Mark Horton MD MSPH April 28, 2011 The Economy, Health Care Reform and TB Control in California

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 2

The TB Landscape 3

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 4

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 5

6 Hierarchy of TB Case Rate Disparities, California, 2009 Case rate Nativity and race/ethnicity 1.2 U.S.-born White 2.7 U.S.-born Hispanic 4.1 Foreign-born White 4.2 U.S.-born Asian 6.7 U.S.-born Black 12.9Foreign-born Hispanic 35.2Foreign-born Asian 99.0Foreign-born Black 6.0 California case rate

Disparities in TB Rates among Race/Ethnic Groups, CA, 2010 Race/Ethnic GroupRate/100,000Difference compared to White White, not Hispanic1.1-- Black, not Hispanic6.25.6x Hispanic6.05.5x Asian/Pacific Islander x 7

TB Case Rate Disparity by Nativity U.S.-born1.8 Foreign-born18.1 8

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 9

Challenges Identify, investigate and aggressively manage cases/outbreaks Reduce the pool of LTBI Maximize disease prevention Focus on Disparities Heighten awareness 10

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 , California lost 1.3 million jobs (>12% unemployment) Source: California FACTS, January 2011, LAO 11

Resource Reductions : CDPH ‘08 – ’09: 10% General Fund (GF) reduction ‘09 – ’10: Targeted GF Reductions –HIV –MCAH –Immunizations –MediCal Other: Furloughs, Hiring freeze 12

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 13

Trend in Local Health Department TB Program FTEs,

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,

Impact on CA TB Programs % 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 Source: TB program assessment tool 16

How may economic pressures affect TB patients? 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 17

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 18

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 evidence- based diagnostics and treatment regimens Strengthen partnerships Enhance public awareness 19

TB Control Indicators 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 genotyp ing Contact Investigation –Contacts elicited, evaluated, treated Adverse Events –TB Deaths –Pediatric cases TB Control Outcomes –Case rates 20

21 Program evaluation: California’s Report Card Culture conversion within 60 days COT within 1 year Contact evaluation Sputum culture reported Drug susceptibility results Universal genotyping Recommended initial therapy U.S. average Contacts elicited Foreign-born TB case rate Data reporting: RVCT U.S.-born TB case rate 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 Better Worse

Health Care Reform and TB What’s the Problem? Opportunities in HCR Partnerships 22

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 23

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 24

The Problem: Gaps Expected in Health Insurance Coverage Many California residents will remain uninsured due to: residency requirements income thresholds lapses in insurance coverage 25

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) 26

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 27

Opportunities for Public Health in HCR –Expanded Access –Focus on Prevention –Focus on Quality 28

Expanded Access Medicaid expansion Insurance Reform Expansion of System Capacity 29

Expanded Access: Insurance Reform 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 30

Expanded Access: System Capacity Expansion of Community Clinic Networks Expansion of Primary Care 31

Focus on Prevention Public Health and Wellness –Council –Prevention Framework –Fund No cost coverage of CPS 32

Prevention and Wellness Fund Public Health infrastructure improvement Epidemiology and laboratory capacity HIV reporting Home Visitation Community transformation Public health education/training 33

Mandatory No Cost Coverage of CPS ACIP USPSTF Bright Futures Preventive Services for Women 34

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 35

Focus on Quality: Accountable Care Organizations ACOs mandated to: –Improve the efficiency and effectiveness of health services –Control costs –Focus on prevention 36

Partnerships Community Clinics/FQHCs Public Hospitals Private Hospitals/practitioners 37

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 38

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 39

Charge of Health Departments and FQHCs LHDs: Population health and health- condition-specific clinical services FQHCs: Full continuum of primary and preventive care services 40

Populations served by community health centers overlap with populations at risk for TB Overlapping populations means increased access to care for many patients at high risk for TB Source: National Association of Community Health Centers 2010 Disproportionately low-income Most uninsured or publically insured Most members of racial/ethnic minority 41

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 42

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 healt h 43

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 44

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 45

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 46

47 TB Deaths during Therapy, by Provider Type,

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 48

Role of Public Health Departments Case management –DOT –Expert consultation –Interjurisidictional transfer of care Community disease control –Response to outbreaks –Extended contact investigations –Media releases –Public and provider education 49

Exciting Innovations for TB Dx and Rx Rapid diagnostics for TB and LTBI Shorter course treatment for LTBI 50

How can public health departments lead the way? 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 51

Summary California TB Landscape Economic and Budgetary Challenges Health Care Reform Focus on Partnerships Role of Local Health Departments 52

.. I am prejudiced beyond debate In favor of my right to choose Who will feel The stubborn ounces of my weight --B. Overstreet 53