Download Presentation - Treatment Access Expansion Project

Improving Accessing to HIV Care
through Health Care Reform
Ryan White All Grantee Meeting
November 28, 2012
Robert Greenwald, Treatment Access Expansion Project
Andrea Weddle, HIV Medicine Association
Anne Donnelly, Project Inform
Learning Objectives
• Participants will be able to describe the latest status of health care reform,
particularly the Medicaid expansion, and evaluate how reforms may affect
access to HIV care.
• Participants will be able to identify recommendations from California
providers and advocates for effectively transitioning uninsured people
with HIV into health care coverage.
• Participants will be able to describe key reform issues relevant to HIV
medical providers.
PRESENTATION OUTLINE
• Part 1: Where We Are, Where We Are
Headed
• Part 2: Federal Implementation Update
• Part 3: Keys to Success: Lessons Learned
from California
Where We Are:
Status Quo = Access to Care Crisis
Medicaid/ Medicare are
lifelines to care, but
disability standard means
they are very limited
Impossible to
obtain individual
insurance and few
insured through
employer system
Demand for Ryan
White care and
services > funding
The Current Crisis
42-59% of lowincome people
living with HIV
not in regular
care
29% of people
living with HIV
uninsured
Ryan White Program Not Keeping Pace with Increased Need
Number of People Living with AIDS in the US vs. Ryan White Funding (adjusted for inflation)
2002
2003
2004
2005
2006
2007
2008
Sources: “Estimated Number of Persons Living with AIDS,” Centers for Disease Control and Prevention,
http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/table12.htm; Ryan White Appropriations History, Heath Resources and Services Administration,
ftp://ftp.hrsa.gov/hab/fundinghis06.xls. Inflation calculated using http://www.usinflationcalculator.com;
www.cdc.gov/hiv/surveillance/resources/reports/2009report/pdf/table16a.pdf; “Funding, FY2007-FY2010 Appropriations by Program, hab.hrsa.gov/reports/funding.html
ACA Implementation Must Address
Engagement and Retention
in Quality Health Care
Engagement in Selected Stages of
HIV Care
approx. 1.1.
National HIV/AIDS Strategy calls for:
• Increasing HIV screening and
improve linkages to care
• Increasing retention in care rates
• Closing the gap between those who
need antiretrovirals (ARVs) and
those who are on ARVs
• Providing needed care and support
services to increase treatment
adherence and number of persons
with undetectable viral load rates
million
infected
100%
90%
80%
70%
82%
(902,000)
66%
(726,000)
60%
50%
40%
30%
20%
10%
0%
37%
(407,000)
33%
(363,000)
25%
(275,000)
Where We Are Going:
Great Potential But Successful
Implementation Will Decide
Improves Medicaid:
Expands eligibility (state option); provides essential health benefits
(EHB) (federal and state regulations); improves reimbursement for
PCPs (only 2013-14); includes health home (state option); allows
for free preventive services (state option for Medicaid).
Creates Private Insurance Exchanges:
Provides subsidies up to 400% FPL (federal and state regulation);
eliminates premiums based on health/gender; provides EHB
(federal and state regulation); supports outreach, patient
navigation and enrollment (federal and state regulation); and
allows for Basic Health Plan (state option).
Only with Successful Medicaid Expansion and Exchange Development
Will We Dramatically Improve Health Outcomes and Meet Prevention Goals
Massachusetts as a Case Study of
Successful Health Reform
Implementation
Massachusetts: A Post Health Care
Reform State in a Pre-Reform Country
• Expanded Medicaid coverage to pre-disabled people living with HIV
with an income up to 200% FPL (2001)
• Enacted private health insurance reform with a heavily subsidized
insurance plan for those with income up to 300% FPL (2006)
• Protected a strong Medicaid program for “already” & “newly” eligibles
• Re-tooled Ryan White Program
– ADAP funding largely spent on insurance not Rx (2006)
– Ryan White Program 75/25 rule waived to allow for increased
support of essential support services (2007)
– Maintaining unrestricted formulary and 500% FPL eligibility (2006 present)
The MA case study provides insight into how health reforms and
Ryan White Program work together to meet NHAS Goals
Massachusetts’ Successful Reform
Implementation Improves Health Outcomes
and Meets NHAS Goals
MA Outcomes v. National Outcomes
100
80
Percent
60
40
20
0
In Medical Care
Taking HIV Medications
Virally Suppressed
Health Good to
Excellent
MA Outcomes
99
91
72
70
CDC MMWR (National Outcomes)
41
36
28
0
Source: Massachusetts and Southern New Hampshire HIV/AIDS Consumer
Study Final Report, December 2011, JSI Research and Training, Inc. Note: MA
Outcomes N = 1,004
Source: Cohen, Stacy M., et. al., Vital Signs: HIV Prevention Through Care
and Treatment — United States, CDC MMWR, 60(47);1618-1623
(December 2, 2011); Note: National Outcomes HIV-infected, N =
1,178,350; HIV-diagnosed, n=941,950
MA Reform Demonstrates Successful
Implementation Reduces New Infections & AIDS
Mortality
• Between 2006 & 2009, Massachusetts new HIV diagnoses
rates fell by 25% compared to a 2% national increase
• Current MA new HIV diagnoses rates have fallen by 46%
• Between 2002 & 2008, Massachusetts AIDS mortality rates
decreased by 44% compared to 33% nationally
Sources: MA Dept of Public Health, Regional HIV/AIDS Epidemiologic Profile of Mass: 2011, Table 3; CDC, Diagnoses of HIV infection and AIDS in the United States
and Dependent Areas, 2010, HIV Surveillance Report, Vol. 22, Table 1A; CDC, Diagnoses of HIV infection and AIDS in the United States and Dependent Areas, 2008,
HIV Surveillance Report, Vol. 20, Table 1A.
