Transcript Slide 1

The Economy,
Health Care Reform
and TB Control in California
Mark Horton MD MSPH
April 28, 2011
• The TB Landscape
• Economic and Budgetary Pressures on
TB Control Activities
• Health Care Reform: Challenges and
Opportunities for TB Control
• The Role of Local Public Health in TB
Control
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The TB Landscape
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Tuberculosis in California
– New active cases at a historic low, BUT
– California reports the largest number of TB
cases in the U.S.
– Reservoir of latent TB infection (LTBI)
exceeds three million persons
– LTBI pool is major source for California’s
future TB cases
– Reactivation in 1 of 10 LTBI patients
– Local transmission indicated by TB in children
and new outbreaks
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TB Disease Burden in CA
2,329 New Cases (’10)
Over 10,000 Suspect Cases
20,000 – 30,000 Contacts
3 million Californians infected
35 million Californians at risk
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Hierarchy of TB Case Rate Disparities,
California, 2009
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Case rate
1.2
2.7
4.1
4.2
6.7
12.9
35.2
99.0
Nativity and race/ethnicity
U.S.-born White
U.S.-born Hispanic
Foreign-born White
U.S.-born Asian
U.S.-born Black
Foreign-born Hispanic
Foreign-born Asian
Foreign-born Black
6.0
California case rate
Disparities in TB Rates among Race/Ethnic
Groups, CA, 2010
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Race/Ethnic Group Rate/100,000
Difference
compared to White
White, not Hispanic
1.1
--
Black, not Hispanic
6.2
5.6x
Hispanic
6.0
5.5x
Asian/Pacific
Islander
21.2
19.3x
TB Case Rate Disparity by Nativity
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U.S.-born
1.8
Foreign-born
18.1
California’s Population
Compared to US population
• More likely to be
– Asian (13% vs. 5%)
– Hispanic (37% vs. 16%)
– Foreign-born ( 27% vs. 13%)
Changes in CA
• 50% increase in persons over 65 in past
decade
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Challenges
• Identify, investigate and aggressively
manage cases/outbreaks
• Reduce the pool of LTBI
• Maximize disease prevention
• Focus on Disparities
• Heighten awareness
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California’s Economy
• California is one of the world’s largest
economies: $1.9 trillion in 2009
• For the first time since 1938, in 2009, personal
income declined in California
• Between July 2007-2010 ,
California lost 1.3 million jobs (>12%
unemployment)
Source: California FACTS, January 2011, LAO
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Resource Reductions : CDPH
• ‘08 – ’09: 10% General Fund (GF)
reduction
• ‘09 – ’10: Targeted GF Reductions
– HIV
– MCAH
– Immunizations
– MediCal
• Other: Furloughs, Hiring freeze
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The Economy and Local Health
Department TB programs in California
• Many LHDs struggling to provide critical
services to uninsured populations
• TB control positions lost
• Some TB control activities have stopped
that previously contributed to
– early detection of TB
– prevention of TB spread
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Trend in Local Health Department TB
Program FTEs, 2006-2010
TB Program FTEs, California
1000
900
800
842
766
796
698
700
650
FTEs
600
500
400
300
200
100
0
2006
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2007
2008
2009
2010
Specific impact reported by California
local TB programs
• Most experienced:
– decrease in funding
– reductions in staff
• Resulting in decreased capacity:
– to monitor disease trends
– to respond to outbreaks
Source: TB Program Assessment Tool
California TB Control Branch, 2010
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Impact on CA TB Programs
2010-2011
• 50% experienced increase in case
manager patient load
• 25% decreased number of patients on
DOT
• 30% had delays in contact investigations
• 30% decreased clinic services
• 35% decreased staff training
• 10% decreased reporting capacity to state
•16 Source: TB program assessment tool
How may economic pressures
affect TB patients?
