CDC History of Tuberculosis Control - Medical and Public Health ...

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).
TB Control at the Millennium
48
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,