Ouch! Feds take knife to cooperative programs

Smaller pots, competition influence decisions

Even before federal dollars are re-awarded to TB control programs in mid-November for fiscal year 2000, one thing is clear: Some programs are going to be hurt.

"We don’t like this either," says Patricia Simone, MD, chief of the Field Services Branch of the Division of Tuberculosis Elimination at the Centers for Disease Control and Prevention (CDC). "It’s no fun to have level funding."

The combination of fewer federal dollars overall, coupled with heavy competition for a relatively small amount of money set aside for targeted screening, has anxiety levels simmering in many TB control programs.

"I guess what scares us a little bit is that the money people get will depend to some extent on the number of cases programs have counted in the last year," says Carol Pozsik, RN, MPH, director of South Carolina’s Division of TB Control, and the president of the National Tuberculosis Controllers Association (NTCA). "In my heart, I know that those of us who’ve done a good job bringing our numbers down won’t be penalized for it — and that’s what they tell us. But we have to be very careful to back up how we’ve spent the money they’ve given us."

A silver lining called the IOM report?

The silver lining, if one is out there, may be found inside a contractual agreement the CDC recently signed, requesting a formal review of TB programs from the National Academy of Science’s Institute of Medicine (IOM) (see related article, p. 40). If all goes well, observers say, the IOM review could help leverage more money for TB programs from federal and state sources.

The recently published IOM review of sexually transmitted diseases, for example, had the effect of doing just that. By riveting press and public attention, the IOM report diverted a welcome flood of dollars into STD programs across the nation.

For now, trimmed-back federal funding for TB programs has been split into two categories, or "pots," says Simone. For carrying out core activities, between $86 million and $91 million will be awarded; for activities geared toward elimination (including targeted screening programs), between $5 million and $10 million will be doled out.

Exactly how much money ultimately will wind up in each pot isn’t yet set in stone, says Paul Poppe, associate director for management and operations for the CDC’s Division of TB Elimination (DTBE).

"Fiscally, [the two activities] aren’t easily divisible," he explains. "We’re not sure how much states are spending on the two kinds of activities, because in practice, they’re often integrated."

The DTBE estimates that about 10% of federal dollars go to targeted testing, says Simone. Though some TB controllers have groused that separating the two pots doesn’t reflect real-life needs of programs, there was a reason for doing so, adds Simone: to make sure there would be enough money given out for core activities.

The nation’s three TB model centers will be put on short rations along with everyone else, adds Poppe. Implicit in the DTBE’s recent announcement that "between two to three awards" will be handed out to model centers means just what it seems to say, he adds: One of the three model centers may not make the cut, and as a result may be shut down.

Competition for money in the second pot will be keen, with programs ranked according to merit in three areas. "It’s important that applicants do a good job of clearly diagnosing their need for TB programs," Poppe says. "They also need to do a good job of documenting their progress toward objectives."

If programs can’t show progress toward meeting national goals, they at least need to demonstrate progress toward meeting their own goals, and to give some indication of when they’ll be meeting national goals, he adds.

"We don’t want [targeted screening] programs out there reinventing the wheel," adds Simone. "We especially want to cut back on unnecessary testing. We’re telling people not to test low-risk groups; and not to test groups unless you think you can get them to complete preventive therapy."

Programs also should have an outbreak response in place, according to Poppe and Simone.

"That’s especially critical in low-incidence areas," Poppe says. "People need to think about what they would do if they suddenly had a half dozen new cases reported. Could they shift some of their own resources around?"

Smaller caseloads may equal less funding

As for money in the first pot — the one designated for core activities — no one will be left out in the cold, say DTBE officials. At the same time, it’s clear that some programs will emerge more equal than others; and that those that have seen big drops in caseloads may see commensurate drops in funding.

"Our intent is not to devastate one program for the sake of others," Poppe says. "On the other hand, we’ve made it clear there will likely be some redistribution of money."

Applications will be rated according to two processes, Poppe says. Applications for money for core activities will be graded on what amounts to a pass/fail system known as a Technical Acceptability Review, or TAR.

"I suspect everyone will pass, and everyone will get some funds, because all areas should have the ability to conduct basic core activities," Poppe says.

For the competitive part of the application, an objective review panel will assign scores and rankings based on specific criteria. Mem bers of the panel won’t necessarily be insiders familiar with TB control programs, Poppe adds, "so in theory it’ll be a truly objective review."

Big cities that have separate funding will be allowed to keep their separate funding status and won’t become just one more city competing for state money, notes Walter Paige, executive director of the NTCA. "We queried states where there was separate funding for big cities, and universally the response was that they all wanted to continue with the present arrangement," he says.