State's power over TennCare boosted

AP ^ | 7/29/5 | LUCAS L. JOHNSON II

[SmithL]

NASHVILLE - A federal judge issued a partial ruling Thursday that gives the state some authority to modify a key consent decree that governs the TennCare program.

U.S. District Judge John Nixon approved two main changes to the expanded Medicaid program: The state can require prior authorization for prescription drugs, and it can limit prescriptions to five per month.

But Nixon's order said the "court reserves ruling on whether the state may deny any claim for reimbursement for a drug for which prior authorization is required but has not been obtained."

In the case of prescription limitation, the judge ordered a "soft" prescription limit, which gives patients a chance to get more medicine if their doctors say they need it.

Currently, the state must pay regardless of lack of prior authorization, and drugs must be dispensed as prescribed unless a pharmacist can convince a doctor to change.

The state also had asked the court to limit appeal hearings and to more clearly define what treatments qualify as "medically necessary," but Nixon said he needed more time to rule on the rest of the case.

"We're gratified that the court has ruled the way that it has," Finance Commissioner Dave Goetz said outside the courtroom. "The judge clearly acknowledged that like all other states, Tennessee should be able to do prior authorization. But this is only a partial ruling. There are almost two dozen key points in the motion that the state made to modify. He ruled on six of them."

Nixon said he issued a partial ruling because thousands of people being cut from TennCare as part of Gov. Phil Bredesen's reform plan will loose their pharmacy benefits on Monday, and thousands of those remaining on the program will face the five prescription limit.

However, the judge's soft prescription limit could change that. Goetz said attorneys for the state would review the judge's ruling with the governor and possibly "have more to say on this tomorrow (Friday)."

"Tonight we're unable to make a decision as to whether or not the changes that are due to take place next week will in fact go forward," Goetz said.

The state has said it needs to modify the decree to hold down costs and keep the sickest enrollees - roughly 97,000 - on TennCare. But plaintiffs' attorneys say the state is uncertain of its ability to save that many people, and that the changes will leave those on the program without certain legal protections.

Gordon Bonnyman of the Tennessee Justice Center, the main advocate for enrollees, said the burden now falls back on the state to spare the medically needy.

To provide the state with even more wiggle room, plaintiffs' attorneys agreed to leave in place a three-day limit of emergency drugs a patient is allowed if they don't have prior approval for them.

On Jan. 1, that limit was supposed to extend to 14 days, but Bonnyman said keeping it as is would save as much as $75 million in six months, which the state could use to keep people on TennCare.

"They've said if they got more money, if they got flexibility, they'd do right by people," Bonnyman said. "I hope they will."

Nixon heard nearly three weeks of testimony from the state and from attorneys representing TennCare enrollees. He issued his ruling soon after closing arguments Thursday.

Bredesen is cutting TennCare rolls and reducing benefits because he says the state cannot afford the program in its current form. He has blamed the consent decrees for blocking his ability to change the program.

The state has already gotten approval to cut up to 290,000 adults from TennCare.

Mandy Murawski of Dickson is scheduled to lose her prescription coverage on Monday. The 25-year-old said she takes 18 drugs a month after having a double lung transplant and is afraid what will happen if the state limits her medication.

"It's life or death," Murawski said. "Let's see if the state keeps its promise, and keeps me alive."

[SmithL]

thousands of people being cut from TennCare as part of Gov. Phil Bredesen's reform plan will loose their pharmacy benefits on Monday

loose?

Lucas L. Johnson II and his editors at the AP are idiots.

[Wally_Kalbacken]

The 25-year-old said she takes 18 drugs a month after having a double lung transplant and is afraid what will happen if the state limits her medication.

I'm not an MD or a pharmacologist - but I have to wonder what the odds are of being able to randomly select 18 drugs that will not have an incredibly serious interaction. Hell, you might suffer gelatin toxicity.

An article like this only scratches the surface - I'd like to see some statistics - for the distribution of payments per capita. Granted that there are some incredibly sick people in the world - and they have some astronomical multiple of the average annual expenditure - but I'd still like to see what it is. And the general problem with TennCare and programs like it (BadgerCare, PeachCare, etc.) is that - as typically administered - the demand for services is some healthy multiple of funding available.