180 KB - Treatment Action Group

Report
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Given the election results,
how will the ACA and
Medicaid expansion affect
the service delivery mix?
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What are the opportunities
to use these mechanisms
to optimize HIV
programmatic success?
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Revitalizing the US Domestic HIV/AIDS
Response:
New Science and New Approaches to
Improve Outcomes and Reduce Costs
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December 11, 2012
Julia Hidalgo, ScD, MSW, MPH
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Positive Outcomes, Inc. & George Washington University
[email protected]
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With Contributions From
Naomi Seiler, JD, Katherine Horton JD, Mary-Beth Harty, JD,
Maureen Byrnes
George Washington University
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Introduction
The Patient Protection and Affordable Care Act
(ACA), Medicaid expansion, and other health
reforms is impacting the HIV care continuum
through changes in
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Coverage
Enrollment mechanisms
Health benefits
Health care system redesign
Payment systems
Information gathering and reporting
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Current Opportunities Available Through the ACA
Coverage changes
 Expanded Medicaid coverage for childless adults with income up
to 138%, with 8 states expanding coverage
 Established Preexisting Condition Insurance Plans (PCIP)
 Extended dependent coverage for adult children up to 26 years of
age
Health benefit changes
 Prohibited individual and group health plans from placing lifetime
limits on coverage, rescinding coverage, and denying children
coverage due to pre-exiting medical conditions
 New health plans must provide
 Prevention services with an A or B rating by the USPSTF for
free including HIV screening for individuals at high risk
 Insurers must provide free coverage for certain women’s
preventive services such as annual HIV counseling and
screening for all sexually active women
 Provides financial incentive to Medicaid programs offering
coverage with no cost sharing for preventive services rated A or
B by the USPSTF
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Current Opportunities Available Through the ACA
Health care systems redesign
 New Medicaid State option for beneficiaries with chronic
conditions to designate a provider as a medical home, with HIV
added recently as a designated condition
 Grants awarded to design person-centered models coordinating
services to Medicaid/Medicare dual eligibles
Payment systems
 Medicaid payments to primary care doctors will increase to
100% of the Medicare payment rates
 Increased funding for federally qualified health centers
(FQHCs) and planning grants for agencies seeking to become
federally qualified
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Opportunities Available Through the ACA in 2014
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Coverage changes
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 Expanded Medicaid coverage for most individuals with incomes up to 138%
of
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the FPL, with 100% federal funding from 2014-2016 and step-wise decreases
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in 2017 and onward
 Creates state-based American Health Benefit Exchanges and Small Business
Health Options Program Exchanges through which coverage can be purchased
 Provides refundable and advanceble tax credits and cost-sharing subsidies to
eligible individuals
 Prohibits pre-existing condition exclusions in issuing and renewing health
insurance
 Prohibits annual limits on the dollar value of coverage
 Requires US citizens and legal residents to have qualifying health coverage
and a phased-in tax penalty for individuals without coverage
 Health benefit changes
 Creates a Basic Health Plan for uninsured individuals with incomes between
138-200% of the FPL who are eligible to receive premium subsidies
 Health plans in the individual and small group markets, Medicaid benchmark
and equivalent packages, and the Basic Health Plan must include an essential
health benefits package
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Minimum Essential Health Benefits (EHBs)
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 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
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Health Care System Re-design: Patient-Centered Medical Homes
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 “Medical home,” “health home,” and “patient-centered medical home” are
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terms used interchangeably
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 One provider or group of providers is responsible for providing or
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coordinating a given patient’s care, with some kind of financial incentive(s)
to do so
 Joint Principles of the Patient-Centered Medical Home from the American
Academy of Family Physicians, American Academy of Pediatrics, American
College of Physicians and American Osteopathic Association (2007)
 Personal physician for continuous, comprehensive care
 Physician directed medical practice, where the physician leads a team of
individuals at practice level who take responsibility for ongoing care
 Whole person orientation, where the physician responsible for all of the
patient’s health care needs or arranging care with other qualified
professionals
 Care is coordinated and/or integrated across all elements of the health care
system and community (e.g., family, public and private community-based
services)
 Quality and safety achieved through accountability, evidence-based medicine,
