninsured 65,921 64,931 81,507 - 1.5 % + 25.5 %
none of their needs.16 TennCare Total 150,777 154,456 139,536 + 2.4 % - 9.7 %
Private Coverage 136,740 133,440 121,201 - 2.4 % - 9.2 %
Many former recipients were able to obtain medi-
cations through prescription assistance programs Medicare Total 71,270 72,907 79,498 + 2.3 % + 9.0 %
(PAPs). Paperwork was reported to be confusing, All Other 13,370 19,799 21,732 + 48.1 % + 9.8 %
if not overwhelming, especially given the relatively
Totals 438,078 445,533 443,474 + 1.7 % - 0.5 %
low literacy levels of many applicants. Safety net
clinics and some social service providers have been Sources: 2005 JAR and hospital reports of 9 responding hospitals with an ED. Two other hospitals provided FY 2006 data;
however, ED payer data for these two hospitals supplied for the 2004 and 2005 TN JAR reports were included in the “all
helping patients with their PAP applications, while other” payer category, making data incomparable.
others received help from family and friends. The
patient’s physician serves as the middleman – the
physician completes the paperwork and mails the that operate a total of five primary care clinics To supplement the 2004 and 2005 Joint Annual
completed application and prescriptions to the demonstrate that, for the most part, clinics were Report data, CRC also conducted a survey of the
pharmaceutical company, which returns filled pre- seeing the same volume of patients. That is, 21 largest Tennessee hospitals (over 175 beds)
scriptions to the physician’s office and are picked increases in uninsured patient volume were offset with fiscal years ending on June 30.19 The survey
up by the patient. Reportedly, some physicians by declines in TennCare patient volume.17 requested preliminary 2006 utilization, financial,
avoid participating in PAPs, charging patients as and ED data. The FY 2006 data reflect activity for
much as $50 for their services. 5. Hospitals have absorbed the cost of a full year following changes to the TennCare pro-
providing care to an increasing number gram and are comparable to previously published
4. Primary care is generally available to of uninsured patients: a survey of large Joint Annual Report data from 2004 and 2005.
disenrollees, both through emergency hospitals found that the number of
room visits and Health Care Safety Net admitted uninsured patients had more Hospitals providing information on 2006 ED use
programs, especially in the more popu- than doubled during the first year of by payment source in the TennCare Impact Survey
lated areas of the state. changes. indicate that in the 12 months following TennCare
reform, uninsured ED patient volume jumped 25.5
As disenrollees lost access to private physicians, Hospital emergency departments report a simi- percent over the previous year. Uninsured ED
many turned to the Health Care Safety Net pro- lar phenomenon regarding uncompensated care. patient volume had previously been relatively stable
grams established by the State. Not surprisingly, some disenrollees are includ- and had actually decreased 1.5 percent from FY
ing hospital emergency departments (ED) as 2004 to FY 2005.20
As a result of the Safety Net initiative, the state part of their personal safety net, knowing they
opened adult primary health care clinics in would be treated regardless of ability to pay. While disenrollees generally have access to
28 rural counties and expanded existing adult Chattanooga area hospital officials reported sig- primary care through emergency rooms and
primary care services in 19 other county health nificantly higher uninsured ED patient volume Safety Net clinics, many who are critically ill do
department clinics. Health department clinics since the TennCare changes, noting that not all not have access to specialty care. Uninsured
offer primary care for a sliding scale fee, with a were new patients: rather, many were TennCare patients who have been hospitalized are usually
$5 minimum charge. disenrollees accustomed to receiving treatment referred to a community health clinic for fol-
in the ED, whether or not their condition war- low-up care. Often, community health clinics
The State awarded over $6 million to faith- ranted emergency department care. In fact, a are able to provide the needed follow-up care.
based, community based, and rural health care 2006 study found that 40 percent of TennCare Most community health clinics, however, are
centers in 35 counties that serve the uninsured. enrollees visiting a hospital emergency depart- not equipped to meet a patient’s specialty care
Over half of these funds went to providers in ment were “not urgently or emergently ill.” 18 needs, for example cancer treatment. In such
the state’s two most populous counties, Shelby instances, the clinic tries to find specialists that
County and Davidson County. Using data from the Tennessee Joint Annual will provide charity care, but specialists are not
Report of Hospitals, CRC compared 2004 and able to accommodate all requests.
The State awarded an additional $6 million to 2005 emergency department utilization for the
Tennessee’s 23 federally qualified health centers 86 Tennessee hospitals operating on a calendar Programs such as Project Access in Chattanooga
to offset some of the losses from treating more year. Calendar year comparisons only reflect and Knoxville, Bridges to Care Plus in Nashville,
uninsured patients. differences that may have occurred from July and Church Health Care in Memphis coordinate
to December of the second year. Nevertheless, specialty charity care for uninsured patients meet-
In the Chattanooga area, community health clin- while emergency department volume increased ing income and residency requirements. Shortages
ics report small to moderate increases in overall 4.8 percent, uninsured patient volume increased of volunteer physicians in some specialties, such as
patient volume after the TennCare disenrollment. 18.9 percent, while Medicaid/TennCare patient neurology, gynecology, and orthopedics, mean that
Clinic data from three Chattanooga organizations volume was relatively flat – increasing by only not all persons qualified for these programs are
0.2 percent. able to get the care they need. 

