Leveraging Health Department Capacities,Partnerships,and Health Insurance for Infectious Disease Response in Massachusetts,2014-2018

Abstract

Policies facilitating integration of public health programs can improve the public health response, but the literature on approaches to integration across multiple system levels is limited. We describe the efforts of the Massachusetts Department of Public Health to integrate its HIV, viral hepatitis, sexually transmitted infection (STI), and tuberculosis response through policies that mandated contracted organizations to submit specimens for testing to the Massachusetts State Public Health Laboratory; co-test blood specimens for HIV, hepatitis C virus (HCV), and syphilis; integrate HIV, viral hepatitis, and STI disease surveillance and case management in a single data system; and implement an integrated infectious disease drug assistance program. From 2014 through 2018, the number of tests performed by the Massachusetts State Public Health Laboratory increased from 16 321 to 33 674 for HIV, from 11 054 to 33 670 for HCV, and from 19 169 to 30 830 for syphilis. Service contracts enabled rapid response to outbreaks of HIV, hepatitis A, and hepatitis B. Key challenges included lack of a billing infrastructure at the Massachusetts State Public Health Laboratory; the need to complete negotiations with insurers and to establish a retained revenue account to receive health insurance reimbursements for testing services; and time to train testing providers in phlebotomy for required testing. Investing in laboratory infrastructure; creating billing mechanisms to maximize health insurance reimbursement; proactively engaging providers, community members, and other stakeholders; and building capacity to transform practices are needed. Using multilevel policy approaches to integrate the public health response to HIV, STI, viral hepatitis, and tuberculosis is feasible and adaptable to other public health programs.

The Massachusetts Department of Public Health (MDPH) Bureau of Infectious Disease and Laboratory Sciences administers an integrated system of prevention, care, treatment, and control for HIV, viral hepatitis, sexually transmitted infections (STIs), and tuberculosis (TB). In this case study, integration refers to the administration of prevention, testing, treatment, and case management for all 4 communicable infections through services delivered by MDPH and contracted health care and nonmedical providers (hereinafter, providers). Integration of the response to these infections is efficient because of the overlap in populations at risk, locations where care is accessed, ability to test a single blood specimen for multiple infectious agents, and likelihood of coinfection. Integration is also an effective strategy to increase co-testing for HIV, hepatitis C virus (HCV), and syphilis through a single blood specimen and to promote treatment for co-occurring conditions.

Integration of public health efforts in Massachusetts has occurred incrementally since 2010 and has required new and expanded public health, laboratory, and contracted provider capacities, as well as adoption of regulatory frameworks and public health strategies. Policies that permit and promote integration are a prerequisite for operationalizing the integration of HIV, HCV, STI, and TB services but require substantial time and resources (eg, training for health department staff members and health care providers) and may take years to demonstrate efficiencies. Policy approaches that support integration include requirements for new laboratory protocols, allowable use of state resources and contractor performance, and legal and regulatory changes.

In this case study, we describe policies that have enabled improved public health response via integration and the time frame needed to achieve integration. Examples from the literature reinforce how policies formalizing structural integration can improve the public health response. Gasner et al ¹ describe how changes in state and local laws enabled data sharing among HIV, STI, viral hepatitis, and TB surveillance systems in New York City and improved the public health response to these infectious conditions, but they note that it took time to accomplish regulatory changes. Fenton et al ² describe policy examples, including HIV/HCV co-testing in a correctional facility in Massachusetts, as well as automated HIV co-testing in an emergency department for patients tested for STI and the addition of opt-out HIV testing to TB contact tracing protocols, both in North Carolina, and reinforce how policies to routinize integration improved the public health response.

Our case study adds to the literature by describing the combined effects of policy approaches at the regulatory, health department, and health care system levels to integrate the public health response to HIV, STI, viral hepatitis, and TB in Massachusetts. Effective policies integrated disease surveillance activities, created new revenue streams, and mandated integrated scopes of services for contracted providers. Whereas Gasner et al ¹ focused on integration of surveillance activities, we analyzed the concurrent implementation of policies to require co-testing for HIV, HCV, and syphilis simultaneously at the Massachusetts State Public Health Laboratory (MSPHL) and in the contracted provider system. We describe ways in which these policy steps were synergistic and increased overall testing volumes and diagnoses of syphilis and HCV infection. Fenton et al ² examined the effects of policies to require co-testing in particular venues (eg, emergency departments, correctional facilities) as well as in the context of TB contact tracing activities. Our case study from Massachusetts further describes opportunities for health departments to implement policies that increase co-testing at multiple venues across a statewide system, such as community health centers (CHCs) and nonmedical community-based organizations, by changing both MSPHL and contracted provider practices.

