Physicians for a Preserved and Improved TennCare (PPIT)
FOR IMMEDIATE RELEASE Contact:
November 24, 2004 James Hudson, MD, (615) 385-0934
cell (615) 975-1582
Concerned physicians from across Tennessee plea that
Governor Breseden and Mr. Bonnyman find a means to a compromise
Nashville, Tenn. - We speak for a group of concerned physicians from across the state of Tennessee. We reside in geographically different areas, some urban, some rural. We represent diversity in background, some from academic medicine, others from private office-based practice, and we represent several clinical specialties. We are united in our concern for the future of the TennCare Program. We have watched with interest, later awe, and finally with the highest concern as this bold experiment in extending health care coverage to uninsured citizens of the state evolved from a fiscally sound system with initial measurable health status improvements to become overwhelmed by escalating health care and pharmaceutical costs exacerbated by a series of administrative mishaps. We now look on with extreme apprehension the impasse now being played out between the office of the governor and the Tennessee Justice Center over the very life of the program.
Through this message, we send our most urgent plea that governor Breseden and Mr. Bonnyman find a means to a compromise middle way that makes sense to all parties and leads to a preservation of the program. While we understand that, in some quarters, some would be pleased to see the TennCare Programís demise, with a sense of ìgood riddanceî and a hope for fiscal relief, we will argue that this notion is grievously short-sighted. The consequences of a reversion to basic Medicaid catastrophic and widespread. None of them would be good for anyone. Such consequences would jeopardize not only the health and financial stability of those dis-enrolled, but also the stability of health care institutions (especially hospitals and emergency room facilities in certain rural areas), the practicing physician community, and ultimately the economic stability of the entire state.
The governor has proposed an expensive state sponsored pre-K school program. While we support this effort in absence of tax increases, we maintain that it is unsound policy to cut TennCare to pay for it. The governor should not cause some citizens to die so that others can be educated.
Numerous studies have shown that families who are underinsured or uninsured put off recommended screening and preventive services and delay treatment of health problems until they become major health events. The result: overcrowded emergency rooms, expensive hospitalizations for conditions that could have been prevented, much unnecessary pain, suffering and economic loss. Last year, an Institute of Medicine report calling for universal health coverage to all U.S. residents estimated that 18,000 uninsured or underinsured Americans die unnecessarily each year due to lack of sufficient care. Closer to home, a study conducted by the University of Tennessee (Memphis) published in 2002 found that persons in this state without health insurance for one year had a 25% greater likelihood of death in the subsequent year than those with insurance. .That report predicted that a reduction of 160,000 enrollees from the TennCare Program would result in 3,000 additional deaths (mainly in older enrollees) over 15 years. Extrapolation to the 430,000 currently projected to be cut, the estimation would be 8,000 additional deaths in 15 years ñ 500 additional deaths per year in this population.
Other studies on the US population report high rates for the uninsured as compared to the insured (70% higher mortality for colon cancer, 30% to 50% higher for breast cancer, 10% higher for high blood pressure). State and hospital data in Tennessee indicate that, in 2002, of all emergency room and inpatient hospital charges, 1/3 were for TennCare enrollees. This number exceeded the total for Blue Cross/Blue Shield, exceeded the total for all other commercial carriers, exceeded the total for Medicaid, and exceeded the total for Medicare. The Tennessee Hospital Association estimates that Tennessee hospitals provided more than $1 billion in uncompensated care in 2002. This represented 1/10 of total charges. If 430,000 enrollees were to be cut from TennCare, on might estimate that uncompensated charges could approach _ of total charges. Especially hard hit would be rural emergency rooms and hospitals in those counties where approximately half the population is on TennCare presently. Additionally, safety-net and not-for-profit hospitals would be especially hard hit. The ultimate result will be extreme overcrowding of emergency rooms. Hospitals will seek relief through the state tax structure, or hospitals will increase charges to compensate for losses from uncovered care, with a resultant increase in premiums for the privately insured. This will amount to over $1 billion cost shift.
At present, most physicians throughout the state refuse to provide services unless the patient arrives in the office with an insurance card or cash in hand. A few will provide uncompensated care out of a sense of public service. As they provide more and more uncompensated care next to those who do not, their time will become swamped, and they will eventually place limits on this service out of fiscal necessity. Community Clinics will be overwhelmed, and the state will become more entrenched into a system of two-class care.
