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Improving Accessing to HIV Care through Health Care Reform


Improving Accessing to HIV Care through Health Care Reform Ryan White All Grantee Meeting November 28, 2012 Robert Greenwald, Treatment Access Expansion Project – PowerPoint PPT presentation

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Title: Improving Accessing to HIV Care through Health Care Reform

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

(No Transcript)
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.

  • Part 1 Where We Are, Where We Are Headed
  • Part 2 Federal Implementation Update
  • Part 3 Keys to Success Lessons Learned from

Where We Are Status Quo Access to Care Crisis
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)
Sources Estimated Number of Persons Living with
AIDS, Centers for Disease Control and
Prevention, http//
Ryan White Appropriations History, Heath
Resources and Services Administration,
Inflation calculated using http//www.usinflationc
Funding, FY2007-FY2010 Appropriations by
ACA Implementation Must Address Engagement and
Retention in Quality Health Care
  • National HIV/AIDS Strategy calls for
  • Increasing HIV screening and improve linkages to
  • 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

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
  • 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
  • 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
  • Ryan White Program 75/25 rule waived to allow for
    increased support of essential support services
  • 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
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,
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
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
  • 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

Californias Ineffective Implementation
Undermines NHAS Goals
Lack of Proper Planning and Oversight Results in
Disruptions in Care (Moving Us in the Wrong
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

  • Part 2
  • ACA Federal Implementation Update

30 Million Newly Insured by 2022
11 million
Medicaid Expansion lt133 FPL
Exchange Coverage gt133 FPL
25 million
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
Medicaid Expansion Update
  • Supreme Court ruled states cant 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
Medicaid Expansion Estimated Increase in
Enrollment by State
Medicaid Expansion Estimated Increase in State
Income Status of Individuals Who Receive Ryan
White-funded Services
Medicaid Primary Care Rate Increase - 2013
  • 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
  • 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.carea
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
  • 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
  • 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//
  • Federal-run Exchange - Contact CMS Regional
  • http//

Ryan White Core Services vs. EHB
  • ACA Essential Health Benefits
  • 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
  • Laboratory services
  • Preventive and wellness services and chronic
    disease management
  • Pediatric services, including oral and vision
  • Ryan White Core Services
  • 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)

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 states selection by Dec. 26th

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

  • Medicaid
  • lt100 FPL none
  • 100 -150 FPL
  • No premiums
  • Up to 10 cost or nominal depending on service
  • Exchanges
  • 100 FPL up to 400 FPL
  • Sliding scale premium credits
  • Adjusted out of pocket max
  • 100 to 250 FPL
  • Cost sharing subsidies

Whats Covered? Whats Not Covered?
Calculator from In addition to
premium payments
Part 3 Keys to Success Lessons learned from

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

Implementation Planning Priorities
  • What changes will/are likely to occur in 2014 in
    your state?
  • What type of transitions will these changes
  • 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)?

Community Health Centers
Private physicians
Public hospitals (DSH, county, state)
HIV System of Care
Community-based organizations
Non-physician providers
University hospitals
Lessons Learned State Advocacy Planning
  • General Overview
  • We have to start now
  • We cant do this alone
  • essential to partner with other advocates state
  • There will not be a road map
  • Cant wait for state specific guidance from HRSA,
    CMS, CCIIO, HHS etc.
  • More questions than answers
  • There are multiple and interrelated decision
  • The HIV community is not likely to be invited
  • It may not be clear where decisions are being
  • People planning likely to have little knowledge
    of HIV
  • Will require innovation in roles and programs
  • Cant 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
  • Key Connections between Medicaid services, state
    HIV specific offices, Exchanges and insurance
  • Can be informal stakeholder and/or work groups
  • Requires new roles and ways of working together
  • In some states there is limited interaction need

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
  • 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)
3) Identify and plan to fill gaps in
  • 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
  • Waiver from the 75/25 rule
  • What new and/or expanded services will be needed,
    i.e more benefits counselors, navigation legal
  • What services need to be co-located with clinics,
    which dont?

Massachusetts ADAP Expenditures by Category
Fiscal Year 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
5) Ensure Safe Transitions
  • No one agency or group in charge of transitions
  • Develop effective communications/education
  • 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

Notes Based on Patients with HIV Attending
Medical Offices Participating in HIVRN N19,235.
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
  • Connections to broader care systems to ensure
    uninterrupted access to care?
  • Community health centers
  • Safety net providers
  • 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?

  • Health Access
  • Center for Budget and Policy Priorities
  • Treatment Access Expansion Project
  • Families USA
  • National Health Law Program

(No Transcript)
Health Care Reform Planning
  • If we wait for governments, itll be too little,
    too late. If we act as individuals, itll 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
  • Robert Greenwald, Treatment Access Expansion
    Project Ph (617) 390-2584
  • Andrea Weddle, HIV Medicine Association
  • Ph (703) 299-0915