TennCare coverage for c-sections reduced

11:03 AM, Mar 17, 2011   |    comments
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TennCare changes are on the way following Gov. Bill Haslam's state of the state address earlier this week.

Among those changes, are reductions in coverage for women who give birth in the state and are covered by the state's Medicaid program.

While the governor's budget increases the amount of coverage by 5% for vaginal births, it reduces the coverage of cesarean sections. Both types of birth will now be covered equally, despite their varying costs.

The goal, according to state leaders, is to discourage elective C-sections.

Kelly Gunderson, spokeswoman for TennCare, said the move is a response to the increase in elective C-sections across the country and in Tennessee. She said, in the late 90s, C-sections accounted for about 20% of births. Now, they make up 30%.

"It first increases the amount we pay for normal births and then brings the amount we pay for C-section births to that level," Gunderson said. "So, physicians well be getting paid more for their normal births, but they'd be getting paid the same for C-section births, and the thought there is that it aligns the incentives properly and would reduce the amount of elective C-sections."

The change affects every C-section, even those that are considered medically necessary.

That's a concern for Russ Miller, Senior Vice President of Communications and Membership for the Tennessee Medical Association.

Miller said he is not necessarily concerned doctors will choose to avoid C-sections when they may be needed because of the cost. Instead, he's worried about the potential long-term impact.

"The real analysis is going to come at the end of the month when they look at the books of reimbursement, and the decision won't be whether they do C-sections or vaginal deliveries but whether they even stay in the program," Miller said. "Access to care is always an issue with any public health program, and TennCare has had trials and tribulations over the years. I'd hate to see a narrow-focused, financially motivated policy endanger care for thousands of patients across our state."

As for East Tennessee hospitals and care-providers, leaders at Mercy Health Partners say they don't believe the change in C-section coverage will have a big impact because those procedures are rarely performed at their hospitals.

However, there is a concern about the drain more, and continuing, TennCare cuts could have on Mercy.

"We do hope that this is not a permanent situation," said Jerry Askew, Mercy's senior vice president for external relations. "Our hope is that, as revenues continue to rebound, and as the state continues to improve its financial situation, the state will be able to take this burden back on because it is a burden that belongs to the taxpayers not to the hospitals, per se."

Askew said the cuts could have hurt more if hospitals across the state had not banded together and agreed to another year of hospital assessment.

With that, each hospital pays a portion of its gross revenues to TennCare, which allows the state to get a two-to-one match in funding from the federal government.

As Gov. Haslam mentioned in his speech Monday night, that effort has, so far, prevented deeper cuts to TennCare.

Also as part of the TennCare reductions:

- There will now be a dosage limit for suboxone, a drug that has been used to reduce dependence on heroin and other narcotics. It has since become one of the top 10 drugs in terms of expenditures for TennCare, and experts say some users have found a way to abuse the drug. Now, dosages will be limited to 16 mg per day for the first six months and 8 mg per day for the six months after that.

- Coverage for sleeping pills will be reduced to 14 doses per month. Experts said the medication should be used intermittently even in the most severe cases.

- Prescriptions for hemophilia treatment will be adjusted. Formerly, the IV medication could have a plus or minus factor of 10% when it came to the key ingredient. That variance will now be narrowed.

- Prescription acne medication coverage will be excluded for adult TennCare patients.

- TennCare will cancel its contract with the American Academy of Pediatrics.

On another note, some of the proposed changes to Hospice care will not happen. One budget proposal included eliminating the emotional and spiritual counseling offered by Hospice. Those changes were rejected, so that counseling will remain intact.

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