In 2006, passage of Massachusetts state health care reform increased access to public and private health insurance coverage. ³ The rates of health insurance coverage further expanded in 2010 after passage of the Patient Protection and Affordable Care Act ⁴ ; in 2017, more than 97% of Massachusetts residents were insured. ⁵ Low-income state residents have access to comprehensive health insurance primarily through the state Medicaid program and through health insurance premium subsidies resulting from state health care reforms and the Affordable Care Act. These benefits entitle Massachusetts residents to coverage for HIV, HCV, STI, and TB prevention, care, and treatment services, although insurance reimbursement alone is insufficient to meet the needs of priority populations at elevated risk of HIV, HCV, STI, and TB infections without additional state and federal investments.

Massachusetts has a robust medical infrastructure, including 52 CHCs and academic medical centers in multiple regions of the state. MDPH began establishing contracts for HIV prevention, care, and treatment services with CHCs and hospitals in the early 1990s by using federal resources from the Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS program, the Centers for Disease Control and Prevention (CDC), and Massachusetts state funds. These investments focused on geographic areas disproportionately affected by the HIV epidemic and agencies that reached populations at risk for HIV, HCV, STIs, and TB (eg, men who have sex with men [MSM], persons who inject drugs [PWID], transgender persons, and persons who are non-US born). Policies that support integration leverage Massachusetts’ health care and health insurance systems.

Massachusetts integrated the MDPH HIV, viral hepatitis, STI, and TB response at multiple levels—including surveillance and laboratory protocols and performance requirements for contracts with providers—by using policies to facilitate adoption of transformative practices. In this case study, we define policies that have contributed to successful integration, highlight opportunities to access health insurance reimbursement and generate revenue for public health services, and describe contracting mechanisms to accomplish integration in direct service programs. We describe policy approaches in 3 areas: regulatory and legislative changes, health department capacity, and contracted service system requirements. We examine the relationship among these policies; increased levels of HIV, HCV, and STI testing and diagnosis; and improvements in the public health response. We describe testing volumes and outcomes for infectious conditions before and after policies were implemented, identify challenges and solutions, and review lessons learned.

Methods

Legislative and Regulatory Approaches

Changes to legislative and regulatory policies supported integration through expanded use of AIDS-specific state funding and enhanced surveillance. The Massachusetts State AIDS budget line item (#4512-0103 HIV/AIDS Prevention and Treatment Services) historically restricted expenditures of state resources from this budget line to AIDS-specific services. In response to increasing rates of STIs and HCV infection, the Massachusetts State Legislature expanded budget language in 2012 to include STI and viral hepatitis services. ⁶ The policy to modify the authorized use of state funds did not substantially change the total amount allocated but did expand the use of funds to respond to all 3 categories of communicable infections. The Massachusetts State Legislature added language to require third-party billing by MSPHL in 2016 ⁷ and added language to authorize the use of funds on this budget line for TB prevention and treatment in 2017. ⁸ Revenue from billing was essential to sustain and expand laboratory and surveillance capacities. Amendments to state disease reporting regulations enhanced surveillance capacity by mandating laboratory reporting directly to MDPH and provided data necessary to initiate public health investigation and to follow up more quickly than is possible with clinician-initiated case reporting. ⁹

Health Department Capacity

Laboratory

MSPHL conducts testing for HIV, HCV, syphilis, gonorrhea, and chlamydia, in addition to chemical and environmental threats. Since 2015, all serum samples submitted to MSPHL have been co-tested for HIV and HCV infection; syphilis co-testing was added in July 2018. Since 2015, all urine and extra-genital samples have been co-tested for gonorrhea and chlamydia. The co-testing policy ensures that patients are screened for multiple conditions of public health importance and gives MDPH immediate access to laboratory results necessary for public health investigation and follow-up. The capacity for MSPHL to integrate testing for these conditions was enabled by revenue generated through health insurance reimbursement.

