Transcript: Affordable Care Act for TB Services in California: Assessment by the California TB Controller s Association Julie Higashi, MD, PhD TB Controller, Disease Prevention and Control Branch, Population Health Division, San Francisco Department of Public Health The Affordable Care Act and Tuberculosis Control: Navigating New Territory A National Webinar August 23, 2013 Archived Webinar Recording: http://www.currytbcenter.ucsf.edu/training/webarchive/acatbc/arch_acatbc.cfm
[Start of recorded material] 00:00:09 Speaker: Julie Higashi It s a real honor to be here with this panel of experts, to talk about the Affordable Care Act- and I really am speaking from two hats- one, as a past president of the California TB Controller s Association, and also as a local TB controller in San Francisco. And I want to say that things are so dynamic with the ACA that you really just sort of have to jump in, and just start trying to work with it and understand as much as you can, and hopefully over time we will all come together and make a path forward. 00:00:51 So, the outline of my portion of this webinar is to really talk about the California TB Controller s Association, or CTCA assessment of TB services for plans on the healthcare exchange. And I must say, that are still a lot of unknowns about what the plans actually are going to provide, as far as services, on healthcare exchange. This is our best guess. And our organization is focusing on diagnosis and treatment of TB infection, and whether or not there was cost sharing for the patient. The CTCA survey looked at how our local TB programs are trying to prepare for the ACA. And then finally, I will go over what I think, or what my vision is, for the San Francisco TB program, as far as getting ready for the ACA. 00:01:50 For the assessment of TB services on the healthcare exchange, the way that CTCA went about this was just simply to review plan benefits available, that were posted on websites. And these are websites of the health insurance companies, who will be participating on the exchange in California- their plans. And the simple way to do this was to search for preventive services, and to search for Tuberculosis, in order to kind of get a feeling for what the plan covered. The other approach we took was to call the companies- I found to cold call them and ask them questions, what is included in preventive TB services in Covered California Plan, Covered California is the healthcare exchange for California- that s just the name of it- And will there be cost sharing for participants for TB services? And so that s how we went about this. 00:02:51 These are the Covered California Plans, you can see that there are about eleven or so plans, and there s all different types of insurance companies. 00:03:04 And these are the Covered California Plans that are available in San Francisco. So one of the things that is important to know is what do you have available on the healthcare exchange in your jurisdiction or in your local area. And so I only need to worry about 1 P age The Affordable Care Act and Tuberculosis Control: Navigating New Territory
these five plans for my SF program: Blue Shield, Chinese Community Health Plan, Health Net, Anthem Blue Cross and Kaiser Permanente. 00:03:34 So one of the important concepts, which Christine s already discussed, is preventive services within the Affordable Care Act, and these are services that are provided to insured patients and these services are not cost shared, so in other words, the patient goes to their provider and doesn t pay any co-pays for that particular activity. And as Christine mentioned earlier, the U.S. Preventative Task Force, grade A or B activities are considered to be preventive services and another advisory panel, advisory committee on immunization practices, any of these recommended services are preventive services. And then there s the HRSA, or the Health Resources and Services Administration Guidelines, of which there s a subset- the American Academy of Pediatrics Bright Futures mentioned some guidelines, guidance or services, or recommend services for TB. 00:04:30 These are the things that determine which activities can be provided to patients that will not be cost-shared. So what is the reality for TB? And as far as TB services, we re kind of limited and this is an unfortunate loophole, or administrative glitch-it s kind of like how I like to characterize it, because in 1992, the USPS Task Force did recommend screening for TB infection as a grade A or B activity. When the Guidance was up for revision in 2002, what happened then was that the USPS Task Force decided to defer CDC recommendation, so they decided not to pursue an actual revision of their rating, and so because of that, that is why TB is not included. And I think I may have misspoke about the original recommendation, I think it was 1996 not 1992. So companies participating in Covered California with existing plans, that cover services as per ACA, we don t know yet which plans are going to exist in the healthcare exchange, we have some basic guidelines that are being based on the Kaiser benchmark plan, but even within Kaiser we know that there can be differences between regions and Northern California region versus the Southern California region. So we really just don t know and this is our best guess. So the plans that are now published by the same companies for: Health Net, Valley Health Plan, Western Health Advantage, Chinese Community Health Plan, and Ventura County Health Plan. They all mirror what the national ACA preventive TB services are. Which is a TB screen, test for HIV/AIDS and children who are considered higher risk. So these are folks that can show up at the door, get a TB screen test and not have a co-pay. Everybody else may have a co-pay for the TB screening test and any sort of subsequent treatment. 2 P age The Affordable Care Act and Tuberculosis Control: Navigating New Territory