decision support tools and other mechanisms
 Enhanced access to care
 Payment that appropriately recognizes the added value provided to patients
Application of the PCMH Model
 About half of States Medicaid programs are currently
implementing medical home initiatives of some form
 New or revised payments to primary care providers to
function as PCMHs
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 Case management fees, performance payments, payments to support shared
teams or networks, support for transformation to PCMHs
 Some, but not all, states require PCMH accreditation by the
National Committee for Quality Assurance (NCQA) or another
national accrediting body
 CMS and HRSA fund the FQHC Advanced Primary Care
Practice Demonstration (500 FQHCs)
 Three-year demonstration to evaluate the effect of the advanced primary care
practice model, in improving care, promoting health, and reducing the cost of care
provided to Medicare beneficiaries served by FQHCs
 Monthly care management fee of $6 each eligible Medicare beneficiary attributed
to their practice
 CMS’s Comprehensive Primary Care Initiative
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Multi-payer- Medicare works with commercial payers and State plans
Primary care providers in selected markets
Monthly care management fee ($20 PMPM for two years, then $15 for two years)
After two years, possibility of sharing in regional Medicare savings
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Medicaid Health Homes in the ACA: Definition
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 CMS requires States that provide this optional benefit, and
the health home providers with which the State collaborates,
to operate under a “whole-person” philosophy – caring not
just for an individual’s physical condition, but providing
linkages to long-term community care services and supports,
social services, and family services
 Eligible Medicaid beneficiaries include individuals with
 at least two chronic conditions, OR
 one chronic condition and at risk for another, OR
 one serious and persistent mental health condition
 States can target specific diseases or regions, and may set
more restrictive criteria, but may not exclude dual-eligibles
 A chronic condition can be a mental health condition,
substance use disorder, asthma, diabetes, heart disease, or
being overweight (BMI >25), or HIV
 Entities serving as a health home include designated
providers, a team of health care professionals, or a health
team
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Medicaid Health Home Services
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 Enhanced federal match is offered for services that provide
the glue to coordinate care
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 Comprehensive care management, care coordination, and health
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promotion
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 Comprehensive transitional care from inpatient to other settings, including
appropriate follow-up
 Patient and family support
 Referral to community and social support services
 Health information technology to link services
 States receive 90% federal match for 8 consecutive quarters
 All other services (underlying medical services, etc.) matched
at usual Federal Medical Assistance Percentages (FMAP)
 States can do more than one health home state plan
amendment, or can do a geographic expansion of an
amendment to new enrollees
 But states can only receive eight quarters of enhanced match for
any individual enrollee
 After 8 quarters, the state may continue to provide health
home services at usual FMAP
 Managed care enrollees must be permitted to enroll in health
homes if offered in their area and otherwise eligible
Key Considerations for the HIV+ Community In Implementing the ACA
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 HIV is not the foremost concern of State policy makers, health     
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exchange panels, Medicaid program staff, and insurers
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 HIV community must organize and mobilize to ensure that HIV+  
beneficiaries’ need are met
 There will be significant variability in state-level coverage, benefits,
and payment systems
 Will States build, buy, or borrow HIV care?
 Systems-level changes will be swift and hard to monitor accurately
at the federal level
 People will be confused, and will need to be educated
 Many HIV+ individuals and their family members will need
significant help in choosing the insurance plan that best meets their
needs
 Managed care service delivery and payment models are likely to be
adopted
 Many HIV programs are likely to be unfamiliar with these models,
may not participate in insurance plans, and their staff may not be
sufficiently credentialed to serve as providers
Key Considerations for the HIV+ Community In Implementing the ACA
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 HIV clinical and support providers must learn to market their     
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services to ensure they have a role in HIV care delivery
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 The essential HIV benefit package is likely to vary considerably  
geographically and by public and commercial systems, insured
population, by insurer, and by service delivery systems (e.g., fee for
service or managed care)
 Payment models are also likely to vary considerably
 The impact of the ACA on HIV surveillance systems is unclear
 Surveillance systems will likely rely on lab reporting
 Ensuring access to HIV screening, medication education, treatment
adherence, access to PrEP, and HERR will be challenging unless
financial incentives are in play
