Transcript Brief description of the program current challenges (cuts

Tuberculosis Control and Health
Care Reform in Massachusetts
The “Real World” perspective
Sue Etkind, R.N., MS
Director, Division of TB Prevention
and Control
Massachusetts Department of
Public Health
Tuberculosis Control and Health
Care Reform in Massachusetts
 Brief
description of the TB program/TB
priorities
 Current challenges
 The MA health care reform model
 Opportunities and lessons learned
 What do TB Programs need in the ACA
environment?
Figure 1: Incidence Rates, United States and
Massachusetts, 1990-2010
Incidence Rate Per 100,000
14
12
10
8
6
MA 2010 - 3.5
4
2
0
90
92
94
96
98
2000
02
04
06
08
10
YEAR
US
MA
Case rates for U.S. not yet available
Figure 18: Tuberculosis Cases by Place of Birth,
Massachusetts, 1999-2010
Percent of Cases
90
80
70
60
50
40
30
20
10
0
99
2000
01
02
03
04
US Born*
05
06
07
08
09
10
Non-US Born
*US Born cases include Puerto Rico
Understanding your epidemiology Why is this important in the health care
reform environment?
Non US Born and Health Care Access
 Undocumented
 Students and other temporary workers
 Cultural barriers
 Language barriers
 Health as a priority
TB Mission
To promote the health and quality of life by
preventing, controlling and eventually
eliminating TB from Massachusetts, done
through:
TB Program Priority: Populations
at Risk


Persons who are suspect for or who
have active TB
High risk persons at risk for, or with TB
infection
• Contacts
• Other identified high risk groups
TB Program Objectives: Primary
Prevention (no vaccine)
 Stop/prevent transmission from current
active TB cases
Prevent potential TB cases emerging from
the reservoir of TB infection
222 active TB
cases
250,000 TB infection
Massachusetts
TB Program Methods for Both
Groups (Active TB and TB
infection)
Early identification
Assuring access to adequate and
appropriate TB care
Assuring clinical case management
and completion of adequate and
appropriate TB therapy .
Massachusetts Public Health: A
Shared Legal Responsibility
351
Local
Boards
of Health
Disease
Control
State Health Dept
(autonomous)
TB Division
TB Lab
State TB Program Services





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Nursing Case management Model
(cases/contacts/health workers/incentives) state
and federal
21 TB clinics state wide (primarily hospitalbased)
TB medications provided through TB clinics
PPD to LBOH for high risk testing
Tuberculosis Treatment Unit at the Lemuel
Shattuck Hospital – voluntary and
involuntary hospitalization
TB laboratory services
Tuberculosis Control and Health
Care Reform in Massachusetts
 Brief
description of the TB program/TB
priorities
 Current challenges
 The MA health care reform model
 Opportunities and lessons learned
 What do TB Programs need in the ACA
environment?
TB Program Balancing Act
Despair
Realism
Optimism
Delusional
Tuberculosis Control and Health
Care Reform in Massachusetts
 Brief
description of the TB program/TB
priorities
 Current challenges
 The MA health care reform model
 Opportunities and lessons learned
 What do TB Programs need in the ACA
environment?
Key Elements
Provides for legal residents who are not
eligible for other public or employersponsored health insurance:
Key Elements
1. Requires adults in Massachusetts who
can obtain affordable health insurance to
do so.
2. Reforms the non-group and small-group
health insurance markets to effectively
lower the price and offer more choices for
individuals purchasing unsubsidized
products on their own.
Key Elements
3. Requires employers of 11+ full-time
equivalent employees in Massachusetts to
make a fair and reasonable contribution
toward coverage for full-time employees,
or pay a Fair Share Assessment, and to
offer both full-time and part-time
employees a pre-tax, payroll deduction
plan (a section 125 plan) for their own
health insurance premium payments..
Key Elements
4. Enforcement – state income tax return
 Penalties: 2007 - $219 2008 - $912
 In 2007, of the tax payers required to file
insurance information – only 1.4% failed to
comply
 Exemptions allowed – unable to afford
insurance; religious
•
•
Programs: Commonwealth Care
(expanded Medicaid)
A subsidized program for adults who are
not offered employer-sponsored
insurance, do not qualify for Medicare,
Medicaid or certain other special
insurance programs
fully subsidized: earn less than 150% of
federal poverty level (fpl) –no premiums
Partially subsidized: earn between 150300% of the fpl.
In 2010, 300% of fpl is $32,508 for an individual; $66,168
for a family of four.
Programs: Commonwealth Choice
An unsubsidized offering of six private
health plans, selected by competitive bidding,
and available through the Health Connector
to individuals, families and certain employers
in the state.
Programs: Commonwealth Choice
 These plans are offered directly through the
Health Connector by seven health insurance
carriers, six of which are non-profit,
Massachusetts based: Blue Cross Blue
Shield of Massachusetts, CeltiCare, Fallon
Community Health Plan, Harvard Pilgrim
Health Care, Health New England,
Neighborhood Health Plan and Tufts Health
Plan.
 Together, these plans represent about 90%
of the commercial, licensed health insurance
market.
Summary
Massachusetts in 2006 expanded health insurance
coverage statewide by:
 Expanding Medicaid – Commonwealth Care
(fully or partially subsidized depending on
federal poverty level)
 Creating an individual mandate
 Creating an employer mandate
 Defining coverage
 Offering subsidies
 Establishing a state-managed authority to
broker access to insurance (Connector Board)
Similarities: MA and the US
 Legal
residents
 Personal responsibility
 Expansion of Medicaid for the poor
 Insurance exchanges


