Tennessee's cap on prescription drugs was a bitter pill for many TennCare enrollees to swallow three years ago.
But the drug limits appear to have been the right medicine to help control one of the costliest parts of the state's health care program, TennCare officials say.
Last year, the $706 million bill for TennCare pharmaceuticals was less than a third of the $2.44 billion expense in 2005, according to Bureau of TennCare figures. Although much of those savings came from cuts in enrollment and increases in Medicare payments, drug costs for comparable TennCare recipients still were down nearly 40 percent in the past three years.
Clayton McWhorter, a trained pharmacist who once headed Hospital Corp. of America and recently led a major health care study in Tennessee, said cutting prescriptions helped save money and lives.
"We are overmedicating in too many instances," Mr. McWhorter said. "We've got some pretty good data to show that we've improved the quality of health care by reducing the number of prescriptions."
Despite the reduction in drug usage among TennCare recipients, the average Tennessean still used nearly 42 percent more prescriptions than the typical American last year, according to a new study of prescription drug usage. The newest Novartis Pharmacy Benefit Report said Tennessee trailed only West Virginia in per capita drug use during 2008.
Studies by BlueCross BlueShield of Tennessee also indicate East Tennessee continues to lead the state in the use of prescription drugs.
debate over limits
Critics of TennCare's drug limits still question the wisdom of setting numerical caps on monthly prescriptions.
"We had an unmanaged, uncontrolled and wasteful program because pharmacy benefits in TennCare were not being managed at all before," said Gordon Bonnyman, executive director of the Tennessee Justice Center.
"But the state then came in and used a meat cleaver to say you could only get five scripts a month, only two of which are name brand, whether you are an elderly person who needs eight or someone who doesn't need any," he said.
Mr. Bonnyman, who sued the state to try to block the monthly cap on prescription drugs, cited published reports in Rutledge and Bristol where physicians blamed the lack of TennCare-provided drugs for the deaths of their patients.
"State officials dismiss negative reports as merely anecdotal or reliant on self-reporting, but they have blocked the kind of quantitative evaluation that would be so valuable," he said.
Joel Standefer, owner of the Standefer Drug Center in Pikeville, Tenn., said the initial TennCare drug cuts were modified to allow persons to get more prescriptions for some chronic illnesses.
"But we still have patients who are doing without some medications that we feel would be beneficial," he said. "And unfortunately, I still don't think the program has curtailed some of the abuses from people who are intent on gaming the system."
A 2007 by Chattanooga's Community Research Council, now the Ochs Center for Metropolitan Studies, said in the first year after the 2005 limits on prescription drugs some TennCare enrollees began rationing their medications by taking every other dose or sharing medicines with friends.
"Others chose between medication and other necessities like rent, utilities, and food," the study reported. "Prescription limits have been particularly challenging for mental health patients."
caps and impacts
Tennessee's monthly limit of five prescriptions for most drugs is one of the lowest in the country, although South Carolina caps its Medicaid population to four prescriptions a month and Mississippi has a similar five-script limit, officials said.
Nicole Woods, the acting pharmacy director for TennCare, said the state provides an appeals process for individuals or physicians to get drugs when "medically necessary" and allows pharmacists to fill short-term prescriptions while appeals are being made.
"We have not heard any adverse impacts from the changes we adopted," she said. "I think we have appropriate safeguards in place to help protect those who may have a legitimate medical need," she said.
Ms. Woods concedes that the state has not conducted a major public health assessment of the sweeping changes that the governor imposed three years ago.
Terry Shea, director of pharmacy management for BlueCross BlueShield of Tennessee, also said no comprehensive assessment of TennCare's prescription limits has been done. But he said BlueCross has not detected any significant change in health patterns because of the cutbacks.
reasons for usage
Dr. Shea said Tennesseeans overall continue to use more drugs because the state tends to be older, more obese and sicker than the U.S. population as a whole.
"Using more prescriptions can be good or can be bad, depending upon how and why they are used," he said. "For people with chronic heart disease or diabetes, regular drug usage is usually beneficial in helping avoid other problems that result in much more expensive hospitalization."
Ken Johnson, a senior vice president for the Pharmaceutical Research and Manufacturers of America, said studies show that since 1980 the life expectancy for cancer patients has increased by three years, primarily due to new drug treatments. The American Heart Association said death rates for cardiovascular diseases fell 26.4 percent between 1999 and 2005 due to drugs used to control blood pressure and cholesterol.
"Medications account for only one-tenth of the nation's spending on health care and are cost-effective because they help to drive down the cost of surgery and hospitalization," Mr. Johnson said.
But Mr. McWhorter, a lifetime health care executive and analyst, said too many times patients demand prescriptions they don't need and physicians are too willing to fill them.
He said his late brother Fred, a former owner of Ridgedale Pharmacy in Chattanooga, repeatedly told him that people taking more than five prescriptions a month are poisoning their bodies.
"Inappropriate use of prescription drugs is a major problem in our health system," he said.