Redstate

By MrsNachos Posted in Economy | Health care | Hillary | Tennessee — Comments (9) / Email this page » / Leave a comment »

If your name is Hillary Clinton, then the theme song for your campaign may be "Everybody Wants to Rule the World." Now, I love some Tears for Fears, but in the middle of the excitement of Hillary running for Presidential nominee, I feel one area is incredibly lacking. You see, for the last several years, while the rest of the country focused on "Will she or won't she?" in regards to her running, Tennessee has been slowly trying to make use of the program that Hillary decided would benefit our fine state. I'm still not sure why she chose Tennessee. I truly wish she would have taken her social economic experiment elsewhere because, for all the people TennCare may help, its bureaucracy and red tape have meant sudden medical coverage death for a great majority of the people on TennCare.

I'm not a politician and I do not have an incredible political base of knowledge. Something I do know about is TennCare. For the last two years I worked at various clinics in the Nashville area and one thing I learned to be true is that TennCare is way more trouble than it is worth. The people that are being most affected in a negative manner by TennCare are the people that need it the most: the elderly and the children.

In my personal experience, TennCare is loathe to pay for anything. If you are lucky enough to maintain your TennCare for more than 6 months, expect long waits for necessary procedures, that is, if you can even get them approved. Having attempted prior authorization for referrals, I can tell you from firsthand experience that not all medically necessary procedures are approved. With the way TennCare is set up, the doctor that reviews a case for a pediatric surgery may very well be an opthamologist.

Part of the issue with TennCare is lack of providers. When a referral to a specialist is done, the first thing to be done is to search for a TennCare provider. TennCare Select, the aspect of this that I am most familiar with, does have a website. If you search for providers, chances are NONE of the ones listed will say that they take TennCare. If the program is so fantastic, why won't doctors take it? Well, if you accept a TennCare patient, you will be paid marketedly less than if the patient has private insurance. You also may have repeated visits from these patients that take the time from other insured patients.

Why is a patient so sick that they require multiple visits? Well, it's pretty simple, actually. Because finding a TennCare provider is a hassle and anyone on TennCare risks the chance that the TennCare will have been terminated without notice and they will be forced to pay for the visits. As such, when the patient finally does seek medical attention, the situation may be far worse than when originally discovered.

Let me walk you through a typical TennCare referral from the point of view of the PCP's office. Every patient on TennCare is REQUIRED to have a referral from their PCP. They aren't even playing. This is HMO to the extreme. If you don't get the referral, chances of getting a retro-active one are slim to none, because if you didn't get one in advance, they honestly aren't required to pay for anything.

The PCP's office then begins the search for a specialist that will accept TennCare. I need to preface this by saying that there ARE some truly amazing doctors that go out of their way to accept TennCare and non-insured patients. I'm privileged to know some of them and this does not apply to them. If the PCP's office has no idea which doctor will take the TennCare, the search begins. I've already mentioned that the website often lists many providers, but in most cases, none of them will take the TennCare. Reasons for this are: "We are no longer taking Tenncare. I do not know why we are listed on the site." Also, "We are not accepting any new TennCare patients at this time." Why wouldn't they accept an insurance that pays them less than what they make in a normal visit? The doctors that do take TennCare, since the ranks are closing, are becoming saturated with these patients. Doctors are making much less just for doing their job. Thanks, Hillary. I know that I want my doctor to be overworked and underpaid when he's examining me. God Bless the doctors that take these patients. Seriously. Bless them.

Ok, so we are now between the rock and the hard place. We have a patient who desperately needs a specialist/procedure/etc, but no providers. You call TennCare and they assign the patient a case manager. The case manager is then put in charge of getting the out of network referral, which could take them 2-3 weeks. The other option is to have a spectacular referral specialist who works on getting the out-of-network approval for a doctor will take less money for the same job simply because they care about the patient.

Here is the tricky part. If there is a single specialist in the area, no matter how unqualified they may be, who will take the TennCare, the patient is at a loss. It doesn't matter if the doctor has done the procedure few times (think the surgeon on The Simpsons), that's the man who will see this patient. It doesn't matter if there are other, more qualified doctors available who will take the patient.

