Providers question governor's TennCare reform plan

By Thomas Wilson

   JOHNSON CITY -- Gov. Phil Bredesen met with upstate health care professionals here at the James H. Quillen College of Medicine on Wednesday afternoon, one day after publicly presenting his proposal to overhaul the state's beleaguered TennCare system.
   Bredesen unveiled a "last chance" TennCare reform plan to the Tennessee General Assembly on Tuesday night. The governor's plan seeks to adjust benefits and to establish limited co-pays for services and pharmaceuticals to salvage the financially troubled program. The overall strategy is expected to generate an estimated $2.5 billion in cost-savings over four years.
   "I need to keep the basic bones of this program in place," said Bredesen. "Every place I have to adjust up, I have to adjust down somewhere else."
   The reform plan is based on findings from a TennCare report prepared by McKinsey & Co. that identified specific initiatives projected to serve as the "building blocks" for TennCare reform. Among other findings, McKinsey projected that TennCare, if left unchecked, will consume virtually all new state revenue -- 91 percent of it -- in 2008.
   Presently, TennCare accounts for 25 percent of the state's total budget expenditures. The McKinsey report said that number could rise from 34 to 40 percent by 2008 if reforms are not made. Bredesen said his aim is to hold TennCare's current spending rate at 26 percent.
   "I think in health care it is unrealistic to think you are going to reduce expenditures," he said. "I do believe we can pin it there for the next five years."
   Proposed benefit reductions will hit about a third of enrollees, people Bredesen calls "able-bodied adults," by limiting doctor visits to 10 a year, prescriptions to six a month, and requiring co-payments that range from $1 to $40. Exempt from those limits and co-payments are 859,000 children, pregnant women and people identified as disabled, a category that includes people with HIV/AIDS and some with mental illness.
   The governor's plan limits pharmaceuticals to six prescriptions per month and 10 visits annually to physicians as well as diagnostic tests such as x-rays and laboratory procedures. Currently, doctor visits and prescriptions have virtually no limits.
   Bredesen said there was little "wiggle room" to raise the cap on six prescriptions per month to TennCare recipients. Pharmacy costs associated with TennCare recipients are expected to be more than $2.3 billion this year. Under the reform plan, TennCare will no longer pay $5.47 per pill of Zyprexa, which treats schizophrenia, but instead will buy a 33-cent alternative that is equally effective, Bredesen said.
   "Half of all the growth is expected to come from pharmaceuticals," he said. "Unfortunately in Tenncare, there are a lot of examples of people who go to multiple doctors and get multiple prescriptions."
   However, meeting attendee Dr. Susan Sloan said the state of Tennessee ranks "horribly" high in patient rates of heart disease, hypertension, cancer and other major diseases.
   "There are several medications you have to be on to get treatment effectively," said Sloan, assistant director of internal medicine at ETSU Physicians and Associates. "That's going to be more than six medications."
   Sloan said standards of care physicians follow are based on "evidence-based medicine" that treats patients according to their diagnoses. If a patient has a combination of major illnesses such as diabetes, hypertension, and high cholesterol, Sloan said he or she needs physician follow-up visits, monitoring of prescribed medication and analysis of a medication's interaction with other drugs used to treat illnesses.
   "If you have a really serious problem with high blood pressure it may take three blood pressure medications to get you safely treated," she said. "Diabetes may require several medications."
   If standards are not followed, a physician opens him or herself up to potential malpractice, Sloan added.
   Bredesen said a portion of his reform wants patients to be under the supervision of a single primary care physician who coordinates prescriptions and care to avoid overlapping doctor's and prescription rates. On average, TennCare enrollees are getting 30 prescriptions a year, compared to a national average of 10.5, according to the McKinsey report. The report also found that roughly 15 percent of TennCare enrollees represent 75 percent of the program's total costs.
   Under the reform measures, TennCare also would no longer cover antihistamines and gastric-acid reducers such as Nexium except in rare cases, because effective remedies are available over the counter, he said.
   Bredesen emphasized his short-term goal is to contain runaway growth in TennCare spending before the state is forced to turn back to a bare-bones Medicaid program, which would strip more than 261,000 Tennesseans of medical coverage.
   The overhaul also includes greater emphasis on enforcement of TennCare fraud and abuse. The Governor said state district attorneys he had spoken with were willing to prosecute cases involving TennCare fraud if they were presented with evidence of wrongdoing. "I think we have not been doing a good job of presenting cases to them," Bredesen said.
   Bredesen indicated he did not have the greatest confidence in the TennCare Bureau's present 24-person unit tasked with investigating fraud and criminal wrongdoing.
   "I don't think it is doing it very effectively," Bredesen said. "What I would like to do is make it more of a law enforcement unit rather than an internal bureaucratic unit."
   Bredesen said after the discussion that no major adjustments to the reform proposals would be implemented based on Tuesday's roundtable discussion.
   Dr. Chris Calendine told the governor that a lack of compensation limits referral options to pediatric subspecialties such as orthopedics and oncology for their patients.
   "We do not have enough pediatric sub-specialists on each TennCare provider," said Calendine, a pediatrician with the Rural Health Services Consortium, which operates 15 clinics in rural Northeast Tennessee.
   As a result, children requiring specialized pediatric care were referred as far away as Chattanooga to a sub-specialist accepting TennCare. Calendine estimates TennCare insured 50 to 60 percent of patients seen by pediatricians through Rural Health Services.
   He also told the governor some type of reform is needed in the "open-door policy" of hospital emergency departments providing care -- a statement that drew audible agreement from other doctors sitting around the table. "In our emergency departments, there is no preventive care; there is no alternative care," Calendine said.
   After the meeting Calendine said he believed the proposals that have been made are moving TennCare in the right direction, but additional reforms need to occur. "We all appreciate the fact that if we continue along the path we are on, we will end up losing the TennCare system," said Calendine.
   Sloan also said afterwards she realizes TennCare reform is needed, but she did not feel limiting use to those best served by TennCare -- the chronically ill and patients from lower socio-economic groups -- was the proper direction.
   "If I don't treat that patient at all, who is going to treat that TennCare patient," said Sloan. "I realize we are in a critical situation and we have to make compromises, but this is not it."