Buy individual policies
Subsidies for those with modest incomes
Tuberculosis Control and Health
Care Reform in Massachusetts
 Brief
description of the TB program/TB
priorities
 Current challenges
 The MA health care reform model
 Opportunities and lessons learned
 What do TB Programs need in the ACA
environment?
Roles and Responsibilities?
Public health
mission, local
and state
???
Health care
reform
What did we have?

TB control system that relied on specialized state
funding for dedicated public health and all TB
clinical services

Federal, state, and local capacity for TB
surveillance, laboratory services, medical
management, and public education largely not
tied to health insurance reimbursement

Limited patient health insurance coverage made
alternative models unreliable or incomplete
What did we get?

Access to TB care improved –particularly for low income
adults
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Expanded health insurance creates an incentive to
bolster TB control programs through reimbursement.
Massachusetts is working with health centers, hospitals,
and specialty clinics to expand billing for TB services

Opportunity to link primary care and historic
specialized TB clinical capacity (esp. through
community health centers)

Support for improved integrated health Information
systems (ELR, EMR, etc.)
Community-Based TB Prevention
Neighborhood Health Center
PPD +
BMC-TB Clinic
- Evaluation
- Chest Radiograph
- Medical evaluation by Pulmonary MD
- Baseline LFT’s
- TB/HIV education (HIV counseling/testing)
- Follow-up appointment at NHC
Monthly follow-up at NHC
- Assess adherence
- Evaluate for side effects
- Address other health care issues
- Reinforce TB education
- Reinforce TB education
- Dispense medications (DOPT if necessary)
- Forward documentation to TB Program
TB Clinic monitors
- Monthly evaluations
- Provide medications
- Completion of therapy for LTBI
- Feedback to NHC
- Education program for NHC staff
-
Pre-Integrated Surveillance Infrastructure: Data Flows
Hospital
Provider
Public Health Laboratory
Reference
Laboratory
CDC
Laboratory
Fax
Fax
EDN Feeds
time delay and
duplicate data
entry
time delay and
duplicate data
entry
TB
·
·
STD
Foodborne
time delay
Local Health
data entry
case investigation
EPI and IMM
time delay and
duplicate data
entry
CDC
·
·
·
RIHP
data entry
case investigation
analysis
Integrated Surveillance Infrastructure: Data Flows
Provider
Laboratory
Reference
Laboratory
Emergency Dept
ro
ic
m
rat
or y
nd
EM
R
real-time electronic reporting
Sy
La
bo
CDC
ED
N
Public Health
Laboratory (SLIS)
Hospital
Re
po
rts
immediate
diseases
MAVEN Disease Surveillance
and Case Management System
LBOH
MDPH
PHIN-MS reports to
CDC
· MMWR
· real time
information
sharing
· data standards/
compliance with
national standards
· quality control/
quality assurance
· case investigation
and case
management
· cluster
identification/
outbreak
management
· analysis
Integrated data systems
 Real
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
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
time electronic reporting
Laboratories (ELR)
Medical Records (EMR)
All TB case reporting
All TB infection reporting
 Real
time information sharing
(LBOH/DPH)
 Case investigation/TB case management
 Outbreak management
Health Care Reform:
Assumptions versus
Observations: a
CAUTIONARY NOTE
Assumptions/Observations
1. Insurance coverage access: All TB
patients will have access to insurance
options
Who are the Remaining Uninsured Adults?
85.4 % Non elderly adult (aged 19-64)
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Male, young, single
Racial/ethnic minorities and non-citizens
Unable to speak English well or very well
Living in a household in which there was no
adult able to speak English well or very well
Long, SK, Phadera L, Lynch V. Massachusetts Health reform in 2008: Who are the
Remaining Uninsured Adults? August 2010 University of Minnesota, The Urban
Institute
Who are the Remaining Uninsured
Adults?
with insured respondents –
lower educational attainment, less
employment, lower family income, and
greater financial stress
 Highest level urban areas (Boston highest)
 42% potentially eligible for Mass Health or
Commonwealth Care (family income
criteria/ US citzenship) (58% not eligible)
 Compared