MA Reform Demonstrates Successful Health
Reform Implementation Reduces Costs
• Massachusetts cost per Medicaid beneficiary living with HIV has
decreased, particularly the amount spent on inpatient hospital care
• Massachusetts DPH estimates reforms reduced HIV health care
expenditures by ~$1.5 billion in past 10 years
Source: MA Office of Medicaid, data request
A Post-Reform State Needs the
Ryan White Program (RWP) to Meet NHAS Goals
YEAR
Full Pay
Co-Pay
Premiums
Total Cost
Enrolled
FY05
$ 9,756,201
$ 1,839,807
$ 6,112,132
$ 17,708,142 4738
FY11
$ 4,467,727
$ 3,175,917
$ 10,990,818
$ 18,634,462 7009
The RWP is essential to reducing gaps in care and affordability
to meet NHAS retention in care and viral suppression goals
• ADAP reduces barriers to HIV medications
- Individuals with income of $16,000 (150% FPL) cannot afford $3,333
- Families with income of $33,000 (150% FPL) cannot afford $6,666
• RWP provides essential care - dental, vision and behavioral health…
• RWP provides essential services - case management, transportation,
food and nutrition…
California’s Ineffective Implementation Undermines NHAS Goals
Lack of Proper Planning and Oversight Results in
Disruptions in Care
(Moving Us in the Wrong Direction)
Both federal and state officials largely failed to account for people
living with HIV who became newly eligible through reform
• Failed to ensure that the health benefits package met HIV
standard of care
• Failed to integrate HIV providers and models of care delivery
• Failed to consider Ryan White Program coordination and
“payer of last resort” provisions
Part 2:
ACA Federal Implementation Update
30 Million Newly Insured by 2022
11 million
Medicaid
Expansion
<133% FPL
25 million
Exchange
Coverage
>133% FPL
Undocumented
Immigrants Left Out
• Barred from state-based exchanges
• Not eligible for non-emergency Medicaid
• Eligible for restricted “emergency” Medicaid
• Eligible for services through community health centers
and/or safety-net providers
Key Implementation Issues
Medicaid
Expansion
Essential
Health
Benefits
Exchanges
Affordability
Medicaid Expansion Update
• Supreme Court ruled states can’t be penalized for
not participating
—No deadline for states to opt in
• 100% federal match applies 2014 to 2016
• States required to maintain eligibility for
enhanced rates (“MOE requirement”)
• CMS considering additional flexibility
Medicaid Expansion:
Where Do the States Stand?
Center on Budget and Policy Priorities.
November 2012.
Medicaid Expansion:
Estimated Increase in Enrollment by State
Medicaid Expansion:
Estimated Increase in State Spending
Income Status of Individuals Who Receive
Ryan White-funded Services
Medicaid Primary Care Rate
Increase - 2013 & 2014
• Internists, family medicine and pediatricians and
NPs/PAs they supervise eligible for enhanced rates
for primary care services
• Specialists trained in IM, FM, and Pediatrics,
including infectious diseases, eligible
• Payment will be equal to provider charge or
Medicare rate, whichever is lower
Medicaid Health Homes
• For Medicaid beneficiaries with 2 or more chronic
conditions
• HIV health homes - Oregon and New York
• Supports comprehensive care management, care
coordination, patient and family support….
• States develop reimbursement models
HIV Medical Homes Resource Center
http://www.careacttarget.org/mhrc
The Role of the Exchanges: Federal Rules
• Regulated market places to purchase insurance
— No denials based on health status or higher fees based on health or gender
• Certify “qualified health plans”
— “Active” or “passive” purchaser
• Educate consumers
– Must establish call center, website, navigators (at least one nonprofit group), premium
calculator
• Conduct or contract eligibility and enrollment
– Streamlined “no wrong door” application process
• Set standards for provider networks
– Required to contract with “sufficient number and geographic distribution of essential
community providers”
– Ryan White providers identified as essential
State Exchange Activity
Deadline
extended:
Dec 14th
All States Will
Have Exchanges!
