TennCare treatment rules slammed

By: Katie Allison Granju, Producer

Recent changes to TennCare will take treatment decisions away from doctors and put them in the hands of insurance companies, critics say.

Doctors now have to provide the “least costly” treatment that is “adequate” for their TennCare patients, under new rules that went into effect last month but will be finalized within the next few weeks.

Some advocates fear that the new standard of treatment will spread to the private sector, allowing medical insurance companies to enrich themselves by denying Tennesseans treatments because the treatments are not the “least costly.”

“To many doctors, that means ineffective treatment to save money,” Dr. Dick Braun, a Pleasant Hill physician, said of the new TennCare standard.

“This interferes with the personal physician-patient relationship when it is imposed upon them by a third party, whose primary interest is on saving money to line their own pockets.”

Braun and other opponents spoke out against the state’s new definition of what care is “medically necessary” at a public hearing Wednesday. Dr. Wendy Long, TennCare’s chief medical officer, called critics’ concerns an “overreaction” and maintained that patient treatment won’t suffer.

“Adequate care is defined as sufficient but not in excess. We believe that is basic common sense,” Long said. “We want to make sure we are good stewards of taxpayer dollars. We want to make sure people get what they need but that we aren’t spending money on treatments that haven’t been proven effective.”

The changes will apply to the 1.2 million people on TennCare. Its officials said they will consider the public’s input and discuss whether to modify the new rule.

The biggest concerns among critics is that the change will give insurance companies participating in TennCare too much power in medical decisions and that patient care will suffer.

“This new definition of medical necessity gives the HMOs free license to deny any care,” said Majorie Bristol, a lawyer with the Tennessee Justice Center, an organization that provides legal services for enrollees.

Tony Garr, executive director of the Tennessee Health Care Campaign, a health advocacy group, said the medical insurance companies have an incentive to deny care because starting April 1, they will be paid a fixed monthly payment per enrollee.

The companies, technically known as managed-care organizations, or MCOs, will get to keep any money they do not spend on medical care.

Long said that there are safeguards in place to make sure enrollees are getting the treatments they truly need and that enrollees can appeal an insurance company decision.

“The MCO is not going to be questioning every X-ray,” Long said. “For very expensive procedures or for procedures that can be misused or abused, doctors need to get prior approval from MCOs. This process applies to a very small minority of services.”

Garr is wary that the changes could set a precedent that will affect everyone with health insurance down the road.

“These managed-care organizations, very few of them are Tennessee-based. They are national groups,” Garr said. “They not only serve TennCare enrollees. They serve people in the private sector. I think it’s a very slippery slope. It opens the door for managed care to be in the driver’s seat to deny people care.”

Yarnell Beatty, the Tennessee Medical Association’s director of legal and government affairs division, fears that the new rules will be a hindrance to doctors.

“We believe if these rules are adopted, the administrative hassles on the physician’s practice, as well as the increase in liability to a physician servicing TennCare patients, may have the chilling effect of decreasing the network of participating physicians and thereby decreasing access in Tennessee for these patients,” he said.
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