Bredesen presents altered TennCare reform plan
NASHVILLE — Gov. Phil Bredesen released Thursday significant changes to the plan he wants to present to the federal government to squeeze a billion dollars worth of growth out of TennCare.
When he first outlined his plan in February in a speech to the General Assembly, Bredesen described it as a “rough cut.” The newest version fleshed out that plan.
The proposal released Thursday will be open to public and legislative comment for a month and then submitted to the federal Centers for Medicare and Medicaid Services, which must sign off on any changes. The federal government pays two-thirds of the cost of the $7.8 billion program for the poor, disabled and otherwise uninsured.
“I don’t claim that this reform is perfect,” Bredesen said. “In an effort this large and complex we will always be working to improve it. We have tried our best to use both our heads and our hearts.”
The plan still has at its core new limits on prescriptions, and doctor and hospital visits, for about 270,000 non-Medicaid eligible enrollees. It also includes pharmacy changes that will affect all 1.3 million enrollees, and higher premiums for some.
The administration estimates the benefit limits won’t affect 1,051,000 enrollees, although all enrollees will face changes in the way prescription drugs are handled.
The governor announced earlier this week that all 618,000 children in the program would be exempted from one of the major pharmacy changes, the elimination of two categories of drugs from coverage, and 38,000 of those would be exempted from cost-sharing responsibilities they now have.
Other major changes to the original plan include the elimination of two safety-net provisions. One was intended to provide coverage where an extra prescription or two or a few more hospital visits were deemed essential to a patient’s survival or ability to function.
That was addressed by decreasing the number of people to whom the benefit limits apply and by a provisional proposal to exclude from the benefits limits things such as insulin and radiation or chemotherapy treatments.
The other eliminated safety net provision would have designated certain hospitals to receive patients who could not afford co-payments. Instead, the number of enrollees who have to pay them has been reduced.
But there some people still will bump up against the limits, TennCare director J.D. Hickey noted.
“There are very difficult choices,” he said.
Bredesen addressed many of his remarks to those “who claim to be advocating for the interests of TennCare enrollees. I respectfully suggest that, however well intentioned, they are not.”
He said he is trying to find a middle ground between continued spiraling cost increases and cutting hundreds of thousands of patients from the program.
The proposal fleshes out two things that particularly concerned advocates. One was the definition of “disabled.” Bredesen has opted for a broad one.
The state AARP said it was pleased with the new definition’s protection for those in nursing homes and others in long-term care institutions.
“Under the new definition of disability, these and other vulnerable, frail elderly and disabled individuals will be protected from benefit limits that could compromise their health,” an AARP statement said.
Advocates also raised questions about the definition of “medical necessity,” which will determine whether a treatment is covered. The waiver amendment specifies that all Early and Periodic Screening, Diagnosis and Treatment requirements, which apply to children, are covered.
It also says “off-label” uses for drugs will be covered if they are “widespread” and “generally accepted by the professional medical community as an effective and proven …”
The new definition still includes cost as a consideration in treatment decisions but specifies that cost “will not override a patient’s medical needs.”
The waiver also would establish a TennCare Advisory Commission with broad powers to recommend to the governor changes in the program as events — mostly finances — dictate without having to go to the federal government.
“We want to make it flexible year-in and year-out so we don’t get to a point where we’re disconnected again,” he said.
A privately funded study of TennCare estimated the program would consume 91 percent of all new state revenue by 2008 if it not changed. Bredesen said that would keep the state from funding other pressing needs, like education and set a goal of reducing TennCare’s growth by $1 billion by then.