Get Involved in Your State
• State Contacts:
http://www.ncsl.org/issues-research/health/stateimplementation-entities-to-implement-theaca.aspx
• Federal-run Exchange Contact CMS Regional Office:
http://www.cms.gov/About-CMS/AgencyInformation/RegionalOffices/RegionalMap.html
Ryan White Core Services vs. EHB
Ryan White Core Services
ACA “Essential Health Benefits”*




•
•
•
•
•
•
•
•
•
•
•
Ambulatory and outpatient care
AIDS pharmaceutical assistance
Mental health services
Substance abuse outpatient care
Home health care
Medical nutrition therapy
Hospice services
Home and community-based health
services
Medical case management, including
treatment adherence services
Oral health care (not an EHB)
•
•
•
•
•
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use
disorder services, including
behavioral health treatment
Prescription drugs
Rehabilitative and habilitative
services and devices
Laboratory services
Preventive and wellness services and
chronic disease management
Pediatric services, including oral and
vision care
Essential Health Benefits
• States selected “benchmark” plan to set coverage
standard for 10 EHB categories +
• EHB applies to Medicaid expansion but with
additional protections (due 2013)
• Comment on your state’s selection by Dec. 26th:
http://cciio.cms.gov/resources/data/ehb.html
More EHB Rules
• Drug coverage equals one drug per class or the same
number of drugs in a class covered by the benchmark
plan (whichever is higher)
• Lifetime and annual coverage limits barred
• Adult dental and long-term/custodial nursing home
care benefits excluded from EHB
• Mental health parity applies
What to Comment On
Would the service limits impede access to
necessary HIV care?
Will all or nearly all of the ARVs be covered?
Will people with HIV have access to chronic
disease management?
New Preventive Services Benefits –
Effective in New Plans August 2012
•
•
•
•
•
•
HIV screening and counseling
Well-woman visits
Screening for gestational diabetes
HPV testing for women 30 years and older
STI counseling
FDA-approved contraception methods and contraceptive
counseling
• Breastfeeding support, supplies, and counseling
• Domestic violence screening and counseling
Affordability
Exchanges
• 100% FPL up to 400% FPL
– Sliding scale premium
credits
– Adjusted out of pocket
max
Medicaid
• <100% FPL – none
• 100 -150% FPL
– No premiums
– Up to 10% cost or
nominal depending on
service
• 100 to 250% FPL
– Cost sharing subsidies
What’s Covered? What’s Not Covered?
ANNUAL OUT OF POCKET MAXIMUM*: $2,083
Subsidy Calculator from www.kff.org
*In addition to premium payments
PART 3:
KEYS TO SUCCESS: LESSONS LEARNED
FROM CALIFORNIA
State HCR Advocacy and Planning
• Federal government develops the framework
• States operationalize
– Will vary state by state
• Both advocacy and planning are essential
– In every state, including those resisting HCR
– Identifying and collaborating with allies
• The timeline is very short
– Lots of decisions being made now
– More questions than answers but need to move
ahead
Top Three State Advocacy Priorities
• Full Medicaid Expansion with an adequate benefits package that
meets the needs of people with HIV
– Provider networks include HIV providers
– Ensure continuity of care provisions
– Ensure adequate formulary – states can have more than one benefits
package
• Plans offered through the Exchange meet HIV prevention, care,
and treatment needs
– Formulary protections
– Adequate provider networks
– Continuity of care provisions
•
Exchanges are well designed and implemented
– Active vs. “Organizer”
– No wrong door for application - HIV information is integrated (very
difficult)
– Navigators have some HIV experience
– Medicaid/Exchange plan networks and benefits are aligned
Implementation & Planning Priorities
• What changes will/are likely to occur in 2014 in your state?
• What type of transitions will these changes bring?
– Movement to Medicaid? Movement to Exchanges? People currently on PCIP?
• How will communication, education, and assistance be provided?
• How will your state/local infrastructure serve the insured and
uninsured populations (RW and non – RW services)?
Private
physicians
Community Health
Centers
Public hospitals
(DSH, county,
state)
HIV System
of Care
Non-physician
providers
University
hospitals
Community-based
organizations
Lessons Learned –
State Advocacy & Planning
General Overview
• We have to start now
• We can’t do this alone
• essential to partner with other advocates & state administrators
• There will not be a road map
• Can’t wait for state specific guidance from HRSA, CMS, CCIIO, HHS
etc.