Disease surveillance

MDPH uses the Massachusetts Virtual Epidemiologic Network (MAVEN) platform for infectious disease surveillance. MAVEN is a secure, web-based disease surveillance and case management system used for all reportable infections in Massachusetts. ¹⁰ From 2014 through 2018, MDPH implemented a policy to integrate sexually transmitted disease (STD) and HIV surveillance into MAVEN. Before 2016, STD and HIV surveillance data were collected in separate systems that did not interact (STD*MIS [Sexually Transmitted Disease Management Information System] and eHARS [Enhanced HIV/AIDS Reporting System]). ¹¹ MAVEN enables the collection of timely and complete disease surveillance information at the person level and allows MDPH field epidemiologists to conduct follow-up, particularly of coinfections, more efficiently than when surveillance information was contained in discrete data systems.

Contracted Service System Requirements

MDPH purchased a set of services that included primary prevention, integrated testing, and linkage-to-care and treatment services for HIV, HCV, STI, and TB. MDPH posted a Request for Responses from organizations eligible to receive state funds and awarded multiyear contracts to deliver integrated HIV, HCV, STI, and TB services. The procurement specified integration of services as an expected outcome, operationalized through unified performance expectations and compliance requirements. ¹² Purchase of these services through contract agreements with funded organizations was an efficient policy mechanism to establish performance requirements of an integrated infectious disease service system as a condition of award, including collaboration with MDPH. Contract requirements to enforce policies related to integration of HIV, HCV, STI, and TB services and that are relevant to this case study included the submission of all samples to MSPHL for HIV, HCV, and STI co-testing and the collection of client health insurance information at the time of testing so that MDPH could be reimbursed for testing services by client insurance. Policies that allowed for billing generated revenue needed to sustain laboratory services and ensured compliance with state budget language. MDPH further enhanced disease surveillance by using Electronic Medical Record Support for Public Health (ESP), an open-source software application that extracts and transmits notifiable electronic health record information from medical care organizations to MDPH. ¹³ Procurement policy requires contracted vendors to participate in ESP, which facilitates compliance with HIV, viral hepatitis, STI, and TB disease reporting. In addition, by supplementing data received through MDPH case report forms, ESP promotes an integrated public health response by providing a more complete picture of medical care and clinical outcomes relevant to public health than what is received from health care providers on case report forms or through electronic laboratory reporting alone.

Outcomes

HIV, HCV, and Syphilis Testing Volumes and New Diagnoses

Policy approaches were associated with an increase in testing overall and for relevant conditions. From 2014 to 2018, the number of HIV tests increased by 106% (from 16 321 to 33 674), and the number of new HIV diagnoses decreased from 191 to 160. Of 847 HIV-positive tests during this period, 195 (23%) were new diagnoses. The number of tests for HCV infection increased by 205% (from 11 054 to 33 670), and the number of new HCV diagnoses increased from 687 to 4971. The number of tests for syphilis increased by 61% (from 19 169 to 30 830), and the number of new syphilis diagnoses increased from 531 to 1539.

The policy that required HIV/HCV/syphilis co-testing was also associated with improved identification of HCV infection and syphilis and with increased testing among MSM and PWID, who have the highest rates of HIV infection (including coinfection with HIV and syphilis) and HCV infection, respectively. The percentage of HCV tests with positive results increased from 6% in 2015, when HCV co-testing was initiated, to 14% in 2018; the percentage of syphilis tests with positive results increased from 3% in 2016 to 6% in 2018, after HIV/HCV/syphilis co-testing was added. HIV/HCV/syphilis co-testing also increased among prioritized populations (eg, PWID, MSM) that are most affected by these infections in Massachusetts: by 63% among PWID and by 48% among MSM. Conversely, the percentage of HIV tests with positive results declined from 1.2% (191 of 16 321) of tests in 2014 to 0.5% (160 of 33 674) of tests in 2018. From 2014 to 2018, linkage-to-care rates, as reported by providers, increased from 69% to 80% among persons newly diagnosed with HIV infection, and from 7% to 48% among persons newly diagnosed with HCV infection. Although we did not track and enforce linkage to care for syphilis in 2014, referral to STD treatment for persons diagnosed with syphilis was 68% in 2014, and 80% of persons diagnosed with syphilis were linked to treatment in 2018.

