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Anguished lament: It’s the paperwork, stupid’
(Editor’s note: Last month, we reported on how one county in California is benefiting from a 1993 amendment to the Social Security Act, which made Medicaid benefits available to anyone with a positive tuberculin skin test. In Wisconsin, by comparison, TB controllers hadn’t decided whether all their diligent efforts to make the program pay off were worth it. This month, we report on experiences of three other states.)
In Oklahoma, TB controllers tell what appears to be a cautionary tale about their experiences with TB-related Medicaid.
"We have definitely had some problems," sighs Julie Cox-Kain, financial officer for the state’s Acute Disease Service. For starters, both health department staff and TB patients alike are anything but keen on the notion of spending time filling out forms for a service everyone knows will be provided, whether paperwork gets done or not.
"Especially among our older patients in rural areas, there’s still quite a stigma attached to welfare, and they don’t want to be on a program they consider to be a welfare program," she says. Health department employees have their own quarrel with the program, she adds: "They feel like we’ve provided TB services all these years free of charge, and without making people go through all this, and that we should still do it that way."
From the start, state officials worked hard to bring human service and public health employees on board. Upper-echelon staff took off on a statewide tour to explain and promote the TB-related Medicaid benefits package.
"We held meetings in every single county and trained everyone," says Cox-Kain. In retrospect, she’s not sure all the work had much impact. A year later, a spot-check showed that even clinic staff in high-prevalence counties were turning up their noses at the new funding formula.
To complicate matters, state legislators, in a bid to introduce managed care to the state’s health care system, decided to split off the chunk of the department of human services that previously handled Medicaid claims and to entrust it to a newly created entity known as the Oklahoma Healthcare Authority.
No one seemed certain what part of TB care would be covered by the new capitation rates under this new system, Cox-Kain says, and when doctors went to collect, coverage often was denied.
Fairly high employee turnover in both departments — the old human services department and the new health care authority — doesn’t help, either. "We’ll have someone at the state level who understands what the cap covers, and then suddenly we’ll lose them," she says.
That has meant, among other things, that when Cox-Kain tried to reduce the paperwork load as a way of bringing balky employees at the county level to heel, she was rebuffed by stressed-out state bureaucrats who assured her that changing the paperwork now would only confuse their employees more.
The upshot of it all is that for the moment, TB-related Medicaid benefits are managing to pay for no more than the salary of the single person who rides herd on the paperwork.
"I didn’t think it was going to be this hard," says Cox-Kain. Still, she’s not ready to throw in the towel. "The health department needs to pay attention to as many funding sources as possible. We need to try one more time to get out the word on this thing."
Minnesota sets up emergency fund
In Minnesota, TB controllers took a long look at the package of TB-related Medicaid benefits, and stepped away. What they did instead was to convince state lawmakers to set aside a fund specifically for TB emergencies. Last month, TB controllers dipped into the emergency fund for the first time, using some of the money to place a homeless, noncompliant TB patient with a history of alcohol abuse into a residential treatment center, where he would finish the rest of his therapy.
With only about 200 cases a year, having an emergency fund set aside to cover costly, uninsured patients has worked well so far. Plus, it didn’t seem as if the trouble of setting up the program would be worth it.
But times are changing. The state’s foreign-born population of TB cases has begun to increase dramatically (see related story, p. 89), spurred on most recently by an influx of Somali refugees. Many of the refugees work in low-paying jobs and are reluctant to spend their hard-earned money on insurance, which means when they reactivate with old TB infections, the state is left holding the bag.
That’s why TB controllers around the state have decided, albeit a bit reluctantly, to take one more look at the TB-related Medicaid option, says Alain Hankey, MS, MPH, division manager for Health Protection Services in the Hennepin County Health Department. What worries Hankey is that the Somalis, though poor, may not be poor enough to be Medicaid-eligible. "So I’m still not sure it’s going to work," she says.
In Tennessee, as in Oklahoma, managed care seems to have collided with early attempts to get the TB-related Medicaid machine running. Armed with a federal waiver, Tennessee was one of the first states to march boldly into the managed care arena; enrollment for indigent residents grew rapidly from a half-million to 1.2 million enrollees, then the program started to have financial troubles, and physicians began bailing out.
"One problem is that poor people tend to wait until they’re sicker than hell and then access their care through the emergency room," says Bill Moore, MD, MPH, state epidemiologist and TB control officer. The result is that with TennCare enrollment closed to all but those under 18 and the disabled, lots of uninsured and underinsured TB patients have out in the cold without coverage, and the state health department gets stuck with the bill.