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Patients delay seeking care
Present with more advanced disease
More patients hospitalized
Patients remain infectious longer and more likely
to spread to families and community
• Patients can’t afford co-pay for drugs and visits
• Patients abandon treatment
• Patients more likely to develop MDRTB
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Patient example in California
2010
When patients and programs cannot afford
TB care:
• Patient with MDR and TB program unable
to pay for MDR TB drugs
• Experienced delays in MDR TB treatment
initiation
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Programmatic Priorities in Face of
Reduced Budgets
• Re-prioritize programmatic performance
targets
• Continue to focus attention/resources on
populations at risk
• Prioritize implementation of new evidencebased diagnostics and treatment regimens
• Strengthen partnerships
• Enhance public awareness
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TB Control Indicators
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Diagnosis
– Culture identification
– HIV status determination
Treatment
– Recommended Initial Therapy
– Timely Treatment
– Directly Observed therapy
– Culture conversion
– Completion of therapy
Surveillance
– Timely Reporting
– Complete reporting
– Universal genotyping
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Contact Investigation
– Contacts elicited, evaluated,
treated
Adverse Events
– TB Deaths
– Pediatric cases
TB Control Outcomes
– Case rates
Program evaluation: California’s Report Card
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Culture conversion within 60 days
COT within 1 year
Contact evaluation
Sputum culture reported
Drug susceptibility results
Universal genotyping
Recommended initial therapy
Better
---------------------------------U.S. average -----------------------------• Contacts elicited
• Foreign-born TB case rate
• Data reporting: RVCT
• U.S.-born TB case rate
Worse
• Pediatric TB case rate
• African-American TB case rate
• LTBI treatment completion for contacts
• LTBI treatment initiation for contacts
• TB case rate (overall)
• Known HIV status
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Health Care Reform and TB
• What’s the Problem?
• Opportunities in HCR
• Partnerships
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The Problem
• Persons with TB need access to prompt
medical care and drug treatment to halt
transmission to others and prevent TB
from spreading in communities
• Uncontrolled TB transmission jeopardizes
public health
• Vast population with latent infection is
persistent source of future cases
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The Problem
• TB diagnosis is slow and often tricky
– Many outpatient visits or inpatient days
may be needed for a TB diagnosis
• TB treatment is lengthy
– TB treatment requires multiple drugs,
frequent medical monitoring, laboratory
testing, and interaction with health
professionals for up to 24 months
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The Problem:
Gaps Expected in Health Insurance
Coverage
Many California residents will remain
uninsured due to:
• residency requirements
• income thresholds
• lapses in insurance coverage
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The Problem:
Barriers to Affordable Care
• Co-pays and other share of cost
provisions are a significant barrier for
critical public health services to uninsured
as well as insured persons (eg infectious
TB evaluation)
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The Problem:
TB services not covered
Public health activities for key uncovered
populations not part of HCR:
• TB diagnosis and treatment
• Patient isolation
• DOT/Case management
• Outbreak/contact investigation
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Opportunities for Public Health
in HCR
– Expanded Access
– Focus on Prevention
– Focus on Quality
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Expanded Access
• Medicaid expansion
• Insurance Reform
• Expansion of System Capacity
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Expanded Access: Insurance Reform
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Mandatory individual health insurance
No pre-existing conditions
No dropping coverage for illness
No maximum life-time benefit
Children covered until 26 yrs on parent policy
Mandatory no-cost coverage of CPS
Tax incentive for small employers
Health Insurance exchanges
Subsidized health insurance premiums
Expanded Access: System Capacity
• Expansion of Community Clinic Networks
• Expansion of Primary Care
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Focus on Prevention
• Public Health and Wellness
– Council
– Prevention Framework
– Fund
• No cost coverage of CPS
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Prevention and Wellness Fund
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Public Health infrastructure improvement
Epidemiology and laboratory capacity
HIV reporting
Home Visitation
Community transformation
Public health education/training
Mandatory No Cost Coverage
of CPS
• ACIP
• USPSTF
• Bright Futures
• Preventive Services for Women
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Specific Opportunities
to Further TB Control
• 3.4 million more Californians will have a
regular source of health care
• More people will be under care for
