Entry Into and Sustained HIV Care: The Role of Federal, State and Private Health Insurance Policies - The Provider Perspective

Andrea Weddle, MSWExecutive Director, HIVMA703-299-0915 / aweddle@hivma.org / www.hivma.org

Institute of Medicine WorkshopJune 21, 2010

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.

• 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.

Access and Retention in HIV Care in the U.S.

Key Health Insurance Policies

Reimbursement - Adequacy of

Provider Network

Cost Sharing

Coverage of Benefits and Services

Eligibility for Health Care Coverage

Entry and Retention

in HIV Care

Adequacy of Provider Network

Access to HIV Medical Providers Improves Patient Care

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.

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

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) programs

The Patient Protection and Affordable Care Act. SEC. 1311: AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS.

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?

• 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.

Medicaid Reimbursement Disparities:A Barrier to HIV Clinic Sustainability

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

APG Example - HIV monitoring visit with diagnosis of HIV DRAFT - For i l lustration purposes only

Hospital only Downstate base rate; effective July 1, 2009Payment weights effective January 1, 2010

CPT Code CPT Description APGAPG

DescriptionPayment Element

Payment Action

Full APG Weight

Percent Paid

Allowed APG

WeightBase Rate

Paid Amount

99213E & M, est. pt.,

low complexity (15 mins)

881 AIDSMedical

VisitFull

payment1.0495 100% 1.0495 $258.90 $271.72

36415 Venipuncture 457 Venipuncture Ancil laryFull

payment0.0602 100% 0.0602 $258.90 $15.59

86360 CD4 count 395Level II

immunology tests

Ancil laryFull

payment0.1625 100% 0.1625 $258.90 $42.07

85025CBC w/

differential408

Level I hematology

Ancil lary Packaged 0.0831 0% 0.0000 $258.90 $0.00

80053Complete

metabolic panel403

Organ or disease

oriented panelAncil lary

Full payment

0.1367 100% 0.1367 $258.90 $35.39

Total Payment (excluding capital) 1.492 1.4089 $364.76

Note: Primary diagnosis is 042; also paid on a fee-for-service basis would be viral load and resistance testing, if ordered

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

Coverage of Services and Benefits

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

Prescription Drug Policies: Challenges to Adherence

Policy Examples How to Improve ItMonthly Drug Limit Mississippi Medicaid – 5

drug limit, 2 brand name limit

• Exemptions for special populations, such as people with HIV• Exemptions authorized by clinician

Preferred drug lists or formularies

Medicare Part DMost Medicaid programsMost private plans

• Carve out or exempt certain drug classes • Exemptions authorized by clinician• Require coverage of all drugs in certain

classes, e.g., Medicare Part D’s 6 protected classes requirement

Prior Authorization Medicare Part D • Simplify and standardize process• Extended authorization, e.g., approve for

one year• Strict and enforced response time

requirements

Cost Sharing

CT

ME

NY

NH

MA

VT

PANJ

RI

AZ

WA

WY

ID

UTCO

OR

NV

CA

MT

HI

AK

NM

MN

ND

IA

WIMI

NE

SD

MOKS

OHINIL

AR

MS

LA

KY

TNNC

VAWV DE

MD

DC

SCOK

GA

TX

FL

AL

10 - 14.9% (22 states)

<10% (13 states including DC)

>15% (16 states)

US Average = 13.5%

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.

Percent of People That Have Not Seen a Doctor in Past Year due to Cost, 2007

Cost Sharing Can Interfere with Medically Necessary Care

Study FindingTrivedi AN, Moloo, H, Mor, V. Increased Ambulatory Care Copayments and Hospitalizations Among the Elderly. N Engl J Med 2010;362:320-8.

In a comparison of a Medicare plan that increased cost-sharing to one that did not:

•Outpatient visits decreased

•Hospitalizations and inpatient days increased

Hsu J, Price M, Huang J, et al. Unintended Consequences of Caps on Medicare Drug Benefits. N Engl J Med 2006;354:2349-59.

Medicare beneficiaries in a plan with a capped pharmacy benefit had:

•Higher emergency room visits

•More non-elective hospitalizations

•Higher rates of non-adherence individuals taking drugs for hypertension, hyperlipidemia, and diabetes

Wallace NT, McConnell KJ, Gallia CA, Smith JA. How Effective Are Copayments in Reducing Expenditures for Low-Income Medicaid Beneficiaries? Experience from the Oregon Health Plan. HSR 2008;43(2): 515-530.

After the implementation of new and stricter cost sharing in Oregon for non-disabled adult Medicaid beneficiaries under 100% FPL their:

•Pharmaceutical expenditures decreased

•Inpatient and hospital outpatient services increased

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.

*Annual income level for an individual 2009/2010 standard.

Medicare Part D Cost Sharing: A Barrier for Individuals with Incomes >150% FPL ( $16,245)*

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

Affordable Cost Sharing

Comprehensive, Coordinated Benefits

Coverage

Clinic Sustainability

Acknowledgements

Thanks to the following for their input on this presentation:• Kirsten Beronio, Mental Health America• Ira Feldman, PhD and Frank Laufer, 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