Long, SK, Phadera L, Lynch V. Massachusetts Health reform in 2008: Who
are the Remaining Uninsured Adults? August 2010 University of Minnesota,
The Urban Institute
Assumptions/Observations
2. Uninterrupted coverage: Once insured,
patients will continue coverage
Patient/System-related Observations
 Patient meets the enrollment criteria for tax
submission purposes, but then drops it due to
cost
 Patients may frequently change insurance plans
looking for more affordable rates
 Insurance cost increases in co-pays, coinsurance and premiums continue to occur
TB in the Emergency Department
Of the 244 TB cases in 2009, 116
(52%) were seen in emergency or
urgent care departments in 41 hospitals
located throughout Massachusetts
during the course of their illness.
Assumptions/Observations
3. Insurance coverage access equals
health care access:
Patient-related Observations
 For the non US born - stigma and fears related
to “government” are obstacles to seeking
insurance coverage
 Some substance using TB patients and some
homeless TB patients are more focused on their
daily existence
 Many TB patients are unemployed and live a
marginal existence
Assumptions/Observations
4. Primary care access: Once insured,
patient will be able to access primary
care
System-related Observations
 Primary care access is limited in some TB
high risk areas.
 Some patients are on waiting lists to be
assigned a PCP
 There may be long waiting lists for
appointments – a significant issue for
potentially infectious TB patients
Assumptions/Observations
5. Public health follow up: Once insured, the patient’s
primary care provider will provide public healthrelated services.
System-related Observations
Primary care is done through a medical service
delivery model. TB requires a medical/public
health model. This model must assure that:
monthly patient follow-up occurs; contact
identification is done; adherence assessment
and provision of outreach services or incentives
are provided as needed; and cluster/outbreak
assistance is provided when required. All of
these are performed by the medical/public
health provider in conjunction with state and
local public health.
Assumptions/Observations
5. Primary care providers can manage TB
diagnosis and treatment
System-related Observations
Many primary care providers do not have
training and experience regarding the
medical and public health complexities of
treating TB.
The bottom line is that health care reform
in Massachusetts has been extremely
successful, but it is not a panacea for the
many shortcomings of the health care
system.
Tuberculosis Control and Health
Care Reform in Massachusetts
 Brief
description of the TB program/TB
priorities
 Current challenges
 The MA Health Care Reform model
 Opportunities and lessons learned
 What do TB Programs need in the ACA
environment?
What do TB Programs need in
the ACA environment?

CDC/DTBE leadership
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US Preventive Services Task Force – TB on the A list
National Prevention Strategy SD-3 Prevention and
public health capacity and SD-4 Quality Clinical
Preventive Services
PCSI
Local and state health department and laboratory
technical assistance – reimbursement, capitation,
billing, etc.
ACA for Dummies
Other existing medical/public health models of TB
care (FQHCs?)
No matter what type of health reform
model
We will need to continue to define, maintain, and
advocate for core public health functions and
capacity at state and local health agencies
including:


Assessment - Surveillance, epidemiologic and outbreak
capacity and targeted screening
Assurance:
• specialized TB clinical capacity for patients and suspects to
diagnose, monitor, and assure full and adequate TB treatment,
wherever provided
• contact identification, investigation and follow up
• Adherence tools: DOT, outreach, use of incentives, enablers
• Educational support

Policy development, guidance and education to enable
partnerships
TB Standards of Care in the
Medical/Public Health Model
 At
a minimum, all providers who serve TB
patients should be expected to:



Understand the basic and current principles of
TB care
Provide TB care that is linked with the TB
public health system
Understand under what circumstances TB
care should be deferred to TB public health
experts