 The prevention with positives paradigm may be unsustainable in a
new financing and delivery system
 Access to HIV-experienced providers may be decreased
 Medication benefits may not be sufficiently covered
Key Considerations for the HIV+ Community In Implementing the ACA
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 Physical and behavioral service payment systems may
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implemented separately
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 Access to HIV care in rural areas will continue to be limited
 HIV clinical providers are likely to insufficiently reimbursed for their
services unless Ryan White (RW) Program funds are used for
balanced billing
 STI, TB, family planning, and other public health systems will
experience significant pressure to integrate in the broader health
care financing system
 Roles for community-based organizations may be available, but will
need to defined and marketed to health care plans and insurers
 Linkage from testing to treatment, patient navigation, and peer
coaches
 The ACA is unlikely to reduce HIV stigma and concerns about
disclosure and discrimination
 Violations of ACA protections are likely and must be documented
 The ACA does not address the need for equity and transportability
of health insurance benefits when HIV+ individuals move to another
state
Key Considerations for the HIV+ Community In Implementing the ACA
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 Some HIV+ individuals will not be included in expanded coverage
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 The District of Columbia is addressed as a state in the ACA
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 Puerto Rico and other territories will not enjoy benefits comparable to
states
 Application of HIV quality measures and improvement processes to
public and commercial health insurance systems will be
challenging
 Significant data granularity will be lost as we rely on insurance
claims systems
 It will be very difficult to measure the impact of the ACA
implementation on HIV+ individuals and the HIV care continuum
 Caution should be used in making a business model or cost saving
rationale for HIV prevention and treatment
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Meanwhile in the RW HIV/AIDS Program
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 Results of efforts to reauthorize the RW Program are unclear
 Transition of core services from RW Program grant-based
budgeting to public and commercial payment systems,
including fee for service reimbursement and prospective
capitation payment
 Increased monitoring of HAB and the RW Program’s grantees
and providers to ensure adherence to statutory requirements
(e.g., payer of last resort, client charges)
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 Balanced billing in which RW Program funds are used to supplement
insurance payments likely to be eliminated
 Demand for RW Program-funded health insurance premium,
co-payment, and deductible assistance is likely to increase
sharply as HIV+ individuals enroll in health insurance
 As medication costs are shifted to insurers, ADAPs’ revenue
from rebates will decrease sharply
 Many ADAPs use rebates to support services or employees
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Meanwhile in the RW HIV/AIDS Program
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 Demand for RW Program-funded health insurance premium,
co-payment, and deductible assistance is likely to increase
sharply as HIV+ individuals enroll in health insurance
 An increasing number of RW Parts A and B grantees will seek a
waiver from the 75% core / 25% support service requirement
 RW client-level data systems vary highly in maturity
 Much critical accurate data are missing
 It is important to acknowledge that the RW Program has some
profound limitations, the quality of clinical and support
services vary considerable, and we have limited capacity to
demonstrate the direct impact of the RW Program
 Our failure to convert the “cascade effect” to a “golden pond
effect” must be acknowledge by the HIV prevention and care
community
 Efforts to help transition HIV+ individuals into insurance
systems must be spear headed by RW-funded Programs
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Design Used to Assess Eligibility Determination (ED)
Activities Funded Five Part A Grantees
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Key Facts
Grantee 1
Grantee 2
Grantee 3
Grantee 4
Grantee
5
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Region
Southwest
Northeast
South
South
South
Service Area
Large urban,
and adjoining
rural areas
Suburban, and
adjoining rural
counties
Moderate
urban, and
adjoining
rural counties
Large urban
Large urban, and
adjoining rural
areas
Providers
1 hospitalbased HIV
clinic, 2
FQHCs, 1 CHC
2 ASO, 2
hospital-based
HIV clinic2, 1
FQHC, 1 county
health dept
3 ASOs (1 colocated in HIV
clinic), 1
county health
dept
Centralized Part
A ED Unit
3 ASOs, 2
community ID
practices, 1
county health
dept
Assessment
Design
Chart review
Chart review
Chart review
Electronic
records
Chart review
Chart
Review Tool
# Charts
Reviewed
Tool measures attainment of HAB and grantee monitoring standards, and assesses key
components of RW Program and third party insurance eligibility
285
407
325
144
493
Findings of ED Quality Assessments Among
Providers Funded by Five Part A Grantees
Grantee 2
Grantee 3
Grantee 4
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Average
Error Rate
Grantee 1
Grantee
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Region
Southwest
Northeast
South
South
South
Average
Household
Size
Not
Assessed
38%
58%
Not Assessed
Not Assessed
Household
Income
Not
Assessed
74%
77%
35%
Not Assessed
Health
Insurance
32%
39%
27%
11%
44%
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