TennCare gets high marks for access and care, but financial and provider problems remain

Researchers from the University of Tennessee Center for Health Services Research in Knoxville say that members of TennCare, Tennessee’s often-maligned managed care program for 1.3 million people who are Medicaid-eligible, uninsured, or uninsurable, are experiencing better health and better health care
than under the previous Medicaid program.

"TennCare has improved access to insurance for Tennesseans, particularly for those with chronic illnesses who often are refused insurance through private insurance companies," says James E. Bailey, MD, an associate professor in the university’s departments of medicine and preventive medicine. Mr. Bailey says, however, that little change has been made in the overall number of Tennesseans who are uninsured, because:

1. Fewer people are being offered employer-sponsored insurance.

2. Private insurers are becoming less likely to insure people with pre-existing conditions.

3. Many people added to the program as uninsured or uninsurable were actually previously insured but changed to TennCare because of its generous benefits package.

Mr. Bailey tells State Health Watch that he had taken on the research project "with a strong bias that TennCare has done bad things for quality." But evidence from 10 other studies he reviewed "is overwhelming that TennCare has not made things worse," he says.

Statewide research using administrative data and a regional study based on chart review data have demonstrated substantial improvements in mammography rates for women served by TennCare. Statewide research using administrative data also has demonstrated marked improvements in well-child visit rates. Two studies have demonstrated no significant changes in exposure and timeliness of prenatal care. A study in Tennessee and North Carolina demonstrated markedly improved coronary revascularization rates for patients under TennCare after a heart attack. Studies also have shown improvements in diabetes care and outcomes for diabetics, improvements in processes and outcomes for HIV and AIDS, decreases in emergency care and hospitalizations for asthma, and either no change or slight improvement in infant mortality and the occurrence of low birth weight in the state.

Familiarity with PCPs helpful

While Bailey and his colleague, David Mirvis, MD, director of the research center, did not pinpoint reasons for improvements in health care, they hypothesize that much of it is due to patients having greater exposure to primary care providers. They say that when patients know who their primary care providers are, there is an increase in visits to the providers and a decrease in emergency room visits. "Paying someone upfront to assume responsibility as a primary care provider yields the greatest share of improvement," Mr. Bailey says. "There are a lot of bad things one can say about TennCare, but when you ask what has happened to patients, you mostly see improvement."

Mr. Mirvis tells SHW that legitimate concerns about the program deal with financing and organizational problems that "threaten the viability of essential safety-net providers and could adversely affect quality of care and public health throughout the state. It’s harder to maintain quality of care as resources fall. If the financing falls apart, the gains we’ve seen are going to be lost."

TennCare has had problems with its effect on providers, according to Mr. Bailey. Particularly affected have been managed care organizations, academic medical centers, and safety-net hospitals. "There still are advantages for providers who don’t care for sick people. The academic medical centers are taking care of the sickest of the sick but are not paid any more. Lots of uninsured patients are going to safety-net hospitals. But all Medicaid disproportionate share payments have disappeared, and it’s been devastating to the array of services that safety-net providers are now able to offer. Per person flat payments under TennCare punish nonprofit and academic medical centers that provide more care for the more severely ill people that go to them."

State looking for solutions

Bailey says an access problem could develop because TennCare accepts people that private insurance will not cover and also offers a more generous benefits package than many private policies. "With the generous benefits, people come out of the private sector and into the public sector, and businesses are off the hook. Unless TennCare directly competes with private industry or private industry is forced to insure the same types of patients, the problem will continue to grow." Mr. Bailey and Mr. Mirvis say a governor’s commission is looking at the TennCare policy, and they contend the state legislature is looking for help in solving the dilemma.

[Contact Mr. Bailey at (901) 545-7196 and Mr. Mirvis at (901) 448-5826.]