Managed Care and HIV/AIDS

1. Managed Care and HIV/AIDS

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 less 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 • New 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. CHALLENGES OF MANAGED CARE • State as a purchaser/regulator • HIV Provider (social/medical) to “reengineer” • PLWH navigating the new system of care • MCOs caring for chronically ill/high cost population

7. CHALLENGES AND CONCERNS OF PLWH • Understanding the system • Enrollment • Choice of MCO • Culturally/linguistically competent materials • Disclosure of provider network • Continuity of Care • Access to experienced HIV providers • primary care • timely & appropriate referrals to specialists • access to clinical trials • out of network providers

8. CHALLENGES AND CONCERNS OF PLWH • Access to Pharmaceuticals • Restrictive health plan formularies • location of pharmacies • Coordination with Social services • Confidentiality of medical information, enrollment • Discrimination • Grievance process

9. CHALLENGES FORHIV PROVIDERS • Understanding the system • Adapting to change • defining Strategic position • changing their mission • Using “business” principles • Maintain Continuity of Care for Patients • Potential loss of Patients/Revenue • Increase Uninsured

10. CHALLENGES FOR HIV PROVIDERS • Development of networks • Protecting their “turf” • Upgrading MIS • -ability to obtain cost & utilization info • Fair Reimbursement

11. CHALLENGES FOR MANAGED CARE ORGS. • Understanding the needs of PLWH & programs • 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

12. CHALLENGES FORMEDICAID AGENCIES • Shift from FFS to managed care • limited resources • antiquated MIS • negotiating contracts • Culture • Pressure to control costs/budgets • Pressure from “interest”groups • -growth of eligible populations • Fair reimbursement to MCOs • Incentives to MCOs to provide care • Assuring quality of care, fair enrollment practices, overseeing enrollment brokers

13. MARKETING • WHO IS RESPONSIBLE?State/local govt’; Contracted MCO; Contracted CBOs; Health Care Providers; Enrollment brokers • WHERE DOES MARKETING OCCUR? Welfare Offices; Direct Mail (State or MCO); Public Meeting Places; Door to Door • Marketing should not occur in: In non-confidential settings; Emergency Room/ Inpatient Units • WHAT METHOD? Brochures & flyers; group/individual education sessions; enrollment incentives; telephone; media • USING ENROLLMENT BROKERS • more states using third party/independent agencies • restricts MCO’s ability to market/ • Avoids coercive marketing tactics • Brokers still must receive training • States must ensure brokers provide accurate/sufficient info

14. MARKETING AND ENROLLMENT ISSUES • What categories of Medicaid beneficiaries will be enrolled? Voluntary or mandatory? Are there any exemptions? • How are PLWH advised about enrollment requirements, exemption options, lock-in periods, changing providers? What is the time period for disenrollment? • Are enrollment materials culturally sensitive and at appropriate reading levels and languages of eligible populations? How will States assure that information on providers and benefits is accurate and includes information on provider specialties/HIV experienced providers? • What is the default assignment algorithm? Can the PLWH be assigned to their traditional provider of care? • Where will enrollment take place and how will patient confidentiality be assured?

15. BENEFIT PACKAGES • COVERED SERVICES • Must include all services under Medicaid FFS • Services must be delivered by network provider • OUT OF NETWORK COVERED SERVICES - Certain covered benefits delivered out of network • NON-COVERED SERVICES • PLWH/A require services typically not covered (e.g., residential care, social services, , hospice care) • CARVED OUT SERVICES • Benefit is covered but MCO or provider not at risk and paid FFS OR another entity responsible for benefit (e.g., mental health, dental) • PRESCRIPTION DRUG BENEFITS • Use of formularies may restrict access • Typically included in capitation but antiretroviral therapy carved out

16. ISSUES ON BENEFIT PACKAGES • How will mix of services ( e.g., Medicaid managed care, Medicaid FFS, grants) be funded? • How is medical necessity defined? What is the definition for emergency services? • How will the state ensure that services are coordinated between MCO gatekeepers and social service providers? • Does the defined benefit package include the continuum of care services for PLWH/A? For carved out services (e.g., dental care, mental health), how will PLWH/A be linked to these services? How will counseling & testing to offered? • How will PLWH/A be given information and access to clinical trials? Will plans be required to cover off-label drugs and experimental treatments?