Residency requirements for coordinated char- The shift from TennCare to charity care has One month after implementation, officials at two
ity care programs also restrict participation to prompted major hospitals in the Chattanooga area area hospital systems reported that about 5 percent
residents of the county where the program is to collaborate in a process to reduce cost by reduc- of their patients have been deferred treatment.
located, effectively excluding about three-quar- ing inappropriate emergency department use. The third system has deferred only about 1 percent
ters of the disenrollees. While these programs of ED patients, but reported that it has had a simi-
hope to extend enrollment to residents of sur- Chattanooga’s three major hospital systems and lar system of deferral for several years and has been
rounding counties, they currently do not have the Chattanooga Hamilton County Medical seeing fewer non-emergent patients.
the required capacity or infrastructure. Society worked together on an initiative “designed
to appropriately focus emergency department Most patients reportedly accept the new rules.
Since its April 2004 launch, the Hamilton resources on emergent and urgent medical condi- Some patients were satisfied to learn their
County Project Access Program has provided tions, reduce wait times for emergency department symptoms were not serious. Many were grate-
over $11.8 million in donated care to 1,261 patients, and help refer non-emergency patients ful to receive the list of area safety net provid-
patients, including $1.9 in donated physician to primary care homes in the community.”23 This ers, stating they had believed the ED was their
care and $9.9 million in donated hospital ser- program, called QMP (Qualified Medical Provider), only option since they were uninsured.
vices.21 It is difficult to ascertain how much was implemented in October 2006.
TennCare disenrollment affected applications, Few patients, however, have followed up with
since the program was still fairly new when Under QMP, all patients who present in the community health clinics, who report seeing
program changes were made. However, Project ED undergo a medical screening by a quali- only about one patient per week deferred from
Access officials report that the avalanche of fied medical person, in conjunction with the the ED. Telephone follow-up has been difficult
applicants newly disenrolled from TennCare ED physician if needed. Patients who do not as patient phone numbers are often incorrect or
that they expected did not occur. Based on have an emergent or urgent medical condition phones have been disconnected.
feedback from hospital ERs, the program’s are redirected to alternative community health
Executive Director believes that many resources. Alternatively, patients may remain 7. In response to TennCare changes,
TennCare disenrollees turned to area emergency for ED treatment for a flat fee (about $200) several social service agencies have
rooms for their immediate need, while others payable at the time of visit or, if they are made significant programmatic chang-
“simply went without care.” 22 insured, the cost of their co-pay. Deferred es in an effort to better meet the needs
patients receive a list of area safety net provid- of disenrollees.
6. To meet patient needs in the new ers, including community health clinics. To
payer environment, some hospitals ensure that deferred patients are seen in a timely During the early phases of implementation of
have moved to limit emergency room fashion, area community health clinics have changes to TennCare, many social service agen-
treatment for patients with non- emer- agreed to reserve up to five appointments per cies changed their program to meet anticipated
gent or non-urgent conditions. week for deferred patients. increased demand for emergency assistance.
Eligibility requirements for assistance were
Joint Annual Reports and supplemental infor-
mation based on a survey of major hospitals
suggest a dramatic increase in hospital visits and Table 5: Summary of Hospital Utilization and Charity Care 2004-2006
costs associated with uninsured patients since   TN JAR data   TN Impact Survey & JAR Data
implementation of the changes in TennCare. Half Year Post Full Year Post
Pre TennCare Pre TennCare
  TennCare   TennCare
Changes Changes
Using 2004 and 2005 Tennessee Joint Annual Changes Changes
Report of Hospitals, CRC compared one-year CY 2004- FY 2004- FY 2004- FY 2005-
changes in utilization and financial data of hospi-    
CY 2005 FY 2005 FY 2005 FY 2006
tals reporting on a fiscal year to hospitals report- # Hospitals Reporting (86) (67)   (13)*
ing on a calendar year. Only hospitals on a cal-
endar year should have seen an impact based on
changes in TennCare. In addition, CRC received Total Admissions - 1.0 % - 1.9 %   + 2.9 % + 5.4 %
preliminary FY 2005-2006 utilization and finan- Uninsured + 37.0 % + 1.1 %   - 2.6 % + 141.1 %
cial data from 13 hospitals responding to the TennCare -2.3 % - 1.9 %   + 5.5 % - 6.6 %
TennCare Impact Survey: These data cover the Outpatient Visits          
first full year of implementation of the changes Total + 1.7 % + 0.4 %   + 0.9 % + 6.9 %
in TennCare and could be compared to 2004-
2005. Both analyses show significant increases Uninsured + 21.5 % - 0.1 %   - 4.5 % + 73.3 %
in uninsured patient volume and charity care in TennCare + 0.8 % + 20.3 %   - 4.1 % - 10.0 %
the reporting periods after changes in TennCare Financial          
compared to the pre-change reporting period. Charity Care 71.8 % + 16.4 %   33.9 % 52.9 %
Most notably, among the thirteen TennCare Sources: Hospital JAR data for 2004 and 2005;
Impact Survey hospitals, uninsured inpatient vol- Preliminary 2006 data submitted by 13 non-profit hospitals in 9 counties
ume increased 141.1 percent. *Only 12 hospitals provided outpatient data

TennCare Reform, One Year Later: An Assessment of the Impact of the 2005-2006 Changes in the TennCare Program

Table 6: Chattanooga 211 Requests for Assistance 8. As of May 2007, nearly 35 percent
(5,685) of TennCare disenrollees with
Comparison to 2004
Total Requests # serious and persistent mental illness
(Percent Change)
(SPMI) have not registered for Mental
July 1 – November 8, 2004 6,171 NA Health Safety Net (MHSN) services for
which they are eligible.
July 1 – November 8, 2005 6,400 + 3.7 %

July 1 – November 8, 2006 5,457 - 11.6 % The Tennessee Department of Mental Health
and Developmental Disabilities developed the
Source: United Way of Greater Chattanooga 211
MHSN “to provide essential mental health
services to those persons who were disenrolled
tightened at some agencies: for example, new Not all social service agencies were faced with
from the TennCare program due to TennCare
restrictions were placed on the number of times a need to reallocate resources to meet increased
reform and were identified as SPMI.”
they provide a family with emergency assistance. demand. One way to gauge overall demand for
At least two Chattanooga area agencies desig- social services in the community is through the
Initially, TennCare officials identified 20,775
nated all of their emergency assistance funds for 211 system. Sponsored by the United Way, 211
individuals on TennCare with SPMI for
prescription medicine assistance. functions as a community-wide source of referrals
disenrollment. Of that number, after appeals,
for individuals needing assistance. Records from
16,478 were actually disenrolled.
Other social service organizations re-evaluated 211 do not suggest dramatic jumps in requests for
the role of emergency assistance programs in assistance. In the three-month period immediately
Several agencies coordinated efforts to enroll
their organizations. One Chattanooga-area agen- following TennCare program changes, requests for
eligible disenrollees in the MHSN. Registered
cy reported that it has moved away from direct assistance were up 3.7 percent over the same time
individuals with SPMI are eligible for assessment,
financial assistance and is working toward devel- period the previous year. During this time, how-
evaluation, diagnostic and therapeutic interven-
oping a sense of empowerment among its clients ever, many people displaced by Hurricane Katrina
tions; psychiatric medication management; labora-
by placing more emphasis on lifestyle education, relocated to Chattanooga and contacted 211 for
tory services related to medication management;
preventative education, and budget counseling. assistance. During the same time period in 2006,
community transitional support; and pharmacy
211 processed 11.6 percent fewer requests than in
assistance and coordination. They are also eligible
Social service agencies also reported increased 2004, prior to TennCare reform.
for RxOutreach, with an expanded formulary of
requests for assistance with food, rent, and utili-
generic drugs (six additional medications) and
ties as families used money budgeted for these The AIM Center, a non-medical non-profit
access to one atypical anti-psychotic medicine, sub-
necessities to purchase medicine. community organization that provides vocation-
ject to a five dollar co-pay.
al and social services for the chronically mental-
Many agencies reported spending significant ly ill in the Chattanooga region, expected a big
The Tennessee Chapter of the National Alliance
staff resources assisting people with their medi- crush of clients in crisis resulting from changes
on Mental Illness (NAMI) conducted 29 com-
cation needs. This included not only helping in prescription medications. The agency reports
munity forums throughout the state, and the
patients get medicine, but also advising patients that the volume of patients in crisis has been
TennCare Partners Advocacy Line and the
how to best maximize their prescription bud- stable, and similar to the crisis volume before
community mental health centers reached 60
gets. Even case workers and other social TennCare changes.
percent of eligible persons by telephone.27 In
service personnel were asked for advice on
addition, some community mental health cen-
rationing medicine, raising some concerns about Anticipated spikes in crisis intervention ser-
ters also went out in the field to look for these
potential medical liability. One pharmacist vices and mental health institute hospitalization
patients and sign them up for the MHSN.
reported spending as long as 30 minutes on the among the severe and persistent mental illness
telephone with individual patients explaining the (SPMI) population did not occur. One com-
Roundtable participants representing community
new medication policy and helping them make munity mental health center added five beds for
mental health agencies have generally been pleased
decisions on filling prescriptions. crisis intervention: however, there has been little
with MHSN services, but are concerned about the
demand for the new beds.
SPMI population who did not enroll. As of May
Community health clinics and several social
2007, 10,793 of the 16,478 (65.5 percent) of the
service agencies provide assistance with filling In some cases, the changes in TennCare
disenrollees known to have SPMI had registered
out forms for PAPs. Some agencies have been resulted in a decrease in the demand for ser-
for MHSN services. Outreach efforts identified
able to designate employees for which such vices. For example, agencies providing medical
other disenrollees eligible for the MHSN – individ-
assistance is their main duty, while others have transportation for TennCare patients had fewer
uals not among the original 16,478 – and registered
added this task to an already full workload. At patients to transport, forcing staff reductions
2,886 newly identified individuals with one of the
least one local clinic is trying to reduce their for some. In the first twelve months after
community mental health agencies.
dependence on prescription assistance programs TennCare program changes, Special Transit
and free up staff resources by directing patients Services, TennCare’s transportation service pro-
The percentage of disenrollees with SPMI not
to fill prescriptions at one of three chain dis- vider for Hamilton County, provided 18 percent
registered in the MHSN varies widely by county.
count stores which, between the three stores, fewer medical related trips than the same time
At the low end, approximately one-fourth of disen-
offer over 350 generic drugs at a cost of four to period the previous year and now employs only
rollees in four counties are not registered – Gibson
five dollars per month.24 about half as many drivers as it did in 2004.25 

