SPECIAL CONTRIBUTION

Tenncare in the Emergency Department:

The First 18 Months

From the Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.

Received for publication November 3, 1995. Accepted Jor pub- lication November 14, 1995.

Copyright © by the American College of Emergency Physicians.

Keith Wrenn, MD Corey M Slovis, MD

See related editorial, p 234.

[Wrenn K, Slovis CM: TennCare in the emergency department: The first 18 months. Ann Emerg Med February 1996;27:231-233.]

BACKGROUND

On January 1, 1994, Medicaid in Tennessee was replaced by a new system of managed health care called TennCare. This new system had its genesis in dissatisfaction with the costs of Medicaid, which were seen as spiraling out of control. There was also concern that too many people who were Medicaid ineligible could not afford private insurance coverage. It was hoped that a state-supervised managed health care initiative would not only control costs but provide broader coverage.

A basic TennCare assumption was that managed care would decrease the number of inappropriate emergency department visits. Patients were expected to be more fre- quent users of primary care providers (PCPs). Under TennCare, patients were expected to seek prior approval for ED visits in all but the most urgent situations. For patients without prior PCP relationships, this was a for- eign notion.

The TennCare initiative was debated for a relatively short time and enacted within a few months. Under- standably, there was initial chaos as hospitals, patients, and TennCare plans scrambled to adjust to the effort to rapidly and completely convert the state's Medicaid popu- lation to managed care. Unfortunately, neither patients nor providers fully understood the system. Patients un- knowingly signed up with plans that uprooted them from institutions to which they had previously gone for all of their care. Furthermore, many of the patients enrolled in or eligible for TennCare had never had access to a PCR Many had relied on the ED as the de facto health care provider. Other patients had obtained their care episodi- cally through a variety of subspecialty clinics. Suddenly the subspecialists' patients were assigned new PCPs or told to find one.

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TENNCARE IN THE ED Wrenn & Slovis

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There was also confusion from the providers' perspec- tive. No definition of "emergency" was set forth. Emer- gency physicians were much more liberal in this definition than some of their primary care counterparts and much more conservative than others. Knowing that patients would be triaged away from the ED setting, the ED physi- cians at our institution worked with the general internists and pediatricians to forge a consensus view of triage grades so that appropriate and timely care could be deliv- ered. Triage guidelines were developed for the most com- mon clinical scenarios.

There was a great deal of initial concern about who would make these triage decisions. Furthermore, there was a startling difference in approach as to which patients should be triaged away from the ED and back to their PCPs. Internists generally believed that almost every com- plaint needed to be seen by a physician in the ED, whereas pediatricians felt much more comfortable delaying a visit until the next day in the office.

Compounding these problems was a paucity of estab- fished referral patterns to PCPs in a specialty- and subspe- cialty-oriented university environment. Timely referral to a PCP was not usually possible. There just weren't enough of them. In addition, patients who obviously needed sub- specialty care could not be directly referred for this care. This was at its worst when an injured patient required follow-up care by an orthopedist. Follow-up for such patients had to be preapproved by an often difficult-to- locate, anonymous PCP. Obstetric and gynecologic referral was easier to arrange because the established clinic system was amenable to referrals from the ED and because ob- stetrics and gynecology was considered a primary care specialty. An additional problem was that some special- ists were less amenable to referrals of patients for whom they believed they would not receive adequate compen- sation. As a result, referral from the ED became either a very time-consuming task, or the patient was told, "See your PCP."

EFFECTS OF TENNCARE

In a study conducted at our institution 3 months after TennCare implementation, it was found that we were triaging about 60 patients per month away from the ED, compared with essentially no triage away from our ED before TennCare. In one quarter of patients, follow-up care was not arranged. When follow up was arranged, a full third of the patients triaged from the ED had been noncompliant with prearranged follow-up. When sur- veyed later, patients who had been triaged away said

they believed their condition was no better or worse 79% of the time. Five percent of these patients were hospitalized shortly after being triaged away. Twenty- two percent of patients were dissatisfied with triage assessments. 1

In another study conducted at our institution 6 months after TennCare implementation, we found that 38% of enrolled patients didn't have a PCP or didn't know their PCP. 2 Of the patients who knew the name of their PCP, 58% had never visited the physician and 68% were not aware that they were to contact the PCP before visiting the ED. Of the patients who tried to contact their PCPs, 31% were unsuccessful. Overall, 28% of enrolled patients were globally dissatisfied with TennCare. However, larger num- bers of patients were dissatisfied with specific aspects of care: communication (48°/8) and follow-up arrangements (41%). 1,2 In a state-sponsored poll, fewer than half of TennCare patients said they believed their care was good as or better than that received under Medicaid. 3

Not all physicians in the state agreed to participate in TennCare. Not only did this result in some patients having to break off long-standing relationships with physicians--particularly private pediatricians--but it resulted in increased referrals to university hospitals for subspecialty care from surrounding areas. Despite near- universal insurance coverage, dumping began to rear its ugly head again.