17. MEDICAID MODELS FOR PLWH • MAINSTREAM • All eligibles mandated into commercial or Medicaid plans • States may or may not have enhanced rate • May require MCOs to contract with AIDS “centers of excellence” • CARVEOUTS • People with AIDS remain in FFS Medicaid • SPECIALIZED AIDS PLANS (or SPECIAL NEEDS PLANS) • Traditional Providers form HMO for PWH/A • AIDS Health Care Foundation, Johns Hopkins, New York State

18. PRIMARY CARE PROVIDERS: GATEKEEPERS • Gatekeeper is cornerstone of managed care • Experienced physicians is critical for HIV care • Kitahta study found direct relationship between PCP experience w/HIV (treated at least 5 patients) & survival • Inexperienced gatekeepers not only provide poor quality care, but cost more in unnecessary ER visits, hospital admissions etc • Options: • Specialist (e.g., Infectious Disease, HIV experienced provider) is PCP • Open ended referrals to HIV experienced provider either in/out of network • HIV experienced provider co-manages patient w/PCP

19. PROVIDER CAPACITY • Are there an appropriate number of experienced providers (primary & specialty)? Are they accessible and within reasonable distance to where PLWH/A live? Are providers culturally & linguistically appropriate ? • Can a PLWH/A designate a specialist as their primary care provider? • Are gatekeepers knowledgeable about appropriate referrals for HIV disease? • To what extent do existing plans serve PLWH and what is their experience? • Will States assure that people with HIV receive the appropriate level of health care and support services for each stage of illness? • How and to what extent is the State planning to assure newest treatments, are available and accessible?

20. NETWORK DEVELOPMENT • Will the State encourage/mandate MCOs to include traditional providers of care, especially Ryan White supported programs in their networks? Will the State give additional points in the RFP process to MCOs that include traditional providers? • How will traditional providers and commercial MCO’s work together to establish an effective and efficient system of care? • Is there sufficient capacity in both the metropolitan epicenters and in more rural areas? • What are the procedures for using out of network providers? Does the plan allow “standing” referrals?

21. FULL OR PARTIAL CAPITATION RATES • States must decide whether to put MCOs on full risk for defined set of covered services (full capitation) OR • Share some of the risk by offering partial capitation rates and carve out certain services to be reimbursed FFS • Benefits Typically Carved-out: pharmacy, particularly new therapies & mental health/substance abuse treatment • MCOs distribute risk by entering into contractual relationships with providers either on full to partial capitation • Risk related to total cost for providing covered services to enrolled population

22. HISTORICAL RATE SETTING FOR MEDICAID • Analyze historical FFS claims data to calculate monthly cost of providing services for each beneficiary class • Multiply the monthly cost by a discounted percentage (e.g., 95%) to provide state with a savings • Calculate costs to subgroups within beneficiary classes by age, sex or health status (e.g., disabled) • Seek competitive bids from health plans around the calculated rate or pay the calculated capitation to all participating plans

23. ISSUES WITH HISTORICAL STATE MEDICAID RATES • Historic provider fees often extremely low • Claims data does not include unreported visits • some providers do not submit claims • patient confidentiality reduces claims submissions (especially HIV/AIDS and mental illness) • lack of access to care decreases historic utilization rates • All benefits may not be included (e.g., pharmacy, case management) • Does not reflect changing demographics of HIV/AIDS epidemic • Does not reflect impact of changing therapies on cost and utilization of care

24. RISK ADJUSTED CAPITATION RATES • RISK ADJUSTMENT: Adjusting the standard rate to allow for greater intensity, frequency and cost of services for a particular subgroup • TWO APPROACHES: • Adopt special rates for HIV/AIDS • Institute global risk adjustment for all enrollees (or all disabled enrollees) • POTENTIAL HIV/AIDS ADJUSTERS: • clinical diagnosis, e.g. HIV+asymptomatic, HIV+symptomatic, AIDS • CD4 Count or Viral Load • Other co-morbidities (e.g. mental illness, substance abuse, or factors (e.g. homeless)

25. RISK ADJUSTED HIV/AIDS RATES Some states are developing AIDS rates because: • High cost of new drug therapies & changing treatment protocols: • Insure access to quality specialized primary and specialty care. • Reduced provider participation without adequate payment • Unpredictability of the state of HIV/AIDS as an illness, and the associated treatment costs. • Concerns that MCOs avoid/underserve PLWH/A, deny treatment, avoid early diagnosis without appropriate reimbursement to cover costs • Potential for poor quality, access, & plan performance with insufficient funding

26. CHALLENGES TO SETTING HIV CAPITATION RATES • Difficult to identify claims of HIV+ recipients • Historical per capita utilization rates may not predict future service use because: • data unavailable for all planned services • based on a small number of patients/heavily influenced by high or low cost users • unable to account for case mix • Historical data on service costs my be: • based on inefficiently operated programs • offset by other grant funding streams • Time allocated for clinical encounters may be insufficient as complexity of medical management increases • Types & combinations of services may change

