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
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
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.