HIV and Viral Hepatitis Outbreak Response

From 2017 through 2019, Massachusetts identified outbreaks of hepatitis A and hepatitis B infection among homeless and substance-using populations in multiple regions of the state. Massachusetts’ integrated surveillance system and the contracted network of health care and nonmedical providers delivering integrated services facilitated a prompt response to these outbreaks. Integration of surveillance data and case management functions enabled prompt identification of outbreaks and provided a mechanism to rapidly deploy interventions. Contracted agencies provided care coordination and linkage supports for viral hepatitis and were contractually obligated to coordinate public health responses with MDPH. These agencies were directed to place vaccination clinics in venues likely to reach persons at risk of HIV and viral hepatitis infection, increase vaccination among subgroups at greatest risk for morbidity and mortality from coinfection, and link newly diagnosed and symptomatic persons to care. Vaccination efforts took place in syringe services programs, shelters, correctional facilities, HIV/AIDS service organizations, and mobile outreach vans. The MDPH Bureau of Infectious Disease and Laboratory Sciences and local health departments supplied state-purchased vaccine directly to contracted organizations, and direct care staff members and public health nurses administered educational interventions and vaccines.

In August 2016, MDPH received notification from a CHC in Lawrence, a city in northeastern Massachusetts, about an increase in new HIV diagnoses among PWID. In January 2017, MDPH received a similar notification from a CHC in the nearby city of Lowell. Both CHCs are contracted by MDPH for integrated testing and linkage, and MDPH in collaboration with CDC initiated an outbreak investigation. MSPHL co-tested blood samples for HIV and HCV infection; persons diagnosed with HIV infection during the acute phase received immediate public health follow-up. When exposure mode was unknown, HCV test results in MAVEN were used as a proxy for current or recent injection drug use among persons newly diagnosed with HIV infection; these HCV-positive test results identified more persons meeting the case definition for inclusion in the outbreak clusters than reliance on exposure mode documented in case report forms alone, which did not document a history of injection drug use for all persons ultimately identified as cluster cases. MDPH sent blood samples to CDC for molecular sequencing and confirmed a regional HIV outbreak involving 157 persons. ¹⁴ The CHCs received increased funds to expand testing and linkage-to-care services for PWID. In both cities, local boards of health authorized syringe services programs, which allowed MDPH to expand access to sterile injection equipment. Policies that required integrated service delivery under the contract enabled the rapid addition of new resources and expanded service scope to respond to the outbreak.

Infectious Disease Drug Assistance Program

Policies that broadened the allowable use of funding in the state budget’s HIV/AIDS Prevention and Treatment Services line item enabled MDPH to build on the infrastructure of the HRSA-funded HIV Drug Assistance Program to improve access to treatment for persons diagnosed with TB infection, as well as to nonoccupational postexposure prophylaxis and preexposure prophylaxis for persons at high risk for HIV infection. The Infectious Disease Drug Assistance Program (IDDAP) enrolls more than 8000 income-eligible persons annually. Most enrollees are state residents diagnosed with HIV infection who receive financial assistance through the HIV Drug Assistance Program to access health insurance premium assistance and/or HIV treatment. Coverage of nonoccupational postexposure prophylaxis and preexposure prophylaxis was added to IDDAP in 1997 and 2016, respectively, and 1995 persons received assistance with preventive medication (1425 received nonoccupational postexposure prophylaxis assistance, 571 received preexposure prophylaxis assistance, and 1 received both) from program inception through June 2019. From the time Tuberculosis Drug Assistance Program services began in 2016 through June 2019, 1347 persons with TB infection received financial assistance to acquire medication. MDPH is exploring the addition of STI treatment and HCV treatment to IDDAP for mono-infected persons. (HCV treatment for income-eligible HIV-positive persons living with coinfection is currently covered by IDDAP.)