County (13.8 percent) has the smallest percentage Table 7: Tennessee Mental Health Institutes Admissions Data 1999-2007
of non-registered disenrollees. However, over half
Year Annual Admissions Percent Annual Change
of the disenrollees in six counties are not registered:
for example, in Monroe County, 63.0 percent 1999-2000 9,905 --
of disenrollees never registered (See Map 1 and 2000-2001 10,945 10.5 %
Appendix A for county-by-county details). 2001-2002 12,443 13.7 %
2002-2003 14,483 16.4 %
Medical providers participating in the round-
tables noted an increase in patients with mental 2003-2004 14,667 1.3 %
health issues. In a provider roundtable six 2004-2005 14,090 -3.9 %
months after the TennCare changes, one partic- 2005-2006 14,811 5.1 %
ipant indicated that mental health related emer-
gency room volume seemed to have tripled. 2006-2007 (projected) 15,100 2.0 %

Source: State of Tennessee Fiscal Information
Yet, the Tennessee Chapter of NAMI reports
that “neither hospitalization nor use of crisis
services has spiked since disenrollment.”28 may have actually lived in a bordering state but 9. Key indicators of the State’s economy
While projections based on year-to-date data used a Tennessee address in order to qualify for reflect national trends and, to date, do
suggest that admissions to state mental health TennCare. not match economic declines predicted
institutes increased slightly in the current fiscal as a result of the TennCare changes.
year (‘06-‘07), the rate of increase was less than It is also possible that some of the SPMI popula-
half the rate the previous year and significantly tion may have become homeless or incarcerated, Many predicted the changes to the TennCare
less than the 10 percent to 16 percent increases conditions often associated with untreated mental program would have a disastrous effect on the
just a few years earlier. And use of crisis ser- illness. For example, approximately 30 – 40 per- State economy. The Center for Budget and
vices actually declined over the past year. cent of homeless individuals in the Chattanooga Policy Priorities predicted thousands in lost rev-
State-wide quarterly reports from the TennCare region are said to have serious mental illness.29 enue and jobs that would result in an $800 mil-
Partners Roundtable show that contacts to Local incarceration data are not available, but lion reduction in state economic activity in FY
mobile crisis units from April through June national figures indicate than people with untreated 2005, increasing to $2.4 billion in 2008.32
2006 were down 5.9 percent from the same mental illness were twice as likely as healthy indi-
time period in 2005. viduals to have contact with the criminal justice One year into TennCare reform, leading financial
system.30 A State survey of jail administrators and ratings agencies praise Tennessee’s economy. Both
There is speculation that some disenrollees county sheriffs in Tennessee suggests that the per- Fitch and Standard and Poor’s upgraded their rat-
have moved out of state, especially if they lived centage of jail inmates may be declining: but that ings on Tennessee’s general obligation bonds from
near the border of one of Tennessee’s eight same survey, in 2006, also found that more than AA to AA+. According to Bloomberg News
bordering states. Despite being prohibited by half of all responding counties reported that there Service, Tennessee is one of only 16 states that
TennCare regulation, some of these individuals had been an increase in the number of individuals currently have an AA+ rating from Standard and
with mental illness in their jail over the past year.31 Poor’s.­­­­­­­­­­­­­ Moody’s, a third provider of independent
credit ratings, raised Tennessee’s credit outlook
from “stable” to “positive.” All three organiza-
Mobile Crisis Contacts tions indicated that the restructuring of TennCare
contributed to the boost in ratings.
41 ,000

40,000 Rather than losing thousands of jobs as predict-
ed, total non-farm employment in Tennessee
Total Contacts

39,000 increased by 34,000, or an increase of 1.2 per-
cent. Unemployment rates decreased 16.4 per-
38,000 cent (from 5.5 percent to 4.6 percent).
Employment in the health care sector increased
37,000 as well, with the healthcare and social assistance
sector reporting 2.3 percent higher employment
than before TennCare reform. Within the larg-
er category of health care and social assistance,
35 ,000
ambulatory health care services employment
Apr - Jun Apr - Sep Oct - Dec Jan - Mar Apr - Jun increased 3.0 percent, hospital employment
2005 2005 2005 2006 2006 increased 2.4 percent, and nursing and residen-
Source: TennCare Partners Roundtable
tial care facilities increased 1.8 percent.

TennCare Reform, One Year Later: An Assessment of the Impact of the 2005-2006 Changes in the TennCare Program

finalizing the amendments required to make such
Table 8: TennCare: One Year Later Economic Indicators
changes to the program. It is hard to determine
  Tennessee United States Sources Time Frame whether the reform initiative would have led to the
 Employment by Sector:         same containment of cost with less of an impact
on the health of current and past TennCare partici-
Total Non-farm
+ 1.2 % + 1.5 % BLS 7/05 - 8/06 pants had it been rolled out differently.
Health Care and
+ 2.3 %  + 2.3 % BLS 7/05 - 8/06 But then again, the program adopted by the
Social Assistance
Legislature was never fully implemented.35
Ambulatory Health Care
+ 3.0 % + 3.0 %  BLS 7/05 - 8/06 Throughout the process, the State sought
to “fine tune” various aspects of the policy
Hospitals + 2.4 % + 2.4 % BLS 7/05 - 8/06 reforms. Without constant monitoring of
Nursing and Residential impact, the outcomes to date could have
+ 1.8 % + 1.8 %  BLS 7/05 - 8/06
Care Facilities been different.

 Unemployment Rate:      
It is clear, however, that there was a high level of
1 yr decrease - 0.9 pts - 0.5 pts BLS 9/05-9/06 confusion for some individuals as reforms were
being implemented. Absent a phase-in period,
Percent Change - 16.4 % - 9.8 % BLS 9/05-9/06 participants were frequently confused – and
        understandably apprehensive – about the changes.
Health and social service providers often lacked
Personal Income + 6.8 % + 7.3 % BEA 2nd Qtr 2005-2006 sufficient information to provide to clients. And,
From AA to during these early stages, individuals slipped
State Bond Ratings  NA Fitch, S&P October 2006
AA+ through the cracks and went without care.

