The Real World perspective Sue Etkind RN MS Director Division of TB Prevention and Control Massachusetts Department of Public Health Tuberculosis Control and Health Care Reform in Massachusetts ID: 738376
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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 HealthSlide2
Tuberculosis Control and Health Care Reform in MassachusettsBrief description of the TB program/TB priorities
Current challenges The MA health care reform modelOpportunities and lessons learnedWhat do TB Programs need in the ACA environment?Slide3Slide4Slide5
Understanding your epidemiology - Why is this important in the health care reform environment?
Non US Born and Health Care Access UndocumentedStudents and other temporary workers
Cultural barriers
Language barriers
Health as a prioritySlide6
TB Mission To promote the health and quality of life by preventing, controlling and eventually eliminating TB from Massachusetts, done through:Slide7
TB Program Priority: Populations at RiskPersons who are suspect for or who have active TB
High risk persons at risk for, or with TB infectionContactsOther identified high risk groupsSlide8
TB Program Objectives: Primary Prevention (no vaccine)
Stop/prevent transmission from current active TB casesPrevent potential TB cases emerging from the reservoir of TB infection
222 active TB cases
250,000 TB infection
MassachusettsSlide9
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 .Slide10
Massachusetts Public Health: A Shared Legal Responsibility
Disease Control
351
Local
Boards
of Health
(autonomous)
State Health Dept
TB Division
TB LabSlide11
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 servicesSlide12
Tuberculosis Control and Health Care Reform in MassachusettsBrief description of the TB program/TB priorities
Current challenges The MA health care reform modelOpportunities and lessons learnedWhat do TB Programs need in the ACA environment?Slide13
TB Program Balancing Act
Optimism
Realism
Despair
DelusionalSlide14
Tuberculosis Control and Health Care Reform in MassachusettsBrief description of the TB program/TB priorities
Current challenges The MA health care reform modelOpportunities and lessons learnedWhat do TB Programs need in the ACA environment?Slide15
Key Elements Provides for
legal residents who are not eligible for other public or employer-sponsored health insurance: Slide16
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. Slide17
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.. Slide18
Key Elements4. 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 complyExemptions allowed – unable to afford insurance; religious Slide19
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 programsfully subsidized: earn less than 150% of federal poverty level (fpl) –no premiumsPartially 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.
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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.
Slide21
Programs: Commonwealth ChoiceThese 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. Slide22
SummaryMassachusetts in 2006 expanded health insurance coverage statewide by:
Expanding Medicaid – Commonwealth Care (fully or partially subsidized depending on federal poverty level)Creating an individual mandateCreating an employer mandate
Defining coverage
Offering subsidies
Establishing a state-managed authority to broker access to insurance (Connector Board)Slide23
Similarities: MA and the USLegal residentsPersonal responsibility
Expansion of Medicaid for the poorInsurance exchangesBuy individual policiesSubsidies for those with modest incomesSlide24
Tuberculosis Control and Health Care Reform in MassachusettsBrief description of the TB program/TB priorities
Current challenges The MA health care reform modelOpportunities and lessons learnedWhat do TB Programs need in the ACA environment?Slide25
Roles and Responsibilities?
Public health mission, local and state
Health care reform
???Slide26
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 incompleteSlide27
What did we get?
Access to TB care improved –particularly for low income adultsExpanded 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.)Slide28
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
-
Slide29
Pre-Integrated Surveillance Infrastructure: Data FlowsSlide30
Integrated Surveillance Infrastructure: Data FlowsSlide31
Integrated data systemsReal time electronic reporting
Laboratories (ELR)Medical Records (EMR)All TB case reportingAll TB infection reportingReal time information sharing (LBOH/DPH)
Case investigation/TB case management
Outbreak managementSlide32
Health Care Reform: Assumptions versus Observations: a CAUTIONARY NOTESlide33
Assumptions/Observations
1. Insurance coverage access: All TB patients will have access to insurance optionsWho 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 InstituteSlide34
Who are the Remaining Uninsured Adults?
Compared with insured respondents – lower educational attainment, less employment, lower family income, and greater financial stressHighest 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 InstituteSlide35
Assumptions/Observations
2. Uninterrupted coverage: Once insured, patients will continue coverage Patient/System-related ObservationsPatient 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 occurSlide36
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.Slide37
Assumptions/Observations
3. Insurance coverage access equals health care access: Patient-related ObservationsFor 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
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Assumptions/Observations
4. Primary care access: Once insured, patient will be able to access primary care System-related ObservationsPrimary 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 patientsSlide39
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.Slide40
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.Slide41
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. Slide42
Tuberculosis Control and Health Care Reform in MassachusettsBrief description of the TB program/TB priorities
Current challenges The MA Health Care Reform modelOpportunities and lessons learnedWhat do TB Programs need in the ACA environment?Slide43
What do TB Programs need in the ACA environment?
CDC/DTBE leadershipUS 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 ServicesPCSI
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?)Slide44
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 partnershipsSlide45
TB Standards of Care in the Medical/Public Health ModelAt 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