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Could states set up contingency funds?
The high cost of treating foreign-born patients with drug resistance is taking a heavy toll on state and local TB programs, say program administrators across the country. Whether or not such patients are documented, they’re often ineligible for traditional funding sources such as Medicaid. At the same time, they’re more likely than U.S.-born patients to have expensive resistant strains of TB, many programs directors say.
To help underwrite the costs, some TB controllers are contemplating such distasteful steps as cutbacks in services and charging patients for the cost of their medications.
"These programs are saying they need help," says Walter Page, executive director of the Atlanta-based National TB Controllers Association. "They’re saying the cost of treating these patients is busting their budgets."
"We can usually handle these [foreign-born] cases when they’re not multidrug-resistant," says Ellen Mangione, MD, Colorado’s TB control officer. A TB strain is classified as multidrug-resistant (MDR) when it has resistance to both isoniazid (INH) and rifampin. "But many of us are seeing more and more MDR. We have two such cases right now, and it’s enough to put us into discussion about discontinuing other program activities, such as treatment for those with latent TB infection."
And that, she adds, doesn’t bode well for the future, because today’s latently infected patients, if left untreated, will provide tomorrow’s cases.
Others in Mangione’s shoes echo the same complaint. "It’s true that we have fewer TB cases overall, but the ones we do have tend to be sicker and harder to treat," says Kimberly Field, RN, head of TB control in Washington state. In 1999, for example, Washington recorded five cases of MDR-TB, compared to 1998, when there were none, or to the entire period from 1993 to 1997, when there were just three.
The cost of treating such cases can be astronomical, Field adds. Two years ago, she says, a rural Washington county got stuck with the tab for treating an undocumented foreign-born patient who proved resistant to six drugs. The cost of treatment exceeded not just the TB control budget, but the entire county budget, she adds.
"The impact of a single case of MDR can be very dramatic in a small county," says Ram Koppaka, MD, chief of TB control in Virginia and the Centers for Disease Control and Prevention technical officer for the state. "A local jurisdiction’s budget for TB control might be very small, so it doesn’t take much to break that budget."
Even cases that don’t qualify as multidrug-resistant can run up high costs, notes Nancy Baruch, RN, MS, MBA, Maryland’s TB control officer. "Increasingly, we’re seeing more of other kinds of patterns of resistance as well, including resistance to INH alone, or to INH and some other drug, such as streptomycin," Baruch notes. "Once you’ve lost INH, right there you’ve already increased the cost of treatment."
Mississippi eyes charging patients for meds
In Mississippi, TB control officer Mike Holcombe, MPA, says he’s contemplating a step he dreads taking. To scrape up money to treat foreign-born patients among his refugee populations, he’s thinking about trying to collect from Medicaid and third-party insurance programs — which translates to extracting payments and copayments from patients for their medications. "It’s exactly the opposite of what we want to do," he adds. "But to get reimbursement from Medicaid and insurance, you have to find a way to collect," he says. "Essentially, what this means is we may have to penalize other patients in the program in order to subsidize the refugee program."
What really smarts, many TB controllers add, is that those who make the decision to place refugees or to admit immigrants seem clueless about where, exactly, the public-health buck stops.
"People outside TB circles seem to assume that when a refugee or immigrant enters the country with TB, someone else’ will take care of the problem," he says. "They also assume that public health resources will automatically be made available to these people, and that public health in its current format will be able to go on absorbing these costs indefinitely. But ultimately, the problem belongs to the local TB program, and that local program has nowhere else to go."
Often, small local programs hit with an MDR-TB case for the first time are shocked to find they can’t simply go to the state program and get bailed out, Field says. The trouble is that the CDC expressly forbids the use of categorical funds to pay for medications. "That often comes as a shock to people when they find out that’s the case," she adds.
As for Medicaid — available in theory to anyone with a positive TB skin test — those funds are available only if states sign up and agree to put forward their part of the matching funds, says Holcombe. "Agencies assume that if someone isn’t eligible for Medicaid, that they can get refugee assistance funding," he adds. But he’s found out the hard way that such funds are available on the same basis as Medicaid, so a refugee who isn’t eligible for one isn’t going to be eligible for the other.
