In the not-so-distant past, the leadership of Tennessee's Medicaid demonstration program spent a significant portion of the day just trying to get up to speed. With a sometimes seemingly insurmountable learning curve and an average tenure of less than 15 months, burnout was common among the executive team.

 

Today, however, that has changed. Darin Gordon has been director of the TennCare Bureau since 2006 and has been involved with the program for nearly a decade. Prior to taking the helm, his posts included serving as chief financial officer and director of managed care programs, giving him a unique understanding of the complex program and its history. Gordon was heavily involved in assembling the current program leadership even prior to being named director.

 

"We've built a really top notch group," he said, adding the executive team now has an average tenure of more than six years, which provides a deeper understanding of the myriad rules and regulations impacting care delivery, as well as a sense of ownership in the program.

 

Having that comfort level and knowledge base has allowed the executive team to expand beyond daily operations to strategically think about the future of the program, which currently serves 1.2 million enrollees. Gordon said that in moving ahead, it was incumbent upon the leadership to find both clinically effective and cost efficient means to provide quality care in a sustainable manner.

 

Of the new services coming online, Gordon said, "The largest by far is the integration of long-term care services into the managed care program."

 

Part of the governor's behest through the "Long-Term Care Community Choices Act of 2008," integrating nursing services and home- and community-based services under the managed care organization's umbrella is intended to give individuals more choices while simultaneously making it easier to navigate the system.

 

It's a lesson learned through behavioral health. "We just reintegrated physical and behavioral health services under one MCO over the last two years," said Gordon. He added that when the services were separate, disagreements over coverage responsibility between the managed care organization and behavioral health organization... particularly for inpatient stays... were not uncommon. By bringing both back under the same umbrella, Gordon said there is "more ownership, less fragmentation, better integration. We just extended that logic to long-term care."

 

Previously, MCOs have had little input in how continued care looked for patients once discharged from the hospital. Gordon noted the strong relationship between hospital discharge planners and skilled nursing facilities has resulted in nursing homes becoming a 'go to' step down solution.

 

"We are such a highly dependent state on nursing home services," he said. "Part of that was because of how the system was set up. We believe we'll see a dramatic shift in the amount of home and community-based services to our enrollees. When it is cost effective, it's our intent to see those services provided in home... and typically, that is the wish of enrollees."

 

Gordon noted the only holdup is waiting for CMS waiver approval. "It will take about six months after that approval comes to go live," he continued, noting that implementation would happen in phases with Middle Tennessee being integrated first, followed by East Tennessee and then West Tennessee.

 

Long-term care is only one area where TennCare hopes to effectively join efforts. "That's still an area that is evolving," Gordon said. "We want to explore other integration opportunities particularly when it comes to Special Needs Plans (SNPs) in hopes that by doing so we can improve care coordination and quality reporting and monitoring for those individuals who are dual eligible."

 

Gordon is hopeful that electronic health records could have a positive impact on this issue, as well as on other quality and safety initiatives. The state has partnered with Shared Health in one of the largest public/private medical data sharing initiatives in the nation. Through the statewide health information exchange, Tennessee's system is moving from being simply a claims repository to one that provides clinical prompts.

 

Shared Health's Web-based technology provides physicians and hospitals with the necessary tools and platforms for e-Prescribing, population management analytics, clinical decision support, disease management registries, case management features, immunization records and EPSDT (Early Periodic Screening, Diagnosis, and Treatment) registries.

 

"It's an evolutionary process," Gordon explained, adding the capabilities are continuously being tweaked as users provide feedback. "Our main focus right now," he continued, "is adoption... trying to get providers to utilize the system that is available to them."

 

Gordon added that he thinks there has been a temporary holding pattern for many providers as they await definitions critical to accessing funding through the federal HITECH program. "A lot of folks are taking a 'wait and see' attitude. What we've been told is that we should get a lot of that information by year's end."

 

While most of the focus is on the future at the TennCare Bureau, the executive team must also continue to deal with the past. Class action suits and judgments from the last several decades continue to shade how TennCare conducts operations.

 

One recent issue that has received a great deal of media attention is the Daniels Re-verification project. At the beginning of this year, TennCare received approval from the federal courts to begin re-verifying the eligibility of approximately 154,000 members in the Daniels class.

 

More than two decades ago... predating the launch of TennCare... a class action suit was successfully adjudicated preventing the state from verifying eligibility of those who once received Supplemental Security Income (SSI) but no longer do. The court injunction didn't simply pertain to the initial group of plaintiffs but has extended to those who have since received SSI benefits and then lost them so that the original group has swelled to its current numbers.

 

"In order for you to have lost them (SSI benefits), you either had too much money to continue to qualify or were no longer disabled," explained Gordon.

 

The January ruling allows TennCare to verify eligibility of this group of enrollees, just as they do with the other 1.1 million on the rolls. Federal statute actually requires Medicaid agencies to re-determine eligibility at least once a year. The process, which began in May, is expected to wrap up later this year. "Catching up will be finished by this fall, then we'll be on a more regular, ongoing, routine process in evaluating individuals who have lost SSI much like is done for the rest of the population," Gordon said.

 

Through Ex parte review, TennCare officials have determined that approximately 106,000... or nearly two-thirds... qualify for a comprehensive government health program whether through continuation of TennCare, enrollment in Medicare, or dual eligibility. A mailing requesting additional information should clear up any remaining questions about eligibility.

 

"We know a lot about these people," noted Gordon. "We've been paying claims for a long time, but two critical factors for eligibility that we don't know is a change of family status or if they had a change in family income. That's why we give them the opportunity to provide us updated information."

 

He concluded, "The goal here is to ensure those people who still qualify remain on the program... it's our responsibility. Our responsibility is also to ensure those who don't (qualify) do not remain in the program. Over 20 years, circumstances change."