27. OTHER RISK METHODOLOGIES • Some states are moving toward a comprehensive risk adjustment system based on groups of diagnosis to predict risks (disability payment system) • Some states provide rate adjustment to MCOs with disproportionate number of HIV/AIDS patients • Some states use stop loss/reinsurance: • Establishes an upper limit on payment of claims for an individual member (catastrophic insurance) • Some states using risk corridors -establishes a ceiling & floor of risk for the MCO or provider

28. EXAMPLES • AIDS RATES: • MD $1,812/ 2,161 - excludes PIT, VLT • MA $2,300/ 2,998 for active/advanced AIDS • CA $1,100 - 1,200 to AHF excludes inpatient • NY - rates being developed for Special Needs Plans • GLOBAL RISK ADJUSTMENT • Implemented: CO, MD • Planned: MI, MN, OR, WA

29. FINANCIAL ISSUES • How will your state reimburse health plans? Does it propose to use risk adjustment methods? If so, what variables will be used? • What services will be carved out of the capitation? Will protease inhibitors and other new pharmaceuticals be excluded? • Does your state plans to use other risk adjustment mechanisms such as stop loss or risk corridors? • How will participating providers be paid? How will MCOs protect participating providers from caring for PWA?

30. INTEGRATING MANAGED CARE APPROACHES INTO THE HIV CARE CONTINUUM CORE SERVICES CAPITATED, MCO BEARS RISK CORE SERVICES CARE ACT PROVIDERS SUB-CONTRACT WITH MCOs TO PROVIDE SOME CORE SERVICES, BEAR SOME RISK FFS AGENCIES BEARING NO RISK PROVIDE WRAP-AROUND SERVICES THROUGH LINKAGE AGREEMENTS

31. PLAN SELECTION CRITERIA • Established provider network • Geographic coverage • Sufficient capacity & accessible services • Acceptable marketing, enrollment, grievance & disenrollment procedures • Established quality assurance program • Fiscal Solvency • Established administrative & governance structure • Meets State managed care licensure criteria

32. PLAN SELECTION AND CONTRACTING • What criteria will be established for plan selection? • cost, contracted providers, geographic access • Will there be an RFP program or bidding process? • Will capitation be lowest bidder, ranges or set amount? • How will state certify MCO’s operational readiness to provide care to PLWH/A?

33. QUALITY MANAGEMENT AND MONITORING • Health care services are available, accessible, and acceptable • Participating providers meet established credential criteria • Inpatient, ambulatory, and emergency services meet defined standards and parameters for medically appropriate care; and • Health outcomes are monitored and meet established criteria • Critical for PLWH/A because of incentives to deny care, cost, complexity of meeting HIV/AIDS health care needs, rapidly changing standards, and MCO’s limited experience in serving PLWH/A • HEDIS only has test measures on prevention for HIV/AIDS

34. STATE QUALITY ASSURANCE ACTIVITIES • Monitor voluntary disenrollment • Consumer/enrollee satisfaction • surveys • enrollee hotlines • ombudsman programs • consumer focus groups • Performance Measures/Contract Compliance • financial audits • medical record reviews • Specialized Studies • Most State QA activities targeted for “typical” beneficiary & often do not consider HIV/AIDS issues

35. GRIEVANCE PROCEDURES AND DISENROLLMENT • Grievance procedures often not timely • delays for PLW/A could be life-threatening • some states moving toward expedited reviews for referrals (e.g., within 24 hours of denial and/or retrospective review) • Disenrollment • with cause - no restrictions • without cause - typically within 30 days then every 6 months or 1 year thereafter

36. QUALITY MANAGEMENT CONTRACT COMPLIANCE • How will the state monitor health plan compliance for state & federal requirements? • How will the state review member satisfaction, disenrollment, and grievances? Will they conduct consumer satisfaction surveys? Will PLWH/A to oversampled to assure representation? • What performance measures has the state developed and how will they monitor them? • How will the data collect data on: primary care encounters, specialty referrals, prescriptions, laboratory testing, counseling & testing?

37. 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

38. HAB TECHNICAL ASSISTANCE AND TRAINING • 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 applied for FY 98/99 funds: OR, VA, WV,AL, AZ, RI, NM, TX, OK • HAB Staff training, Project Officer Guide, Resource List

39. HAB TECHNICAL ASSISTANCE: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)

40. HAB TECHNICAL ASSISTANCE: 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 • Available early 1998 • Train the Trainers • plan to identify consumers to become trainers of managed care in key states

41. HAB TECHNICAL ASSISTANCE: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 model contract project • “White Papers” on quality of care • Guide for federal/state officials, purchasers of care, advocacy organizations on best practices

42. HAB TECHNICAL ASSISTANCE:STAKEHOLDERS • Federal Agencies • HCFA - cross trainings, waiver reviews, review guidelines • DHHS Managed Care Forum - AIDS Workgroup • National Association of State Medicaid Directors • 4 regional meetings- Chicago, Sante Fee, 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