State uses board rules to control managed care
After attending a workshop last year on managed care and tuberculosis, the state TB controller of Colorado hit on a way to hold managed care responsible for needed care without having to be at the table every time a contract was written for care of TB patients. The solution? Rewrite the state’s board of health rules and regulations.
"We came away from that meeting thinking we should try to update our regs because we aren’t going to be at the negotiating table whenever these plans are put together," says Richard Hoffman, MD, TB control officer for the Colorado Department of Public Health and Environment. "So we came away from that meeting saying, Let’s try to update our regs.’"
At first, the main objective of the regulatory changes was to make sure managed care organizations didn’t see directly observed therapy (DOT) as optional. In the end, however, health officials added provisions for bringing laboratory reporting up to par and assuring that all hospital and nursing home employees, including physicians, are annually skin-tested. "We weren’t trying to restrict ourselves just to DOT, but rather we tried to think how we could do modern TB treatment, which means not only DOT but good laboratories and baseline information on health care workers," Hoffman tells TB Monitor.
The regulatory changes, approved by the board last spring, are believed to be one of the first of their kind as a method of setting standards for managed care of tuberculosis. Colorado had achieved widespread use of DOT and had provided funds so that many rural areas also had the resources to carry it out. Private physicians, however, were not reimbursed for DOT and faced the ongoing problem of losing control of their patients if they used the health department for DOT, Hoffman says.
While the regulatory changes required no legislative action, they have the enforcement power of law. Violators can be assessed penalties up to $1,000, Hoffman notes. Having yet to fine anyone, Hoffman says the penalty is not as much a deterrent as the threat of civil suits for negligence is.
Here is a thumbnail sketch of the new rules pertaining to the treatment and control of tuberculosis:
A. All confirmed or suspected cases of active TB disease must be reported to health departments or health agencies within 24 hours.
B. Physicians, health care providers, and health care facilities are required to report within a week positive ppd tests for workers employed by health care, correctional, or detention facilities.
C. Laboratories have 24 hours to report active TB disease results.
D. Laboratories that perform the tests must report them. However, an in-state lab that sends specimens outside the state also must report the results.
E. A laboratory may fulfill requirements in C and D by providing sputum specimens to the state laboratory or facilities located in five counties.
F. If cultures test positive for TB, a laboratory must store the isolate until it receives notification from the state or local health department that the patient has completed treatment.
G. State or local health departments have the authority to evaluate the timeliness of laboratory diagnostic processes.
H. The board requires that all people with active TB receive directly observed therapy. DOT is required for the full course of therapy unless a variance is obtained for a particular patient.
If a patient misses one dose, providers have seven days to report the patient’s name to the state or local health department, which can, if requested, provide DOT to outpatients.
I. Hospitals and health care facilities that provide in-patient treatment for active TB patients must notify the state or local health department after plans are made to discharge the patient, at which time the treatment plan and follow-up care is discussed.
J. All hospitals and nursing home facilities must maintain a register of TB skin test results of health care workers, including physicians and physician extenders who are not employees of the facility.
"OSHA rules enforce this requirement at the nursing home level, but they don’t include the doctors who aren’t employees," Hoffman explains. "The docs are all over the joint, and they’re like above the law, so we tried to say Uh-uh TB doesn’t know whether you’re a doc or a nurse’s aide."
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