Transcript Document

The State of ADAPs
Review of the 2011 National ADAP Monitoring Project
Annual Report and Update on the ADAP Crisis
Britten Pund
National Alliance of State & Territorial AIDS Directors
July 5, 2011
Presentation Agenda
 Highlights from the 2011 National ADAP Monitoring
Project Annual Report
 Update on the ADAP Crisis
 Questions and Answers
National Alliance of State &
Territorial AIDS Directors (NASTAD)
 Represents the nation’s chief health agency HIV/AIDS
and viral hepatitis staff in all 50 states, the District of
Columbia, Puerto Rico, the U.S. Virgin Islands and
the U.S. Pacific Islands
– Provides technical assistance and other support to
health department HIV/AIDS and viral hepatitis
programs
– Provides national leadership on HIV/AIDS and viral
hepatitis policy and programs
– Educates about and advocates for necessary federal
funding
Highlights from the
2011 National ADAP Monitoring Project
Annual Report
Methodology
Respondents
 All ADAPs receiving federal ADAP earmark funding
through the Ryan White Program were surveyed.
– 57 jurisdictions were surveyed in September 2010; 52
responded.
– 57 jurisdictions were surveyed in February 2011; 49
responded.
 Non-responders represent <1% of estimated living
HIV and AIDS cases in the United States.
Requested Data
 Survey requests data and other program information
for:
– A one-month period (June 2010 or December 2010)
– The current fiscal year (FY2010)
– Other periods as specified
 Data offers a monthly “snapshot” comparison from
previous survey periods.
The Report
Module One
 Detailed information related to :
– ADAP budgets
– Client enrollment and utilization
– Client demographics
– Program eligibility
– Program management and administration
Module Two and
Module Two Supplement
 Detailed information related to:
– Prescription distribution and payment methods
– Expenditures and prescriptions filled
– Insurance coordination
– ADAP coordination with Medicare Part D
– ADAP coordination with Pre-existing Condition
Insurance Plans (PCIPs)
– Updated client enrollment and utilization
– Hepatitis treatments
Highlights from Module One
The National ADAP Budget
 In FY2010, the
national ADAP
budget grew to
$1.79 billion, a 13%
increase from
FY2009.
The National ADAP Budget, by Source, FY2010
Drug Rebates
$522,589,581
(29%)
Part B ADAP
Earmark
$800,033,562
(45%)
Other State or
Federal
$5,018,513
(<1%)
Part A Contribution
Directed to ADAP
$15,288,430
(1%)
 All funding
streams increased
incrementally over
the last year.
Part B ADAP
Supplemental
$41,750,000
(2%)
State Contribution
$346,239,277
(19%)
ADAP Emergency
Funding
$24,999,313
(1%)
Part B
Supplemental
Contribution
Directed to ADAP
$12,500,358
(1%)
Total = $1.79 billion
Part B Base
Contribution
Directed to ADAP
$20,573,517
(1%)
The National ADAP Budget
National ADAP Budget, by Source, FY1996-FY2010
11%
26%
43%
19%
7%
6%
18%
5%
9%
7%
17%
10%
10%
9%
7%
7%
5%
7%
9%
10%
12%
15%
17%
17%
17%
16%
19%
19%
22%
22%
6%
7%
18%
21%
7%
7%
6%
31%
29%
14%
19%
21%
21%
28%
25%
65%
68%
66%
64%
65%
61%
53%
59%
40%
56%
54%
51%
49%
45%
26%
FY1996
$200 m
FY1997
$413 m
FY1998
$544 m
FY1999
$712 m
FY2000
$779 m
FY2001
$870 m
FY2002
$962 m
ADAP Earmark
FY2003
FY2004
FY2005
FY2006
FY2007
FY2008
FY2009
FY2010
$1,071 m $1,187 m $1,299 m $1,386 m $1,428 m $1,522 m $1,582 m $1,789 m
State
Rebates
Other
The National ADAP Earmark
Part B ADAP Earmark, FY1996-FY2010
$900
222%
$800
$764.7
$692.9
Millions of Dollars
$700
$779.8
$775.3
$774.1
$778.6
$800.0
$728.0
$619.8
$571.3
$600
$527.6
$500
$460.6
$400
71%
$300
$285.5
15%
$167.0
$200
$100
61%
8%
8%
12%
2001
2002
2003
5%
5%
2%
-1%
0%
1%
3%
2004
2005
2006
2007
2008
2009
2010
$51.9
$0
1996
1997
1998
1999
2000
ADAP Emergency Funding
 In August 2010, the Obama Administration
reprogrammed $25 million to address ADAP waiting
lists and other unmet ADAP needs.
 Funding awards were made to 30 states.
 Funding amounts ranged from $38,111 in Alaska to
$6.9 million in Florida.
