TennCare Pausing Episodes of Care Rollout

Memphis Medical Society along with Tennessee Medical Association have been asking the state for a pause-and-fix since fall 2017. MMS and TMA last year increased their efforts to persuade TennCare to improve the transparency, accuracy and fairness of the program. Tennessee physicians are celebrating an announcement from TennCare this week that the state will temporarily stop expanding its episodes of care payment model. TennCare reports that it will not design future episodes to concentrate on improving and maintaining episodes already in place.

“After months of discussions and years of meeting about episodes, I am ecstatic to get this news that TennCare has agreed to pause expansion and work on what is in place to hopefully avoid more problems and frustrations in the future,” said Matthew L. Mancini, MD, a Knoxville surgeon and President of the Tennessee Medical Association.

In yesterday’s announcement, TennCare says it will continue to work on improving provider engagement and analysis of episode performance data. There will not be any Technical Advisory Groups (TAGs) held this fall and the following episodes will be paused:

  • The 20 episodes in waves 10 and 11 that have not been designed
  • The five episodes with incomplete design due to data issues – Neonatal 31 weeks or less, Neonatal 32 to 36 weeks, Neonatal 36 weeks or more, Mastectomy, and Breast Cancer Medical Oncology
  • Anxiety and Non-Emergent Depression episodes have been removed from the episodes program

“This great news for Tennessee’s healthcare community, and ultimately for our Medicaid program. We appreciate the TennCare Bureau and state government for taking this necessary step, and we are especially grateful to Sen. Rusty Crowe , Sen. Bo Watson and Rep. Cameron Sexton for their audience to listen to the plight of physicians and to initiate legislative action on this complicated issue,” Dr. Mancini said.

Initially, TMA worked with the state’s pilot project to support an alternative payment mechanism that would help control TennCare costs and promote quality care. The association helped promote participation in program design work groups and TAGs among the medical community and helped physicians better understand and navigate the transition from fee-for-service to value-based reimbursement.

The administration made some changes and improvements over the course of its implementation, but four years after the first wave of episodes there are still serious flaws in the program design and questions about its effectiveness. Physicians, hospitals and other healthcare providers became increasingly frustrated as TennCare continued to roll out episodes without implementing important recommendations from physicians who voluntarily served in TAGs.

To date TennCare has rolled out 48 episodes of care that are active or in progress but has not addressed TMA’s longstanding concerns about data collection, data reporting and accuracy, and overall transparency of the episodes of care program.

TMA will continue representing physicians’ interests with state officials as the TennCare Bureau works to improve the existing episodes. TMA also plans to engage gubernatorial candidates on the issue prior to the November elections.

Physicians are encouraged to send comments about their experiences with episodes of care to communications@tnmed.org.