A July, 2004 report by the Washington, D.C. based Center for Budget and Policy Studies analyzed the economic impact on the state of Tennessee should the TennCare Program be reverted to basic Medicaid. This would achieve an initial reduction in TennCare expenditures of $850 million in FY 2005. By 2008 this would grow to a $2.8 billion reduction in expenditures. Such reductions, however, would be balanced by a $553 million loss in federal dollar match in FY 2005, up to a #1.8 billion loss in FY 2008. Most worrisome would be the deleterious impact on health care institutions, leading to a $762 million loss in state economic activity in FY 2005, up to a $2.4 billion loss in FY 2008. The report predicts a loss of 6,800 jobs statewide in FY 2005, There would be a loss of 20,000 jobs in FY 2008. The health care industry in Tennessee, in the dace of this magnitude of job loss will still be expected to care for the 430,000 individuals when they become seriously ill while caring for insured patients as well. Predictable results: a diminution in quality, increased waiting times, increasing unavailability of services.
Given the above projected outcomes, it becomes imperative that some middle ground compromise be struck to salvage the Program and maintain the existing wavier containing the two-to-one federal-to-state dollar match. We maintain, however, that a compromise solution preserving the Program as is will not be sufficient to insure its fiscal integrity. We believe that two major reforms mentioned as suggestions in the McKenzie Report, not yet enacted, need urgent attention:
First, it is imperative that an effective and clinically sound system of disease management be implemented and addressed at an appropriate segment of the top 4 percent of enrollees who account for 43 percent of program costs. The McKenzie Report indicates that approximately half of these remain high cost from year to year. The track record of the MCOs in initiating effective disease management has been dismal. We strongly urge that the MCOs be placed again at risk, and that disease management be concentrated into one single MCO. When placed at risk, this MCO will have a high incentive to subcontract out the disease management activities to a nationally experienced firm with sound processes concentrating on those chronic disorders and co-morbidities that contribute to high cost care and are most likely to respond to clinically sound management efforts.
Second, a much more systematic and aggressive approach must be made to curtail the explosive drug cost escalation. We suggest that the preferred drug list (PDL) compiled by the TennCare Pharmacy Advisory Committee be made mandatory and expanded to drugs used in the behavioral health segment of the Program. We strongly support this suggestion of the McKenzie report. It is sound from a clinical standpoint, and it could quite likely obviate the necessity for the controversial proposal for a six prescription per month per enrollee limit. Further, we urge more aggressive use of the drug utilization review (DUR) program that is currently available, but underutilized.
Finally, we believe that significant savings could be realized through multi-state drug purchasing arrangements, and we urge the governor to reconsider this avenue. All of these suggestions are contained in the McKenzie report. To date, none have been implemented. The governor, given his background in the field of managed care, has the experience necessary to guide this effort.
In summary, we believe a decision to revert the TennCare Program back to basic Medicaid, abandoning the favorable federal-to-state dollar match would result in catastrophic consequences to not only the 430,000 individuals who would be cut from the program, but also to the practicing community, to health care institutions, and to the public-at-large. To save the fiscal integrity of the program in the long-run, more aggressive disease management and drug management systems must be implemented. Other states (Maine, Vermont, California, Missouri, Georgia) have initiated moves towards systems providing health care coverage for all their citizens. Tennessee, ranked 48th in general health of all states, cannot have the least healthy citizens and expect not to have high health care costs. Strong management controls should ameliorate these costs.
Physicians for a Preserved and Improved TennCare (PPIT)
Richard Braun, M.D. Pleasant Hill - (931) 277-5677
Josh Gettinger, M.D. Madisonville - (423) 337-1188 cell
Robert Herring, Jr.,M.D. Nashville - (615) 579-5075 cell
James Hudson, Jr., M.D. Nashville - (615) 385-0934; 975-1582 cell
Thomas Jenkins, M.D. Crossville - (931) 528-5787; (931) 528-3637
James Powers, M.D. Nashville - (615) 746-8916
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Contact Person:
James Hudson, M.D.
2170 Golf Club Lane
Nashville, TN 37215
phone 615-385-0934
cell 615-975-1582
fax 615-292-6268
e-mail jhydson718@aol.com