Lessons Learned

From 2014 through 2018, a combination of sequential policy approaches in Massachusetts led to integrated HIV, viral hepatitis, STI, and TB activities and improved response to these infections at both the health department and contracted system levels. MDPH began with a foundation of high rates of health insurance coverage and established CHC and public health capacities. This foundation, combined with legislative and regulatory changes, policies to promote functional linkage of health department surveillance and response activities, and service contract requirements, helped achieve integration. Before 2014, although contracted providers could request syphilis and HCV co-testing from MSPHL, rates of co-testing were low. Laboratory requirements to perform HIV, HCV, and syphilis co-testing; integrated surveillance of HIV, HCV, and STI diagnoses; and public health follow-up, in addition to contract requirements to integrate prevention, care, and treatment services for these infections, created synergies that increased testing volumes for all infections.

We encountered multiple challenges with policy implementation. First, because the state public health laboratory lacked an infrastructure for billing, an external billing agent handled procurement and contracting. The engagement with an external billing agent required participation by senior MDPH staff members with expertise in health insurance coverage rules and billing practices and identification of mechanisms to receive, store, and transmit billing data. Activities to plan and implement third-party billing created additional work for staff members and took more time than anticipated; however, it was an essential step to secure the resource base to sustain the costs of integrated testing at MSPHL. Second, we had to negotiate extensively with private health insurers and establish a state-retained revenue account to collect revenue generated by third-party billing of MSPHL services, a process that also took more time than anticipated and led to delays in implementation.

Third, the requirement for contracted providers to submit blood specimens for all HIV, HCV, and syphilis testing required investment in phlebotomy training and proper specimen submission practices, which had to be completed before integrated testing could be operationalized. A shift to require blood-based testing through phlebotomy also required near-complete elimination of contract support for rapid HIV testing (RHT), which raised concerns from providers who relied on RHT to perform HIV testing in the field or other nontraditional settings, to respond to client preferences for specimen collection via finger stick rather than venipuncture, and to deliver testing and results during a single encounter to persons perceived to be unlikely to return for a follow-up visit. We facilitated discussions with community members and advisory groups to describe the benefits of integrated blood-based testing and hear and respond to their concerns about the shift from RHT to blood draws, and we developed training for providers to support this transition. Health departments that are looking to increase integrated testing for HIV, HCV, and syphilis by requiring blood draws should anticipate the need to examine the role of RHT and either disallow or substantially limit RHT because, in our experience, the option to perform RHT reduced motivation to transition to blood-based testing.

Fourth, contracted providers were initially resistant to requesting health insurance information from clients because many direct care providers perceived that requesting health insurance information created an access barrier to integrated testing services and was inconsistent with low-threshold entry to care, which requires minimal or no conditional requirements for clients to access HIV prevention services. We created new training resources to support the collection of health insurance information, and we closely monitored the uptake of providers collecting client billing information so we could reinforce billing expectations with providers who were out of compliance. However, we had delays in generating the levels of revenue initially projected because of the lengthy process associated with establishing contracts with health insurers.

Fifth, although HIV/HCV co-testing substantially increased the detection of new HCV antibody-positive cases, MSPHL did not implement HCV nucleic acid testing until July 2018, which made it difficult to confirm chronic HCV infection and link infected persons to care. Confirmation of chronic HCV infection by HCV RNA is a prerequisite for health insurance coverage of HCV treatment and may be a more powerful motivator for persons who test positive for the HCV antibody to link to care than a positive HCV antibody test alone. Although rates of linkage to care and treatment for persons with HIV, HCV, and syphilis increased after integration, continued improvement in this area is a priority for MDPH.

Sixth, integrated testing also contributed to a higher-than-expected proportion of HIV diagnoses reported among persons previously identified as HIV positive. In 2017, 77% (652 of 847) of positive HIV tests were found among persons previously diagnosed as HIV positive. The high proportion of HIV-positive tests among persons previously diagnosed as HIV positive may be a result of increased HIV testing as a result of required co-testing. For example, persons who presented for HCV or STI testing who may have been HIV positive were automatically co-tested for HIV because of MDPH’s co-testing policy. Fenton et al ² similarly described that 100% of persons identified with HIV infection as a result of HIV testing integrated into TB contact investigations were previously diagnosed but that previously HIV-diagnosed persons were relinked to care and prioritized for latent TB treatment. In Massachusetts, we also found that the requirement for co-testing increased the proportion of HIV diagnoses among persons previously diagnosed as HIV positive, but it presented an opportunity to identify and relink to care HIV-positive persons who may have fallen out of care.

