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CONSULTING THE PROFESSIONALS

Gov. Bredesen talks TennCare with physician, gives few solid answers.

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Consulting the Professionals “I’m 60 years old and this is the most difficult thing that I’ve ever worked on,” Governor Phil Bredesen told a roomful of doctors and medical professionals Wednesday afternoon. On the governor’s agenda was the issue of TennCare, the state’s health-care program for 1.3 million Tennesseans. Bredesen spent almost two hours detailing his proposed reform plan for TennCare, which if approved by the federal government, will go into effect January 1, 2005. The plan is designed to reduce the operating cost of the program by $3 billion. If left in its current form TennCare’s costs cold grow by as much as 80 percent by 2008, accounting for the majority of state revenues. The reform, first proposed by the governor in February, was conceived using a “Fred Smith” executive approach, according to the governor, and calls for a savings program which includes benefit limits, patient co-pays, and patient premiums. To combat rising pharmaceutical costs, which account for more than 50 percent of program costs, the plan calls for limiting patients to six prescription drugs. Bredesen had been quoted as saying that the purpose of the reform was to “let everybody have the bronze plan and keep everybody on it instead of putting some people on the absolute platinum plan and the rest have no coverage.” Approximately 435,000 enrollees would be affected by the plan and become responsible for sliding-scale doctors visit copay cost, annual premiums, and limited hospital stays and doctor visits. The remaining 900,000 enrollees, mostly children, pregnant women, and the disabled, would maintain their current benefit status. While none of the physicians in Wednesday’s meeting objected to the need for a program overhaul, some questioned the governor’s implementation methodology. “I’ve examined my patient list and more than 1,000 of them will be affected by the [prescription drug limit], and I need to know before January 1 what I can do to get them ready for this,” said Dr. Regina Lindsey. About 50 percent of the patients of Lindsey’s Millington private practice are TennCare enrollees. Bredesen assured Lindsey and others that any changes becoming effective would be preceded by at least a 90-day notice, as required by law. Physicians also questioned Bredesen about the plan’s definition of “medical necessity,” which some critics have said could leave some patients without necessary care. At issue is the statement in the plan that TennCare will pay for procedures that meet four criteria: required to diagnose or treat a medical condition, safe and effective, least costly alternative course of diagnosis, and must not be experimental or investigational. Under the current program’s rules, TennCare paid for almost all treatments ordered by physicians regardless of costs. Prior to this meeting, TennCare enrollee advocacy organizations, including the Tennessee Justice Center, led by Gordon Bonnyman had criticized the governor’s plan saying that the large amount of proposed savings is unnecessary. “We’re saying that the first thing you have to do is take a hard look at the numbers,” said Bonnyman. “Is that $3 billion savings really necessary? We don’t think so.” Bonnyman and his group have also accused Bredesen of attempting to convert TennCare into a private insurance program. Physicians at Wednesday’s meeting did not question the savings, but were concerned about the reimbursement rate that physicians are paid for caring for TennCare patients. “It is extremely difficult to retain TennCare provider physicians with the reimbursement rates because of the disparity between the reimbursement rates for private doctors,” said Dr. Jeffery Warren. “A doctor whose practice only consists of TennCare patients can’t survive.” Warren’s practice, Primary Care Specialists, consists of a mix of public, Medicare, and TennCare patients. He is reimbursed for about 50 percent of the cost of patient care. Unfortunately key TennCare officials, like commissioner J.D. Hickey, who would have been able to answer more detailed questions were not present at the meeting. Governor Bredesen promised to contact individual physicians with additional information.

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