As the program has evolved, hospitals have shifted alliances with various plans, and ED physicians and PCPs have been confused about who is eligible to receive care at a given institution.

This confusion has interrupted established referral patterns. It has also made transfer of patients from one institution to another, for economic reasons, both more common and more difficult. In particular, it has become harder to accept referrals to the ED for subspecialty care.

After the first year of TennCare there was a predicted deficit in the TennCare funds available from the state. The shortfall resulted from underestimation of costs, failure to collect copayments from enrolled patients who were not eligible for totally free coverage, and withhold- ing of funding from the federal government. Enrollment of uninsured people was temporarily closed in January 1995. Sliding-scale premiums are now being charged to patients with incomes above the Medicaid eligibility CUtOff, 3 Just a few days before residency match list sub- mission, the state announced its intention to withhold graduate medical educational (GME) funding in an attempt to accommodate this deficit. As a result, hospi- tal training programs were suddenly confronted with

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T E N N C A R E I N T H E ED Wrenn & Slovis

shortfalls of their own. Vanderbilt Medical Center lost more than $12 million of anticipated GME funds. The immediate response across the state was the elimination of residency positions and the threat of downsizing. Program directors began to scramble for alternative sources of funding, including the shifting of residents to other hospitals willing to fund positions and the elimi- nation of research years for residents. Expansion of almost any existing program became impossible.

Reimbursement of individual EDs has been less of an issue to date than expected. Although claims are denied after the fact as nonemergencies and communication breaks down between ED providers and PCPs, as well as between PCPs and the managed care plans, most claims are eventually paid. Although reimbursement rates are not at desirable levels, near-universal coverage makes up in number of claims paid for the shortfall in pay- ment amounts.

Early on, total ED volumes at our institution decreased by more than 25%. Pediatric visits to the ED decreased by almost 40%. Beginning about 6 months after Tenn- Care implementation, this trend reversed; and 9 months after implementation, volumes had returned to previous levels and were increasing at a rate similar to that seen before 1994.

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cation must be much more extensive and focused. Emer- gency physicians have a vital interest in being involved with such a planning process and should make them- selves visible and readily available.

REFERENCES 1. Belcher RS, McKinzie J, Wrenn K: Triage of patients oat of the emergency department: Compliance with follow-up and impact on patient satisfaction (abstract). Ann Emerg Med 1995;25:146.

2. Socha CM, Belcher RS, McKinzie J, et al: Patient understanding of access to emergency care under TennCare (abstractl. Acad Emerg Med 1995;2:437.

3. Mirvis DM, Chang CF, Hall C J, et al: TennCare: Health system reform fur Tennessee. JAMA 1995;274:1235-1241.

Reprint no. 47/I/70898 Address for reprints:

Keith Wrenn, MD

703 Oxford House

Vanderbilt University Medical Center Nashville, Tennessee 37232-4700

615-936-1157

Fax 615-936-1316

FUTURE OF TENNCARE

TennCare continues to evolve. The state has declared the program a success, and other states will undoubtedly use TennCare as a template for their health care initiatives. From the practitioner's point of view, the reviews are decid- edly mixed. The amount of money needed to successfully fund this program keeps growing. Patients now wait longer to be triaged in the ED, more staff is required to process them, referrals are more difficult, and ED-to-ED transfer is more common and much more time consuming. On the positive side, however, more patients are using PCPs for minor complaints, more patients are covered by some form of health insurance, and more physicians, nurses, and administrators are paying attention to the appro- priate use of hospital and ED resources. It is too early to tell how TennCare will ultimately affect medical education. GME funds will likely resume, perhaps at a somewhat reduced rate.

It is clear that when sweeping changes are made, con- siderably more planning must be done. As other states consider such a system, attention should be paid to the negative aspects of TennCare implementation, and more practicing physician input should be sought. Patient edu-

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