Gasner et al ¹ describe the value of data sharing among HIV, STI, TB, and viral hepatitis surveillance systems to provide a more complete picture of cases (eg, demographic characteristics, coinfections) and how enacting laws and policies that enabled analyses across discrete infectious disease surveillance systems provided a better understanding of syndemic conditions and affected population groups and improved the public health response. In Massachusetts, we integrated HIV, STI, viral hepatitis, and TB surveillance into a single data system (MAVEN), which similarly optimized an integrated response but without the need to perform analyses across discrete data systems. MAVEN provides immediate access to person-level, real-time data across HIV, HCV, STI, and TB, a degree of timeliness Gasner et al noted was missing in the New York City experience. This timeliness was particularly useful in the responses to the 2016 and 2017 outbreaks of HIV infection in PWID in northeastern Massachusetts noted in our case study. We examined internal MDPH policies related to personnel access to surveillance data across HIV, STI, viral hepatitis, and TB to confirm adherence to MDPH data security and confidentiality requirements. Compliance with these requirements was facilitated by the inclusion of HIV, STI, viral hepatitis, and TB divisions under the unified administration of the MDPH Bureau of Infectious Disease and Laboratory Sciences. We also shared plans with our Massachusetts Integrated HIV Prevention and Care Committee to integrate HIV, STI, viral hepatitis, and TB surveillance and response activities and provide opportunities for questions and feedback from advisory group members. For health departments that are planning to integrate HIV, HCV, STI, and TB services, we strongly recommend expanding the advisory charge of existing integrated HIV prevention and care planning groups; we found that those groups were well prepared to provide guidance on all 4 infections.

Although beyond the scope of this case study, operationalizing the policies that promote integration requires investment in training, education, and development of system capacity to support their adoption and is necessary to facilitate the success of these policies. Both state and federal funds are needed to cover costs associated with implementing policies that promote integration. Programmatic interventions alone, such as clinical advisories, capacity-building offerings, and evidence-based interventions, may be insufficient to generate the necessary motivation or momentum to accomplish integration and demonstrate improvements in health outcomes. Expanded health department infrastructure—notably laboratory, surveillance, and epidemiologic capacities—was a result of policy approaches and may also have contributed independently to integration. The policy requirement to deliver integrated services as a condition of contract award increased testing volumes, established an infrastructure to scale up public health responses to outbreaks, and advanced communication and collaboration between funded providers and MDPH. A decline in the HIV seropositivity rate may be an outcome of increased volumes of persons tested, as a result of the requirement for integrated testing and because co-testing for HIV infection reaches more persons than previously possible. In our experience, the value of increased testing for all 4 infections and increased diagnoses of syphilis and HCV infection (including coinfections) outweighed the outcome of lower HIV seropositivity rates. However, the lower HIV seropositivity rates may have implications for how state and local health departments, CDC, and other funders set performance benchmarks to identify new HIV diagnoses in the context of integrated testing. Policy approaches combined with coordinated investments in integrated testing, linkage to care, and treatment for HIV, HCV, STI, and TB operationalized levels of integration that would not have been possible had these policies been launched independently.

Conclusion

Massachusetts found success in using policy approaches to promote integration of public health responses to HIV, HCV, STI, and TB. Policy approaches took substantial time and resources to implement but resulted in improvements to our laboratory, surveillance, testing, and linkage-to-care capacities relative to HIV, HCV, STI, and TB. We are encouraged by these successes and will apply strategies and lessons learned to other infectious conditions. For example, we may further seek to use regulatory or legislative strategies to expand disease reporting requirements or to allow health insurance billing for other services performed by MSPHL. Similarly, refinement of our policy for providing integrated prevention, care, and treatment services for HIV, HCV, STI, and TB may allow for integration of testing and treatment services for other infectious conditions, such as hepatitis A and hepatitis B, and for providing vaccination services.