TennCare still plagued by access problems, providers and consumers tell lawmakers
TennCare Access Problems
November 30, 1997
6 minutes read
Nearly four years after its launch, the TennCare program continues to be plagued by inadequate networks of specialists and primary care providers, lack of orthopedic care, and long waits for dental care, Tennessee legislators were told during two days of hearings on access problems in TennCare Oct. 20-21.
"It is known that the orthopedic medical community is boycotting TennCare," said Tony Garr, executive director of the Tennessee Health Care Campaign, in testimony he submitted to the TennCare Oversight Committee.
"MCOs are finding it very difficult to get orthopedists to sign contracts. We are still hearing about cases having to travel many miles to get a broken bone fixed or having to wait to get it fixed."
While Tennessee requires that managed care organizations (MCOs) provide enrollees primary care providers (PCPs) within 30 minutes or 30 miles of their homes, even networks that pass this "geoaccess" measure can be inadequate, according to Kathy Wood-Dobbins, executive director of the Tennessee Primary Care Association.
One reason: Providers commonly limit the number of TennCare patients in their practice and don’t always take new patients.
Ms. Wood-Dobbins said a 12-county survey conducted by her organization found that only 58 of 126 primary care providers listed in MCO directories would make an appointment with a new TennCare patient.
"A new TennCare patient has a 50-50 chance of being able to make an appointment by going through the directory," said Ms. Wood-Dobbins.
"What we have in an MCO directory is a list of providers who have signed a contract. It doesn’t tell us how many patients they’re willing to see. They may only see one patient. It doesn’t tell us what the actual capacity is."
In Williamson County, which has a population of 7,578, MCO directories listed 31 providers, but only five said they would accept a new TennCare patient, Ms. Dobbins said. The association was unable to reach four providers, 17 providers said they were not accepting new patients and five providers participated in BlueCare and HealthNet, MCOs which had closed enrollment in the county.
The survey points out the importance of community health centers and health departments in some counties, she said, noting that in the most underserved counties there would only be two to four providers without these centers.
Limiting TennCare volume
No MCO representatives testified at the hearing. But, in an interview, Douglas Henry, MD, medical director of Health Net, a TennCare MCO, said doctors have the right to decide when they are too busy to accept new patients. "The last thing we want them to do is to load themselves down with 4,000-5,000 members," said Dr. Henry, who noted that too many patients in a practice only leads to consumer complaints.
HealthNet generally asks doctors to accept 100-300 TennCare patients when they sign contracts. Some doctors do not want to be too dependent on TennCare, he said, so they often limit their practice to a certain percentage.
Dr. Henry said some of the access problems in TennCare have to do with the "maldistribution of physicians" in general and the fact that in rural areas "there aren’t doctors within 30 miles." Many parts of "rural Tennessee are without physicians," he said.
He acknowledged that in some counties he would like "more ophthalmologists and gastroenterologists." He said HealthNet does have some orthopedic surgeons in its network, but he acknowledged that the "orthopedic community seems to have chosen not to contract with TennCare MCOs." While they choose not to contract, Dr. Henry said, orthopedic surgeons often agree to treat patients and accept TennCare reimbursement.
Problems accessing specialty care were a common complaint at the hearings, but John Morgan, executive assistant to the state’s comptroller of the treasury, painted a rosier picture of access in the same 12 counties surveyed by the Tennessee Primary Care Association. When specialists on provider lists furnished by MCOs were surveyed by the state, 73%, or three out of 4 specialists said they would see a new
TennCare patient. Appointments could be scheduled within 30 days. Only 7% of specialists said they did not accept new TennCare patients. Others could not be reached because the phone numbers were incorrect, had been disconnected, or the provider did not have time to give the information.
"Ability to get an appointment was reasonably good," said Mr. Morgan. However, the survey did not look at travel distances to specialists, at whether there were an adequate number of specialists in the region, or if the response rates of specialists varied by specialty.