While the State worked to communicate these
One year into reform, Governor Bredesen hospital and medical facilities have petitioned changes as they were occurring, communication
achieved his goal of limiting TennCare spend- the State for permission to proceed with build- efforts seem to not have been sufficient.
ing to 26 percent of tax revenues. The addition ing projects totaling close to $2.3 billion – a
of two new programs – the Health Care Safety 400 percent increase over 2005. The three Access to Health Insurance vs. Access
Net and Cover Tennessee — however, brings largest requests include $320 million for a to Care
State spending on health care programs for the hospital expansion project in Chattanooga,
uninsured up to 27.5 percent of tax revenues. $28.35 million to relocate a hospital in Many predicted that the result of the changes to
Reducing the number of people covered by Murfreesboro, and $234.4 million for a hospital TennCare would be that tens of thousands of
TennCare reduced state spending by $647 mil- expansion in Nashville.34 Tennesseans would be left without health insur-
lion. This spending reduction, however, was ance and without access to health care. In the
accompanied by a $644 million loss in federal Considerations short term, that has not been the case. While it
matching funds. The State also lost $30 million One year after implementation of the recent appears that it has been challenging for TennCare
in revenue from premiums paid by some of round of changes in the TennCare program, it recipients who lost coverage to gain new cover-
the disenrollees. is important to consider some possible lessons age, most have continued to access health care.
learned – both from the process and from early However, the difference now is that more of the
In 2006, the combined costs of the three pro- outcomes. cost of their health care is being absorbed in the
grams, TennCare, Health Care Safety Net, growing cost of charity care.
and Cover Tennessee, are expected reach Necessity for sufficient planning, policy
$2.8 billion -- 8 percent more than the cost development, and communication And, while some alternative volunteer pro-
of TennCare before reform. State officials The programmatic overhaul to TennCare was put grams expected to bear the brunt of providing
indicate, however, that the rate of spending into place within months of it first being proposed. this care, the reality was that former TennCare
growth has slowed to a more manageable rate. It did not occur in a vacuum, however. After nego- recipients relied on hospitals for their health
TennCare spending growth approached 18 per- tiations with advocacy groups to reduce costs to care needs. Again, this phenomenon may only
cent in 2004: state officials expect TennCare the hemorrhaging program failed, it was a strategy be short term: it is too soon to tell what, if
spending to grow only one half of one percent of last resort. Some critics have said that the pro- any, effect the new Qualified Medical Provider
in the current year, although the new programs gram changes occurred without adequate planning program will have or whether hospitals will take
will add to health care expenses.33 and detailed policy development. On the other other steps to limit their role as an informal
hand, the state believes it invested a significant safety net. Also, as hospitals continue to try to
While the increase in charity care has had a amount of time and energy towards planning the meet the demands related to the growth in char-
fiscal impact on hospitals, it has not deterred TennCare changes – particularly with the Centers ity care, they may have to scale back even more.
some facilities from going forward with ambi- for Medicare and Medicaid Services (CMS) – and
tious expansion projects. In 2006, Tennessee

