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Tennessee's moves to cut health care costs raise national eyebrows

WASHINGTON—Faced with a $650 million shortfall to pay for his state's Medicaid program, Tennessee Gov. Phil Bredesen cut 191,000 low-income people from the struggling health plan.

That action and other cost-saving measures outraged advocates nationwide, who accused the Democratic governor and former health care executive of endangering the well-being of the state's poorest residents.

Similar criticism has greeted Bredesen's latest move, which is unmatched anywhere in the country: Tennessee is the only state that won't pay to cover a widely used class of anti-seizure medications for 560,000 poor adult Medicaid enrollees.

In addition, Tennessee is the only state that won't cover these people for eight other types of drugs—including fertility and weight-loss medications—that the federal government allows states to purchase under Medicaid.

The moves may burnish Bredesen's reputation for cost-cutting. But there's widespread concern that people who can't afford to buy the anti-seizure drugs on their own will suffer in silence or end up in emergency rooms across the state.

With Medicaid draining record amounts from state budgets nationwide, some worry that Tennessee's latest drug coverage cut will be repeated in other states.

"Each time somebody takes one of these actions that 10 or 15 years ago would have been considered so callous as to be inhumane, it just makes it that much easier for the next person to do something similar because they don't have to be accused of being the first," said Steve Hitov, managing attorney at the Washington office of the National Health Law Program, a public-interest group focused on health issues facing the poor.

Tennessee's $8 billion TennCare program was once a national model for serving the poor and uninsured. Recently, Bredesen called it a "damaged vehicle."

But the program cuts and enrollment trims that have ruffled so many feathers also have helped TennCare reduced its funding gap from $650 million to $115 million.

Bredesen recently announced plans to use some of the savings to try to expand health coverage for 150,000 children through a separate program funded mainly by the federal government. Tennessee currently has the nation's most restrictive income limits for children enrolling in Medicaid, according the Kaiser Family Foundation, a health research group.

Bredesen, who's running for re-election, is also trying to develop public-private partnerships to help cover 600,000 working poor who can't afford coverage on their own. He said recently that the changes could restore "the dream of TennCare" without breaking the budget.

"The enrollment cuts that we were forced to make created a great deal of pain and uncertainty that was avoidable had there been more constructive help, but we tackled it and brought it under control. ... By living within our means, we've turned the corner, and we are now able to move forward again," Bredesen said in his recent state-of-the-state speech.

A federal judge in November 2005 approved Bredesen's plan to reduce benefits and cut 191,000 people—mostly the working poor—from the program. The judge ruled that alternative measures sought by patient advocates were insufficient to sustain "one of the nation's most progressive and generous Medicaid programs in a state that has one of the nation's lowest tax burdens per person."

So Bredesen's cuts continue to ripple through the state.

Epilepsy care groups in Tennessee have reported a sharp rise in people seeking help in paying for the seizure medications, known as benzodiazepines. They include drugs such as Valium, Xanax and Ativan.

"This is a public health crisis as far as I'm concerned," said Beth Coleman, executive director of the Epilepsy Foundation of Southeast Tennessee in Chattanooga.

Also vulnerable under the coverage ban are poor, mental-health patients who use the drugs to treat depression, anxiety, panic disorders, insomnia and tremors. Benzodiazepines also help control muscle spasms in cerebral palsy sufferers such as Timothy Rickett of Wartburg, Tenn.

David Beshara, chief pharmacy officer of TennCare, said halting coverage of the drugs was about safety, not saving money. Benzodiazepines are central nervous system depressants that are fairly inexpensive. But they're highly addictive, frequently abused and over-prescribed, Beshara said.

"Although we might be different from our colleague states, we are no different from the federal government," Beshara said of Medicare's ban on covering the drugs.

A study by University of Tennessee Health Science Center found that 2.5 percent of TennCare patients, or about 3,843 people, who used the medications in 1999 inappropriately used the drugs.

Asked why the state didn't act sooner on its safety concerns, TennCare spokeswoman Marilyn Elam said the staff has been "consumed with litigation efforts and fighting back a crippling $650 million budget hole."

Experts in geriatric care say the drugs are also problematic for seniors because they can cause drowsiness that could lead to falls and broken hips.

"Quite frankly, I would not give one of these drugs to my mother," Beshara said.

Dr. Richard Stefanacci, executive director of the Health Policy Institute at the University of the Sciences in Philadelphia, agreed that the drugs pose a concern for seniors. But he said that's not a reason to stop covering the drugs for Tennessee's entire adult Medicaid population. For acute seizure and anxiety disorders, benzodiazepines are the medication of choice, he said.

"If clinical situations support their use, you put in safeguards to make sure they're used appropriately," Stefanacci said.

Tennessee's decision to halt the drug coverage has angered the state's 15-member Pharmacy Advisory Board, which recommends the drugs TennCare should cover. The panel wasn't consulted about the change.

"Individually, I can tell you that all members of the committee do not favor this and certainly would never have voted for this if we had known about it," said Dr. James Powers, chairman of the advisory board and a geriatrics specialist at Vanderbilt University Hospital in Nashville.

Beshara said the board's charter doesn't require notification on such coverage changes, but he acknowledged that the panel has had input in similar decisions.

Some people affected by the cuts have relatives who help them purchase their drugs. Others can get them for free through pharmacy assistance programs run by drug companies. But enrollment in those programs isn't assured and there's no guarantee that those offerings will continue.

Rickett, 30, is already struggling under the policy change. He's taken a benzodiazepine, Clorazepate, for about five years to combat depression and muscle spasms associated with his cerebral palsy.

His doctor tried to substitute an antidepressant, Effexor, which was covered under the new Medicare benefit.

"After three days, I was shaking so bad I had to quit taking it," Rickett said. "It actually made things worse."

With his $623-a-month income from Supplemental Security Income and Social Security already spoken for, Rickett can't afford the $64.88 a month it would cost to buy Clorazepate. So he borrows Xanax and other drugs from relatives to tide him over.

Rickett is filing an appeal with his Medicare drug plan for a coverage exception, but he doesn't expect an answer for several weeks. He said that without the medication, he can't continue vocational classes to land a job in Web site design.

"After a few days without it, I start to have problems. Without the drugs, it would be hard for me to go out in public, work or go to school or basically live a normal life," Rickett said.

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To find out whether your state Medicaid program covers the nine categories of drugs that Tennessee has decided not to cover, go to www.cms.hhs.gov/States/EDC/list.asp

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(c) 2006, Knight Ridder/Tribune Information Services.

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