BY CINDY SANDERS

The Tennessee Medical Association (TMA), Tennessee Hospital Association (THA) and Tennessee Nurses Association (TNA) have set their collective sights on the challenges and goals of the coming year.

Working independently on issues specific to their membership and collaboratively on agenda items that impact the broader healthcare industry, the state's provider organizations hope to be an instrument for change as they work with key government staff and legislative leadership on a state and federal basis.

As Gary Zelizer, director of government affairs for the TMA, pointed out, "First and foremost, come the second Tuesday in January, there are going to be a lot of new faces … new leaders … in the General Assembly."

Although some players may be new, many of the issues remain stubbornly unresolved.

"2007 is a continuation of 2006 in that medical liability reform is still our number one priority and will be until reform is enacted by the General Assembly," Zelizer promised.

Last February, the AMA deemed Tennessee the 21st crisis state in the nation in terms of medical liability. Zelizer said the current environment is now affecting access to care as physicians cut back their practice, leave the state or retire early. He added that medical residents are also opting to leave Tennessee.

"The State Health Department has reported a 40 percent decrease in full-time equivalent OB providers in the 91 non-metropolitan counties. Certainly one of the reasons for that is the double digit increases in malpractice premiums over the last eight-to-10 years," he said.

The TMA, along with more than 50 other coalition partners, is asking the State Legislature to enact MICRA-type legislation that includes caps on non-economic damages and requires expert witness certification to avoid frivolous lawsuits.

"We'd also like to see a sliding scale on attorney's fees so the larger the award, the smaller the percentage the trial attorney recovers," he continued.

Two other key areas of interest in the coming year are delays in the credentialing process and the growth of silent PPOs.

Whether willful or not, Zelizer said delays in getting physicians credentialed to participate in a plan are all too frequent.

"We believe once a company receives a completed credentialing form, the plan ought to complete the process and make a determination as to whether or not they want the physician on the plan in a relatively short time," he stated. "We are working with representatives of the insurance industry to try to resolve this so we can go forward and so that patients can have improved access to care."

In the complicated arena of the silent PPO network–also referred to as a rental network PPO or the unregulated secondary discount market–physicians often find themselves tied to discounted rates without benefit of contractual agreement.

Self-insured companies "rent" a provider network from a carrier. Zelizer said repricers, who have access to every discount a physician has agreed to across all the plans, find the lowest rates and apply those. On the physician end, a bill is submitted and reimbursement comes back at a lower-than-expected rate with no explanation.

"The one theme through this whole process is the lack of transparency," Zelizer said, adding his organization plans to bring legislation in 2007 to address this issue, which is particularly prevalent in the worker's compensation arena.

"The access to physicians in worker's comp cases may well be jeopardized in the future because of this practice," he warned.

For the Tennessee Hospital Association, two key advocacy issues that have previously been pegged as top priorities remain in the forefront in 2007.

Craig Becker, president of the THA, said, "We're still going to be fighting for the DSH payment. Every state in the union has these but Tennessee."

The disproportionate share payment for hospitals helps offset some of the costs of charity care. With changes to TennCare, the state now operates a program that more closely resembles a traditional Medicaid system. As a result of enrollment cuts, charity care numbers are on the rise at hospitals across the state.

The Finance Department at Vanderbilt University Medical Center in Nashville recently reported an 80 percent increase in total uncompensated care–charity care, medically indigent care and bad debt–for fiscal year 2006 as compared to the previous fiscal year.

Becker estimates DSH payments would mean an additional $450 million a year to Tennessee hospitals.

"We have to get federal approval first. Then we have to get the state to fund their part of it," he said, adding that so far state legislators and officials have been receptive.

The key will be getting the necessary federal dollars. The estimated federal price tag is $900 million over a five-year period.

"If we don't get it during the lame duck session, we'll push it again next year," Becker vowed. He added that hospitals would be forced to raise commercial rates if they don't start receiving DSH payments. "It has to be covered somehow."

Also of great interest to the THA is the continuation of the state's Certificate of Need program.

"There may be a push to get rid of that, and I know our hospitals are going to continue to be supportive of the Certificate of Need process," he said. "It keeps some sanity in our medical care system."

Becker noted hospitals have already seen increased competition within the Tennessee healthcare system as physicians have taken procedures offsite.

"Obviously, they're taking the commercial business … not TennCare or charity care," he said. Becker added hospitals aren't afraid of competition, but the playing field becomes notably less crowded when it comes time to "compete" for uncompensated care.

This past summer, the Tennessee Nurses Association welcomed Sharon A. Adkins, MSN, RN, as the organization's new executive director. Improvement in safety initiatives and workforce quality issues top Adkins' priority list in 2007.

"The TNA will be working with the Tennessee Hospital Association, and the Tennessee Organization of Nurse Executives, as well as the THCA (Tennessee Health Care Association), to look collaboratively at patient safety issues and environmental issues … nurse fatigue, overtime, et cetera," she said.

She added that the organization was also "most interested in seeing what kind of legislative challenges present themselves" in the coming year.

Whether proactively fighting for new initiatives or reacting to proposed legislation that would impact their membership, the state's major healthcare organizations await the promise and challenge of 2007.




December 2006