Impact on Vulnerable Populations earlier, there are clearly long-term implications 400 percent of the federal poverty level. Individuals with
incomes at or above 400 percent of federal poverty levels
of the changes that cannot be assessed at this
could buy-in to the program and pay non-subsidized
We don’t have enough information to know about time. In the interim, however, this report high- premiums. By the end of 1994, TennCare enrollment was
the real impact of the cuts in TennCare to those lights the real consequences of these changes by approaching capacity and the State closed enrollment to
people in the uninsured category. Enrollment remained
individuals with SPMI. Like other former recipi- giving a voice to those affected.
open in the uninsurable category.
ents who did not know how to access alternative 7 Anna Azer, Marsha Gold and Cathy Schoen, “Managed
means of obtaining care, these individuals may TennCare was implemented as an experiment Care and Low-Income Populations: Four Years’
Experience with Tenncare,” Kaiser/Commonwealth
have fallen through the cracks. Individuals with in substantial reform; by doing so, the state had
Low-Income Coverage and Access Project, May 1999.
untreated SPMI are particularly vulnerable. to accept the risks that come with attempting 8
something new. The entire health care sector Servlet?action=viewFile&id=18
9 Prior to disenrollment, the State conducted an internal
As this paper has also highlighted, a portion of evolved in the state as the TennCare program
review to determine whether individuals were quali-
the disenrollees have become ‘silent’ to an extent. grew. Likewise, with its retrenchment, patients, fied for TennCare under the new eligibility guidelines.
In some circumstances, the changes in TennCare providers, and the state will have to realign and Potential disenrollees received a request for information
with a form to be completed to determine continued eli-
resulted in a decrease in the demand for services. make the system work, hopefully in a more
gibility under the core Medicaid program.
There are many reasonable explanations for this. effective manner. 10 TennCare did set up a process to allow enrollees who
The larger question, however, is when will these were subject to benefit limits to get additional drugs even
if they had reached their limit. One process, called the
individuals re-appear in the system, and in what Endnotes Auto Exemption process, consists of a list of over 500
state of health will they be? 1 Christopher J. Conover, Hester H. Davies, “The Role of drugs that do not count against the benefit limit. Another
TennCare in Health Policy for Low-Income People in program, launched in February 2007, called the Prescriber
Tennessee,” Urban Institute, 2000, http://www.urban. Attestation process, consists of over 600 medications that
Not Just Health Care Providers org/url.cfm?ID=309341 can be accessed when a prescriber attests to TennCare that
2 According to the state, 40,000 of the 170,000 persons there is an urgent need for his patient to have the drug.
who were disenrolled were dual eligibles, meaning that
The provider roundtables suggest that the prac- 11 The city of Chattanooga (2000 population: 155,509) is
they were Medicare beneficiaries. These people would not wholly located within Hamilton County, Tennessee (2000
tical impact of the rapid changes in TennCare be considered ‘uninsured.’ population: 307,896), the largest county in Southeast
fell at least as much on social service agencies 3 According to the state, nearly 9,000 TennCare disenroll- Tennessee. Hamilton County health care providers and
ees with serious and persistent mental illness (SPMI) have
as it did on health care providers. While state many social service agencies serve residents of nearby
not registered for Safety Net services for which they are counties as well.
officials were able to put a Health Safety Net eligible: in 16 Tennessee counties, over half of eligible 12 Community Research Council, The 2006 State of
in place, there was no comparable “back up” disenrollees have not registered. Of the 20,775 originally Chattanooga Region Report, November 2006.
identified as SPMI only 16,816 were actually disenrolled
to the redirection of emergency assistance to 13 A 2005 study found that the proportion of non-elderly
from TNCare. (This reduction in the number of SPMIs former and current welfare recipients reporting fair or
health care. who were disenrolled was in part the result of enrollees poor health was three times that of the general popula-
exercising their appeal rights.) Of those disenrollled, tion. (Tyrone Chang, The Impact of Welfare Reforms,
10,934 were registered with one of the 20 MHSN provid-
Economic Impacts Health, and Insurance Status on welfare Recipients’
ers. By October 2006 in spite active outreach efforts by Health Care Access, Journal of Health Care for the Poor
National Alliance for the Mentally Ill (NAMI) approxi- and Uninsured 16.3, 2005.) National BRFSS data indicate
Dire predictions of lost jobs and closing hos- mately 6,000 of the identified SPMIs had not contacted that adults with less than $15,000 household income were
a Community Mental Health Agency (CMHA) to register
pitals have not yet been fulfilled – at least in three times more likely to have diabetes, 2.3 times more
for services.. There was a liberalization of the MHSN likely to smoke, and 1.9 times more likely to have asthma
those areas that were the focus of this study. criteria for eligibility and by October 27, 2006, 2083 indi- than adults with $50,000 or more in household income.
Arguably, the increase in health care employ- viduals--who had not been identified previously as SPMI (Centers for Disease Control and Prevention, Behavioral
(out of the 190,000 who were disenrolled) were registered
ment in Tennessee would have been even Risk Factor Surveillance System Survey Data. Atlanta, Georgia:
with a CMHA in the MHSN. U.S. Department of Health and Human Services, Centers
greater had TennCare continued to grow at its 4 According to the state, nearly 6,000 TennCare disenroll- for Disease Control and Prevention, 2005.)
past rates. But, at least in the short term, the ees with serious and persistent mental illness (SPMI) have 14 See footnote 8
not registered for the Mental Health Safety Net (MHSN):
loss of funding has not led to dramatic reduc- 15 According to the state, enrollees were notified several
in 12 Tennessee counties, nearly half of eligible disenroll- times, and well in advance, of being disenrolled. An
tions in employment. One reason may be that ees have not registered. Of the 20,775 originally identi- initial notice with a “Request for Information” was sent
so much of the reduced funding was in the area fied as SPMI only 16,478 were actually disenrolled from to enrollees asking them to send information that would
TennCare. (This reduction in the number of SPMIs who
of prescription costs, not labor costs. Thus, have helped the state determine eligibility for a Medicaid
were disenrolled was in part the result of enrollees exer- category. If the enrollee did not respond to the initial
the impact of the cuts may have fallen dispro- cising their appeal rights.) Of those disenrolled, 10,793 notice or they did respond but were determined ineligible,
portionately on out-of-state pharmaceutical were registered with one of the 20 MHSN providers. By they then received additional notices announcing the dis-
May 2007, in spite of active outreach efforts by National
companies, not in state health care workers. enrollment and offering appeal rights.
Alliance for the Mentally Ill (NAMI) approximately 6,000 16 For example, the formulary does not offer the more
In terms of hospitals, an October 2006 report of the identified SPMIs had not contacted a Community specialized medications for less common illnesses, such as
by Moody’s Investor Services found that the Mental Health Agency (CMHA) to register for services. rheumatoid arthritis, seizure disorders and other neuro-
There was a liberalization of the MHSN criteria for eligi-
TennCare reform “has not been as significant logical disorders, psychiatric disorders, and gastroenterol-
bility and by May 21 2007, 2,886 individuals disenrolled ogy conditions. Further, for the illnesses the formulary
as originally anticipated, allowing hospitals an from TennCare who had not been identified previously as does treat, some generic drugs do not work as well as the
opportunity to successfully offset the majority SPMI were registered with a CMHA in the MHSN. brand drugs for many patients.
5 It should be noted that the number of uninsured people
of the unfavorable changes through revenue 17 Clinic Group 1 operates on a fiscal year, and comparisons
in Tennessee had been growing, separate and apart from to the previous year reflect a full year of post TennCare
enhancement and cost control initiatives.” the disenrollments that occurred in 2005. TennCare com- reform data. Clinic Group 3, however, operates on a cal-
missions a yearly survey that provides estimates of the endar year, and comparisons to the previous year reflect
number of uninsured people in the state. These estimates
As Tennessee continues its implementation of only a half year’s post TennCare reform data.
have been climbing each year since 2002. 18 Bureau of TennCare, “Proposal to Reduce Inappropriate
the Cover Tennessee program, it will be impor- 6 Members of the TennCare expansion group were subject Utilization of the Emergency Department by TennCare
tant to see how the TennCare program settles to monthly premiums. Premiums were set on a sliding Enrollees,” August 2006.
scale based on income for individuals with incomes up to
in as a far more modest program. As mentioned

TennCare Reform, One Year Later: An Assessment of the Impact of the 2005-2006 Changes in the TennCare Program

19 All Tennessee hospitals that report on a June 30 fiscal 26 Tennessee Department of Mental Health and estimate of the number of inmates diagnosed with mental
year are nonprofit or government-run. Developmental Disabilities: Division of Recovery illness. A higher percentage responded to the ques-
20 TennCare Impact Survey - Surveys were mailed to the Services, “Mental Health Safety Net Information Packet,” tion of whether there had been an increase or decrease
chief executives of the 21 largest Tennessee hospitals October 23, 2006. in number over the last year – twenty five reported an
reporting on a June 30 fiscal year. A total of 13 hospitals 27 Sita Diehl, “TennCare Changes, Effects on Children increase, six reported a decrease and fifteen reported
responded, although only 9 provided requested informa- and Adults with Mental Illness,” TennCare Oversight no change. In addition, according to the report, “three
tion on ED use. Committee, NAMI Tennessee, April 10, 2006. counties report experiencing an increase in the population
21 Hamilton County Project Access Program Report, 28 Ibid. of inmates with mental illness due to lack or loss of insur-
November 2006. 29 City of Chattanooga and the Chattanooga Homeless ance benefits in the community.”
22 Correspondence with Rae Young Bond, Executive Coalition, “The Blueprint to End Chronic Homelessness 32 Center on Budget and Policy Priorities, “Will the
Director, Hamilton County Project Access. in the Chattanooga Region in Ten Years,” 2004. New TennCare Cutbacks Help Tennessee’s Economy?”
23 Chattanooga and Hamilton County Medical Society cor- 30 P. Ditton, “Mental health and treatment for inmates July 8, 2004.
respondence, September 20, 2006. and probationers,” Washington, DC: Bureau of Justice 33 Chattanooga Times Free Press, “Medical growth a shot
24 Programs available at Wal-Mart/Sam’s Club, K-Mart, and Statistics, 1999. in the arm for economy,” October 8, 2006.
Target. Tennessee law prohibits the sale of prescription 31 D. Ducote and P. DeWitt, “County Jails in Tennessee: 34 Ibid.
drugs at prices below cost, which affects an additional Third Survey Report,” June 28, 2006. According to the 35 The State did not go forward with the elimination of
51 generic drugs. These 51 additional drugs may be pur- survey, the percentage of inmates with diagnosed mental coverage for the 97,000 residents in the medically needy
chased for $9 for a 30-day supply. illness dropped from 18% in 2002 to 15.6% in 2005. spend down category, although enrollment in this cat-
25 Special Transit Services (STS) data. STS made a monthly Unfortunately, while 2002 and 2003 surveys were based egory was closed to non-pregnant adults. For those
average of 4,250 medical trips month from July 2004 on responses from officials representing all or nearly all remaining on TennCare, proposed limits on physician vis-
through June 2005, and an average of 3,480 medical trips of the county jail facilities in the state, the 2006 survey its, covered inpatient and outpatient care were postponed
during the same time period the following year, a decrease had a much lower response rate: for example, only 38% indefinitely. (See Background section)
of 18.1 percent. of all counties responded to the question asking for an

