Los Angeles witnesses alarming decline in TB clinic visits
Singing the infrastructure blues
The fiscal crisis of 1995 that forced Los Angeles County to cut back its public health infrastructure to the bare bones may be starting to bear bitter fruit, administrators say.
With public health clinics trimmed from 49 to just 10, visits to public clinics were down 80% over the past year, says Shirley Fannin, MD, the county’s director of communicable disease control. Part of that drop, it appears, reflected a "precipitous" decline in tuberculosis screenings and visits related to prophylaxis for TB infection, says Paul Davidson, MD, MPH, the county’s chief of TB control. "If that’s true, then our real troubles are down the line," Fannin adds.
Paradoxically, the big piece of good news in the TB control picture looks terrible: Reported TB cases for 1996 aren’t down nearly as much as early reports had suggested. When the numbers were added up for the first quarter of 1996, it appeared that there had been a 40% drop in TB cases so shocking a decline that Fannin says she panicked when she saw the figures. "TB is a chronic disease things don’t change that quickly," she says.
Though it took the county some head-scratching to figure out what may have happened to produce the steep drop in cases, the reason for the decline in screenings and prophylaxis is simple. "There are fewer places doing it," Davidson says. "With just ten public health clinics left, people sometimes have to travel miles and miles to get to one. So sometimes they just don’t go."
Luckily, it’s different with patients assigned to directly observed therapy, he says. "They’re sick. Plus, we come after you if you don’t come in. With preventive therapy, we don’t do the outreach."
Exactly how big a decline there has been in clinic visits for prophylaxis and for screening is hard to say. Nothing requires that providers report skipped visits to pick up medication for prophylaxis or (with the exception of children three years old and under) positive skin tests. "We have a computerized system to track people on prophylaxis within our own system," Davidson says. But with quantities of patients getting shuffled into managed care and newly created public-private partnerships, the tracking systems of other providers still are taking shape, Davidson adds.
When the stomach-churning first-quarter figures first appeared, the Centers for Disease Control and Prevention quickly dispatched an operative to the scene to try to figure out whether, as Fannin and Davidson initially feared, the county’s fractured surveillance system had simply come unglued, leaving quantities of infectious TB patients walking the streets undetected and untreated.
Fortunately, by year’s end, the 40% drop had leveled out to a more plausible-sounding decline of about 15%, says Davidson. The CDC investigator never was able to pinpoint exactly what had happened to produce the 40% figure, Davidson says. It may have been an artifactual blip attributable partly to paperwork delays, as patients’ charts from clinics that had closed finally caught up with their owners at the remaining clinics.
Or, on the brighter side, some of the decrease may have been related to a hike in the percentage of TB patients receiving directly observed therapy, which Davidson’s department had worked hard to push up to where it now stands 43% of all TB cases.
In any event, by year’s end, the new, revised figures showed 1996 cases dropping just 15% over the previous year. "I’m still not entirely comfortable with that," says Fannin. "I’d be feeling better if we’d had only a 10 to 12% drop." To Davidson, 15% isn’t especially out of line with what’s happening in the rest of the state or with downward trends in TB cases the state had been experiencing over the past four years.
"I don’t think there are people wandering the streets no more than the average numbers from past years, that is with active TB who’ve fallen through the cracks," he says. "They’re getting picked up. They’re getting reported. And I think they’re getting care."
Still, it’s hard to be sure of that, thanks to another pair of on-going situations.
For one thing, the whole state is in the throes of shifting its "MediCal" patients (as Medicaid patients are called in California) into managed care. The managed care systems picking them up are supposed to be tending to screening and prophylaxis needs, but the verdict is still out on how well the MCOs will do.
"They’re just beginning to realize that preventive care includes that as part of their responsibility," Davidson says.
The new managed care system was supposed to gear up earlier this month, but as TB Monitor was going to press, the start day had been postponed. The problem? Medicaid patients had been instructed to pick a managed care group but were told they’d be assigned by computer if they failed to make a choice. With little information to go on, many patients expressed no preference; then, when a computer made the decision for them, patients in a neighboring county found some family members had been assigned to a clinic around the corner and others to a clinic a hundred miles away, Davidson says. And so it was back to the drawing board.
Once the system gets up and running, there’s the question of who will provide directly observed therapy (DOT) to TB patients who need it.
If the managed care systems opt to do it themselves, that will create a monitoring headache of immense proportions, Davidson says. "In the past, the community’s always been more than happy to have the county take care of TB," he adds. Tentative plans call for a "carve out" of DOT, which is for the better, he says. At the same time, given its sharply reduced capabilities and just ten clinics remaining, will the county be able to cope?
Cutting back on inpatient care
As if the move to managed care weren’t providing enough distraction, the county health department also is under orders to cut back on inpatient care and replace it with less costly outpatient care, Davidson says. The inpatient to outpatient shift is one of the conditions of the $364 million bail-out package provided by the federal government, which stepped in at the last second to allay a looming fiscal crisis that threatened to plunge the county into bankruptcy. (See TB Monitor, January 1996, p. 1.)
The terms of the bail-out left the county scrambling to form public-private partnerships with facilities that can take up the slack. "Setting them up has been a kind of nightmare," says Davidson. The "partners," many of which are community-based health care organizations, are frequently capable of doing TB skin testing, but not all have an X-ray machine, says Davidson. That means, patients who test positive will have to be referred someplace else to a facility on the other side of town, perhaps to get their chest X-rays.
The county took pruning shears to its infrastructure in October 1995 when 49 public health clinics were folded into ten and 25 health districts into nine. True, some of the clinics that were shut down were just service centers, not full clinics, Fannin says. But the end result of the process has not been a happy one, she adds.
Overcrowded staff are having a hard time finding a place to plug in their telephones and park their desks, much less the necessary space to take care of patients, Fannin says. Morale is low. "People who had a vision find they can no longer carry that vision through," she says.
Increasing population poses problem
Even if space in the small, antiquated clinics that remain were not a problem, the sheer numbers are discouraging. The ten clinics that remain must serve the needs of the county’s 9-plus million population, which is spread out over 4,080 square miles. During the last decade alone, Fannin points out, the county added 1.5 million people. "In most places, public health services would be burgeoning, not shrinking," Fannin says.
The downsizing was not accomplished slowly and thoughtfully, she adds. "It was the most disorderly process I’ve ever witnessed," she says. "You can’t turn a $2.3 billion system around on a dime; it takes massive planning efforts, day-by-day leadership." Instead, the system was rudderless several months until the county’s new "health czar" was finally appointed.
"As a numbers person, I don’t believe you can make those kinds of massive changes in numbers on one side of the equation, without causing significant changes on the other side as well," Fannin says. "You can’t do that and still be sure you’re seeing the part of the population you need to see." Exactly how much TB care will be impacted remains to be seen, she admits. "But you can’t wait around until the stats come in," she says. "You can’t just sit on your hands and say, Well, let’s see what happens!’ That’s not what public health is supposed to be about."
"We’re experiencing a lot of what you might call growing pains right now," says Davidson. "With everything else that’s going on, trying to fit TB into the picture is almost the least of our worries."
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