THE VAST BUREAUCRATIC MORASS THAT GOVERNS PRESCRIPTIONS UNDER TENNCARE

Below is just the introduction to a very comprehensive article

These days, Phil Bredesen and Gordon Bonnyman don’t see eye to eye on very many issues. Quite possibly, the governor and his old-friend-turned-public-rival hold only one sentiment in common when it comes to this state’s Medicaid program. In Bonnyman’s words: “Not to put too fine a point on it, but we’re all drugged out in Tennessee.”

The 57-year-old public interest lawyer in the bug-eyed spectacles isn’t talking about the state’s high levels of methamphetamine abuse; he’s talking about its predilection for prescription drugs—a $5-billion-a-year habit that’s been incredibly hard to kick. So hard, in fact, that Gov. Bredesen decided it was necessary to stage an intervention: over advocates’ objections, he made plans to remove a few hundred thousand adult Tennesseans from the state’s health insurance rolls—before reinstating up to 97,000 of them—and limited the number of prescriptions available to the 1.1 million who remained. That, the governor said, was the only way the state could save TennCare: rein in the skyrocketing cost of prescription drugs by cutting the rolls and capping the number of scripts-per-enrollee.

So he did. Now that the enrollment and pharmacy cuts have been put into place, effective management will be crucial to the program’s success. After all, both advocates and the administration agree that bad management got the state into its TennCare crisis; could good management, over time, get the state health insurance plan back to the national model it once was?

Perhaps. But after Bredesen—who made his fortune as a successful HMO entrepreneur—is done reforming TennCare, it may look more like a private health plan than a public one. Today, for example, drug purchasing decisions are made by state bean-counters (themselves hired from the private sector) using clinical and cost information and recommendations supplied by the private company that manages TennCare’s pharmacy benefit program. A high-level committee of doctors, pharmacists and an attorney offers clinical input, but it can be overruled for financial reasons—although the state doesn’t tell them what those reasons are, citing contractual requirements with drug companies.

Taxpayers—among them sick TennCare recipients—are left to trust that state officials will make the best possible drug purchasing decisions both for their health and their pocketbooks. No one’s checking their work when it comes to clinical benefits vs. financial costs because no one outside a handful of government officials and a private contractor is allowed to see all the information. State officials don’t even write numbers down for fear they’ll become public. Meanwhile, effective drug use review—another management technique designed to curb pharmaceutical costs—still doesn’t seem to be happening.

As the state implements painful health care cuts that are putting a serious strain on some Tennesseans’ ability to obtain health care, prescription drug management moves to center stage. To be sure, TennCare has gotten leaner—but has it gotten any smarter?

Say you’re a TennCare recipient who’s making a visit to the doctor’s office this month. No matter what you have wrong with you—hypertension, acid reflux, allergies, diabetes, herpes, MS—unless it’s on a short list of the most severe diseases, you get five prescriptions for the month. Up to two may be brand-name medications and the other three must be generics. Your doctor has a seven-page preferred drug list, or PDL—here’s where the many abbreviations start flowing—from which your drugs are chosen; if for some reason your “provider,” as doctors are called in the medical care industry, believes that a non-preferred drug would be best for you, she must get “prior authorization” (PA) before a prescription will be filled. High cholesterol? Zocor is preferred, along with two other drugs; Lipitor, on the other hand, is one of six meds listed as “PA Required.”

Who decides which drugs make the list? The murky answer to that question involves a state pharmacy board, a handful of TennCare bureaucrats, a politically connected managed care company based in Virginia and the pharmaceutical companies themselves—depending on the rebate they’re willing to offer the state

More here

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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