Appendix A
Table 7: Registration with the Mental Health Safety Net by County

Registered Not Registered
County Number Disenrolled SPMI
Number % Disenrolled Number Percent Disenrolled
Monroe 127 47 37.0% 80 63.0%
Sevier 301 119 39.5% 182 60.5%
Cheatham 104 44 42.3% 60 57.7%
Loudon 144 63 43.8% 81 56.3%
Blount 397 182 45.8% 215 54.2%
Jackson 27 13 48.1% 14 51.9%
Bedford 110 56 50.9% 54 49.1%
Fentress 43 22 51.2% 21 48.8%
Humphreys 62 32 51.6% 30 48.4%
Perry 31 16 51.6% 15 48.4%
Lincoln 87 46 52.9% 41 47.1%
Houston 34 18 52.9% 16 47.1%
Grundy 48 26 54.2% 22 45.8%
Knox 1,067 584 54.7% 483 45.3%
Dickson 198 109 55.1% 89 44.9%
Marshall 115 64 55.7% 51 44.3%
Macon 75 42 56.0% 33 44.0%
White 69 39 56.5% 30 43.5%
Montgomery 320 181 56.6% 139 43.4%
Stewart 47 27 57.4% 20 42.6%
Hardin 92 53 57.6% 39 42.4%
Robertson 156 90 57.7% 66 42.3%
Coffee 174 101 58.0% 73 42.0%
Bradley 228 134 58.8% 94 41.2%
Claiborne 117 69 59.0% 48 41.0%
Warren 140 83 59.3% 57 40.7%
DeKalb 52 31 59.6% 21 40.4%
Smith 33 20 60.6% 13 39.4%
Putnam 160 97 60.6% 63 39.4%
Rutherford 343 210 61.2% 133 38.8%
Williamson 124 76 61.3% 48 38.7%
Lewis 75 47 62.7% 28 37.3%
Overton 54 34 63.0% 20 37.0%
Hamblen 153 97 63.4% 56 36.6%
Tipton 209 134 64.1% 75 35.9%
Lauderdale 134 86 64.2% 48 35.8%
Davidson 2,082 1,340 64.4% 742 35.6%
Bledsoe 51 33 64.7% 18 35.3%
Giles 142 92 64.8% 50 35.2%
Franklin 117 76 65.0% 41 35.0%
Wilson 178 116 65.2% 62 34.8%
Cumberland 165 108 65.5% 57 34.5%
Clay 29 19 65.5% 10 34.5%
Polk 35 23 65.7% 12 34.3%
Haywood 63 42 66.7% 21 33.3%
Moore 15 10 66.7% 5 33.3%
Sequatchie 51 34 66.7% 17 33.3%
Van Buren 21 14 66.7% 7 33.3%

TennCare Reform, One Year Later: An Assessment of the Impact of the 2005-2006 Changes in the TennCare Program

Registered Not Registered
County Number Disenrolled SPMI
Number Percent Disenrolled Number Percent Disenrolled
Hickman 145 97 66.9% 48 33.1%
Dyer 174 117 67.2% 57 32.8%
Sumner 330 222 67.3% 108 32.7%
Hardeman 69 47 68.1% 22 31.9%
Jefferson 138 94 68.1% 44 31.9%
Union 91 62 68.1% 29 31.9%
Chester 44 30 68.2% 14 31.8%
Meigs 41 28 68.3% 13 31.7%
McMinn 194 133 68.6% 61 31.4%
Maury 307 213 69.4% 94 30.6%
Shelby 1,447 1,005 69.5% 442 30.5%
Fayette 60 42 70.0% 18 30.0%
Cocke 189 133 70.4% 56 29.6%
Wayne 75 53 70.7% 22 29.3%
Pickett 14 10 71.4% 4 28.6%
McNairy 74 53 71.6% 21 28.4%
Marion 92 66 71.7% 26 28.3%
Hamilton 716 516 72.1% 200 27.9%
Crockett 36 26 72.2% 10 27.8%
Morgan 38 28 73.7% 10 26.3%
Scott 46 34 73.9% 12 26.1%
Roane 128 95 74.2% 33 25.8%
Rhea 121 90 74.4% 31 25.6%
Anderson 189 141 74.6% 48 25.4%
Decatur 67 50 74.6% 17 25.4%
Hawkins 185 139 75.1% 46 24.9%
Obion 89 67 75.3% 22 24.7%
Lake 49 37 75.5% 12 24.5%
Cannon 29 22 75.9% 7 24.1%
Weakley 87 66 75.9% 21 24.1%
Benton 84 64 76.2% 20 23.8%
Henderson 163 125 76.7% 38 23.3%
Hancock 26 20 76.9% 6 23.1%
Carter 152 118 77.6% 34 22.4%
Washington 310 243 78.4% 67 21.6%
Trousdale 28 22 78.6% 6 21.4%
Madison 309 243 78.6% 66 21.4%
Sullivan 463 366 79.0% 97 21.0%
Greene 171 136 79.5% 35 20.5%
Johnson 47 38 80.9% 9 19.1%
Grainger 63 51 81.0% 12 19.0%
Henry 105 85 81.0% 20 19.0%
Unicoi 77 63 81.8% 14 18.2%
Lawrence 192 158 82.3% 34 17.7%
Carroll 113 93 82.3% 20 17.7%
Campbell 138 114 82.6% 24 17.4%
Gibson 159 137 86.2% 22 13.8%
Out of State 15 2 13.3% 13 86.7%
TOTAL 16,478 10,793 65.5% 5,685 34.5%
Source: Tennessee Department of Mental Health and Developmental Disabilities: Division of Recovery Services, Mental Health Safety Net, May 22,2007
'11 suicides heighten concerns
5 Summit Towers residents took their own lives last
By Josh Flory

Sunday, May 6, 2012

Crystal Hachey was waiting for the cable guy when the first man jumped to his death.

It was the morning of Jan. 4, 2011, and Hachey recently had moved into a 10th-floor unit
at Summit Towers, the government-subsidized apartment building on Locust Street.

When she heard a noise outside the door, she assumed it was the cable company, but
when she opened it, she saw a man in black shorts and a yellow shirt, climbing out of the
hall window.

His foot got caught in the strings of the blinds, she said later, but he wriggled free, held
onto the ledge, then let go. He didn't say a word before falling 83 feet.

"If you looked at his eyes, it looked like he was already gone," Hachey recalled.

John Acree's death was a tragedy, and it was also unusual.

In recent years, only a tiny fraction of the Tennesseans who committed suicide have done
so by jumping or putting themselves in the path of moving objects.

In 2011, though, Summit Towers was a shocking exception. Acree was the first of three
men who would fall to their deaths from the apartment building, and according to police
reports at least two more residents committed suicide by other methods.

The string of suicides cast ripples through the state's mental health community and
through the building's remaining residents, many of whom were dealing with trials of
their own.After Acree's death, Hachey — who suffers from a form of bipolar disorder —
said she was scared every time she heard someone outside her door. She stayed in the
building for only a few months and described it as a lonely place. "I was really sad when
I lived there," she said.
Summit Towers has 277 apartment units and more than 300 residents, approximately
two-thirds of whom are either mentally or physically disabled. Rent rates are based on
each tenant's income, and residents pay anywhere from $25 a month to — in at least one
case — more than $600 a month, with utilities included.

