Entry Into and Sustained HIV Care:
The Role of Federal, State and Private Health
Insurance Policies - The Provider Perspective
Institute of Medicine Workshop
June 21, 2010
Andrea Weddle, MSW
Executive Director, HIVMA
703-299-0915 / aweddle@hivma.org / 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
Cost Sharing
Entry and
Retention
in HIV
Care
Coverage of Benefits
and Services
Eligibility for
Health Care
Coverage
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 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
APG Example - HIV monitoring visit with diagnosis of HIV
Hospital only
DRAFT - For illustration purposes only
Downstate base rate; effective July 1, 2009
Payment weights effective January 1, 2010
Payment
Element
Payment
Action
Full APG
Weight
Percent
Paid
Allowed
APG
Weight
Base Rate
Paid
Amount
CPT Code
CPT Description
APG
APG
Description
99213
E & M, est. pt.,
low complexity
(15 mins)
881
AIDS
Medical
Visit
Full
payment
1.0495
100%
1.0495
$258.90
$271.72
36415
Venipuncture
457
Venipuncture
Ancillary
Full
payment
0.0602
100%
0.0602
$258.90
$15.59
Ancillary
Full
payment
0.1625
100%
0.1625
$258.90
$42.07
Ancillary
Packaged
0.0831
0%
0.0000
$258.90
$0.00
Ancillary
Full
payment
0.1367
100%
0.1367
$258.90
$35.39
86360
CD4 count
395
85025
CBC w/
differential
408
80053
Complete
metabolic panel
403
Level II
immunology
tests
Level I
hematology
Organ or
disease
oriented panel
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/pk
g/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., colocation 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 It
Monthly 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 D
Most Medicaid programs
Most 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
Percent of People That Have Not Seen a Doctor
in Past Year due to Cost, 2007
VT
WA
NH
ME
ND
MT
MA
MN
SD
OR
WI
ID
WY
NV
UT
CA
MI
IL
KS
MO
WV
OK
NM
TX
AK
NC
AL
MD
DC
SC
AR
MS
DE
VA
TN
RI
NJ
OH
IN
KY
AZ
CT
PA
IA
NE
CO
NY
GA
LA
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.
Cost Sharing Can Interfere with
Medically Necessary Care
Study
Finding
Trivedi 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): 515530.
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
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
Clinic
Sustainability
Affordable
Cost Sharing
Comprehensive,
Coordinated Benefits
Coverage
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