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

1. Tuberculosis Control and Health Care Reform in MassachusettsThe “Real World” perspective Sue Etkind, R.N., MS Director, Division of TB Prevention and Control Massachusetts Department of Public Health

2. 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?

5. 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

6. TB Mission To promote the health and quality of life by preventing, controlling and eventually eliminating TB from Massachusetts, done through:

7. 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

8. 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

9. 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 .

10. Massachusetts Public Health: A Shared Legal Responsibility 351 Local Boards of Health (autonomous) State Health Dept Disease Control TB Division TB Lab

11. 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

12. 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?

13. TB Program Balancing Act Despair Realism Optimism Delusional

14. 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?

15. Key Elements Provides for legal residents who are not eligible for other public or employer-sponsored health insurance:

16. 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.

17. 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..

18. 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

19. 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.

20. 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.

21. 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.

22. 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)

23. 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

24. 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?

25. Roles and Responsibilities? Public health mission, local and state Health care reform ???

26. 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

27. 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.)

28. 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 - Providemedications - 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 -

29. Pre-Integrated Surveillance Infrastructure: Data Flows

30. Integrated Surveillance Infrastructure: Data Flows

31. 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

32. Health Care Reform: Assumptions versus Observations: a CAUTIONARY NOTE

33. 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

34. 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

35. 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, co-insurance and premiums continue to occur

36. 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.

37. 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

38. 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

39. 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.

40. 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.

41. 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.

42. 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?

43. 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?)

44. 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

45. 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