According to his brother, John Acree was diagnosed with paranoid schizophrenia around
1980. Joseph Acree said that after college his younger brother had worked as a teacher in
California but later moved back to Tennessee. Over the course of 30 years, Acree said his
brother's condition worsened, mainly when he stopped taking his medication. He was
dirty, delusional about relationships and his family would sometimes call the police when
he ran off.

"There was a long history of that," said Joseph Acree. "He did that a lot."

Joseph Acree said he helped his brother move into Summit Towers in 2005, after about
six months in which the two lived together. Joseph Acree said he liked the building's
concierge service — a woman who would help residents with daily needs — but said
things changed over the years.

In particular, he said the building went downhill after a bedbug infestation forced the
ownership to take eradication measures in the apartments. Some residents, he said, had to
throw their furniture away, and on visits he would sometimes see piles of mattresses and
furniture in the back parking lot.

Acree said Summit staffers became more hard-nosed about everything. His brother had to
submit certain paperwork because of his Social Security income, Acree said, and the
management would be sticklers about the details.

Already a difficult personality, John Acree didn't take well to those types of demands, or
to the bedbug situation. Joseph Acree said he could sort of understand why the building
management might be "a little PO'd" with his brother, but said he wished they had done

"They were just (a) real hard-ass with him, I think ... in a stupid kind of way," he said.
"And then ... what I'm kind of sympathetic with here is the unfortunate bug problem.
There's no good way to deal with that. He was just stuck with it."

Bill Acree, another of John Acree's brothers, took a more sympathetic approach, saying
the management at Summit Towers had actually cut John some breaks when he broke the
rules, and even let him stay when he was late with his rent.

"Where would these people go if it wasn't for a place like that?" he said. "It's a very sad
situation. (The management) did try to help within what they could, I think."

Mixed Reviews
When it was developed by Lawler-Wood Associates in the late 1970s, Summit Towers
was behind City Hall. Since then the government has moved off the hilltop, but the
building remains in an enviable spot — just north of the downtown core, within walking
distance of Market Square, World's Fair Park and the Old City.

Surprisingly unassuming for its hilltop location — particularly when the trees along
Summit Hill Drive are in leaf — the building's design doesn't quite live up to a lofty
name that evokes multiple skyscrapers. It's essentially a sideways rectangle of bricks and
windows that would look more tower-like if it were lifted off the ground and balanced on
one end.

Inside, though, the 12-story structure is relatively clean and well-lit, with a community
room and even a library on the sixth floor. The building hosts church services on Sundays
and Tuesdays, and Second Harvest distributes food on a weekly basis.

As for the quality of life, it depends on whom you ask. Some residents described an
atmosphere in which they pull together to help each other.

"On the outside, a lot of people want to put this building down, but they don't know what
they're talking about," said Sandra Garland, who has lived at Summit for more than three

Other residents complained about drug-dealing. Charlie Hoffman, who has lived at
Summit Towers for about 12 years, said there are only two elevators. On some days, he
said, you might be stuck on your floor for 30 minutes or more.

But other concerns reflect the building's unique mission, which can include sheltering
people with severe mental illnesses.

On a sunny afternoon in March, a group of residents gathered in Summit's community
room, and described how the residents try to help each other, and reach out to those in
need. On the other hand, they sometimes find themselves looking over their shoulder.

"You have to watch who you get on the elevator with," said Janice Thompson.

When it comes to the overall mood, the recent string of tragedies has had an impact.
Garland said the building can be depressing because of the sickness and deaths. "You'll
be talking to someone and the next day you'll find out they're dead," she added.

Another resident indicated that gallows humor has been a coping mechanism, saying the
building is now referred to as "Plummet Towers" by some tenants.

Not Making Friends

Summit Towers is managed by Lawler Wood Housing and owned by an entity called
Summit Towers II L.P., which includes investors with ties to the management company.
The community manager at the building is Elva Saylor, a veteran of the apartment
industry who took over that role in October 2009.

Saylor made a lasting impression shortly after becoming manager, when she announced
in a meeting that she hadn't taken the job to make friends.

One resident cited that comment in saying the manager squandered any good will she
brought to the post, but Saylor doesn't back down from the sentiment.

Speaking in a tone that indicated the question has come up before, she said in an
interview that a prior employee told her that if she followed the rules she wouldn't make

Saylor's response — that she had come to run a business, not to make friends — got
around and she was eventually asked about it at a tenant meeting. "And did I answer the
same way? Yes, I did," she said. "Because I am here to run a business. There's a
difference between being friendly and being friends."

She said that if a manager befriends residents, they'll expect favors and ask questions they
shouldn't, while other residents will assume the friend has inside information. "I treat
every resident equal," she added.

In one sense the ruffled feathers are a microcosm of the balancing act facing a company
like Lawler Wood, whether it's related to eradicating bedbugs or trying to prevent
desperately ill men from taking their own lives.

While some residents may want a more human, personal touch from management, the
managers themselves must juggle the needs of more than 300 tenants and the
bureaucratic demands of the federal government.

Asked if some of her residents would be better off in an assisted-living environment,
Saylor said she couldn't answer the question. "If they qualify to live here, I have to rent to
them," she said.

Not Assisted Living

Lawler Wood has made an intensive effort to eradicate the bedbugs, and continues to
treat apartments in the building regularly.Suicide prevention is also a priority.
Management provided chaplain and hospice services in the wake of last year's incidents,
and recently hosted training sessions aimed, among other things, at helping employees
recognize the signs when someone is at risk for suicide.

Residents of the building receive refrigerator magnets with the phone number for a
suicide prevention hot line, and the staff has been working with the Tennessee Suicide
Prevention Network, which hosts a regional meeting every month.
David Eddleman has been the service coordinator at Summit for more than two years.
The ex-Marine's job is to connect residents with the myriad of local programs that are
available to support them. The federal government recently approved a grant for a second
coordinator at the building.

Eddleman said a lot of help is available to those who ask for it. "But very few, especially
that have a crisis like we're talking about, will come to me and ask for help," he said. "We
find out when it's too late. … I can't go door to door knocking, checking on everybody
every day, and say, 'Hey, did you take your medicine? Are you OK?'"

Saylor, the property manager, indicated that when it comes to individualized care,
Summit Towers is essentially the same as conventional housing.

"We're not supposed to be taking care of these people. OK?" she said. "If you went and
rented an apartment today, would you expect somebody to come and clean your
apartment, would you expect them to meet your every need? … We are not assisted

Residents may also be facing financial stress. According to Saylor, one of the men who
jumped was in the process of being evicted. A police report about another suicide victim
— not one of the jumpers — quoted a friend who said that victim also was being evicted
and was very upset about the possible loss of her apartment, although that woman was
also facing emotional difficulties related to family tragedies.

Chris Mynatt of Lawler Wood Housing wrote in an email that she couldn't comment on
specific residents but added that "generally, (a) resident's mental capacity sometimes
results in (the) inability to live independently and results in infractions and/or evictions."

Dealing With Mentally Ill

Some of the people at Summit Towers who have significant mental illnesses would
almost certainly be better served with more proactive, hands-on care. As one resident put
it, "I think they need to be somewhere where they can get help, and I don't think the
proper help is here for them."

