Date of Award


Degree Type


Degree Name

Doctor of Philosophy



Major Professor

Sandra P. Thomas

Committee Members

Marian Roman, Joanne Hall, Dulcie Peccolo, Craig Ann Heflinger


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.

Files over 3MB may be slow to open. For best results, right-click and select "save as..."

Included in

Nursing Commons