Tennessee has outsourced most of its contact tracing to a medical billing company with no experience in epidemiology. And despite spending tens of millions of dollars on the effort, the state has published very little evidence to show how the company is doing.
Every state in the country has had to build a contact tracing program to handle the scale of this pandemic. And there weren’t even close to enough contact tracers to do the job, so they’ve had to train them. Many take the same one-day crash course from Johns Hopkins University.
At this point in the pandemic, contact tracers are mostly focused on getting positive patients to isolate, convincing their contacts to quarantine for 14 days and identifying clusters of cases in hopes of stopping transmission. But to be most effective, it requires moving quickly. And many families interviewed by WPLN News have stories like Kellie Baker, a real estate agent in Williamson County.
“I mean, what’s the point of finding this out 11 days later?” she asks.
Her teenage son had been exposed to someone who tested positive for COVID at his high school.
But by the time they got the call in early October, he only had a few days left to quarantine. And he’d been hanging out with friends and going to his after-school job. He even went to the zoo, oblivious that he should be holed up in his house.
“I don’t know that there’s a good reason to keep contact tracing if it’s not going to work in a timely fashion,” Baker says.
But it’s unclear if the anecdotal delays are improving over time or worsening. The company hired by the state to manage contact tracing doesn’t publish any data that would show its productivity.
Struggling to stay ahead of infections
At first, Tennessee repurposed hundreds of idled state employees to monitor contacts but needed to replace them once their usual jobs resumed.
Documents obtained under the state’s open records law show the state Department of Health signed an initial $20 million contract in June with XTend Healthcare based in Hendersonville. That amount has likely grown as they’ve hired hundreds more contact tracers than first estimated — around 900 at this point.
The company pays $16 an hour for employees to make calls from home on their own computer while charging the state nearly $40 an hour for each worker’s time, according to its contract.
WPLN News interviewed four Xtend contact tracers who were not authorized by the company to talk to the media. They described extended backups when they were sometimes reaching patients after their infectious periods had passed or, for close contacts, after the point that they would have to quarantine.
It’s hard to confirm through information disclosed to the public whether the Tennessee delays have improved. An October analysis by NPR found that 22 states are publishing the progress of contact tracers on a government website. But unlike a growing number of states, Tennessee hasn’t regularly reported those figures.
Several other Xtend employees described a similar delay. But Xtend, whose primary business is medical bill collections, did not make anyone available for an interview, nor did its parent company, student loan giant Navient.
“Prior to the pandemic, we were not doing contact tracing, but our expertise and infrastructure allows us to ramp up quickly and communicate effectively with large numbers of citizens,” Navient spokesman Paul Hartwick wrote in an email. “A fundamental strength of Xtend is conducting patient communications on a large scale while displaying respect for people dealing with health issues, appropriately handling sensitive and protected health information, and complying with relevant regulations.”
Other states have also outsourced contact tracing, At least four states have turned to government contracting giant Maximus, including Tennessee neighbors Kentucky and North Carolina. Florida also uses Maximus and does regularly release some contact tracing information, like how many cases had contact with other known cases.
Hard to tell progress without metrics
“I’ve been really shocked, frankly, that the state of Tennessee has not put out any contact tracing metrics,” says Melissa McPheeters, an epidemiologist and professor at Vanderbilt University who used to work for the state health department.
An internal report from September showed it was taking about two business days to make the first call. But that’s only after people ended up in a state database, which could be several days after they tested positive or were named by a patient as a close contact. About one in five people reached by contact tracers either wouldn’t answer questions or never returned calls.
The state does have weekly reports from Xtend, though they’re mostly focused on call volume and not effectiveness. But even those metrics are not publicly available and required WPLN News to make an open records request.
McPheeters says people need more transparency so they’ll be motivated to help contact tracers do their jobs and abide by quarantine and isolation orders.
“I think that it’s fundamental for us to know what is our department of health doing,” McPheeters says. “But without any metrics, it’s, it’s hard to tell.”
Local officials trying to respond to outbreaks also want more information.
Several county mayors say the health department, if it indeed knows, has been unwilling to share any specifics about where cases are originating, even though identifying clusters is a primary purpose for contact tracing. Coffee County Mayor Gary Cordell says they cite patient privacy.
“We’re not asking for names or addresses or anything like that,” Cordell says. “We’re just trying to find out for the sake of our county as to what do you think is driving this? What are the issues? But [they say] it’s HIPAA protected, we can’t tell you. So we don’t know.”
But other health departments, including Nashville’s, have found a way to release fairly specific cluster data.
For its part, the state acknowledges there have been bumps in the outsourcing of contact tracing. But epidemiologist Jane Yackley, who oversees the program, defends the decision to privatize much of the operation.
“We went from really not having enough staff to do the job, and we could have been getting zero information, to now having enough staff to at least reach you and begin to get information,” she says.
Yackley points out that thousands of people are being interviewed every day.
“There are natural delays in this process that some can be fixed and some can’t be,” she says.
She says she doesn’t see the “utility” in reporting more detailed metrics, like how long it’s taking to reach people.
Like any job, contact tracing is one you can get better at over time, says epidemiologist Emily Gurley of Johns Hopkins University. She created a seven-hour online crash course used by Tennessee and many other states.
“Most of the programs I know are still a work in progress,” she says.
But even incremental improvements, like reaching contacts one day earlier, make a measurable difference in slowing the pandemic, she says.
“But you’ve got to have data coming out of the program to be able to make evidence-based decisions on how to improve.”
Gurley says being transparent is a good sign that a contact tracing program is ready to learn and willing to be held accountable.
How we reported this story:
WPLN News began background interviews with Tennessee contact tracers in September, leading to multiple open records requests to the Tennessee Department of Health for contracts and internal reports. A dozen patients and close contacts of positive cases shared their experiences with state monitors.