Setting Priorities for Public Health Infectious Disease Programs

Transcription

1 Setting Priorities for Public Health Infectious Disease Programs Jay K. Varma, MD Deputy Commissioner for Disease Control New York City Department of Health and Mental Hygiene

2 New York City Department of Health and Mental Hygiene One health department for >8 million people Board of Health can pass regulations with force of law 6,000 staff Total budget $1.6 billion 100 outbreaks/year

3

4 Office of Viral Hepatitis Coordination Eric Rude, Nirah Johnson, Outreach Ashly Jordan, Program Manager OFFICE OF THE DEPUTY COMMISSIONER, DIVISION OF DISEASE CONTROL Jay K. Varma, MD Deputy Commissioner CDC Kevin Mahoney, MSW, Ass t Commissioner, Division Management Debora Mack,, Administrative Services Beth Cohen Barusek, Program Support Specialist Joycelyn Tait, Principal Administrative Associate BUREAU OF TB CONTROL Celine Gounder, MD, ScM Ass t Commissioner BUREAU OF IMMUNIZATION Jane Zucker, MD, MSc Ass t Commissioner CDC BUREAU OF PUBLIC HEALTH LABORATORY Jennifer Rakeman, PhD Ass t Commissioner BUREAU OF STD CONTROL Susan Blank, MD, MPH Ass t Commissioner CDC BUREAU OF HIV/AIDS PREVENTION & CONTROL M. Monica Sweeney, MD, MPH Ass t Commissioner BUREAU OF COMMUNICABLE DISEASE Marcelle Layton, MD Ass t Commissioner Vacant Deputy Dianne Turner Program Management Officer Vacant Deputy Sam Sebiyam Program Management Officer Lori Cohen, MPH of Administration Gee Abraham Administrative Services Michelle Macaraig, PhD, MPH Ass t, Policy & Planning Christopher Zimmerman, MD Medical David S. Haddow Administration Susan Wright STD Clinic Operations Colin Shepard, MD HIV/AIDS Epidemiology & Field Services Don Weiss, MD, MPH Surveillance Mary Masterson Administrative Services Diana Nilsen, MD Medical Affairs Shama Ahuja, PhD, MPH Surveillance & Epidemiology Amy Metroka Citywide Immunization Mark Misener, MD, MPH Clinical/Emergency Prep Martin R. Evans, PhD Technical Affairs and Environmental Sciences William Oleszko, PhD Associate Virology Julia Schillinger, MD, MPH Epidemiology & Surveillance CDC Anne Lifflander, MD, MPH Medical Affairs Graham Harriman, MA Interim Care & Treatment John Rojas, MPA of Housing Annie Fine, MD Medical Data Analysis Unit Scott Harper, MD, MPH Medical Zoonotic, Influenza & Vectorborne Disease CDC Errol Robinson Clinic Operations Christine Chuck Field Operations Edward Wake Adult Immunization Vacant Associate Microbiology Millicent Freeman Outreach & Education Brian Toro Regional Supervisor Case Investigations & Partner Services Blayne Cutler, MD, PhD HIV Prevention Program Sharon Balter, MD Medical Enterics Waterborne and Hepatitis Unit Martha Alexander, MHS, Education, Training & Outreach Kim Kong STD/TB Pharmacy DIVISION OF DISEASE CONTROL DIVISION AUGUST OF DISEASE 2012 CONTROL AUGUST 2012

5 Surveillance Major Activities Outbreak investigations Medical consultation Administer preventive interventions, including: Vaccines Condoms Public education

6 Diagnose disease Major Activities Directly: STDs, TB, public health lab, HIV Indirectly: HIV Treat disease Directly: STD, TB Indirectly: HIV

7 Major Activities Applied public health research Reference lab services, including bioterrorism response Policy and regulation Emergency preparedness

8 The Age of Austerity Hitting infectious disease programs hard ~50% of Department budget protected by law (none of it infectious diseases) New emphasis on chronic diseases New infectious disease threats and opportunities but no funding, e.g., Hepatitis C, resistant gonorrhea Threat of programs being eliminated before diseases are, e.g., TB

9 New York City Funds, Staffing for Infectious Disease Control Fiscal Yr City Funds (in millions) FTE 2008 $ $ $ $ During this time, Federal grants declined from $260 $246 million Push to move staff to grants Most FTEs (~ 700) now grant funded

10 Criteria to Assess Value of Infectious Disease Programs Legal requirement Likelihood that someone else will do it Incremental value health return on investment Revenue generating Are the Feds paying for it?

11 What s Left on the Table Public health laboratory Clinical services

12 Public Health Laboratory Unlike epidemiology programs, predominantly funded by local dollars An easy target for accountants Work in isolation and in facilities that no one wants to visit Low volume Lots of private laboratories Value difficult to quantify No natural constituency

13 Why You Can t Eliminate the Public Health Laboratory An unbiased reference laboratory Many labs don t perform classical microbiology and need us to definitively identify pathogens Low volume, high consequence testing, e.g., botulism, rabies

14 Why You Can t Eliminate the Public Health Laboratory Low clinical, high epidemiology value testing, e.g., genotyping Outsourcing is not cheaper over the long term Clinical labs pull you in with bargain prices, then suddenly increase price Once gone, you can t bring it back without enormous investment

15 Whither Clinical Services? 50% of TB cases, >80% of STD cases already treated in private sector A population health focus means we should shift focus toward assurance Mandated by state law to insure free, confidential treatment for TB and STDs Major cost is infrastructure, so substantial savings even with outsourcing

16 Whither Clinical Services? Authorized to collect 3 rd party reimbursement for some services State law does not allow us to bill for diagnosis, treatment of STDs, but does allow us to bill for other services provided in STD clinics, e.g., HIV testing For TB, global experience that private sector does not reliably adhere to standards when diagnosing, treating Clinical services creates a constituency

17 Staffing The Biggest Challenge New hiring frozen by City, with intermittent, erratic thaws Even grant funded positions not always approved, threatening grant performance Recruitment hampered by restrictions on salaries, prolonged hiring delays Turnover increasing with reductions in support staff, loss of perks, low morale

18 What Can We Do? Re-align ourselves according to services only public health departments can provide E.g., surveillance, assurance, policy Reassess value of services that public health has been paying for E.g., partner services for some patients with bacterial STDs, individual and group level HIV behavioral risk reduction

19 What Can We Do? Let the rich take care of the poor Creative ways to use funding from wealthy programs to support poorer programs Focus on cheap, effective approaches Regulation and other policies Leverage health information technology, e.g., immunization information systems Regionalization and shared lab services Small morale builders