If the PCP is willing to put in the work for a qualified specialist, then it goes to a peer-to-peer review where a PCP may be trying to appeal the procedure to an opthamologist when the procedure needing approval is a complex surgery. I have no idea where anyone got the idea that an opthamologist would be qualified in determining if a patient should see a more qualified specialist in any case, but someone thought "Hey, this will cut costs."

The case will either be approved or denied again. If it is denied, it goes to appeals, which can take YEARS. Keep in mind that the patient is in pain NOW. Once a case goes to appeals, it is rarely approved.

Now that you have some background as to what it is like to get just one procedure taken care of, let's look at some other nifty little things about Hillary's big plan. Take a little look at the TennCare timeline. Do you notice anything interesting about it? How about the fact that the timeline stops in 2004? In the summer of 2005, there were hundreds of thousands cut from TennCare. Many complained that it was without notice. Why? Because the state can't support the state-funded insurance.

Guess what happened in January 2006? Another cut with more people that had no idea it was coming. In my 2 years, I have talked to over 1,000 people, no exaggeration there, that have lost TennCare without a single notification. Now for the kicker: we're not talking healthy, middle-aged people who may be able to go without coverage. We're talking about the elderly and children. Sure, middle-aged folks were part of the cuts, but children are often cut from the program due to simple things like misfilings within the company. The parents find out when the bill arrives from a specialist or doctor's office stating that they owe money. If they had money, they wouldn't be on TennCare.

One other reason people get cut is that they have finally been able to hit the poverty level. This means that they are no longer eligible for TennCare, but are unable to provide insurance for themselves. Not only does TennCare kick them when they are down, through non-approval of services, but then kicks them when they finally start to break through and see the light at the other side of this.

In a study, "A Comparison Study of Access to Health Care Under a Medicaid Managed CareProgram" by Cynthia J. Rocha and Liz England Kalbalka (1999), TennCare was used to determine whether state-managed programs can be both cost effective and provide a high standard of care. According to the study, TennCare was set forth in 1994 due to the state health care crisis and lack of funds for the evergrowing Medicaid crowd. In the introduction, it is noted that doctors were initially concerned about TennCare and that TennCare was pushed forward more quickly to thwart doctors who may protest. According to Daniels, 1994, which was noted in the Rocha & Kalbalka study, even in the first 6 months of TennCare's existence, patients were getting the short end of the stick with non-notification of PCP change, lack of knowledge of how to get care, and not having a doctor within driving distance who would accept the insurance. You'll notice that the article was written in 1999. That leaves 7-8 years of information we're lacking. The only thing we know is that things are headed downhill for TennCare patients. Research cited in the Roche & Kalbalka article indicates that quality of care in managed care programs suffers.

Roche & Kalbalka took 2 samples from the TN area. What they found was that insurance status significantly affects the quality of care offered to individuals. Less TennCare patients than insured patients had regular physicians and they had increased difficulty in getting their medicine. The only people that had a harder time finding a physician were the uninsured, for obvious reason. Keep in mind that most of the uninsured make just above the "TennCare cutoff line."

In the interest of time and space, I won't go into the 5 other studies I found that said essentially the same thing. Feel free to google them. It's not hard to find a dissatisfied patient who is willing to tell you about TennCare experience. The bottom line is that TennCare is INEFFECTIVE.

What is my point and why should you care if you aren't in Tennessee? Well, because Hillary is running for presidential nomination. She had one big idea and then cut and run when push came to shove with TennCare. She has shown that she is willing to put something forth, that may have merit, but not take the time or effort to truly think it through. It's all a means to an end. She wants to be your next President. All the children and elderly should fall where they may. She has lots of "solutions" but no idea how to get there or what it takes to be a feasible solution to a real issue. Tennessee is feeling the brunt of her impulsive and, in my opinion, thoughtless program that has been pushed upon the state. We're struggling to find ways to make this work and, in the process, people are losing insurance all over the place. It doesn't just affect TN anymore. She wants to make her bad decisions in an official capacity. Please don't let her do this to the country. Protect those that she claims to have in mind, but refuses to truly help. She's extreme even for the democratic point of view in that she is a proponent for government assistance, but does not exhibit any kind of care or concern for the well-being of the hundreds of thousands in the state she's already brought down. We can stop this. We don't control the democratic presidential nomination, but we still have the ability to be firmly against her.