Little-used Medicaid program is well worth the trouble, fans say
First step is to have lunch with your state Medicaid officer
Most TB control programs know by now that since 1994, a special category of TB-related Medicaid benefits — a juicy-looking package that provides reimbursement for directly observed therapy (DOT) and directly observed preventive therapy (DOPT), prescription drugs, and laboratory and physician services — has been available to indigent patients who wouldn’t qualify otherwise.
Yet only eight states currently are taking advantage of the Medicaid TB-related option. The remaining states, some TB experts say, are just plain missing the boat.
"To me, it’s incredible that other people aren’t taking advantage of this," says Karen Smith, MD, medical consultant to the TB control program in Santa Clara County, CA. "We get a significant amount of revenue from this program."
In Santa Clara County, that revenue is used mainly to pay for care of documented immigrants and refugees, including Class B-2 immigrants, a classification that refers to an immigrant or refugee with chest X-ray changes consistent with old, healed TB lesions. It provides reimbursement for DOPT, DOT, prescription medicines, and a host of physician and laboratory services, including molecular fingerprinting. Just as important, Smith says, the extra revenue frees up categorical funding for other needs, such as providing services for undocumented immigrants who aren’t eligible for Medicaid but still need TB-related services.
Santa Clara County’s success with the program has caught the eye of the state’s head of TB control, Sarah Royce, MD. "The question to me is, how can we increase use of this program in the rest of California?" says Royce. "We’re really interested in expanding its use."
Not only does Royce like the way the program frees up scanty categorical funding for other much-needed purposes, she likes its quality of "expandability," meaning that all a county has to do to get more revenues is to find some eligible clients. Try doing that with categorical funding, she says.
Reports from Wisconsin, one of the other states where the option is being used, aren’t quite as glowing. Even so, TB experts there say they’re far from ready to give up on the program. "Our experience has been a mixed bag, but I’d much rather have this [program] than not," says Savitri Tsering, MSSW, public health educator for the state TB control division.
The reason some public health departments have had better luck than others — and why others haven’t tried using it at all — may be partly the result of a lack of communication between Medicaid and public health officials, says Tim Westmoreland, JD, the senior policy fellow at Georgetown University Law Center who, as an aide to Rep. Henry Waxman (D-CA), crafted the TB option in 1993.
"In many states, state health officers and Medicaid officials just don’t talk to each other," Westmoreland says. "That means that on one side of the state capitol building, there’s a state Medicaid eligibility officer who doesn’t think this eligibility class is really needed, and somewhere on the other side of the building, the state public health officer is sitting there needing a lot more money for TB services."
Getting the state Medicaid officer to sign off on the TB-related eligibility category may be easier said than done, says Mike Holcombe, MPA, TB controller for the state of Mississippi. After all, Medicaid is a matching program, which means states must put up as much as half (or, in some cases, as little as a quarter) of the money that goes into the Medicaid pot. "It could be more states aren’t using this because the state Medi caid folks have their money committed to other stuff. They may not want to come up with additional money," Holcombe says.
In Wisconsin, TB controllers say they’ve had success in arguing that it’s better to pay now — by providing DOPT, or by making sure indigent, uninsured TB patients get the medical care they need — than to pay later, Tsering notes.
In California, with a much higher TB incidence rate than Wisconsin and a big supply of undocumented cases also needing attention, the decision to use the TB Medicaid option has been an even easier call.
But just opening the doors of communication at the state level hasn’t been enough, TB experts in both states say. "Most of the [social service] people who do Medicaid aren’t even aware of this program," Smith says. "So you end up having to educate them, even though they might think they’re the world’s experts. Once you’ve set up these relationships, the whole process becomes so much easier."
Social service workers with attitude
That’s certainly been the case in Wisconsin, Tsering says. Even though she’s made sure everyone in public health knows about the TB-related option, she says her biggest challenge so far has been to convince county social service workers that the option really does exist. "There’s been a little bit of animosity," she concedes. "It’s like, Who are you to tell us about our jobs?’" Once the state Medicaid office makes good on a recent promise to send out a memorandum to all its employees on the subject, she trusts matters will improve.
Then there’s the not-so-minor matter of paperwork, along with other logistics. "The paperwork is voluminous," says Betty Kinoshita, RN, manager of the Santa Clara County TB clinic and by all accounts the person who’s done the most to get the wheels of the system running smoothly. One of Kinoshita’s solutions to the paperwork logjam — a stroke of genius, says Smith — was to convince the state Board of Regents it would be a worthwhile investment to provide, up front, enough money to hire two TB clinic-based "eligibility workers."
The board agreed; now the two eligibility workers’ only job is to guide potential recipients, many of whom need the services of a bilingual interpreter, through an 18-page maze of paperwork. As for whether the investment would be a sound one, Kinoshita’s instincts have proven correct: The increased Medicaid revenues have more than made up for the two workers’ salaries.
Even better, Kinoshita says, the county Medi caid office recently assigned two clerks full-time to the job of processing the eligibility forms; that has markedly reduced the turnaround time from application to receipt of eligibility.
