Entry Into and Sustained HIV Care: The Role of Federal, State and Private Health Insurance Policies - The Provider Perspective Institute of Medicine WorkshopJune 21, 2010 Andrea Weddle, MSWExecutive Director, HIVMA703-299-0915 / email@example.com / www.hivma.org
HIV Medicine Association HIVMA is a membership organization that represents more than 3,700 frontline medical providers and researchers. We advocate quality in HIV care and a comprehensive and humane response to the HIV pandemic informed by science and social justice.
Access and Retention in HIV Care in the U.S. • An estimated 30% of people diagnosed with HIV are not in ongoing care. (Fleming, et al, CROI, Abstract 11, 2000) • Only around 50% of people with HIV in need of antiretroviral treatment are receiving it. (IOM, Public Financing and Delivery of HIV/AIDS Care, 2005) • An estimated 55% of 15 to 49 year olds with HIV eligible for treatment receiving it. (Teschale, et al, CROI, Abstract 167, 2005) • We need better data on people with HIV disease that are in and out of care, and on antiretroviral treatment.
Key Health Insurance Policies Reimbursement - Adequacy of Provider Network Entry and Retention in HIV Care Eligibility for Health Care Coverage Cost Sharing Coverage of Benefits and Services
Patients managed by experienced HIV medical providers are more likely to have positive treatment outcomes, be prescribed antiretroviral therapy appropriately and to receive more cost effective care. Selected References: Kitahata MM, Koepsell TD, Devio RA, et al. N Engl J Med1996 Mar 14;334(11):701-6. Landon BE, Wilson IB, Cohn SE, et al. J Gen Intern Med 2003;18:233-241. Wilson IB, Landon BE, Ding L, et al. Med Care 2005;43(1): 12-20. Bozzette SA, Joyce G, McCaffrey DF, et al. N Engl J Med 2001;344(11):817-823. Access to HIV Medical Providers Improves Patient Care
Policies that Facilitate Access to HIV Medical Providers Federal Level: • Require plans to include HIV medical providers in their Provider Networks Plan Level: • Allow HIV provider to serve as primary care provider • Create a standing referral to an HIV provider • Allow direct access to a specialist
Standing Referral to HIV/AIDS Specialist State of California, Department of Managed Care. Knox-Keene Health Care Service Plan Act of 1975 Including Amendments Enacted as of February 2010. Accessed online 6 12 2010: http://wpso.dmhc.ca.gov/regulations/10kkap/10kkap.htm.
Access to Other Specialists • Ideal: Insurer supports a robust, coordinated and integrated provider network to treat range of issues affecting people with HIV, including endocrinologists, psychiatrists, gynecologists, gastroenterologists, cardiologists, dermatologists, hepatologists , etc. • Challenges: Reimbursement, specialist availability, knowledge and comfort with HIV disease
The Questions: Will plans proactively contract with RW providers? Are RW programs prepared to negotiate contracts? Do RW programs have the capacity to bill and respond to admin requirements of private plans? Health Reform and Access to HIV Providers The Good News: • Health plans operating in state-based exchanges beginning 2014 required to contract with essential community providers, such as 340(b) programs, including Ryan White (RW) programsThe Patient Protection and Affordable Care Act. SEC. 1311: AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS.
Medicaid Reimbursement Disparities:A Barrier to HIV Clinic Sustainability • Medicaid rates for primary care average 66% of Medicare rates • Range from 47% (California) to 140% (Alaska) • Increased 15.1% from 2003 and 2008 BUT the consumer price index increased 20.3% Stephen Zuckerman, Aimee F. Williams, and Karen E. Stockley. Health Affairs 28, no. 3 (2009): w510–w519.
