Drug Abuse 

Why the governor can't blame Gordon Bonnyman for the state's drug costs

Why the governor can't blame Gordon Bonnyman for the state's drug costs

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.

Sullivan told state legislators Monday that the program could save as much as $500 million annually with better management. His ideas hardly qualified as rocket science. Restrict brand-name prescriptions, encourage generic drug use and implement co-pays for everyone. None of those measures would violate the consent decrees, he said. And there would be no need to eliminate health coverage for anyone.

But the Bredesen administration said this won't stop the bleeding fast enough.

"A lot of these things fall under the category of 'these are good things to do down the road,' " TennCare spokesman Michael Drescher told The Tennessean.

Of course, Bredesen has been governor for more than two years now. During that time, he has implemented needed reforms that have saved the state millions of dollars. But he has also oversimplified some of the issues facing the program.

For the Bredesen administration, the Grier consent decree is the BTK of the TennCare program: an all-encompassing, diabolical force that silently wreaks havoc for the state's health care plan. But Grier's effects are being overstated. The TennCare Bureau has tracked 50,000 additional prescriptions in any given month that were filled because of the legal requirements of Grier, a staggering number, to be sure. But Bonnyman says that many of those prescriptions would have been filled anyway under federal law. And whatever additional expenses the consent decree might be adding to the system, the TennCare Bureau could mitigate through better management. To its credit, the state is already working with doctors and pharmacists to prescribe more generic drugs, instituting computer checks that monitor abuse of prescriptions and looking into cheaper options to expensive behavioral health drugs. Bonnyman can't prevent them from implementing any of those measures; in fact, in some areas, he's aided their efforts.

Bredesen and his staff, though, continue to insist that Grier prevents the state from steering TennCare enrollees to generic drugs. "Our attorneys feel that if we put in place a serious formulary, we would be acting contrary to a consent decree which has the force of federal law and we can not responsibly do that without changes in those consent decrees," the governor told PBS's NewsHour with Jim Lehrer.

But just like his anecdote about the two expensive drugs, the governor could be accused of being disingenuous about a complex issue. Even under Grier, the state has been able to set up a formulary. And no one in the governor's administration has been able to argue convincingly why Grier prevents the state from expanding it.

Marilyn Elam, a TennCare spokesperson, concedes that Grier "does not explicitly" say the state can't have a new preferred drug list. But like everything, the devil is in the details. Thanks to Grier, if a doctor prescribes an expensive, brand name drug to a TennCare enrollee—even when the cheaper one is available—TennCare can't step in. Here's what often happens: doctors work with many different patients under many different types of health plans. When it comes time to write the prescription, not every doctor will consult TennCare's list of preferred drugs. Some don't have the time or inclination; others simply write prescriptions out of habit. If an enrollee takes a prescription for a more expensive, non-preferred drug, the pharmacist is supposed to call the doctor and ask if the prescription can be changed to a drug on the PDL.

In most private plans, doctors and patients aren't permitted to use a trademark drug if a generic equivalent on the PDL is available—or else the patient has a higher co-pay. But in TennCare, if the doctor and the patient want a drug that's not on the PDL, or the pharmacist is simply unable to contact the physician when the order is brought in, the enrollee is entitled to a three-day supply of the non-PDL drug, no matter the cost. This happens as many as 40,000 times a month, according to the TennCare Bureau. Bonnyman says this would still occur under federal Medicaid law; the TennCare Bureau says that Grier gives TennCare enrollees more rights than they would have in any other state. In any case, if after three days the doctor still hasn't changed the prescription to a preferred drug, the enrollee can return to the pharmacy and receive the remainder of the order. This happens as many as 11,000 times a month and even Bonnyman concedes that, in this latter case at least, Grier gives enrollees more rights than they would have in any other Medicaid program.

"Grier takes away our ability to say no," says Dr. Long, TennCare's chief medical officer. "And if you don't have that ability, you're going to see abuses in the system."

But if Grier does impose additional costs on the TennCare pharmacy program in these instances, the state can—and, in fact, already is—mitigating those costs. Doctors have more control over drug expenses than patients do; if they prescribe drugs on the PDL, a patient has almost no chance of filing a successful appeal. When the PDL was first introduced two years ago, doctors prescribed from it about 90 percent of the time. That's an excellent rate, according to various health care experts, especially when you consider that at least 5 percent of the time a generic drug won't be suitable. In addition, the state has just implemented an incentive program for pharmacists that essentially encouraging them to work with doctors to make sure they're prescribing from the PDL. But why is this just happening now?

"In my opinion, if you design the program in such a way so that you have therapeutically sound options for whatever a doctor might want to prescribe and well thought out treatment guidelines, and doctors follow these guidelines, then you don't have issues with Grier," Sullivan says.

So the trick now is expanding that PDL and convincing doctors to continue to prescribe from it. That's where the state can begin to contain the costs of its pharmacy program. Like a lot of things in health care, that's easier said than done. Physicians don't want to hear from a TennCare bureaucrat that they're prescribing too many expensive brand-name drugs. And TennCare can't exactly punish physicians for ignoring the PDL by kicking them out of the network, since the program already lacks enough providers. But Bonnyman says that in other state Medicaid programs, physicians—not office workers—are enlisted to review the prescribing patterns of the program's doctors, which is more effective. In any case, an enrollee can't really begin to take advantage of Grier if the physician prescribes from the formulary at the outset.

"You can want a brand name drug all you want," says Bonnyman. "But you ain't going to get it unless a TennCare doctor writes a prescription and a pharmacist doesn't check back."

Already, the state and the TennCare Bureau have begun looking at expanding the PDL, so it's bizarre for Bredesen to say that Grier prevents him from doing what he's already doing. In fact, Bredesen has earned some bragging rights. Since he took office, TennCare has switched from having a different PDL for nearly every managed care organization—as many as 12 altogether—to having just one. This has made life easier for doctors, who have justifiably complained for years that TennCare submerges them in time-consuming paperwork. In addition, by having just one benefits manager administer the pharmacy program, Tennessee has drastically increased its purchasing power, enabling the state to achieve more than $600,000 in rebates last year. Earlier this year, Tennessee also announced plans that it would join eight states to buy drugs in bulk, which will bring even greater savings.

So there are pain-free measures the Bredesen administration has taken to contain the exploding costs of the pharmacy program, and there are more yet that it could employ. Then there are the more drastic measures the governor has announced, including his plans to limit adult prescriptions to four a month. Many states cap prescriptions, but many also have soft limits that allow for extenuating circumstances. Bredesen's plan doesn't, even if a doctor says that a patient needs more than the predetermined limit. This will undoubtedly save the program hundreds of millions of dollars on the backs of TennCare's sickest enrollees, who will be forced to choose which drugs they'll have to skip because of an artificial limit drawn up in a faraway state building.

It's unclear how much, if anything, Bonnyman can do to stop the measures. But what is undeniable is that Bredesen's proposal completely alters the program Bonnyman recently described as "the most exciting thing in my life" when it started in 1994. "I and other people, who had been either literally or figuratively sitting at the bedside of people who were dying without health insurance, knew immediately that this was not just about saving the budget, this was about saving lives."

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