July 8, 2005

Evidence-based care key to TennCare reform

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Harry Jacobson, M.D.

Evidence-based care key to TennCare reform

Vice Chancellor for Health Affairs Harry R. Jacobson, M.D., testified June 29 in U.S. District Court in Nashville as an expert witness on behalf of Gov. Phil Bredesen, whose administration is seeking relief from settlements reached previously between the state and enrollees in the TennCare program.

At issue in Jacobson's testimony was the degree to which the state should be allowed to apply evidence-based medicine guidelines to TennCare.

TennCare funds health care for 1.3 million residents, including the poor, the disabled, and those turned down by commercial insurers because of a chronic disease or condition. Facing budget pressures, the state recently won approval in the U.S. Sixth Circuit Court of Appeals to cut some 323,000 enrollees from the program. Bredesen has more recently agreed not to cut certain chronically ill patients from the rolls, provided in part that the state is given legal rein to reduce costs by curbing overuse of certain treatments by some patients and their doctors.

Where medical testing and treatment of TennCare patients is concerned, Jacobson told the court that current law inhibits the state from placing effective restrictions on unwanted variability of medical practice. In his prepared testimony and under questioning, he stressed the effects of evidence-based medicine on health care quality.

“The potential to implement evidence-based guidelines for the TennCare population will have a profound impact on the quality of care afforded its enrollees, and ultimately to every citizen of the state,” Jacobson said. “In my judgment, it is the key to reforming our current health care system in general, and to fixing TennCare in particular.”

Jacobson cited a Dartmouth study that tied more intensive utilization of medical resources to inferior medical outcomes, and a study conducted in Chicago that found that up to 26 percent of health care costs could be eliminated if evidence-based guidelines were followed. As examples of variability in medical practice, he questioned why clinicians in Nashville are “65 percent less likely to use coronary angiography than clinicians in Memphis, but are 41 percent more likely to treat bacterial pneumonia compared to Memphis clinicians.

“Medical necessity should be based on evidence-based medicine,” he said. “It will help ensure that the right thing and only the right thing will be done at the right time. It will reject unnecessary tests, procedures and prescriptions. It will protect patients and save costs. To allow any provider to practice in any other manner is fiscally irresponsible and less safe for patients.”

Jacobson said doctors and patients should have the power to make evidence-based appeals when guidelines disallow a chosen test or treatment. In the conclusion of his prepared testimony, he outlined his recommendations for starting an evidence-based system.

“Adopting evidence-based medical necessity as the standard for coverage, putting limits on tests, drugs and visits for which evidence is not strong, adjusting the appeals process for providers and the state to include evidence as a consideration are the three starting points I encourage.”

Hearings in the case before Senior U.S. District Judge John T. Nixon are scheduled to conclude in mid July.