conditions that promote TB progression
(eg diabetes, smoking, ESRD, HIV)
• Expanded opportunities for early TB
detection and TB disease prevention
• LTBI testing and treatment of high risk
groups can become routine
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Focus on Quality:
Accountable Care Organizations
ACOs mandated to:
– Improve the efficiency and effectiveness
of health services
– Control costs
– Focus on prevention
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Partnerships
• Community Clinics/FQHCs
• Public Hospitals
• Private Hospitals/practitioners
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Models for public health
care delivery
• Referral of TB patients to public health
clinic
• Contract with private or FQHC providers
for TB services
• Both models currently in operation within
California
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Challenges with TB service partnership
models
• Partners may have less experience with
TB case management and prevention
• Difficult to accomplish patient centered
management to extent performed by TB
programs
• Responsibility for population protections
and surveillance needs strong public
health infrastructure
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Charge of
Health Departments and FQHCs
LHDs: Population health and healthcondition-specific clinical services
FQHCs: Full continuum of primary
and preventive care services
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Populations served by community health
centers overlap with populations at risk for
TB
• Disproportionately low-income
• Most uninsured or publically insured
• Most members of racial/ethnic minority
• Overlapping populations means increased
access to care for many patients at high risk for
TB
• Source: National Association of Community Health Centers 2010
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Partnership: LHDs and FQHCs
Well positioned to be strong partners with
long history of coming together to improve
both individual and population health
Common goals:
– Improve health of target populations
– Eliminate health disparities
– Promote health equity
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Partnerships: Community Health
Centers
LHD and FQHC partnership needed to meet ACA
goals:
• Address health issues of underserved
• Eliminate disparities
• Improve and document value of
interventions/services
• Use of health information to improve population
health
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Partnership Examples: promote
individual and population health
• Smoking cessation in patients with LTBI
prevents TB disease
• Treat LTBI in diabetics- prevent disease
progression
• Identification and treatment of LTBI among
HIV-infected can prevent TB
• Decrease mortality in TB/HIV- Identify HIV
infection in TB patients; promote HAART
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Partnership: Public Hospitals
• New funds to public hospitals to cover
expanded patients and improve care
quality
• State and LHDs have lead role to define
best practices/standards related to TB
care and control
– Show what is cost-effective
– Role in measuring outcomes and
creating /implementing measures
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Partnerships: Private Providers
• Private providers care for nearly half
of TB patients
• Opportunities for better prevention
and case management through
partnership
• LHDs needed for TB subject matter
expertise and disease control
functions
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TB Deaths during Therapy, by
Provider Type, 1994-2009
20
18
Percent
16
14
12
10
Private Provider
Health Department
8
6
4
2
19
9
19 4
95
19
96
19
9
19 7
98
19
99
20
0
20 0
0
20 1
02
20
03
20
0
20 4
05
20
06
20
0
20 7
08
20
09
0
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Year
Role of Public Health Departments
• TB surveillance:
– oversee reporting and case registries
– Epidemiologic trend analysis
– Monitoring TB control /outcome
measures
• Define/ promote evidence-based
interventions
– Develop and communicate TB control
best practices and standards
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Role of Public Health Departments
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• Case management
– DOT
– Expert consultation
– Interjurisidictional transfer of care
• Community disease control
– Response to outbreaks
– Extended contact investigations
– Media releases
– Public and provider education
Exciting Innovations for
TB Dx and Rx
• Rapid diagnostics for TB and LTBI
• Shorter course treatment for LTBI
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How can public health departments
lead the way?
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• Ensure these innovations are understood:
– What is the evidence they work?
– Are they better than the old tools?
– Do they improve outcomes?
• Ensure innovations are absorbed and
accessible
– Provide technical expertise
– Provide guidance to providers
– Evaluate implementation
Summary
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California TB Landscape
Economic and Budgetary Challenges
Health Care Reform
Focus on Partnerships
Role of Local Health Departments
. . I am prejudiced beyond debate
In favor of my right to choose
Who will feel
The stubborn ounces of my weight
--B. Overstreet
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