It’s all about fairness
Leaving local programs holding the bag strikes Holcombe and others as patently unfair. "If these folks arrive with no other funding available, and the State Department has let them come in, then I believe that the money for treating them should come out of State Department dollars," Holcombe says.
It’s not a question of wanting to keep out foreigners, Koppaka adds, but of providing for their care in a reasonable way. "If you’re a member of a refugee group, then you’ve got nowhere else to go, and you belong here," he says. "Still, people should give some thought about where the money will come from to treat these people. Is it fair to add that to the burdens of a local program, or should there perhaps be a national procedure to ensure treatment will be provided?"
One idea would be to establish some sort of trust fund for the treatment of such patients. Getting the feds to agree to foot the bill for such a program would take a major change in CDC policy because categorical money can’t be used to pay for TB medications.
That idea gets a chilly reception at the CDC. "The best way to deal with MDR-TB is to treat ordinary TB appropriately," says Zack Taylor, MD, new chief of the Field Services Branch at the CDC’s Division of TB Elimination. "We could get drawn into pouring a lot of money into treating MDR, and before you know it we’d be spending half our budget on it. Personally, I think CDC’s best strategy is to fund strong TB control programs."
That leaves MDR treatment up to individual states, or perhaps regions. In Washington State, a working group created the same year the state got hit with four MDR cases has been pitching just such a notion to the state lawmakers, says Field. The proposal has been presented twice, but so far hasn’t gotten anywhere, she adds — partly, she thinks, because other measures tacked onto the package distracted lawmakers from getting the real picture.
More money would help, but that’s not the only thing lacking, says Holcombe. Better notification and screening would go at least partway toward solving his headaches, he adds.
Take a recent episode involving a group of refugees from Kenya. Holcombe says he heard first that about 20 Kenyan "boys" would be arriving in Mississippi soon. That figure then changed to 40, then 50, and then 80. As the refugees began trickling in, it became clear that some of the "boys" were in fact adults, many of them toting newborn babies.
Meanwhile, paperwork on the Kenyans drifts in periodically to Holcombe’s desk, announcing that another handful of Kenyans arrived several weeks ago. That means that with luck, the refugees will still be where they’re supposed to be once TB control field workers catch up with them. With more luck, all they’ll need will be treatment for latent infection, not active disease or disease complicated by resistance.
Past experience with this kind of situation has made Holcombe less than optimistic, he adds. "I believe something needs to happen at the national level to modify both notification and screening procedures," he says. "The State Department knows when these people are coming - they don’t just materialize out of thin air. Why can’t they tell us when they’re coming? We shouldn’t be getting notifications after the fact."
Knowing beforehand at least would give him time to move extra personnel around, if needed, and would prevent refugees from moving on before TB investigators can locate them.
Screening needs to be tightened, too, Holcombe says, especially if more money for treatment is not forthcoming. Shortening the interval between the time an immigrant is screened and the time he or she is allowed to enter the United States is one much-needed step, he says. So is putting in place a better set of proficiency standards for those doing the screening. "I know that only a relative few slip through with active disease," he says. "But why should there be any? Why should I have one? Why should Carol Pozsik [the TB controller in South Carolina] have one?"
In Maryland, Baruch says she’s been able to juggle her expenses by shifting the costs of some patient care to a state facility, where the TB program traditionally sends both MDR cases and co-infected patients. Trouble is, the state facility has begun to balk at the high cost of treating these patients. For two weeks last month, in fact, it refused to take any such patients at all. With a temporary reprieve under her belt, Burr says she’s breathing easier these days.
But for the long run, TB controllers say, it’s going to take something more. Back in Washington, Field recounts an eye-opening visit she made recently to an electronics plant, where skin-testing was under way for 700 co-workers of a foreign-born patient with highly infectious TB. "I met people who were working there who were from Russia, Bosnia, Mexico, China, and Korea," she marvels. "To me, that says this trend will continue — and the issue we’ll be dealing with will be the cost."