Management of an ADAP Waitlist: Virginia and North Carolina Experiences

1. Management of an ADAP Waitlist: Virginia and North Carolina Experiences Steven Bailey, VA Department of Health Anne Rhodes, VA Department of Health John Furnari, NC Department of Health & Human Services RW All grantees Meeting November 2012 Washington Dc

2. Background: Waitlist Factors, VA and NC

3. Initial Planning: Late 2010, Virginia

4. Planning: January 2010, North Carolina Input from DHHS Management Identify Cost Saving Strategies Consultation With Medical Advisory Committee Identify Areas Where Efficiency Could Be Improved

5. North Carolina Waiting List Progression Federal Emergency Relief Funding Received and Waiting List Reduced in Sept. 2010, Oct. 2011, August 2012.

6. Waitlist Tracking, Virginia

7. Waitlist Tracking, North Carolina

8. Waitlist Tracking, North Carolina • Monitoring Access to Medications • Early Monitoring Activities (the first six months): • Calls to clients • Chart Audits (when possible) • Later Monitoring Activates (every four to six months): • Calls to Case Managers or Providers • Calls to clients if above was unsuccessful • Other Monitoring Activities: • Checking Welvista Dispensing Data (monthly when available)

9. Program Monitoring, Virginia Reports

10. Fiscal Monitoring, Virginia Reports

11. Program Monitoring, North Carolina • Monthly Enrollment and Cost Spreadsheets: • ADAP: • Clients Enrolled • Clients Served (percent served) • Number of Dispenses (average scripts per client served) • Value of Dispensed Medications • Dispensing Fees • Total Cost • Cost Per Enrollee • SPAP: • Clients Enrolled • Clients Served (percent served) • Number of Claims (average scripts per client served) • Claims Paid • Fees • Total Cost • Cost Per Enrollee

12. ADAP Forecasting, VA and NC

13. Capacity Projections, Virginia

14. Change of Program (include PCIP), Virginia

15. Scenario Projections, Virginia Elimination of Waitlist Changing of enrollment criteria (different CD4 levels, different FPLs), with or without disenrollment Increase in funding of a certain amount and impact on the waitlist Change in formulary Change in dispensing policy Implementation of TrOOP

16. Projections, North Carolina • Projections • ADAP Only (SPAP separately) • Available Funding for ADAP next SFY Determines Capacity this year • Projected Enrollment (monthly) based on 12 month average • Cost Per Enrollee (12 month average) • Accounting for factors that skew averages or projections • Scenarios • Increase Eligibility • Expand Formulary • PCIP Pilot

17. Moving to Sustainability, Virginia

18. ADAP Program Management, Virginia • Increased program efficiencies during 2011 • Shifted FY 2011 Ryan White service funds to help cover ADAP medication costs • Improved ADAP client eligibility and recertification processes • Instituted state residency policy for ADAP clients • Addressed inactive clients and intermittent use of ADAP

19. ADAP Program Management, Virginia • Increased pharmaceutical efficiencies • Sustained the 30-day prescription dispensing policy implemented in 2010 • Sustained aggressive inventory strategy to monitor pharmacy inventory and daily drug costs at all ADAP pharmacies, including the main State Central pharmacy • Referred patients to PAPs and other medication sources • Pharmaceutical company patient assistance programs (PAPs) • Welvista – central hub for number of ARVs

20. ADAP Program Management, Virginia • Maximizing Use of Other Medication Programs • Increased Medicaid back billing revenue for purchase of ADAP medications, including developing agreements with Medicaid HMOs for backbilling • Used ADAP dollars for Medicare Part D co-payments that are counted as True Out of Pocket (TrOOP) expenses • Secured 340 B Rebate Status allowing VA ADAP to pursue rebates for co-pays for Medicare Part D clients’ drug costs; in 2011, VDH spent $400K in co-pays for ARV medications and received $1.1 million in rebates (a return of $2.84 for each dollar spent)

21. Sustainability, North Carolina

22. Program Changes, North Carolina • Increase in State Appropriations in 2010 • ERF Funding in 2010, 2011, 2012 • SPAP implementation in 2011 • Increased Staffing in 2011, 2012 • Change in Pharmacy Vendor in 2011 • Change in Inventory Process in 2011 • Change Recertification Process in 2012 • New analysis/projection procedures created in 2010, 2011, 2012 • Contracted with an Actuary in 2012 • PCIP pilot planned for 2013

23. Expanding and Sustaining Access, Virginia • Virginia ADAP has expanded ADAP enrollment criteria and reduced the wait list over last year: • November 2011: CD4 count at or below 200 • December 2011: CD4 count at or below 350 • April 2012: CD4 count at or below 500 • July 2012: removal of clinical criteria • August 2012: began immediate processing of new applications (no longer placed any new persons on waitlist) • Eliminated the wait list as of August 30, 2012.