• More questions than answers
• There are multiple and interrelated decision “tables”
• The HIV community is not likely to be invited
• It may not be clear where decisions are being made
• People planning likely to have little knowledge of HIV
• Will require innovation in roles and programs
• Can’t necessarily rely on old fixes, i.e. RW may not be able to fill
all gaps
1) Ensure a voice for HIV at the state level
• Advocacy:
– Identify: key decisions and decision makers
– Is anyone with HIV expertise participating?
– Identify allies and make connections
• Implementation:
– No one agency in charge
– Need for leadership from state HIV entities
• Probably not charged, staffed or funded to do the work
– Key: Connections between Medicaid services, state HIV specific
offices, Exchanges and insurance regulators
• Can be informal; stakeholder and/or work groups
– Requires new roles and ways of working together
• In some states there is limited interaction; need collaboration
2) Identify and plan for gaps in coverage
• What services will not be offered under new coverage,
i.e. vision & dental?
—Peer outreach, linkage and care engagement services
• What populations are left out of health care reform and
how will they obtain coverage?
—Undocumented people: are there sufficient Ryan White services?
can people access quality HIV care in community health clinics? what
do state programs cover?
—Recent immigrants: who will need additional assistance to purchase
in the Exchange? is your state considering a Basic Health Plan?
• Identify and plan for service limitations
—Is the case management in new programs sufficient for PWHA?
—What exactly will be covered under a managed care capitated rate
or a medical home?
How Will Ryan White Integrate Into New
Systems? (Payer of Last Resort)
Mental Health & Substance Use
Treatment
• Will there be limits on the number of visits
offered in Medicaid and private plans?
• Is substance use treatment appropriate and
sufficient for your population?
• Where and how can RW funds wrap around
services?
• Are current providers able to bill both new
systems and RW?
Case management
• What will Medicaid cover?
• Is it sufficient for your population?
• Should case management services be co-located
with clinical services?
• Will case management include referral services
to food pantry or Food Stamps enrollment
assistance, housing and other essential
services?
• Do those services need to be co-located with
clinic services and/or medical homes?
3) Identify and plan to fill gaps in
affordability
• Insurance premium and co-pay assistance
4) Prepare Ryan White Systems
• ADAP must be able to wrap around premiums and other
out of pocket costs
Fiscal Year
Massachusetts ADAP Expenditures by Category
Full Pay
Co-pay
Premiums
FY 05
$9,756,201.76
$1,839,807.23
$6,112,132.85
FY 10
$4,635,751.00
$2,930,016.65
$9,320,425.00
• Waiver from the 75/25 rule
• What new and/or expanded services will be needed, i.e
more benefits counselors, navigation & legal assistance?
• What services need to be co-located with clinics, which
don’t?
5) Ensure Safe Transitions
• No one agency or group in charge of transitions
• Develop effective communications/education network
– Most HIV positive people and providers look to HIV specific entities for
information
• Develop materials and training for those assisting clients in
transitions – ensure there is sufficient capacity for assistance
• Ensure medical and non-medical providers are engaged in new
systems of care
• Ensure strong continuity of care provisions in Medicaid and
plans under Exchange, including access to drugs and ancillary
services
• Plan for delays in enrollment / eligibility determination &
churning between systems – fill gaps
Notes: Based on Patients with HIV Attending Medical Offices Participating in HIVRN; N=19,235. Medicaid includes those with Medicare coverage. Source: Data from K. Gebo and J. Fleishman, in Institute of Medicine, HIV
Screening and Access to Care: Exploring the Impact of Policies on Access to and Provision of HIV Care, 2011. Excludes 8% “unknown” coverage.
6) Role of Local Communities
Planning for health reform at the local level
—Infrastructure of ASOs to handle insured client base?
—Connections to broader care systems to ensure uninterrupted access to care?
o Community health centers
o Safety net providers
o Medicaid
—Individual transition planning and assistance for most vulnerable?
—Engagement in education and training in new systems to provide assistance to
clients?
—Funding decisions aimed at outreach for testing, linkage, engagement and
retention in care?
Resources
 www.statereforum.org
 Health Access
www.health-access.org
 Center for Budget and Policy
Priorities
www.cbpp.org
 Treatment Access Expansion
Project – www.taepusa.org
 Families USA –
www.familiesusa.org
 National Health Law Program
– www.nhelp.org
Health Care Reform Planning
“If we wait for governments, it’ll be too little, too late.
If we act as individuals, it’ll be too little. But if we act
as communities, it might just be enough, just in time.”
Transition network
Contact Us
Anne Donnelly, Project Inform
Ph 415.558.8669x208 [email protected]
Robert Greenwald, Treatment Access Expansion Project
Ph (617) 390-2584 [email protected]
Andrea Weddle, HIV Medicine Association
Ph (703) 299-0915 [email protected]