AIDS Drug Assistance Programs (ADAPs) Adequate versus Ideal models

1. AIDS Drug Assistance Programs (ADAPs) Adequate versus Ideal models Joey Wynn, Chairman, South Florida AIDS Network (SFAN) aaa+ conference, Washington D.C. July 21st, 2009

2. Ideal versus Adequate ADAPs Initial Dialogue about the concepts of ideal ADAP models versus adequate programs (The good, bad & the ugly!)

3. Ideal versus Adequate ADAPs Our goals for today’s discussion: • Identify and create awareness of the importance of appropriate characteristics for ADAP Programs nationwide • Identify & Understand the barriers and challenges associated with evaluating ADAP Programs throughout the country (widen the net to see the real picture!) • Begin to identify primary questions, & needed data to answer them • Hold an interactive dialogue resulting in a clearer understanding and expectation of what ADAPs should be doing for their clients based on their local environments • Evaluate the need for further investigation into this topic and the usefulness of such data for the community

4. Ideal versus Adequate ADAPs • Key elements (core or medical model) of a local HIV primary care system • Number of Patients accessing services • Primary care visits (System-wide capacity) • Laboratory diagnostics (availability and capacity) • Specialty Labs (Genotype, Pheno, Virtual Pheno, etc..) • Medications (Formulary Management, PBM, etc…) • Financial resources to maintain system

5. Ideal versus Adequate ADAPs • Other elements to consider • Payor Sources – Funding stream Matrix • Financial Limitations (Rationing Care) • Level of Sufficiency of resources versus demand /need • Patient’s “Quality of Life” index • Loss of productive time for Patient • Loss of productivity levels – Staff • Patient mortality

6. Ideal versus Adequate ADAPs • Who Pays for these Medications????? • ADAP • General Revenue (State Tax Dollars) • State Medicaid • Federal Medicare Programs (A,B,C,D) • Ryan White A – F (formerly I, II, III, IV) • Private Insurance Plans • Local Indigent Plans – Hospital DSH programs • Patient Assistance Progams – PAPs….. www.PPARx.org

7. The Cost of Care! Check please! (Pharmaceuticals)

8. UNION JUNE 2006 BREAKDOWN OF COUNTY HEALTH DEPARTMENTS BY PHARMACY CATEGORY HOLMES OKALOOSA JACKSON ESCAMBIA SANTA ROSA WALTON NASSAU WASHINGTON GADSDEN JEFFERSON HAMILTON CALHOUN LEON MADISON BAY DUVAL BAKER SUWANNEE LIBERTY WAKULLA COLUMBIA TAYLOR CLAY GULF LAFAYETTE BRADFORD FRANKLIN ST JOHNS ALACHUA GILCHRIST PUTNAM DIXIE FLAGLER LEVY MARION VOLUSIA LAKE CITRUS SEMINOLE SUMTER HERNANDO ORANGE BREVARD PASCO OSCEOLA HILLSBOROUGH POLK PINELLAS CATEGORY I – County Allocation W/Staff Pharmacist INDIAN RIVER MANATEE SARASOTA OKEECHOBEE ST LUCIE HIGHLANDS CATEGORY II – County Allocation W/O Staff Pharmacist DESOTO MARTIN HARDEE GLADES CHARLOTTE CATEGORY III – All Other Counties Share Communal Funding Allocation PALM BEACH HENDRY LEE BROWARD COLLIER MONROE DADE 13

9. JUNE 2006 FLORIDA AIDS DRUG ASSISTANCE PROGRAM DRUG EXPENDITURE BY COST APRIL EXPENDITURE MAY EXPENDITURE 5,614,365.675,943,824.77 9

10. JUNE 2006 FLORIDA AIDS DRUG ASSISTANCE PROGRAM TOP TEN DRUG EXPENDITURES Total Amount $5,214,228.88 11

11. JUNE 2006 FLORIDA AIDS DRUG ASSISTANCE PROGRAM ADAP FORMULARY- TOTAL 69 MEDICATIONS *By prior authorization only #Seasonal availability only Pediatric formulations may be available by special arrangement with Central Pharmacy 14

12. Medicare Part D Standard Drug Plan Benefit in 2006 Out-of-pocket Threshold Catastrophic Coverage Total Spending $250 $2250 $5100 75% Plan Pays Coverage Gap 80% Reinsurance $ + Deductible ≈ 95% Total Beneficiary Out-Of-Pocket 25%Coinsurance $250 $750 $3600 TrOOP 15% Plan Pays 5%Coinsurance Direct Subsidy/ BeneficiaryPremium BeneficiaryLiability Medicare Pays Reinsurance

13. Distribution of ARVs by Costsin the Florida Medipass system Q3 2005 Dade & Broward reporting

14. Ideal versus Adequate ADAPs • The Ideal ADAP would have: • Culturally appropriate staff with evening & weekend hours • Ample staffing resources and counseling options available for adherence services, drug reaction management, utilization review & Pain management services • A variety of geographic locations • Negotiated the lowest prices possible • Delivery options available for certain cases • The broadest, robust formulary possible • Web-based options for eligibility that used existing data from local service delivery system & ease of use for clients & case managers • Experienced staff for drug to drug interactions • A widely known process to use in the medical community • Frequent reporting about the program available easily with the community • Established outcomes & performance indicators • Annual Report on outcomes & expenditures • An evaluation component for Insurance purchasing and Premiums assistance • A co Pay assistance program • A P.A.P. service model on site

15. Ideal versus Adequate ADAPs • Reality Check!!!!! Typical Barriers to care: • Inadequate funding • Lack of staffing resources • Complex infrastructure – (band-aid effect) • Indigent Population vulnerabilities • Geographic accessibility • Hours of operation • State Gov’t Bureau

16. Ideal versus Adequate ADAPs • Questions and Answers: • Where do we go from here? • Is this topic useful? • Which stakeholders would benefit from this type of information?

17. Ideal versus Adequate ADAPs Thank you for your time and your thoughts