24. Medical Model for Waitlist Reduction, VA • Clients with CD4 counts <200 are often diagnosed late and/or enter medical care late and have shorter survival times (Schwarcz, 2006) and higher costs of care than those with higher CD4 counts (Krentz, 2004). • Clients with CD4 counts under 350 who are not on antiretroviral therapy have been found to be less likely to survive over time and more likely to be lost to care (Franke et al, 2011) • Current public health guidelines emphasize having all those with CD4 counts under 500 on antiretroviral therapy

25. CD4 Count Distribution of VA Waitlist

26. VA ADAP Wait List Removals

27. NC ADAP Wait List Removals Data Source: AIDS Drug Assistance Program Waitlist Data NC Department of Health and Human Services, November 1, 2012

28. VA ADAP Waitlist Removals: Reasons Each client removed from waitlist was assigned reason for removal Those with CD4 counts under 200 often had other payer sources

29. Enrollment Expansion Process, VA

30. Enrollment Expansion and Education, VA Community education plan familiarized stakeholders with PCIP/ADAP enrollment criteria. VDH planner met with consumers, physicians, case managers, client advocates, consortia, and others to present VDH plan and answer questions Regional calls held before each expansion to explain change and receive input from stakeholders

31. VA ADAP: Persons and Cost, 2010-2012 Source: VA-ADAP database, Division of Disease Prevention, Virginia Department of Health, August 2012

32. Restructuring the Model for Medication Access, VA • Strengthening and improving the eligibility processes for all HIV services • Moving toward a model of insurance coverage • Transition of eligible clients to coverage under the Pre-Existing Condition Insurance Plan (PCIP) • PCIP is cost-effective and covers services and medications • Acquired Pharmacy Benefits Manager (PBM) to handle Medicare Part D and PCIP programs

33. Cost Effectiveness of PCIP: Direct Purchase ADAP vs. PCIP Costs Annually for a Client, VA * Avg. client is 40 years old on a common protease inhibitor regimen

34. Program Sustainability & Increases in Demand, VA and NC • Expected increases in client demand from increased testing efforts and linkage to care efforts • Expanded Testing efforts • SPNS Systems Linkages & Access to Care 4-year grant (NC and VA) • CDC Grant to HIV Prevention for increased linkage activities • New HIV Treatment Guidelines promoting a “test and treat” philosophy • Treatment lowers amount of virus in the body and keep patient healthier • Treatment reduces transmission of virus to others

35. Stakeholder Involvement, Virginia • Consumers • Outreach and contact efforts • Currently forming a consumer advisory board for SPNS project that we hope will serve for ADAP as well • Providers • ADAP Advisory Committee • Consortia • Part A Planning Councils • Virginia legislators and policy makers

36. Lessons Learned, Virginia Gather insurance eligibility information (PCIP) Involvement of ADAP Advisory Committee Proactive approach with agency administration Improvements in tracking clients Stakeholder involvement critical Rebates will support program sustainability

37. Lessons Learned, North Carolina Improvements in data analysis and projections Increased frequency of analyses and projections Improvements in client monitoring Improvements in program efficiencies SPAP Savings and Rebates will contribute to sustainability of program expansion PCIP Savings may contribute to sustainability of program expansion Stakeholder Involvement (Clients, Case Managers, Providers, Advisory Committee, Vendors, Policy Makers)

38. Conclusion VA ADAP has expanded enrollment criteria through aggressive program, fiscal, and pharmaceutical efficiencies VA and NC ADAP are monitoring increases in client demand from testing and linkage to care efforts Sustained funding from federal and state resources will be necessary to support sustained and increased client demand in VA and NC