Sometimes, though, Summit Towers is the best option.

Clif Tennison, chief clinical officer at the Helen Ross McNabb Center — which provides
outpatient mental health services — said the "deinstitutionalization" of the 1960s and '70s
isn't going to be reversed, and that mentally ill people will need housing in the
community. "The days of the insane asylum, where you can live out your life in humane
support for your mental illness are over, so people only go (to a hospital) in an acute
need," he said. "(They) get the acute need relatively settled back down and then (are)
discharged back to the community again. So housing is the issue."
Tennison said that when a group of at-risk people are gathered in one place, it can be a
good thing in terms of developing ways to provide treatment more efficiently. On the
other hand, he said, it will inherently result in more problems.

The good news, from the clinician's perspective, is that some of the known risk factors
for suicide can be treated. Tennison said that among people with suicidal thoughts, risk
factors that make suicide more likely in the short term include substance abuse, difficulty
sleeping, difficulty concentrating and "anhedonia," or a loss of pleasure in activities that
once were enjoyable.

Those factors, he said, are "exactly the sort of things that therapists know how to treat."

The Chess Master

Francis "Scotty" Zingheim cried incessantly as a baby and did not adjust well to school.
At age 15, he was diagnosed with paranoid schizophrenia.

He was able to earn a college degree and later was married, but the marriage didn't last
and he struggled to keep a job. In 1997, his parents moved to Fairfield Glade near
Crossville, and Zingheim eventually moved to Tennessee as well.

They discovered the Program of Assertive Community Treatment that was offered by the
Helen Ross McNabb Center and provided intensive case management — including
regular communication to ensure that Zingheim took his medicine — but allowed him to
live on his own. Around 2003, according to his parents, Zingheim moved to Knoxville
and into Summit Towers so that he could participate in PACT.

Stephen "Seed" Heathcock met Zingheim through the Greater Knoxville Chess Club.
Zingheim was a highly accomplished player, and Heathcock introduced himself, knowing
that he could learn a lot from the older man.

The two men began playing chess from time to time, and Zingheim even accompanied
Heathcock and some friends to Cincinnati for a tournament.

Heathcock described Zingheim as a religious man who was gifted, the "kind of person
that could memorize the Bible word for word." When they talked on the phone,
Heathcock said, he could talk through a game for around 25 moves and Zingheim, in his
head, could track the position of every piece on the board.

The two would sometimes combine their chess meetings with prayer, and Heathcock
came to see Zingheim as something of a counselor.

In 2010, though, Heathcock didn't see his friend for several months, and when they
finally reconnected, he noticed some changes. When they played chess, Zingheim's knee
was jumping up and down — something Heathcock had never noticed — and he
complained of skin rashes.
Heathcock — who now lives in Chicago — said he learned that Zingheim had been
committed to a mental health facility, and noticed other differences, particularly in his
chess game.

"The way he was playing he just was really dispirited and not seeing things that he
normally sees," Heathcock recalled. "So, you know, for chess players, that's a really good
measure of where you're at. … You have a very intimate relationship to their mind
through their game."

Zingheim had lost access to the PACT program several years earlier, after he was
removed from TennCare, the state's Medicaid program. TennCare had paid for Zingheim
to participate in PACT, but adult enrollment in the program was dramatically reduced
during the administration of Gov. Phil Bredesen because of skyrocketing costs.

In March 2011, Zingheim was admitted to mental-health facility Peninsula Hospital,
according to his father. Frank Zingheim said the hospital told him and wife Ann that
Scotty had some marks on his neck, but they weren't able to get a definitive answer about
whether he had tried to commit suicide.

After he was released from the hospital, Frank and Ann took Scotty to lunch and drove
him to some errands. They dropped him off at Summit Towers, and as he walked into the
building, Scotty Zingheim told his parents he loved them.

On March 31, 2011, he fell to his death, apparently after jumping from a 12th-floor
window. When his parents cleaned out his apartment, they found six months worth of
medications that he had not been taking.

His parents attribute part of the blame for their son's death to the cutbacks in TennCare,
the program that had allowed him to receive services under PACT.

The Zingheims distributed an obituary in which they lamented the "lack of effective, vital
mental health treatment" and said PACT for years kept their son out of a mental hospital.

They also helped a friend write a much longer article about their son, titled "Your Family
won't be the First, but it could be Next." That article indicated that the incident that led to
Scotty Zingheim's previous hospitalization would have been a "major alarm" for a PACT
crisis team, and it cited statistics about the number of people living with mental illness.

Scotty, the article said, lived and died with mental illness. The article concluded with a
question: "Do we need to ask, 'Was his dying necessary to get our attention?' "

Other deaths

On Dec. 9, 2011, John Greer jumped from his window on the seventh floor of Summit
Towers. Greer, who had been involved in several run-ins with law enforcement in the
years before his death, was taken to the University of Tennessee Medical Center but died
from his injuries. A relative declined to comment about his death.

Acree, Greer and Zingheim weren't the only residents of Summit Towers to commit
suicide in 2011. Police reports indicate that a woman who lived on the 12th floor took her
own life in October, while a woman who lived on the fifth floor strangled herself in
September, using a pale green velour robe belt.

In the latter case, a police report quoted a friend of the victim who said the woman had
received a notice of eviction and was very upset about the possible loss of her apartment.
The friend also told police that the victim's 20-year-old son had shot himself
approximately four years earlier, and that her husband had shot himself approximately
two years after that, while the couple were lying in bed. The friend told police that the
woman "had never gotten over their deaths and had previously tried to commit suicide."

Leading prayer

Bill Harvey, by his own description, was raised in a family of drunks and bootleggers. "I
was one myself, (until) God got ahold of me," he said.

Born and raised in Knoxville, he recalled that his life changed one October night in Fort
Bragg, N.C., when he was heading out to get drunk with some Army buddies. As he
stepped off a bus, a little old lady with a Gideon Bible stopped him and led him to the

After leaving the Army, Harvey worked as a printer and eventually went to work for the
News Sentinel, but on the second Wednesday in February 1968, he announced his call to

He stayed at the newspaper until his retirement in 1981, and eventually pastored three
churches and served as the interim pastor for two more. For the past two decades, he has
also led a Tuesday-night worship service in the community room at Summit Towers.

On a recent evening in April, a small handful of residents gathered for singing, prayer
and a sermon. Harvey preached about the death of Jesus, using Matthew 27 as his text
and telling his listeners Christ suffered, bled and died so that others could go to heaven.
He preached in a rapid-fire shout, an impassioned delivery that wouldn't have seemed out
of place at a tent revival, and as he got worked up he wiped at his mouth with a

By his stripes we are healed, he told the congregants, a reference to the lashes Jesus
suffered before the crucifixion. "And one of these days we will be healed," the minister
added. "There will not be a pain in our bodies anywhere."

The hope of resurrection was stirring when voiced in a place that had witnessed so much
suffering in recent months. But the moment was also tinged with the sense of a missed
connection — on that Tuesday night, for whatever reason, the minister's words of
comfort went unheard by the vast majority of Summit Towers' souls.

Harvey said there have been some times when the room has been full, although not very
often. Asked if it's discouraging, Harvey said no. God, he said, "tells us to go preach. And
he didn't say there's going to be a crowd. He just says preach."

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