Managed care is moving into treatment of TB
Here’s what to include in contracts
As more state Medicaid programs come under managed care, public health departments are finding opportunities for contracting with managed care organizations for what they do best. Contracts, however, are often vague and many departments don’t have policies and procedures in place to meet managed care standards, report TB managed care experts.
"The big thing for tuberculosis and public health right now is that a big portion of Medicaid patients are going into managed care systems," says Bess Miller, MD, associate director of science for the division of TB elimination at the Centers for Disease Control and Prevention. "We want public health to be at the table assuring that these things happen."
With such fundamental change taking place so rapidly in public health care delivery, many health departments have not had guidance or developed the expertise in how to work with managed care groups to ensure their continued involvement in disease prevention and control or to ensure that patient needs are met, she says. Reflecting these concerns, the Centers for Disease Control and Prevention has created an office of managed care to evaluate the impact of managed care on public health. Already, as many as 40% of Medicaid patients in the country are enrolled in what is called mandatory managed care, and many state Medicaid agencies are developing contracts with managed care organizations to spell out responsibilities for treatment and prevention of infectious diseases, including TB.
Managed care companies have set up various arrangements with public health departments for treating Medicaid patients who are diagnosed with TB. One of the more common arrangements is to carve out certain services, such as directly observed therapy and contact tracing, which managed care does not perform as well as health departments. The health department is subcontracted to perform these services either at a fee-for-service or capitated rate.
Some of the specific areas in TB that Miller says should be addressed in managed care contracts include:
• Tuberculosis requires long-term treatment, making it difficult for patients to take drugs without supervision.
• Directly observed therapy is the only way to ensure patients are compliant.
• Because TB is highly infectious, facilities must be vigilant about infection control, such as keeping infectious patients in isolation rooms.
Contracts a new tool for setting standards
Indeed, the contracts are a unique way of setting standards of health care delivery for managed care organizations that conform with public health practices. Many states, however, have been relying on written statements called memorandums of understanding. These agreements can become fairly specific in delineating responsibilities i.e., the health department will conduct contact tracing while the managed care organizations will treat the patient and in helping lay the groundwork for setting minimum standards for managed care in public health. At the same time, however, these memorandums, in many cases, are not legally binding, says Miller. (See related story on one state’s alternative to contracts, p. 29.)
For those state health departments that have developed contracts that include tuberculosis, many are deemed inadequate to ensure that managed care organizations will not drop the ball when it comes to diagnosing and treating tuberculosis, Miller notes.
In a partnership project with the Center for Health Policy Research at George Washington University in Washington, DC, and the CDC’s office of managed care, the division of TB eliminations has been reviewing state contracts between state Medicaid agencies and managed care organizations regarding TB. They have found that few contracts specifically mention how managed care will care for TB patients.
"For the most part, it wasn’t really in the contracts," Miller says. "A few states, such as California and New York, had some specifics in a couple of areas, but by and large, the states aren’t addressing specific disease circumstances and communicable disease issues."
Consequently, the CDC is developing a series of model contracts for tuberculosis, HIV, sexually transmitted diseases, immunizations, and other public health services that will provide states with a template to use when hammering out a contract.
"We think it is important in setting up a new way of doing business, a new way of setting medical standards through legal channels," Miller explains. "We have to get public health departments this information and from a legal point of view get them in a contract with managed care."
The model contract for TB is the first to be completed. The 20-page prototype deals with all aspects of TB control and prevention, including reporting cases, practicing infection control, controlling disease transmission, and guaranteeing treatment completion. A draft has been written and is being reviewed by state health officials and experts. By later this spring, it should be published in a peer-reviewed medical journal, Miller adds.
As subcontractors for managed care organizations, public health departments are selling their expertise in the treatment and follow-up of infectious diseases. And while they often can do a better job in this area than managed care organizations, many are not prepared to meet standards set by managed care, says Bradley Gilbert, MD. He is a former TB controller and current medical director of Inland Empire Health Plan, a Medi-Cal managed care company serving about 125,000 members in the Riverside, CA, area.
"Health departments believe they do the best job in terms of treatment and follow-up, and in many cases that is true," Gilbert tells TB Monitor. "But then what they say is, We want you to subcontract with us but we don’t want to really meet all your standards because it will cost us money or we have never had to meet them before.’"
As private health care providers have long known, working for managed care companies involves a flood of paperwork, requiring detailed information about their patients and the type of treatment provided.
"It’s not that health departments don’t have good standards; it’s just that they haven’t had to address some of the issues we have in managed care," Gilbert notes. "I’ve got all kinds of standards from the people who regulate me, and just because a health department subcontracts doesn’t mean we can give them a break."
Miller agrees that many health departments are not set up to meet the demands of managed care particularly in the areas of information processing, billing, and facility requirements.
The area in which they need most improvement is developing up-to-date billing systems, she says. A recent CDC survey of how managed care has impacted TB programs in state and major cities in the United States found that one-third did not have billing services and that nearly one-half are not getting reimbursed for the services they provide.
"Believe it or not, in many areas there are actually no billing systems in health departments, and we think that within this changing environment they are going to need to develop these systems," she says.
Not getting billed would sit just fine with some managed care companies, but Gilbert says his company wants to get billed because of the information the process provides about care.
Public health departments may also have trouble meeting other requirements, such as having 24-hour access to patients or providing adequate facilities, Gilbert notes. As a consultant hired to help a health department in California prepare for managed care, Gilbert says the changeover doesn’t require a lot of additional money but rather making sure the right policies and procedures are in place, particularly with medical records.
"Policies might include everything from an emergency plan to how you handle problems in the clinic with patients, how you triage, etc.," he says. "Most of this is taken for granted in private medicine, but most health departments haven’t been in the business of care under contractual arrangements."
For public health departments that are eager to get a piece of the managed care pie, writing a business plan can be a good way of selling themselves to managed care companies, he says. "I can write in one day a business plan that could prove to a managed care company that you could save them money through contact tracing and finding cases early, and that can be a major motivator," he says. "If there is a bad TB case that spreads into the community because you [the managed care company] didn’t take care of business, you are going to be on the front page."
For those tuberculosis programs already working with managed care companies and not happy with the relationship, Gilbert says it is not out of line to provide examples of where the care has been substandard. "Pick some bad cases and show how they were mishandled through the normal managed care methods," he says. "The fact is managed care is not organized to take care of people with infectious diseases. We are organized to take care of the individuals . . . but we are not good at contact tracing, finding other cases, and getting them treated."
With recent studies having found that too many TB patients have been hospitalized unnecessarily (see TB Monitor, March 1996, p. 30), managed care is expected to increase the use of outpatient treatment, but only as long as public health remains an active player in the cycle of care, Miller notes. "If there is a good tight system, then I think optimally there will be less hospitalization of TB patients. Unfortunately, what happens sometimes is that if you don’t have that type of system and patients are cared for in managed care settings, but there isn’t the follow-up, sometimes those patients wind up in the hospital."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content