Challenges and Opportunities: Caring for People With HIV/AIDS in Managed Care

1. Challenges and Opportunities: Caring for People With HIV/AIDS in Managed Care • Financing • Movement To Managed Care • Challenges/Opportunities

2. FINANCING CARE: FEDERAL PROGRAMS • MEDICAID • Largest payer of direct medical services for PLWH/A • FY 1998: $3.5 billion (est) on HIV/AIDS medical services • 53% of all people with HIV/AIDS are on Medicaid. 90% of all children with AIDS are on Medicaid • PWA are fewer than 1% of beneficiaries, 2% of total cost • MEDICARE • FY 1997: 1.4 billion- est. 6-20% of PWA (excludes RX) • RYAN WHITE CARE ACT PROGRAMS • FY 1998: $1.15 billion • OTHER FEDERAL - SAMSHA, NIH, federal prison, VA, IHS, HUD

3. MOVEMENT TOWARD MANAGED CARE • Growth in Medicaid Managed Care • As of June, 1997, approximately 47.5% Medicaid recipients in managed care (vs 12% in 1995) ; majority increase in fully capitated plans • States shifting risk from State to MCOs • Focus shifting from TANF(AFDC) to SSI (65% of expenditures) • WHY? • Control Costs/ Predict Medicaid budget • Get out of insurance business- fewer staff?; negotiate with few MCOs vs all constituent groups • Increase Quality & Access- fragmented FFS system; low provider participation; coordinated care • HOW?- 1915(b)/1115 waivers, State plans(BBA)

4. BALANCED BUDGET ACT (BBA) • Section 1932(a) of SSA - States submit State Plan amendment to enroll beneficiaries into managed care w/o waivers • exceptions: dually eligibles; special needs children; tribes • REQUIREMENTS: • choice of 2 managed care entities (MCEs) • disenroll any time for cause in first 90 days; 12 months thereafter • HCFA approval of model contracts • subject to new quality assurance, timely payments provisions • default enrollment based on prior provider-patient verification of access to providers • info on providers, enrollee, rights, grievances etc in readable format

5. TRENDS • Nearly half of all enrollees in Medicaid dominated plans (more than 75% membership is Medicaid) number of plans serving Medicaid market increased from 166 to 355 b/n 1993-96 • Medicaid dominated plans more likely to serve SSI/disabled population • 87% enrollees in 16 states: AZ, CA, CT, FL, IL, MI, MN, MO, NJ, NY, OH, OR, PA TN, VA & WA • Newly formed plans dominate new Medicaid plans

6. PEOPLE LIVING WITH HIV/AIDS HIV SERVICE AND MEDICAL PROVIDERS MANAGED CARE ORGANIZATIONS STATE MEDICAID AGENCIES ACCESS COST CONTINUITY OF CARE QUALITY CHALLENGES AND OPPORTUNITIES

7. Challenges/Opportunities for:People Living With HIV/AIDS • Understanding & navigating the system • Enrollment • Choice of MCO • Disclosure of provider network • Access to experienced HIV providers • primary care • timely & appropriate referrals to specialists • access to clinical trials • out of network providers

8. PLWH (continued) • Access to Pharmaceuticals • Restrictive health plan formularies • location of pharmacies • Coordination with Social Services • Confidentiality of medical & enrollment information • Discrimination • Grievance process Opportunity to receive coordinated care with an emphasis on prevention & early diagnosis

9. HIV PROVIDERS • Understanding the system • Potential Loss of Patients/Revenue • Increase Uninsured • Adapting to Change • defining Strategic position • changing their mission/repackaging services • Using “business” principles • Upgrading MIS • ability to obtain cost & utilization info • limited resources

10. HIV PROVIDERS(continued) • Development of networks • Protecting their “turf” • Fair Reimbursement • Risk Adjusted Capitation Opportunity to diversify revenue streams & increase patient base

11. MANAGED CARE ORGANIZATIONS • Understanding the needs of PLWH • Maintain profitability • risk adjusted rates • Meeting contractual obligations • Turnover of Medicaid population • Develop delivery networks for PLWH • # of PLWH members vs actual membership • Confidentiality vs assuring care Opportunity to diversify membership & provide quality care

12. STATE MEDICAID AGENCIES • Shift from FFS to managed care • limited resources & staff • antiquated MIS • negotiating contracts • Internal/External Pressure • control costs/budgets • growth of eligible populations • assuring quality care • Incentives to MCOs to provide care • reimbursement rates Opportunity to improve access to care for eligibles

13. HAB MANAGED CARE STRATEGIC PLAN • Enhance the capabilities of HIV providers to participate in managed care • Improve HAB’s knowledge base about MC and HIV, especially with regard to various financing and reimbursement methodologies • Educate people with HIV/AIDS about managed care to improve their ability to access services • Assure quality care for HIV/AIDS members enrolled in managed care • Collaborate Efforts with HCFA, States and Other Key Stakeholders

14. HAB’s TRAINING AND TECHNICAL ASSISTANCE • Strengthen the infrastructure within individual states for RW programs to participate in managed care by providing customized, state based training & TA • Build collaborative relationships between key stakeholders including MCOs, State Medicaid agencies, HCFA and RW funded programs • Up to $20,000 in JSI TA monies can be used for training, TA from individuals/groups of consultants, facilitated meetings between key stakeholders, data analysis, or other activities requested by the State • 7 States participated in pilot: CT, NJ, PA, MD, FL, IL, WA 9 States currently funded: OR, VA, WV, AL, AZ, RI, NM, TX, OK • HAB Staff training, Project Officer Guide, Resource List

15. HAB TA:EXPAND KNOWLEDGE BASE • Expert Panel on Risk Adjustment • addressed policy, development and implementation; proceedings published as TA document • 1115 Waiver Study • examined capitation rates, benefits, eligibility & enrollment requirements related to HIV service delivery in 9 States (OSE) • Evaluation Studies (Center for Managed Care) • impact on Medicaid Managed Care on providers (Mathmatica) & safety net providers (IOM) • Managed Care SPNS Grantees • Updated Medicaid Guide (AIDS Action)

16. HAB TA:CONSUMER EDUCATION • Joint Project with National Association of People with AIDS • consumer resource guide to help PWH/A navigate the system-diary to record information and “what to ask for” • Spanish & English • Will be tested in several markets in March, 1999 • Train the Trainers • plan to identify consumers to become trainers of managed care in key states

17. HAB TA:QUALITY • Purchasing Specifications • contract with GWU Center for Health Policy Research • modules for contracts between State Medicaid agency & MCOs to assure access to care for PLWH • coordination with CDC • available in February 1999

18. HAB TA: RELATIONSHIP WITH STAKEHOLDERS • Federal Agencies • HCFA - cross trainings, waiver reviews, review guidelines • National Association of State Medicaid Directors • 4 regional meetings- Chicago, Sante Fe, Austin, Boston • HRSA program directors (MCH, PCA, AIDS) & Medicaid Directors • American Association of Health Plans • National Association of State Health Policy Officials • National Association of Insurance Commissioners