Highlights

While advocates for TennCare enrollees agree that TennCare needs reform, we differ on some aspects of how it ought to be done. The attached report summarizes studies by the advocates, along with questions, principles and recommendations. We believe that the current plan can harm TennCare enrollees by limiting the care they can receive, largely because the plan focuses on economics at the expense of science and medicine. In our view, TennCare is not now nor has it ever been a “platinum” program for its enrollees. We believe that much of its escalating cost is a symptom of the way Managed Care Organizations (MCOs) have been permitted to abdicate their responsibilities for care and cost management. Accordingly, we believe that returning to true “managed care” is essential to TennCare’s survival and fiscal integrity. The study groups focused on the following aspects of the Governor’s proposed plan:

Disability Definition: There are already good definitions of which TennCare enrollees are “disabled.” New definitions are not necessary. Disabled TennCare enrollees should not be limited in their use of TennCare services, including prescription drugs, nor should they be required to make copayments. In addition, disabled TennCare enrollees should be allowed, even encouraged, to return to work without losing their benefits. They should not be penalized for returning to the work force.

Services for Children: TennCare should provide for both the physical and mental health of children in ways that are appropriate for them. In addition, the family should be made an integral part of the services provided by TennCare. TennCare should not force families to break up or force children into state custody in order to get care.

Safety Net: TennCare should be the “safety net” for TennCare enrollees. Adding yet another layer of administration is likely to add more costs and more delays in providing needed services, without improving them.

Disease Management: To encourage TennCare enrollees to participate in disease management programs, those who do should not be limited in their utilization of services. All disease management programs used by TennCare should be based on standard best medical practice guidelines, and program funding ought to focus on care rather than administration. In addition, TennCare ought to invest in an effective electronic medical records program that would improve care and reduce costs.

Pharmacy: Drugs permitted for TennCare enrollees need to be selected on the basis of science, medicine and economics, not solely on the basis of economics. TennCare should encourage the use of “true” generic drugs (of the so-called “AB generic” type). The State should use its purchasing power to buy prescription drugs at reduced prices for both TennCare enrollees and State employee health plans. If a TennCare enrollee needs drugs that are available in less expensive and equally effective but non-prescription form, TennCare ought to pay for these non-prescription drugs, requiring only the regular copay.

MCO Optimization: Originally, Managed Care Organizations (MCOs), were responsible for managing TennCare costs, care and paperwork. In essence, they had care they were required to provide and a budget for it they had to live within. Today, TennCare MCOs no longer manage costs or care, just paperwork. As a result, care has deteriorated and costs have escalated. Advocates for TennCare enrollees believe TennCare needs to return to a true “managed care” program, in which the MCOs have a financial incentive to keep enrollees healthy and out of emergency rooms. In our opinion, if anyone today has a “platinum” program, it is not TennCare enrollees, but MCOs who collect fees but do little else.

Our Pledge: As advocates for TennCare enrollees, we stand ready to meet with the Governor and his designees at any time, at any place to discuss how TennCare’s fiscal integrity can be preserved while minimizing harm to TennCare enrollees.

Tony Garr
Tennessee Health Care Campaign
1103 Chapel Ave.
Nashville, TN 37206
615-227-7500
Office 430-8319
Cell 615-227-7551
Fax 1-800-280-8682 Toll free
tgarr@thcc2.org

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