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TB Notes 1, 2000
Where We've Been and Where We're Going: Perspectives from CDC's Partners in TB Control
Changes I've Seen
TB Control in New York City: A Recent History
Not by DOT Alone
Baltimore at the New Millennium
From Crickets to Condoms and Beyond
The Denver TB Program: Opportunity, Creativity, Persistence, and Luck
National Jewish: The 100-Year War Against TB
Earthquakes, Population Growth, and TB in Los Angeles County
TB in Alaska
CDC and the American Lung Association/ American Thoracic Society: an Enduring Public/Private Partnership
The Unusual Suspects
The Model TB Prevention and Control Centers: History and Purpose
My Perspective on TB Control over the Past Two to Three Decades
History of the IUATLD
Thoughts about the Future of TB Control in the United States
Where We've Been and Where We're Going: Perspectives from CDC
Early History of the CDC TB Division, 1944-1985
CDC Funding for TB Prevention and Control
Managed Care and TB Control - A New Era
Early Research Activities of the TB Control Division
The First TB Drug Clinical Trials
Current TB Drug Trials: The Tuberculosis Trials Consortium (TBTC)
TB Communications and Education
TB Control in the Information Age
Field Services Activities
TB's Public Health Heroes
Infection Control Issues
A Decade of Notable TB Outbreaks: A Selected Review
International Activities
The Role of CDC's Division of Quarantine in the Fight Against TB in the U.S.
The STOP TB Initiative, A Global Partnership
Seize the Moment - Personal Reflections
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TB Notes 1, 2000

Managed Care and TB Control A New Era

by Bess Miller, MD, MSc
Associate Director for Science, DTBE

After the TB sanatoria were closed during the 1960s and 1970s, typically both clinical care and public health functions for TB control were carried out in the health department setting. However, during the past three decades, there has been an increasing trend toward the provision of clinical care for patients with TB by the private sector. By 1998, about 50% of the care for patients with TB was provided either partially or totally by the private medical sector. More recently, the managed care transformation has increased this movement of patients with TB away from clinical care in health department settings. Patients with TB may be enrolled in managed care organizations as a result of coverage under employee benefit plans, privately purchased insurance policies, or as a result of enrollment in Medicaid or Medicare programs. The Omnibus Budget Reconciliation Act of 1993 (OBRA) permitted states to extend Medicaid coverage to persons with TB, and some states have used this legislation to enroll such patients in their Medicaid programs. In addition, as part of overall Medicaid managed care restructuring, a few states have expanded coverage to include previously uninsured persons. The vulnerable populations among the newly insured are likely to include persons at high risk for TB. The shifting of care of patients with TB into managed care plans, with the emphasis on management of costs, has raised new concerns in the public health community with regard to the ability to maintain adequate community TB control as well as to provide optimal management of patient care in light of these changes.

A survey of state and big city TB controllers conducted in collaboration with the National TB Controllers Association in late 1997 revealed the following: 1) health departments are still acting as the traditional provider of TB clinical services in most areas of the country; 2) in some areas, however, managed care has changed the way TB clinical services are being delivered (examples of these new arrangements included managed care organizations as providers of clinical services to their enrollees with TB, health departments acting as members of managed care organizations provider networks, and health departments acting as non-network, fee-for-service providers to managed care organizations); 3) health departments are providing the majority of public health services for TB patients who are enrolled in managed care organizations (contact tracing, providing directly observed therapy, and returning lost patients to care); 4) many managed care organizations are using their own or other private laboratories to process TB specimens, rather than state laboratories; and 5) in many areas, health departments are not being consistently reimbursed for providing TB services to patients with private insurance coverage or Medicaid coverage.

The pioneering industrial social worker Lee Frankel envisioned insurance as a powerful means toward improving the lot of the underprivileged. When he was hired by the Metropolitan Life Insurance Company, he established MetLife's Welfare Division. Frankel's early work centered on the prevention of TB, the "white plague" that accounted for 20 percent of all death claims. He realized that public education was the key. In 1909, 10,000 MetLife agents delivered Frankel's pamphlet A War Upon Consumption to millions of urban poor, who are most at risk for TB (source: Metropolitan Life Insurance Co. Web site).

During the past several years, there have been a number of symposia addressing the impact of managed care on TB control, which were conducted at national meetings of the American Public Health Association, the National TB Controllers Association, and the Centers for Disease Control and Prevention. In these symposia, a number of themes have emerged, including the urgency of ensuring quality care for TB patients by health care providers with expertise in treating TB; continuous treatment and completion of therapy with the use of DOT; use of laboratories with expertise in mycobacteriology; timely reporting of cases to the health department and initation of contact investigations; development and use of performance measures to monitor patient care and "public health performance"; and systems to ensure ongoing dialogue between health department staff and managed care organization providers.

At the same time, there is recognition that the delivery of health services through managed care organizations presents opportunities to public health leaders, including improved access to high-risk populations for preventive services and to health care providers for training and education on best practices. In addition, the administrative data systems of managed care organizations may provide opportunities for improved surveillance and evaluation of quality of care. The Division of Tuberculosis Elimination has collaborated with Harvard Pilgrim Health Care, a large mixed model health maintenance organization in New England, to review the use of administrative data systems to augment tuberculosis surveillance and the use of pharmacy records to assess the management of tuberculosis. (Please see "Supplementing tuberculosis surveillance with automated data from health maintenance organizations." Yokoe DS, Subramanyan GS, Nardell E, Sharnprapai S, McCray E, and Platt R. Emerging Infectious Diseases 1999; 5:779-787, and "Using automated pharmacy records to assess the management of tuberculosis." Subramanyan GS, Yokoe DS, Sharnprapai S, Nardell E, McCray E, and Platt R. Emerging Infectious Diseases 1999; 5:788-791). Administrative data sets provided useful information in both studies.

To assist health departments, State Medicaid Agencies, and managed care organizations in the development of written agreements to ensure the provision of quality patient care and public health TB prevention and control practice, DTBE has collaborated with the Office of Health Care Partnerships of the Epidemiology Program Office, CDC, and with the George Washington University Medical Center's Center for Health Policy Research to develop model contract specifications. (Refer to the article "Tuberculosis control in a changing health care system: Model contract specifications for managed care organizations." Miller B, Rosenbaum S, Stange PV, Solomon SL, and Castro KG. Clin Infect Dis 1998;27:677-686.) These specifications can be accessed on the internet at the following website:


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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