State officials, advocates examine future of TennCare
Legal battles consumed the past year as officials tried to rein in spending on the $8 billion Medicaid program while advocates argued for alternatives other than dropping people from the rolls.
Gov. Phil Bredesen said the cuts were difficult but necessary.
“At this point we have achieved what we needed to financially,” he said. “It’s been very, very painful, but it’s been achieved.”
TennCare covers 1.2 million poor, uninsured and disabled individuals. Officials have said mismanagement contributed to out-of-control costs that plunged the program into a fiscal crisis. While other states are dealing with similar financial problems, Tennessee’s situation is unique because of the drastic reforms taken to get the program under control.
Last January, Bredesen announced he was overhauling TennCare by eliminating nearly 300,000 adults from the program and reducing benefits to thousands of others. He preserved full benefits for the 640,000 children on TennCare.
A federal judge questioned the state’s procedures for disenrollment and blocked the cuts later that month. The 6th U.S. Circuit of Appeals overturned the ruling several months later, saying the state’s disenrollment procedures were legal.
The process for cutting people began in June. In early August, however, another federal judge granted the state relief from an agreement with advocates for TennCare patients in 1999. The governor said that decision would allow the state to retain coverage for 97,000 of the sickest enrollees, many of whom suffer from chronic illnesses such as cancer and diabetes.
Just recently, Bredesen presented those medically needy individuals with more good news when he announced the state will to bring them on earlier than expected with more generous eligibility guidelines.
Instead of having to wait until July, the governor said the medically needy category could open as early as February and will provide applicants a full 12 months of coverage without proof of medical bill expenses every three months as outlined in an original legal agreement.
The plan must meet federal approval, but Bredesen’s optimistic.
Bredesen said the state is also trying to get additional legal relief to adopt a “soft limit” on prescription drugs. Currently, there’s a limit of five prescriptions — two name brand and three generic. But the change would allow doctors to prescribe over that amount if a patient is deemed medically necessary.
That’s good news for enrollees such as Mary Sue Bennett, who said she needs 17 prescriptions for ailments that include severe sleep apnea, diabetes and emphysema.
“We had to change every medicine I had,” said the 47-year-old Murfreesboro resident. “Some of those medicines I had to change entirely, and the new medicines haven’t helped me much.”
Bennett is among the 70,000 appeals that have been filed concerning TennCare coverage. Of that number, about 8,000 hearings have been granted and officials said they expected to have most of those completed by the end of December, even though some could be continued into the new year.
Advocates, however, say the cuts would not have been necessary if the state had used money from TennCare reserves and budget surplus money, as well as reforms being used by other states.
They include disease management and the use of a computerized drug review, which “uses computers to profile doctors who prescribe too much and patients who use too much,” said Gordon Bonnyman of the Tennessee Justice Center, one of the main advocates for enrollees.
Bonnyman said he does not understand why the state would not have used such a computerized program since officials complained out-of-control pharmacy costs are a major problem for TennCare.
A main goal of advocates now, Bonnyman said, is to inform the public of reforms the state could have taken but did not. He said he wants people to know “the facts.”
“We will point to financial and management reforms that other states have shown are effective, like computerized drug use reviews and disease management,” he said. “Our state has promised them for years but not implemented them.”
TennCare Director J.D. Hickey said the state does plan to add disease management programs and has taken other steps, such as increasing financial risks for managed care organizations, that benefit enrollees as well as TennCare.
Bredesen said the changes have allowed him to “feed some money back into the program,” such as upgrading his so-called health care “safety net” initiative that provides transitional assistance to people kicked off TennCare, particularly the sickest individuals.
He recently announced the state will extend private duty nursing to eligible enrollees and postpone indefinitely the implementation of other service limits. Nursing services were scheduled to end in December, and limits on TennCare doctor visits, hospital stays and other non-pharmacy services were to take effect Jan. 1.
While the governor said the state is doing what it can for those who were dropped, he also wants to help the nearly 580,000 other Tennesseans who never had health insurance, which is about one in 10 Tennesseans, according to a state report. Keeping TennCare costs under control will help the state accomplish that, he said.
“What I want to do is invent the program for 2015 and 2025. I’d like to do something for all of the people in Tennessee who don’t have health insurance, not just some.”
TennCare timeline: Events over the last year
A 2005 timeline of TennCare, the state’s public health care program for the poor, disabled and uninsurable.
Jan. 10 — Gov. Phil Bredesen announces TennCare overhaul, eliminating 323,000 adults from the program and imposing across-the-board benefit limits on the 396,000 adults left in the program, while preserving full benefits for the 612,000 children on TennCare.
Jan. 28 — U.S. District Judge William J. Haynes blocks Bredesen’s plan to cut the rolls.
April 12 — The 6th U.S. Circuit Court of Appeals in Cincinnati rules that state officials don’t need a federal judge’s approval to cut 323,000 adults from TennCare.
April 28 — Haynes rules that about 300,000 enrollees slated to be cut or have their benefits reduced can seek a hearing to appeal the loss of coverage.
May 27 — Appeals court overturns Haynes’ decision and rules that the state’s disenrollment procedures are legal.
June — State begins process for disenrollment by sending request for information notices.
July 31 — State moves from unlimited pharmacy prescriptions for enrollees to a hard cap of five per month — two name brand and three generic drugs.
August — U.S. District Judge John Nixon grants the state relief from an agreement made with legal advocates for TennCare patients in 1999, which the governor said would allow him to retain coverage for 97,000 of the sickest enrollees.
December — Positions of special hearing officers for appeals eliminated.
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For more information about the Tennessee Safety Net and other services call 1-888-486-9355, or visit http://www.tnhealthoptions.com