Tennessee's much-maligned TennCare program suffered two more significant setbacks this month and faces a key deadline in March, but state officials are stepping up their efforts to ensure the long-term viability of the Medicaid-style program.
"I feel a sense of guarded optimism," says Barrett Rosen, M.D., president of the Tennessee Medical Association. "For the first time since 1993, when TennCare was first proposed, someone from the governor's office came to us and said, 'Help, we need advice.' That was very refreshing."
Rosen's practice, the 36-physician, Nashville-based Tennessee Orthopedic Alliance, effectively withdrew from TennCare on Jan. 1 when it ended its contract with the BlueCare HMO. BlueCare, operated by BlueCross BlueShield of Tennessee, is the largest of the TennCare HMOs, with about 580,000 enrollees, but it is in the process of leaving the program.
However, the Blues will stay involved indefinitely as an "administrative service organization" to provide temporary care for as many as 100,000 enrollees should another payer drop out of TennCare on short notice, says Lola Potter, TennCare spokesperson.
TennCare provides health insurance to nearly 1.4 million low-income, disabled and uninsurable Tennessee residents, including about 350,000 adults who would not qualify under the traditional Medicaid program.
Tennessee Blues says that 595 of 7,000 physicians, or about 8%, dropped out of BlueCare during the second half of 2000.
Although only about 10% of the practice's patients were TennCare enrollees, "The cost of doing business was so high that we were losing money, and it was affecting our ability to deliver care to our other patients," Rosen says. The cost includes time and staff needed to refile claims repeatedly.
Sloppy record-keeping by the second-largest TennCare HMO caused state officials to go to court in a bid to place the Access MedPLUS HMO in receivership. But the Davidson County Chancery Court ruled Jan. 16 that the Department of Commerce and Insurance was unable to prove that Access MedPLUS was in "hazardous" financial straits. The HMO is under state supervision, as it has been since last May, because it has been slow to reimburse physicians for services provided to its 360,000 enrollees.
Rosen met with Gov. Don Sundquist earlier this month to discuss the future of TennCare. The state has until mid-March to tell the federal government whether it will continue the program, which receives two-thirds of its $3.7 billion annual budget from federal sources.
"The governor wants it to survive," Rosen says.
"I think that state legislators are aware that they can't let the program die," says Tony Garr, executive director of the watchdog group Tennessee Health Care Campaign. The group has been a frequent critic of TennCare's often-lax oversight of the eight private HMOs that administer and pay TennCare claims.
Despite the setbacks, TennCare officials are determined to make the program work. "We have no intention of going back to Medicaid fee-for-service," Potter says. "We are operating as if this program is going forward."
Some good news came Jan. 19 when TennCare announced it was releasing $109.4 million in long-awaited funds for "essential providers," more than 100 hospitals and 1,500 specialists, that had been tied up in state and federal bureaucracy since July. Hospitals will get $90 million of the money, while pediatric primary care providers, community health centers, HIV/ AIDS clinics, orthopedists, neurologists and dentists will share the remaining $19.4 million.
Potter says TennCare recently won approval from HCFA to raise premiums and co-payments for a limited number of enrollees who are covered under TennCare but who do not receive free care.