TennCare wouldn’t cover cancer screenings, doctors say
NASHVILLE (AP) — Under Gov. Phil Bredesen’s TennCare reform proposal, a patient must have rectal bleeding to get a colon cancer test covered, and that’s often too late, a doctor said Monday.
The state would not have to pay for cancer screenings and other such preventative care under the definition of “medical necessity” in the governor’s legislation, said Dr. Robert Herring, a Nashville gastroenterologist who has been a persistent critic of the cost-cutting measures proposed for the $7.3 billion TennCare health program for the poor, disabled and uninsured.
“The way it’s worded, you’d have to have a disease in order to get a service,” he told reporters shortly before the Legislature’s TennCare Oversight Committee began debating the merits of the bill. “… In the case of colon cancer, and other cancers as well, if you wait for symptoms, most of the patients are incurable and they die.”
Immunizations, diabetes screening, Pap smears and mammograms would be among other preventative care no longer covered by TennCare because of the way “medical necessity” is defined, according to the Tennessee Health Care Campaign, which advocates for enrollees and organized a news conference with Herring and two other doctors.
Enrollee advocates also say pain medication that doesn’t treat or diagnose would be uncovered, including prescriptions for the terminally ill or those with chronic illnesses such as multiple sclerosis, epidural anesthetics for women in labor and nausea medication for cancer patients in chemotherapy.
Bredesen said emphatically that such contentions are “exactly the kind of irresponsible nonsense” he hoped would not be used by critics of his proposal.
“This stuff does a disservice to the people who are on TennCare,” the governor said after a public bill-signing ceremony.
“To suggest for a moment that this bill means that TennCare would no longer cover preventative care for children and adults, immunizations, pain medications for the terminally ill, that’s the kind of scare tactics, that the worst kind of participation in the public process, and I just want to say how disappointed I am in the advocates who put this stuff out.”
During the TennCare Oversight Committee meeting, Yarnell Beatty of the Tennessee Medical Association said doctors are worried about several aspects of the bill, including the definition of medical necessity.
He said TMA is concerned about the potential penalties for providing care to enrollees fraudulently on the program and the mechanics of the TennCare Foundation, which will make case-by-case determinations of which enrollees can exceed limits on services such as prescription drugs and doctor’s visits.
“If physicians are saddled with increased liability risks by participating in TennCare, they cannot afford to participate,” Beatty said.
The committee also heard from representatives of mental health organizations, who said they feared the program would reduce or eliminate “maintenance” medicines that keep mental illnesses under control.
Jan Jones, CEO of Alive Hospice in Nashville, which provides end-of-life care for the terminally ill, said the bill could be read to restrict coverage to procedures that are medically required.
“Hospice is not required. It’s simply the right thing to do,” she said.
Bredesen said his plan is an attempt to ensure that TennCare enrollees can continue getting services and that some 300,000 remain on the rolls. TennCare now serves 1.3 million people.
But its costs are growing so fast that TennCare is estimated to require 90 percent of the state’s new revenues during the next five years if changes aren’t made.
Dr. Richard Braun, a general practitioner for 15 years in Crossville and now medical director of a nursing home, said he applauds the governor’s efforts and regularly sees patients who’ve received care he finds unnecessary. But he said there are better ways to control spending.
He suggests training doctors on how to be more cost-conscious and less concerned with malpractice lawsuits, and to deal with demanding patients.
Braun called the governor’s proposal, particularly the medical necessity definition, “a giant step backward.”
“Are we to tell a TennCare patient that ‘Because you’re on TennCare, you’re a second-class citizen and I cannot give you this optimal standard of care?’ … I don’t know of any ethical doctor who could countenance this double standard of care,” he said.
If such restrictions are to be enacted, they should apply equally to all Tennesseans, Braun said.
Dr. James Hudson, a Nashville pediatrician, said he’s concerned about the way the word “adequate” is interpreted.
The legislation’s medical necessity definition says, in part, that “it must be the least costly alternative course of diagnosis or treatment that is adequate to address the medical condition of the enrollee.”
Hudson said he’s concerned an asthmatic child might not get the most effective treatment because it’s more costly. He also said he’s worried TennCare won’t cover an experimental lifesaving treatment, like the use of Viagra for infants suffering from pulmonary hypertension.
He suggested the state establish a panel of experts with no vested interest in TennCare to consider such cases.
“Without that, people in fact will be put in jeopardy,” he said.
Bredesen said he doesn’t think the definition of medical necessity creates a “second tier,” and that TennCare coverage in many ways will remain superior to coverage offered by private insurers.
“What I’m trying to do is say the state is a party at the table when it comes to trying to decide what things are covered and what not, that we can no longer afford to simply say several thousand doctors get to make those decisions about how we spend the public’s money entirely on their own,” the governor said.
Definition of TennCare medical necessity in governor’s bill
Among the most controversial aspects of Gov. Phil Bredesen’s proposed TennCare overhaul is the definition of medical necessity, which will be used to determine whether the state pays for a particular service, treatment or medication. The proposed definition in Section 23 of Senate Bill3392/House Bill 3513 says:
“(b) To be determined to be medically necessary, a medical item or service must satisfy each of the following criteria:
“(1) It must be required in order to diagnose or treat an enrollee’s medical condition. The convenience of an enrollee, the enrollee’s family, or a provider, shall not be a factor in determining whether a medical item or service is medically necessary;
“(2) It must be safe and effective. To qualify as safe and effective, the type and level of medical item or service must be consistent with the symptoms or diagnosis and treatment of the particular medical condition, and the reasonably anticipated medical benefits of the item or service outweigh the reasonably anticipated medical risks based on the enrollee’s condition and scientifically supported evidence;
“(3) It must be the least costly alternative course of diagnosis or treatment that is adequate to address the medical condition of the enrollee. Where there are less costly alternative courses of diagnosis or treatment, including alternative settings, that are adequate to address the medical condition of the enrollee, more costly alternative course of diagnosis or treatment are not medically necessary. An alternative course of diagnosis or treatment may include observation, lifestyle or behavioral changes, or where appropriate, no treatment at all. A determination that a course of diagnosis or treatment is adequate to address the medical needs of an enrollee need not be based upon the prevailing practice of any geographic area;
“(4) It must not be experimental or investigational. A medical item or service is experimental or investigational if there is inadequate empirically based objective clinical scientific evidence of its safety and effectiveness for the particular use in question. This standard is not satisfied by a provider’s subjective clinical judgment on the safety and effectiveness of a medical item or service or by a reasonable medical or clinical hypothesis based on an extrapolation from use in another setting or from use in diagnosing or treating another condition.”
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On the Net:
Read SB3394/HB3512 and SB3392/HB3513 at http://www.legislature.state.tn.us