Public health monitors networks
Since April 1, the 143 public health departments in Tennessee have been enrolling children and other eligibles in the TennCare program as well as providing benefits education and assistance with grievances. In their new role, they keep up-to-date information on provider networks in the state’s 95 counties.
Doris Spain, assistant commissioner for the Tennessee Department of Health, acknowledged that the primary care provider networks of some MCOs have been found to be inadequate. "There may not be as many specialists as we would hope across the state," she conceded.
Local health departments in Tennessee have identified the following access problems:
• large numbers of dentists have chosen not to participate in the TennCare program because of low reimbursement;
• pregnant women with presumptive eligibility for TennCare are being refused service by some providers, although MCOs are contractually required to accept presumptive eligibility, and some pharmacists also have refused to fill a pregnant woman’s prescriptions until she shows up on the TennCare rolls;
• requirements by some MCOs that a pregnant woman obtain a referral to an ob/gyn from a primary care provider are delaying access to prenatal care;
• there is poor access to pediatricians in some pockets of the state; and
• there is poor access to specialists, especially to orthopedists (sometimes participating TennCare specialists will refuse to treat a resident from outside the county).
Access problems not new
These access problems are not new to
TennCare, Ms. Spain noted. Rural counties that were underserved under the old Medicaid system continue to be underserved under TennCare, she concludes in her written testimony. Managed care has not brought additional providers to these underserved communities although there are early indications that this is changing.
Despite these access problems, Ms. Spain said some recent outcome measures show improvement in public health measures. Infant mortality in 1996 (8.5/1,000 births) is the lowest on record and the immunization rate of two-year-olds is 84%, close to the national goal of 90% by the year 2000.
Mr. Garr believes that part of the problem is that the state has not been strict enough with MCOs about issuing provider directories with complete and accurate information. At least one MCO does not list specialists in its directory, only hospitals, physicians, pharmacists, he said.
Theresa Clarke, assistant commissioner, Bureau of TennCare, TennCare Partners, Department of Health, told legislators the state will be validating networks more frequently, including random monthly telephone surveys of primary care physicians and dentists. Currently, the TennCare Bureau is calling all primary care providers and ob/gyns in the state to find out whether they provide only prenatal care or deliver babies, whether they accept new TennCare patients, whether they accept presumptive eligibility, how long it takes to get appointments and which MCO networks they participate in.
"We are continuing to delve deeper and deeper into networks, to go beyond geographical access, to use other outcome indicators and to do particular samplings and validations," Ms. Clarke said.
"We hear about problems getting access to ob/gyns early in pregnancy and we want to make sure the networks are appropriate," Ms. Clarke said. "Not all providers have to accept new patients for an adequate network, but there has to be an adequate network for new patients," she said.
Barry Hale, director of the Quinco Community Mental Health Center, Inc. in Bolivar, TN, said a better measure of access is to look at utilization of services by 1,000 members by geographic area. "It’s only when you begin breaking it down by county into number of sessions per members that you can see whether or not services are being provided."
In behavioral health, some of the utilization rates that should be monitored, Mr. Hale said, are the rates for case management, partial hospitalization, psychiatric and day treatment sessions per 1,000 members by county.
Ms. Clarke said the state is poised to provide more data on MCO performance in the state. Report cards soon will be issued on rates of preventive services by MCO and by community service area, she said. Utilization rates for mammograms, pap smears, well child visits, dental visits and hospital admissions for ambulatory-sensitive conditions will provide some indication of access, said Ms. Clarke. She adds that the state is also completing a study of emergency room utilization which looks not only at paid claims but at denied claims. These reports will all give some indication of access. Mr. Garr adds that they will also help to single out and put pressure on MCOs that are not performing well.
Contact Mr. Garr at 615-227-7500, Ms. Wood-Dobbins at 615-329-3836, ext. 14.
TennCare still plagued by access problems, providers and consumers tell lawmakers
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content