00:06:44 So what about MediCAL TB services? We re lucky in California that MediCAL provides access to diagnosis and treatment of TB disease and infection without cost sharing. And it s a real boon to our TB control and elimination activities, that MediCAL provides such comprehensive services. And so there are some companies that are participating in Covered California that have existing plans with MediCAL eligibility requirements. And these are the two plans, Molina Healthcare and LA Health Care Plan. So we hope that there s not going to be a disparity in the preventive TB services offered amongst the plans on the healthcare exchange. And we re actively working to understand what the services are going to be. 00:07:39 These are the kinds of questions you should be asking of your local health plan. Other approaches to TB prevention from different companies- and these are the other plans. And they just it s interesting because these plans actually have different approaches to what they consider preventive treatment. The Blue Shield plan will allow, as preventive service, TB screening up to age 19, which includes a risk assessment and test-really like that approach; Contra Costa County explicitly states there s no cost for TB treatment regardless of residency status; Kaiser Plan- it s really difficult to understand what the benchmark is- we know that there s at least a national standard, provided on some of the plans that are published on their website, and one Southern California website included an adult assessment of TB and preventive care. So that s a little bit different than the national health plan. And then for the Sharp Health Plan, it was at least the national standard, at least the ACA and possibly some wiggle room for preventive service, depending on some sort of internal policy. 00:08:48 The take home points from this part of the presentation is that Covered California has not defined the scope of preventive TB services. So that s a basic question to ask of your healthcare exchange. And that the ACA does not include TB diagnosis and treatment without cost sharing to the patient, particularly for TB infection. And we know from experience that for active TB treatment, that patients still share (in many insurance plans) co-pays. For meds, for labs, for doctor visits. So you need to understand which plans will be available in your local jurisdiction on the exchange. The TB services covered as prevention, the TB services that will be cost shared, and the fraction of your population that will not have insurance. When we looked at our population in San Francisco, our estimate is that 15-30% of our population is potentially eligible for the healthcare exchange. And so actually in reality the impact of what this exchange is going to be for us, we really don t understand well. So what will be nice is if some of our currently uninsured patients do have access. The 3 P age The Affordable Care Act and Tuberculosis Control: Navigating New Territory
ones that are undocumented will not, but time will tell. So it may be that it is a fraction of your population, so understanding that this is not going to apply to everybody, but just some of your population, and understanding what that fraction is, is important. 00:10:23 Ok, I m going to be moving on to the CTCA survey of local health jurisdictions and how they are preparing for the ACA. This was a fairly informal survey the quick and dirty approach of trying to just get a feeling for what local health jurisdictions were doing to get ready for ACA as far as TB. And we asked them four questions: How will ACA change the way you deliver TB services? Who will be seeing the undocumented for TB services? Who will be providing care for patients with active TB disease? and Who will be providing care for the diagnosis and treatment of latent TB infection? 00:10:59 And we did not get a high response rate, we only got 8 responses out of the 61 jurisdictions, however we got a nice sort of spread across the high, medium and low burdened health jurisdictions. So we just get a quick- cross sectional look. 00:11:16 And so to the question How will ACA affect the delivery of TB services in your county? about half the respondents said it s really not going to change things. We re going to continue to direct services in one county; already transferred direct services to the community in two counties; transferred LTBI treatment to the community in one county; and then the other responses: transfer LTBI diagnosis and treatment to community; more patients will wait for services, and I don t understand, which I think is a very realistic and honest response. 00:11:54 Who will be seeing the undocumented in your county? Public health clinics in more than half of the respondents. And then it looks like the federally qualified health centers (FQHCs) are really what public health or TB programs are looking to for providing TB services. But you can see that they already know that there are going to be limitations, FQHCs, but only for emergency care. FQHCs and county hospitals for suspects and cases, unsure-direct to FQHC. So we are looking either at the public health clinic to deliver these services, or the federally qualified health centers. 00:12:34 Who will be caring for patients with active TB disease in your county? Three said they have a dedicated clinic. Another, public health will diagnose and local providers will treat, sort of a hybrid model, county system will have MediCAL and uninsured, the private providers will have the insured, in the other large group of three. And then private providers with the local health department oversight, so this is a county in which there is no direct service for active TB treatment. 4 P age The Affordable Care Act and Tuberculosis Control: Navigating New Territory