Reimbursement Policies that Better Support HIV Care • Fee for Service: • Cost-based reimbursement • Payment for providing coordinated, comprehensive “medical home” care • Enhanced rates for HIV care • Managed Care: • Risk adjusted capitation rates or special HIV rates • New York Special Needs Plan HIV Rate: $1,328 per member/ per month • “Carve outs” for certain services, such as prescription drugs and laboratory monitoring
New York’s Ambulatory Patient Group Payment • Prospective • sets payments for services in advance • An APG assigns or “groups” • Patients with similar clinical characteristics and • Services with similar resource use and costs • APG assignment is based on standard claims information • CPT/HCPCS and ICD-9 diagnosis codes Slide provided by Franklin Laufer, PhD, from the New York Department of Health AIDS Institute
Slide provided by Franklin Laufer, PhD, from the New York Department of Health AIDS Institute
Carve-Outs • Chemotherapy drugs and certain other therapeutic injectables – billed as a referred or an ordered ambulatory service • HIV counseling and testing • Therapeutic visit for designated AIDS centers • HIV resistance testing • Other services (e.g., blood factors) Slide provided by Franklin Laufer, PhD, from the New York Department of Health AIDS Institute
Health Reform Increases Medicaid Payments to Primary Care Physicians for 2013 and 2014: Leaves Many HIV Physicians Out Health Care Education and Reconciliation Act of 2010 – Public Law -- Public Law 111 – 152. www.gpo.gov/fdsys/pkg/PLAW-111publ152/content-detail.html
Gaps in Mental Health and Substance Abuse Treatment Impede HIV Care • Private and public mental health coverage generally inadequate • 2/3 of primary care providers report unable to get outpatient mental health care for patients1 • Medicaid coverage of supportive community-based services can be better than private plans • Coverage of substance abuse treatment is poor • New parity law could improve • Mental health and substance abuse treatment will be part of the “essential benefits” package for plans operating in the state-based exchanges in 2014 1Cunningham, PJ. Health Affairs 2009;28(3):w450-w501.
Medical Case Management Important to Entry and Retention in Care • Facilitates entry into care for newly diagnosed • Important for it to be linked to medical care, e.g., co-location or integration with the HIV medical care team • Key to coordination of care and to assist patients with meeting range of medical, psychosocial and basic living needs • Ryan White critical source of funding • Covered for people with HIV by approximately 25% of Medicaid programs1 1Health Resources and Services Administration. Medicaid Case Management Services by State. http://www.hrsa.gov/reimbursement/TA/webcast-Sept1-Case-Mgmt-by-State-040825.htm
IL Percent of People That Have Not Seen a Doctor in Past Year due to Cost, 2007 NH VT ME WA ND MA MT MN NY SD WI OR MI RI CT ID PA IA WY NJ NE OH IN NV KS MO WV DE UT CO VA CA MD KY NC DC TN OK SC AZ NM AR AL GA MS TX LA AK FL HI <10% (13 states including DC) US Average = 13.5% 10 - 14.9% (22 states) >15% (16 states) SOURCE: Statehealthfacts.org analysis of Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2007.
Medicare Part D Cost Sharing: A Barrier for Individuals with Incomes >150% FPL ( $16,245)* *Annual income level for an individual 2009/2010 standard. Data from a search conducted using the Medicare Prescription Drug Plan Finder (6/15/2010): http://plancompare.medicare.gov/on. The zip code “20002 “ in Washington, DC was used.
Policies that Reduce Financial Barriers to Care • Cost sharing assistance or subsidies for lower income populations • Monthly and annual caps on overall out of pocket expenses • No denials for failure to pay • No annual or lifetime coverage limits
Health Insurance Policies: The Goal for HIV Providers Timely and Reliable Access to Effective HIV Care and Treatment Comprehensive, Coordinated Benefits Coverage Clinic Sustainability Affordable Cost Sharing
Acknowledgements Thanks to the following for their input on this presentation: • Kirsten Beronio, Mental Health America • Ira Feldman, PhD and FrankLaufer, PhD New York Department of Health AIDS Institute • Harold Henderson, MD and Deborah Konkle-Parker, PhD – University of Mississippi Medical Center • Jennifer Kunkel – Total Health Care, Inc., Baltimore, MD • Christine Lubinski, IDSA