A Critical Case Study of Program Fidelity in TennCare

Carole R. Myers Dr., University of Tennessee - Knoxville


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.


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 have been overshadowed by pervasive operational problems, a failure to fully

implement basic building blocks of managed care, such as risk-sharing and competition,

and effectively manage the vendors employed by the state. Conclusions related to the

three themes show a pattern of missed opportunities and a troubling inability to transition

from the chaos of TennCare’s implementation to effective program operation. The

illuminated themes will be informative to planners of similar state initiatives.