Tuberculosis Control and Health Care Reform in MassachusettsThe “Real World” perspective

Sue Etkind, R.N., MSDirector, Division of TB Prevention

and ControlMassachusetts 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

0

2

4

6

8

10

12

14

90 92 94 96 98 2000 02 04 06 08 10

US MA

Incidence Rate Per 100,000

YEAR

Case rates for U.S. not yet available

MA 2010 - 3.5

Figure 18: Tuberculosis Cases by Place of Birth, Massachusetts, 1999-2010

0

10

20

30

40

50

60

70

80

90

99 2000 01 02 03 04 05 06 07 08 09 10

US Born* Non-US Born

Percent of Cases

*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 identificationAssuring access to adequate and

appropriate TB careAssuring clinical case management

and completion of adequate and appropriate TB therapy .

Massachusetts Public Health: A Shared Legal Responsibility

Disease Control

351Local

Boards of Health

(autonomous)

State Health Dept

TB Division TB Lab

State TB Program Services Nursing Case management Model

(cases/contacts/health workers/incentives) state and federal

21 TB clinics state wide (primarily hospital-based)

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

OptimismRealismDespair 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 employer-

sponsored 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 150-300% 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

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 BMC-TB Clinic

PPD + - 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 TB Clinic monitors - Assess adherence - Monthly evaluations - Evaluate for side effects - Provide medications - Address other health care issues - Completion of therapy for LTBI - Reinforce TB education - Feedback to NHC - Reinforce TB education - Education program for NHC staff - Dispense medications (DOPT if necessary) - Forward documentation to TB Program -

Pre-Integrated Surveillance Infrastructure: Data Flows

Provider Laboratory

FaxFax

· data entry· case investigation

· data entry· case investigation· analysis

CDC

time delay and duplicate data

entry

time delay

ReferenceLaboratory

Hospital

TB

Local Health

time delay and duplicate data

entry

time delay and duplicate data

entry

Public Health Laboratory

STD

EPI and IMM RIHP

Foodborne

CDC

EDN Feeds

Integrated Surveillance Infrastructure: Data Flows

EMR

Syndromic

PHIN-MS reports to CDC

Provider Laboratory

immediate diseases

Reference Laboratory

Hospital

· MMWR

Public Health Laboratory (SLIS)

real-time electronic reporting

Emergency Dept

· real time information sharing

· data standards/ compliance with national standards

· quality control/ quality assurance

· case investigation and case management

· cluster identification/outbreak management

· analysis

MAVEN Disease Surveillance and Case Management System

Laboratory Reports

LBOH MDPH

CDC

EDN

Integrated data systems

Real 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)

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?

Compared 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)

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/Observations2. 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, co-insurance 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/Observations3. 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/Observations4. 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 health-related 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/Observations5. 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 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