One more advantage of Kinoshita’s system is that simply by having the eligibility workers stationed in the clinic, the state has located many additional clients eligible for "straight" Medicaid (called MediCAL in California) who otherwise might have slipped through the cracks.
That only leaves a few details for Kinoshita to iron out. For one thing, she says, it’s very important to warn clients what they’re getting into. Let them know the first paperwork session will be long and arduous, she advises.
Also, because many recipients in Santa Clara County are immigrants who intend to apply for citizenship, some were initially reluctant to apply for what they perceived as a government "welfare" program, a move they feared might later be held as a mark against them. Their fears were laid to rest when the Department of Justice issued a statement, published in the Federal Register May 26, 1999, declaring that receipt of Medicaid services would not cause an immigrant to be labeled a "public charge."
Finally, Kinoshita had to reassure the clinic-based eligibility workers that they wouldn’t get TB by spending two days a week in the TB clinic. "I had to do a lot of education," she says. "We have ultraviolet lighting, negative air flow, and many other protective measures. I let them know they were probably at greater risk for getting TB in the grocery store than the clinic."
A remedy born of urgency
Other states where at least some counties are using the TB-related benefit include Texas, Minn esota, Tennessee, Utah, Oklahoma, and Wyoming. TB controllers in Washington, DC, also are taking advantage of the Medicaid benefit.
Until recently, New York state also used the option; but once the state got permission to use an "1115 waiver" — a complex mechanism designed to let states waive the usual Medicaid eligibility requirements, usually for the purpose of conducting a pilot program — state health officials decided to lump TB-related cases in with the rest of the waiver package, says Rob Kenny, a state health department spokesman.
The TB-related Medicaid option was born out of what TB controllers said was an urgent need at the time, says Westmoreland.
In 1993, Waxman served as chair of the Commerce Committee’s subcommittee on health and the environment, which provided funding for the Centers for Disease Control and Prevention in Atlanta. "When the TB epidemic underwent a resurgence in the early 1990s, many state and city health officers came and told us that their biggest group of TB patients didn’t fit into any of the categories for Medicaid eligibility," Westmoreland says.
That is, the TB patients were indigent enough to meet the Medicaid mean-test for income, but often they didn’t fit into at least one of the other requisite categories: They weren’t mothers with dependent children on welfare; they weren’t disabled; and they weren’t over age 65.
All the same, these medically indigent patients were running up enormous bills. They needed therapy for MDR-TB; they needed DOT; and in some cases, they needed lengthy hospitalizations.
To remedy some of those problems, Waxman introduced legislation that became part of the 1993 budget bill, creating a special category of eligibility for TB suspects, TB cases, and people latently infected with TB. That meant states, which already were paying for these patients’ medical needs, could begin collecting federal matching funds for a wide range of outpatient services.
Though the new category provision didn’t provide for hospitalization, Westmoreland is convinced states still can recoup hospitalization expenses, at least in some cases.
"Anyone who needs inpatient services for TB is, by definition, disabled," he reasons. Thus, by declaring such patients disabled, states could, in theory, collect matching funds for their inpatient care under "straight" Medicaid, by invoking the conventional eligibility category for the disabled.
Like Royce, Westmoreland avows that states not using the option are missing out on a big opportunity. "It lets states save more of their categorical money to strengthen their programs in ways they couldn’t do otherwise," he says. "They can save these categorical funds for people who aren’t eligible for Medicaid, either because they’re undocumented or because they make too much money."
That brings up the issue of income eligibility. To be eligible for Medicaid, Westmoreland points out, "you have to be very, very poor." States set their own eligibility levels, but generally, "very poor" translates to having assets worth no more than about $2,000. Income eligibility levels are equally tough: In the strictest states, Medicaid recipients can’t make more than about $200 a month.
Numbers of eligible patients grow
It isn’t always easy to predict how many TB patients may meet such requirements. In Santa Clara County, Kinoshita figures that about 20% of her patients are receiving Medicaid, but whether they’re getting "straight" Medicaid or the TB-related kind, she can’t say. In Wisconsin, state TB controller Tanya Beyer knows that about 20% of her patients are eligible for "regular" Medicaid but not how many more could be getting TB-related Medicaid.
Still, as clients eligible for TB-related Medi - caid have been pulled into the system, Beyer has watched the number of patients getting TB benefits grow from an average of 29.5 a month in 1996, to 66.8 per month in 1997, to 175 per month in 1998.
The only source of increased funding
One thing is certain, says Westmoreland: The Medicaid TB option is the only source of increased TB funding out there at the moment. At a recent meeting of the Institute of Medicine, where Westmoreland had been invited to speak on the prospects for increased TB funding from Congress, he was blunt. "I told them there is no prospect at all — not with things they way they are now, at least."
That doesn’t mean there is no hope, he adds. The Medicaid option is the single most underused mechanism for funding increases, he says. His advice: More TB control programs ought to get out there and try using it.
(Editor’s note: Next month’s TB Monitor will explore what other states are doing with the TB-related Medicaid option.)
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