00:13:04 Who will be screening and treating patients with TB infection? In three counties: the primary medical doctors, in three counties: the public health clinic and private providers, so it s going to be a mix, public health clinic- not enough capacity to do a good job, public health will diagnose and PMD will treat. So it s really a mixture of who is going to be doing TB infection, treatment and diagnosis. 00:13:32 So what are we doing in San Francisco to prepare for the ACA? I ve tried to group our activities under the overarching principles that I think are the big ticket items, in the ACA. One of the big goals is to consolidate care in their medical homes. And so us in San Francisco, we want to support better diagnosis and treatment of uncomplicated LTBI in the medical home, because we feel that we are not going to really make inroads with our numbers for active TB cases until we actually get some more of the pool of infected patients with TB infection. And in order to support those, we are implementinghopefully soon- an electronically based referral consultation portal through our health record, in order to provide support to primary care providers, and eventually an access to our TB program database, so that PMDs can look at a patient s public health record to see if they ve had prior diagnosis and treatment. For both active TB and latent TB. And then establish clear guidelines for referral, screening and treatment of active TB disease and TB infection, and we re just revising our criteria so that we can accommodate treatment for more patients because we want it to be supported in the medical home and it s not just limited to what our clinic can handle. 00:15:06 Another overarching principle is efficiency gained by using electronic medical records sort of the high tech part of the ACA. And so we want to support implementation and meaningful use of TB screening and treatment in our county health system electronic medical record, so that means creating care pathways for diagnosis and treatment. And implementing again, the e-referral system I just referred to and then advocating for inter-operability between our new public healthcare system surveillance system that s in the process- or just about to begin implementation in the electronic county health record. So thinking ahead, about this electronic medical record, and how your county interacts with it- I think there s a lot of value in doing that now, because a lot of people are putting things in place. And our dream would be that the TB module of the public health surveillance system will eventually become the county TB infection registry. 00:16:11 Another theme is that there may be more reimbursement opportunity since more people have access to insurance. We want to be a specialty provider, our TB clinic in San Francisco, that may participate in any accountable care organization in any health system in San Francisco. So that may require setting up memorandums of 5 P age The Affordable Care Act and Tuberculosis Control: Navigating New Territory
understanding with different health care systems, and increasing our capacity to bill for services. And the early word is that the reimbursement that we are going to be getting from the exchange may be less than what we have been seeing in the past from MediCAL, and so we may not be- we shouldn t be expecting that this is going to be a huge revenue source. There will be a population health focus reimbursement type performance another sort of overarching principle coming out of the ACA and so under this sort of principle, the plan is to advocate for TB treatment to become a performance indicator performance indicators at the local, state and national levels of quality measures. I d like to see us implement report cards of TB performance indicators for health centers and health systems. And then the curve which means get to that pool of TB infections so that you re really, really reducing active cases by focusing on prevention, that is another principle of the ACA- to advocate for inclusion of TB diagnosis and treatment without cost sharing at the local, state, and federal levels. We made some inroads with this at the Advisory Council for Elimination of TB cost resolutions supporting this principle and recently the American Medical Association passed a resolution that advocated no cost sharing for Tuberculosis medication. So, you know, these are the types of things that if you have the opportunity to talk to your decision makers, and educate them about the limitations we have currently with the ACA, it may end up opening up doors for you to provide services for patients. 00:18:20 So I d like to acknowledge the California TB Controller s Association, and I put this list of people here because these are the people who are currently really working actively on Affordable Care Act issues. So if you re in California, I just wanted you to know that Barbara Cole, Charity Thoman, Peter Kerndt, Mike Carson, Judith Thigpen-who s CTCA s Executive Administrator- have really been working and thinking about ACA and how it affects TB. The California Department of Public Health-Jan Young- helped us with a lot of the calls to the health care companies and what came out of her calls to these companies was really no plan had been put in place. National TB Controllers Association, John Warkentin, who is past president- Jenny Flood, president, who are helping us coordinate a national effort to address the opportunities and limitations of the ACA. And finally, our point person who is centrally located at the Division of TB Elimination, CDC, Christine Ho. 6 P age The Affordable Care Act and Tuberculosis Control: Navigating New Territory