Drug Abuse

In February 2004, in a speech before the General Assembly, Bredesen launched his formal bid to reform the state's health care program for the poor and uninsured. His message was simple. The state can't afford to fund the program in its current form and must reduce benefits for just about all of the program's 1.2 million enrollees. Just how expensive had the program become? Well, Bredesen took just one slice—the program's exploding pharmacy costs—and placed it in a context that was downright alarming.

"Just two drugs in TennCare—Zyprexa and Zocor—cost our state more than we appropriate to run the University of Tennessee medical school," the governor said. "That's a firebell in the night. Something is wrong."

Later in the speech, the governor said both of those drugs have much cheaper alternatives that are just as effective. To Bredesen, that added "insult to injury."

A combination of drugs equally effective as Zyprexa costs only 33 cents per dose. Compare that to the trademark drug, which costs $5.47 a pill. Patients take up to four pills daily for life, and state and federal tax dollars pay for every single one.

But Bredesen's anecdote neglected a salient detail. Zyprexa is for people who suffer from schizophrenia and manic depression. Tennessee, like many states, has been reluctant to put cheaper generic mental health drugs on its preferred drug list, because the margin for error is high. This has nothing to do with Gordon Bonnyman, the public interest lawyer the Bredesen administration has repeatedly cited for being an obstacle to reforming the program.

And with Zyprexa, there is no generic equivalent, only an alternative combination of drugs. A recent study showed that this combination is just as effective. But when a doctor has kept a patient's depression or schizophrenia in check for years, he or she is going to be understandably reluctant to prescribe a different course of treatment. Currently, the TennCare Bureau is looking at including behavioral health drugs on its preferred drug list (or PDL), although nobody expects it to be easy.

"It will be a controversial process," says Dr. Wendy Long, chief medical officer for TennCare. "It's not nearly as cut-and-dried as putting in a grade A generic equivalent. The behavioral health drugs are just complex, and some drugs are more efficient than others."

As for Zocor (the other drug the governor mentioned), a cheaper, alternative pill is already on TennCare's drug list. Patients will use it if doctors prescribe it. But a more expensive alternative to Zocor is also on the PDL, and other states refrain from recommending it. Why? There's probably no easy answer. Figuring out what drugs are on your preferred drug lists, and which expensive ones fall into the non-preferred category, is a complex—although absolutely vital—process that blends the most difficult aspects of medicine, economics and public policy. It takes constant management. "It's hard work," as SNL's caricature of George W. Bush might say. But who said being governor was easy?

For the last year, Gov. Phil Bredesen has loudly and repeatedly blamed the Tennessee Justice Center and its soft-spoken executive director, Gordon Bonnyman, for preventing him from reforming TennCare, particularly its financially volatile pharmacy program. Thanks to Bonnyman, portrayed by the administration as just another out-of-touch attorney, the state is blocked by federal court orders—or consent decrees—from using cheaper, generic drugs and monitoring prescription drug abuse. Those orders, particularly the infamous Grier consent decree, they claim, also inhibit the state from using a preferred drug list that can keep costs under control without compromising patient care. And if you can't control TennCare's drug costs, which totaled more than $1.5 billion in state and federal spending last year and which have risen about 20 percent annually, you don't have a prayer of keeping much more than a sliver of the program intact.

But Bredesen's portrayal of himself and the state as helpless as the costs of prescription drugs exceed other vital expenditures is flat-out wrong. In happier times, back in 2003, Bredesen and Bonnyman together developed a preferred drug list that saved the state as much as $150 million annually. And there's nothing to prevent Bredesen from adding more generic drugs to the PDL. Yet, it's been nearly two years since the state updated its preferred drug list. In that area, the Bredesen administration is on its own, and it can't blame a public interest lawyer for neglecting the issue. "As long as you're managing the program, I would agree with Gordon," says Leo Sullivan, TennCare's ex-pharmacy chief. "Grier is not a problem. But you can't sit back for the last two years and not add any drugs to the PDL."

When the governor and his aides cite Bonnyman for their inability to control drug costs, they are at best overstating their case. At worst, they are creating the dragon in order to slay the dragon. Bonnyman could give up his law practice, ask a federal court to incinerate the consent decrees and move to an undisclosed location, and Bredesen would still confront the same opportunities and obstacles he does now. No one is saying Bonnyman has made the state's life easy—after all, that's not the charge of a legal advocate—but the consent decrees have far less to do with TennCare's drug woes than the governor wants everyone to believe.