University of Tennessee, Knoxville TRACE: Tennessee Research and Creative Exchange Doctoral Dissertations Graduate School 5-2006 A Critical Case Study of Program Fidelity in TennCare Carole Lynn Myers University of Tennessee, Knoxville Follow this and additional works at: https://trace.tennessee.edu/utk_graddiss Part of the Nursing Commons Recommended Citation Myers, Carole Lynn, "A Critical Case Study of Program Fidelity in TennCare. " PhD diss., University of Tennessee, 2006. https://trace.tennessee.edu/utk_graddiss/4055 This Dissertation is brought to you for free and open access by the Graduate School at TRACE: Tennessee Research and Creative Exchange. It has been accepted for inclusion in Doctoral Dissertations by an authorized administrator of TRACE: Tennessee Research and Creative Exchange. For more information, please contact [email protected]. To the Graduate Council: I am submitting herewith a dissertation written by Carole Lynn Myers entitled "A Critical Case Study of Program Fidelity in TennCare." I have examined the final electronic copy of this dissertation for form and content and recommend that it be accepted in partial fulfillment of the requirements for the degree of Doctor of Philosophy, with a major in Nursing. Sandra P. Thomas, Major Professor We have read this dissertation and recommend its acceptance: Marian Roman, Joanne Hall, Dulcie Peccolo, Craig Ann Heflinger Accepted for the Council: Carolyn R. Hodges Vice Provost and Dean of the Graduate School (Original signatures are on file with official studentecor r ds.) To the Graduate Council: - I am submitting herewith a dissertation written by Carole Lynn Myers entitled "A Critical Case Study of Program Fidelity in TennCare". I have examined the final paper copy of this dissertation for form and content and recommend that it be accepted in partial fulfillment of the requirements for the degree of Doctor o� Philosophy, with a major in Nursing. Sandra P. Thomas, Major Professor We have read this dissertation and recommend its acceptance: Acceptance for the Council: ��Vice Cha:� n of Graduate Studies A CRITICAL CASE STUDY OF PROGRAM FIDELITY IN TENNCARE A Dissertation Presented for the Doctor of Philosophy Degree The University of Tennessee, Knoxville Carole Lynn Myers May 2006 Copyright© 2006 by Carole Lynn Myers All rights reserved. ii ACKNOWLEDGEMENTS I am immensely grateful for how selflessly each of the people I interviewed shared their time and perspectives with me. Although respondents shared a plurality of perspectives about what is "right" and what is "wrong" with TennCare and TennCare Partners, and what the programs intended to accomplish and what was actually accomplished, I was profoundly impressed with the singular purpose and dedication of each interviewee to the idea of access to high quality health care for all citizens of Tennessee. The fact that this goal has not yet been accomplished is not a reflection of their commitment, but rather it is testimony to the complexity of the problem of health care delivery and the need for a new paradigm that must be developed through broad­ based dialogue of all stakeholders beginning at the national level and reaching deep into each state. I am indebted to the Gamma Chi Chapter of Sigma Theta Tau for their funding of my research and the consultation and encouragement I received from members, most notably Ors. Mary Gunther and Linda Mefford. A key to success in life is to surround yourself with good people. Any success I have achieved in the conduct of this study is a reflection of my visionary, pragmatic and encouraging Dissertation Committee Chairman, Dr. Sandra Thomas; my close and essential confidant, Dr. Marian Roman; the inspiration and challenge Dr. Joanne Hall instills in me like few others; the willingness of Dr. Craig Ann Heflinger to allow me to enter her world on the promise that I would share her dedication to policy research for the purpose of improving the delivery of health care for the less fortunateamong us; and to Dr. Dulcie Peccolo, a noteworthy teacher who possesses a keen and adventurous intellect. iii Lastly, we are not whole without close and loving personal relationships. The unfailing support and love of my husband and son, Glenn and Graham Myers, makes the work I do and my life a joy. iv ABSTRACT A Critical Case Study of Program Fidelity in TennCare Purpose: The purpose of this study was to evaluate the fidelity of the design of Tennessee's Medicaid managed care program in comparison to the actual program operation. Program fidelity is a broad measurement of how true the implemented program is to the intended program (Heflinger & Northrup, 2000). Background: In the span of only 15 years, the introduction of managed care and other market-based strategies from the private sector precipitated a transformation of the delivery of Medicaid services in the United States. These monumental changes remain poorly understood. The implementation of managed care in Tennessee's Medicaid program is an excellent public policy exemplar because of the far-reaching scope of the program and the ongoing development of the program. Method: A hallmark of case study research is that detailed information is collected from multiple sources (Creswell, 2003; Feagin, Orum and Sjoberg, 1991; Stake, 2000; Yin, 2003). Source data for this single case study design included interview data from key stakeholders and a variety of documents. Documents analyzed included: newspaper and journal articles; correspondences; the original TennCare and TennCare Partners waiver applications; judicial decrees; legislative documents; task force reports; and other case studies. Interviews were conducted with 26 informants, including two former Governors of Tennessee; a former HCFA Administrator; a variety of state government and managed care executives and advocates; and a complement of provider representatives including administrators, managers and caregivers. Themes were developed to organize the vast amount of interview data. The salience of themes that emerged in early interviews were challenged, clarified and further distilled by an iterative process of content analysis and data triangulation that included multiple close readings of interview transcripts and documents, clarification and testing of ideas with selected stakeholders and confirmation of details with document sources. The triangulation of retrospective recollections of events and key impressions captured in recorded interviews with a wide variety of time-stable documents provided a rich understanding of people and events that shaped the development and operation of TennCare. Each theme was also organized and developed through the construction of a chronological history of events. Findings: An intricate web of circumstances and people shaped the initial development and evolution of TennCare. Although TennCare has been successful in extending health care coverages, this success has been overshadowed by a myriad of operational problems. Thematic analysis illuminated both the promises and failures of TennCare. Three themes were prominent in the telling of the TennCare story: authority, management and fragmentation. Governor McWherter (1987-1995), the creator of TennCare, established a strong executive authority to model and implement TennCare; a void was created when he left office. Subsequent administrations have not adequately transitioned to a more balanced and inclusive authoritative structure, nor have they developed an adequate oversight model. Continued mismanagement of the administration of benefits and failure to meet established care standards set the stage for the imposition of federal judiciary authority. V Management of the operational phase of TennCare has largely been reactionary and politicized and, in many instances, inappropriately abdicated or conferred upon the wrong or unprepared people or entities. Turmoil and turnover in state government hindered stabilization of the program. The stability and evolution of the marketplace that McWherter expected has not been broadly realized; the state has retreated from basic managed care principles. The state failed to integrate the management the health, behavioral health and pharmacy carve-outs. This fragmentation resulted in diffuse accountability across vendors and within state government, unnecessary duplication of services, gaps in the delivery and management of patient care and increased patient hassle and frustration. More broadly, the state was found to have conflicting roles as both the manager of the behavioral health vendors and a direct provider of behavioral health services. The web of connectivity between themes changed over time, as themes presented as a cause, catalyst or consequence of the others at different times in TennCare's history. A poignant example of this connectivity is how the mismanagement of TennCare program after the initial implementation led to the breakdown in key alliances and the eventual imposition of federal judicial authority in the form of the consent decrees. Consent decrees resulted in reactive and disjointed management which significantly contributed to the gap between what was envisioned for TennCare and what actually resulted. Conclusions: The study illustrated that an intricate web of circumstances and people shaped the initial development and evolution of TennCare, a program designed to solve a state-level problem with national implications. Although TennCare has been successful in increasing the number of Tennesseans with health care coverage, these successes