Bredesen should ask Bonnyman for solutions

by Frank Cagle

In its 10 years of existence TennCare has gone through 10 directors, three governors and innumerable permutations. There is only one guy that’s been around the entire time in an oversight capacity, and that’s Gordon Bonnyman, head of the Tennessee Justice Center.

You remember Bonnyman. He is the fall guy if TennCare reform fails. He and his lawsuits on behalf of TennCare patients are being blamed if TennCare is abolished and Gov. Phil Bredesen goes back to Medicaid. Before Bonnyman gets dragged into the public square and flogged, maybe we ought to ask him what his solutions would be to save TennCare without bankrupting the state.

The only money-saving reform Bredesen has implemented during his first two years in office was to establish a preferred drug list. This tells doctors and pharmacies which drugs TennCare will reimburse; if it isn’t on the list it isn’t covered. Not only did Bonnyman support this cost savings, he suggested it. He had been suggesting it for years.

Bonnyman has also been asking, for several years, that TennCare do drug-use reviews. In other words, look back at the data, available on computers, to find anomalies. Are there doctors who are prescribing way more prescriptions than that average? If a patient is getting an inordinate amount of prescription drugs, investigate and find out why. Bonnyman says it makes more sense to find out who is causing the problem than to just make a rule—Bredesen’s solution—to limit everyone to a specified number of prescriptions. He says the administration has resisted implementing such a system.

Last week TennCare investigators announced that almost 8,000 people receiving 155,000 prescriptions worth $14 million were being looked at for suspicious behavior—mostly going to pharmacies more than 100 miles from home and receiving pain killers and anti-depressants. This is the beginning of a vigorous effort to root out TennCare fraud.

Bonnyman concedes that there is fraud and abuse in TennCare. But he doesn’t believe fraud alone accounts for the spiraling costs in drugs in recent years. He says Tennessee’s medical establishment has over-prescribed drugs for decades, predating TennCare. He says reviews could find instances of doctors over-prescribing, and then a peer review panel of doctors could review the cases and offer counsel. Bonnyman says this accounts for much more of the state’s higher-than-average per-capita drug use than fraud.

He points to some Middle Tennessee counties where children have been prescribed antibiotics for viruses to the point that some areas have developed antibiotic-resistant infections.

The premise of TennCare was the state using managed-care organizations to hold down costs, thus making the state able to cover more people. The feds also approved a higher than normal number of things covered, since the experimental program would cover more people.

But rather than contract with Blue Cross to provide the managed care, the state “invented” a couple of other managed care organizations to spur competition and satisfy political constituencies in Memphis and Nashville. These two managed care organizations, undercapitalized from the start, went bankrupt, and Blue Cross wound up taking over coverage. But by that time, Blue Cross refused to operate as a managed-care entity. It agreed only to handle the work for a fee.

Bonnyman says TennCare has to go back to a managed-care system to hold down costs.

He also points to the waning days of Gov. Don Sundquist’s administration, when the governor was desperate to enact some sort of TennCare reform to give him credibility on the need for a state income tax. (Tax opponents argued that TennCare costs were eating the budget, it was not a problem with the tax structure.) Bonnyman says the feds took the opportunity to announce an agreement on TennCare reform in return for cutting the amount of federal money TennCare receives. (Bonnyman says the federal negotiator “took their lunch money.”) He says Bredesen and Sen. Bill Frist ought to get the feds to put the reimbursement formula back where it was. He also argues that the feds should make it retroactive to help cover the current $650 million hole in the TennCare budget.

So the solution for TennCare is clear:

• Establish drug reviews to find trouble spots and solve them.

• Re-establish managed care to hold down costs.

• Negotiate with Health and Human Services to put the funding back where it was and to reimburse the state for the money lost during the last two years.

• Make Gordon Bonnyman TennCare director.

Frank Cagle is the host of Sound Off on WIVK FM107.7, WNOX AM990, FM99.1 and FM99.3 each Sunday 8-9:30 a.m. You can reach him at [email protected].

December 16, 2004 • Vol. 14, No. 51 © 2004 Metro Pulse