Tennessee state officials have developed a definition of the term"
medical necessity" that could weaken federal requirements
concerning access to care through its Medicaid program called TennCare.
At the urging of Gov. Phil Bredesen (D), the legislature passed a bill in
May that would result in copayments of $1 to $40 for certain services for most
beneficiaries, cap coverage at six prescription drugs a month, and require
most beneficiaries to use the cheapest prescription drugs available. It would
also limit days of hospitalization and doctor's visits annually, according to<www.kaisernetwork.org>
Before implementation, those changes must be approved by the Centers for
Medicare and Medicaid Services (CMS) as a waiver.
The limitations proposed are not new, although the combination exceeds the
cost cutting measures undertaken in most states.
The real threat to access, notes the National Health Law Program (NHLP), is
the unprecedented definition of "medical necessity" contained in
the legislation. The NHLP is a public interest law firm in Washington, D.C.,
that focuses on health issues for the poor.
The new definition contains four parts, all of which must be met for the
patient to receive care.
Peter Frizzell, M.D., president of the Tennessee Psychiatric Association,
told Psychiatric News that there was concern among psychiatrists
about the proposed definition.
Karen Rhea, M.D., vice president for medical services for Centerstone, gave
Psychiatric News the following statement. Centerstone is a multisite
community mental health center in Tennessee.
"The rising role of the uninsured defines our national health care
crisis. Tennessee through TennCare has approached more closely than any other
state, except Hawaii, the goal of universal health insurance coverage. We do
understand, however, that there are budgetary constraints, which will
precipitate tradeoffs between coverage and scope of benefits.
"We are especially concerned about the patient population with
serious and persistent mental illness and their potential for recovery with
continued access to cutting edge pharmacotherapy and efficacious psychosocial
services. However, we are cautiously optimistic and have been promised the
opportunity to participate as providers in the dialogue, which will define the
working details of medical necessity."
Forensic psychiatrist and former APA president Paul Appelbaum, M.D.,
identified several problems with the proposed definition (see box).
David Fassler, M.D., a child psychiatrist in Vermont and member of APA's
Board of Trustees, told Psychiatric News, "The proposal appears
particularly problematic with respect to child and adolescent psychiatric
treatment. Under the revised definition of medical necessity, many of our
routine clinical interventions would be classified as `experimental' and
thereby excluded from coverage. In an attempt to save money, the legislation
would create barriers to access. Whatever modest savings might be achieved
likely will be more than offset by increased spending on special education,
juvenile justice, and social service programs.
"In addition, while the legislation purports to emphasize
`evidence-based medicine,' it imposes random and arbitrary limits on monthly
prescriptions and annual visits, procedures, or lab tests. The primary
emphasis clearly is on cost containment, as opposed to access to necessary and
appropriate clinical services."
Ron Pollack, executive director of Families USA, and other health care
advocates fear that approval of the definition by the CMS eventually could
result in a weakening of federal requirements nationally concerning care for
Senate Majority Leader Bill Frist (R-Tenn.) backs the change, according to
an article in the July 7 USA Today.
Reporter Skip Cauthorn speculated in the Nashville City Paper on
July 6 that the proposal would be particularly appealing to Republicans as a
way of setting a precedent because it was developed by a Democratic governor
and supported by a Democratic state legislature.
The Bush administration, in early 2003, proposed changes to Medicaid that
would have given states greater flexibility in terms of cutting beneficiaries
and services in exchange for a short-term infusion of funds. The proposal was
withdrawn when it failed to secure support from the National Governors
Association (Psychiatric News, March 7, 2003). ▪