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Hiring retired HRSA staffer was first step
TB control programs struggling to pay for foreign-born patients with multidrug-resistant TB are watching California with especially keen interest these days.
Already known for their wizardry in tapping into Medicaid funding — the program goes by the name of MediCAL in California — state TB controllers in California are now considering how best to drill for additional Medicaid gushers.
Already, certain jurisdictions in the state have better-than-average success in enrolling eligible TB patients into Medicaid, rendering local jurisdictions eligible for reimbursement on a fee-for-service basis for directly observed therapy and directly observed preventive therapy. At $19.20 a visit, that’s not a bad start.
Also, under the present arrangements (in California as elsewhere), local jurisdictions can get paid for inpatient care for "emergency" patients — but only assuming the MediCAL program can be persuaded that the patient is truly an "emergency." That sounds good in theory, but proves a tough sell in practice, most TB administrators say, because it means they have to convince a hospital to take a patient on the off chance that the patient will be deemed an emergency at some point.
What the California TB policy wonks want now are three more things, says Stuart McMullen, the senior public health advisor assigned to the state TB control program.
First, he says, they’re working to expand MediCAL benefits to cover inpatient as well as outpatient care. That would fill the gaps for someone who needs to be hospitalized but who doesn’t qualify for "emergency" status.
Second, the program wants to expand the definition of "emergency" to cover all TB cases in which a cure is still pending.
Third, it wants to extend MediCAL benefits to undocumented patients as well as documented patients.
Finally — and most promising, perhaps — the program is considering collecting fee-for-service reimbursement for directly observed therapy and other outpatient services performed in a specific setting: namely, places known as Federally Qualified Health Centers (FQHCs).
As McMullen explains it, any local jurisdiction can declare itself an FQHC if it’s willing to tackle the paperwork, which includes enumerating all reimbursable costs and all patient visits and then divvying them up so as to arrive at a reimbursement rate for each center.
The good news, as it turns out, is that the FQHCs in California haven’t been billing for outpatient services performed by many staff members, even though they apparently can start doing so, McMullen says. How did this oversight occur? It seems the health centers can legally bill the feds only for patient visits performed by either a physician, a physician assistant, or a nurse practitioner. Thus, the bean-counters at the centers had duly not billed anyone at all for costs of their clinic nurses and field workers.
But it would be perfectly legal for the centers to seek reimbursement under the old fee-for-service arrangement, adds McMullen, which is exactly what he hopes MediCAL officials will start letting them do.
It’s a scheme that ought to work for any state where there are FQHCs, he says. "The only caveat here is that the health centers can’t use state or federal money to hire these outreach workers, since that would be double-dipping," he points out.
The real question may not be whether the Californians will score hits on all these fronts, but how they were so clever as to think them up in the first place. It turns out that the answer to that one is easy.
"We found a retired guy from HRSA," the Health Resources Services Administration of the federal Department of Health and Human Services, McMullen says. "And we hired him. He’s been sorting all this stuff out for us."
Even with such a resource at hand, dealing with Medicaid isn’t an easy proposition, McMullen admits. It’s extremely complicated; plus, the social service workers whose task it is to guide patients through the mountains of paperwork are often ticklish about spending lots of time cooped up with a TB patient, he says.
To keep jurisdictions on an even keel, the state offers periodic inservice training sessions in how to deal with the Medicaid beast.
For the rest of the world -- or at least for programs that can’t find their own retired HRSA staffer to hire -- TB controllers who want to know more about how Medicaid works can contact McMullen, he says.