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DAY THIRTY-FOUR: Six lies of Governor Bredesen, Part Two.

Examination of the governor’s spin campaign about the TennCare changes.

By Tim Wheat

Sit-in activists meet outside the governors office.(BOULDER, COLORADO) Governor Phil Bredesen has not been honest with Tennessee citizens; he promised to fix TennCare and is now dismantling it, and he cut services to ventilator users one month after he directly told vent users he would not cut their services. Similarly the governor has used misinformation to push his Medicaid proposal on the people of Tennessee. 

Although Bredesen has generally avoided public scrutiny, here are three of six statements, twisted beyond truth, which the governor and his administration have used to “spin” the TennCare changes:

Four: Tennessee Governor Phil Bredesen says, “I wish I could” stop TennCare enrollment.

“I am committed to try to keep people who genuinely qualify on the rolls - to save TennCare rather than just cut the enrollment.” 

-Gov. Phil Bredesen, Address to the General Assembly. February 17, 2004.

This is more of the administration spin. “I wish I could” makes it sound as if the governor has attempted to keep his pledge to keep people on the TennCare rolls, but Bredesen has ignored the cost-saving ideas available from other states. He also has not attempted to explain why such a capable healthcare bureaucrat like Phil Bredesen has been unable to develop a proposal that does not cut enrollment. Bredesen promised to fix TennCare and he has abandoned his word. He said he was committed to keep enrollment and the governor has ignored solutions to press his own drastic plan. 

Here are some of the program changes suggested that have been ignored by Governor Bredesen, instituting a few of them would ensure the future of TennCare:
  1. Money Follows the Person:
    This proposal is budget neutral. Currently, people eligible for nursing home services have few alternatives than expensive institutions. Money follows the person allows someone eligible for nursing home services to instead get home and community based services to keep them out of expensive nursing facilities. Diverting just 6,000 people, already identified by the state as wanting out of nursing homes, would save about $138 million. Cutting the nursing home population in half would save the state about a half-a-billion dollars. More importantly, Tennesseans would much rather live in their own homes. Good ideas to save money have been ignored by Governor Bredesen.
  2. Retrospective drug use review (DUR)
    Tennessee has never implemented an effective DUR program. Without such a program, TennCare prescription drug use remains much higher than in TennCare programs in other states. Excessive prescription drug utilization is a problem of long standing that is not limited to TennCare, but affects all insurance plans in Tennessee. Former Pharmacy Director Leo Sullivan recommended a Retro-review program to monitor all TennCare prescriptions. This addition to the TennCare pharmacy program could save the state up to $500 million a year, but Bredesen would not accept the cost-savings; his administration only disputed the figures.
  3. Disease Management
    The sickest 15% of TennCare enrollees account for 75% of costs; the sickest 4% incurs 43% of costs. Because so much of TennCare's budget is spent on a relatively small population of chronically ill patients with multiple diagnoses, intensive clinical management of those high cost patients offers a major source of potential savings. 
    Governor Bredesen’s proposal does just the opposite from managing disease. The burden of the proposed service limits and cost-sharing policies will fall most heavily on the very population who would most benefit from disease management. By creating barriers to needed care, the proposals would make it more difficult to manage their health in a cost-effective way. 
  4. Preferred Drug List for Behavioral Health
    Adding behavioral health drugs to the PDL, and using the same careful selection process that was used last year for medical drugs would yield savings conservatively estimated in the range of $35 million in state funds.
  5. Payments to Managed Care Organizations
    This year TennCare will pay its managed care contractors $245 million, or nearly 5% of the $4.96 billion in health services which they administer. Those rates are relics of a past when the contractors were true HMOs that accepted financial risk. They are now only administrative services organizations (ASOs). They do not manage care.
  6. Fraud and abuse enforcement against pharmaceutical manufacturers.
    In the last two years, the federal government in cooperation with some states has begun to pursue Medicaid fraud and abuse litigation against drug manufacturers. Some manufacturers have reported false pricing information for purposes of calculating the rebates they must pay to the federal government and states as required under Medicaid.
  7. Price disclosure to calculate more accurate pharmacy reimbursement rates. 
    The Office of Inspector General (OIG) at the U.S. Department of Health and Human Services has released numerous reports finding that states are likely paying too much for drugs, particularly brand name drugs with competitors and generic drugs.
  8. Use of clinically appropriate fail-first or step therapy requirements.
    Under these policies, an individual must first use a drug that is likely to be as effective but is lower cost than other alternative drug therapies. If a physician concludes that the lower cost drug ends up being ineffective or clinically inappropriate for the individual’s medical needs, the physician can then prescribe a more expensive alternative therapy. According to a recent national survey, about two-thirds of states used fail-first or step therapy policies in 2003, more than twice the number of states in 2000.


Five: Bredesen is providing a safety net for those disenrolled.
Don’t be fooled by this generalization. Hundreds of thousands of people are being cut from their healthcare with no replacement. The governor will continue to use the “safety net” analogy because it seems to cover everyone, but it does not. It is a simple answer to a complex question. 

Prescription Assistance is available and part of the safety net, but drug companies often do not offer assistance for the higher cost drugs. The biggest setback to prescription assistance is that it may be only temporary. The state “safety net” only offers insurance information, but providing affordable insurance is up to individual companies and likely not available at all.

Community Support is what the state calls passing the buck. County and local healthcare facilities will have to pick up the additional costs of thousands without insurance or adequate healthcare. Providing acute care for people that must do without basic healthcare and long-term care is a costly trade-off. To save on the state budget, the governor has handed the responsibility to local communities, which will have to provide care through expensive Emergency Room admissions and medical aid facilities.
Six: It is impossible to keep current enrollment and fund other necessary state programs
More spin from the governor. The state will still have to budget for the governor’s Medicaid program and will have fewer options to save state money than with the current TennCare program.

The governor’s Public Relations team knows that most people do not directly use TennCare and by suggesting that TennCare may take away from other programs, the governor’s spin aims at turning the population against TennCare. The nonpartisan Henry J. Kaiser Family Foundation released a poll this month showing strong support for Medicaid. The survey indicates that 74 percent of the public considers Medicaid a "very important" government program, behind only Social Security (88 percent) and Medicare (83 percent).

Citizens who believed his promise to fix TennCare elected Bredesen, and Tennesseans trusted the governor to keep his commitment not to cut enrollment. Can the typical citizen really have confidence that Governor Bredesen will keep his word in other areas? People who use ventilators are likely to answer that the governor cannot be trusted. Bredesen directly said he would not cut services to vent users, a month later the state issued a press release that vent users would lose services in six months.

Six lies of Governor Bredesen, Part One.

- Tim Wheat


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