"Bold" Solutions
A health care executive and Bredesen ally comes to the governor's defense
by Stryker Warren Jr.
The Nashville Scene's Jan. 13 editorial portrayal of Gov. Bredesen's handling of the TennCare overhaul seems deliberately inaccurate. The Scene postulates, "Bredesen's failure to preserve TennCare in something close to its current form is probably the disappointment of his career." Tragic you conclude this. Phil's objective was never to further saddle taxpayers, patients and health care providers with "something close to its current form." Inheriting a fundamentally flawed program that everyone has an opinion about, Gov. Bredesen actually spent his time thinking about how to preserve fiscal solvency, provide care superior to what has existed to this point, and bring a level of discipline to the overall program that it has lacked from its inception. All this with great transparency and with broad-based support that included TennCare enrollees.
Few health care executives have the command Phil Bredesen has of medical loss ratios, actuarial science, benefit design, demand management, disease state management and outcomes measurement. And, that's both public and private sector. In late 2002 and the months leading up to Phil's inauguration as governor of Tennessee, there were but two items consuming him, both inextricably linked: the budget crisis and TennCare.
Phil Bredesen has never been one to confuse activity with results. This predates his mayoral tenure and his current responsibilities as governor. This confounds many who have come to believe that elected politicians take positions intentionally designed from which to barter, negotiate and arm twist—while always expecting something in return. TennCare was never a board piece in a larger game, nor were his positions contrived so as to give and take with the advocacy groups to "get what he wanted."
The Nashville Scene portrays this governor as an introvert who prefers "neat answers to complex problems." Gov. Bredesen has always demonstrated meticulous preparation and thoughtful presentation of his ideas; he has a history of seeking out others in formulating proposals; he is tireless in his efforts to educate and build consensus; and he very much internalizes those issues dealing with lives, livelihoods, safety and the next generation. Make no mistake, Gov. Bredesen had a plan intending to preserve full enrollment, but with reasonable limits on benefits and spending; the plan resulted from a broad base of input—a plan with broad support among legislators, health care providers and TennCare enrollees. And the plan was broadly shared through dozens of meetings attempting to avert disenrollment. The advocates blocked the plan. This gives "entitlement" a bad name.
The advocates' criticism is that the governor should have employed retrospective drug utilization review—something that never would have been necessary were it not for a wide-open drug formulary, the legacy of the Grier Consent Decree, which effectively took proven, conventional wisdom about rational prescribing and emasculated it. Further criticism suggests that the governor has failed for not seeking a federal remedy—in the form of a bailout of sorts as Louisiana and Alabama have done—and for not introducing new sources of revenue (a.k.a. "taxes"; is there anything else?). Financial bailouts. Silly? No, irresponsible and indicative of how shortsighted the critics are. This is a zero-sum game for any taxpayer: tell me about how you intend to manage fixed dollars for one of the richest health care programs in the country before you talk to me about turning to Washington or introducing new taxes. Phil, too proud to reach out for help? Hardly. Simply old school: get your spending in order before looking elsewhere for help. Refreshing to me, despite the Scene's inability to wrap its mind around such a wildly novel approach for a politician.
Phil Bredesen is an extraordinarily accomplished business executive who happens to have a storied health care service background. "Neat answers to complex problems?" Sure. The governor has sought and introduced stronger management from the top down in TennCare; he is reinstituting a meaningful managed care model; he is introducing innovative disease management programs; and he is leveraging information technology to ensure a higher quality of care. Unfortunately, that leaves little time for the most vexing of impediments: legal hurdles that require the courts' intervention. TennCare rehabilitation is significantly affected by legal limitations that constrain the governor's ability to institute change.
I make but one suggestion: if Mr. Bonnyman can manage the TennCare program without additional taxes and a federal bailout, I know the governor is always open to recruiting talent. Let's remember, though, we begin at least $650 million in the hole. Do I think Mr. Bonnyman is well intentioned? Yes. Most certainly "a noble legal aid advocate for the poor." But naive as to the fiscal and administrative aspects of TennCare. He proposes very old solutions: taxes, a federal bailout or loan. Phil Bredesen has proposed a plan far superior to what has existed in the recent past if one simply examines the overall cost and rates of inflation, but the Scene characterizes them as "Cold Solutions."
In Phil Bredesen we have a governor who has exhibited the courage to address the real issues in something he inherited: a horribly flawed program that others were unwilling or unable to address. "Cold Solutions?" No, "Bold Solutions." If the Scene is honest, I trust it will agree that this governor has difficult decisions to make about numerous good things, but with a limited budget. As taxpayers, we should be grateful we have the leadership necessary to make unpopular decisions that are in the best interests of the long-term viability of the state as a whole.
"Not marveling at all" and a federal bailout are the Scene's final opinions? TennCare was ill-conceived from the start, grew into a fiscal monster, and has now received its long overdue fix—after all options were contemplated. But Phil Bredesen has never permitted his "considerably comfortable existence" to cloud his thinking or cause him to seek short cuts. I presume the Scene and critics have not lost their respect for the man; simply the "marvel" part.
So, back to the final decision on TennCare. Unpopular? Yes. Unfortunate? Yes. Avoidable? No—given the circumstances.
Stryker Warren Jr. is president and CEO of CIMplify, a Franklin-based computer software company providing services to help physicians manage their businesses.