State Funding
State Funding, FY1996-FY2010
$400
133%
Millions of Dollars
$350
$346.2
$328.5
$304.9
$300
$294.1
$252.8
$250
$226.6
$200
$149.6
$150
$117.4
$125.5
2%
5%
61%
$171.9
$128.8
32%
16%
$100
$50
$119.4
$160.4
$215.3
3%
7%
12%
7%
21%
12%
-4%
$50.4
-34%
$0
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Drug Rebates
Drug Rebates, FY1996-FY2010
$600
$500
Millions of Dollars
$497.6
90%
$522.6
$400
$327.1
$300
$262.6
49%
$200
32%
$100
$11.9
$22.6
$33.7
1996
1997
1998
$46.4
$196.5
39%
38%
$54.5
$60.0
17%
10%
2000
2001
$83.1
52%
$230.3
33%
$146.2
34%
$109.9
5%
25%
17%
14%
$0
1999
2002
2003
2004
2005
2006
2007
2008
2009
2010
Cost-recovery
 “Cost-recovery”
for medications
purchased through
ADAP (other than
drug rebates)
represented $50.5
million in FY2010.
 Private insurance
recovery
represented 58% of
all cost-recovery.
Cost Recovery and Other Cost-Saving Mechanisms
(Excluding Drug Rebates), FY2010
Other
$5,570,345
(11%)
Private Insurance
$29,176,302
(58%)
Medicaid
$15,764,359
(31%)
Total = $50.5 million
ADAP Expenditures, FY2009
 In FY2009, ADAPs
expended $1.4 billion
on prescription drugs,
representing 85% of all
ADAP expenditures.
 ADAPs expended
$176.1 million on
insurance payments,
representing 10% of all
ADAP expenditures.
 Two percent of ADAP
funds were expended
for program
administration costs.
ADAP Expenditures, FY2009
Adherence and
Monitoring
$10,791,413
(1%)
Client Outreach
$1,363,314
(<1%)
Quality
Management
$3,373,897
(<1%)
Program
Administration
$27,146,476
(2%)
Insurance Copayments and
Deductibles
$74,457,786
(4%)
Client Enrollment
Costs
$4,537,753
(<1%)
Other
$6,923,355
(<1%)
Insurance
Premiums
$101,623,665
(6%)
Prescription
Dispensing Costs
$17,090,460
(1%)
Prescription Drugs
$1,430,230,842
(85%)
Total = $1.7 billion
ADAP Client Enrollment and
Utilization
 On average, 2,806 new clients were enrolled in ADAP
each month in FY2009.
ADAP Client Utilization, June 1996-2010
160,000
39%
135,596
140,000
125,479
Clients Served
120,000
110,047
100,000
94,577
24%
80,000
61,822
53,765
60,000
43,494
40,000
69,407
12%
15%
76,743
80,035
96,404
96,121
101,987
85,825
14%
11%
10%
7%
6%
4%
31,317
2%
20,000
8%
8%
-0.3%
0
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
ADAP Client Gender,
Race/Ethnicity, and Age




ADAP Clients Served, by Race/Ethnicity, June 2010
Seventy-seven percent
(77%) of ADAP clients are
American
Indian/Alaskan
male.
Native
<1%
Blacks and Hispanics
Native
Hawaiian/Pacific
comprise 55% (33% and
Islander
<1%
22% respectively) of ADAP
Asian
1%
clients served.
Almost half (48%) of ADAP
clients are between the
Hispanic
22%
ages of 45 and 64.
Seventy-five percent (75%)
of ADAP clients had
income levels at or below
200% of the Federal
Poverty Level (FPL).
Multi-Racial
5%
Other
1%
Unknown
2%
Non-Hispanic
Black/African
American
33%
Non-Hispanic
White
35%
ADAP Client Demographics
ADAP Clients Served, by Income Level, June 2010
Unknown
3%
Federal Poverty Level
>400% FPL
1%
301-400% FPL
5%
201-300% FPL
14%
134-200% FPL
19%
101-133% FPL
11%
≤100% FPL
45%
0%
5%
10%
15%
20%
25%
Percent of Clients
30%
35%
40%
45%
50%
ADAP Client Insurance Status
 Twenty-two
percent (22%) of
ADAP clients had
private insurance.
 Seven percent (7%)
of ADAP clients
were dual
beneficiaries of
both Medicaid and
Medicare.
ADAP Clients Served, by Insurance Status, June 2010
Medicaid
9%
Medicare
13%
Dually Eligible (Medicaid &
Medicare)
7%
Private Insurance
22%
Uninsured
61%
0%
10%
20%
30%
40%
Percent of Clients
50%
60%
70%
ADAP Eligibility Criteria
 ADAP income
eligibility in June
2010 ranged from
200% FPL in eight
states to 500% FPL
in six.
 Fourteen ADAPs
reported having
asset limits in
place in June 2010.
ADAP Management Policies
 Thirty-three ADAPs have specific ADAP management
policies in place, including:
– Three ADAPs (6%) require client cost-sharing
– Three ADAPs (6%) limit clients to a maximum number
of prescriptions per client per month
– Twelve ADAPs (24%) maintain a clinical criteria for
client access to some medications on the ADAP
formulary
– Twenty-six ADAPs (51%) require prior authorization
for clients access to some medications on the ADAP
formulary
Highlights from Module Two
ADAP Client Utilization
 ADAPs provided
medications to
127,998 clients in
December 2010.
135,5967
127,998
125,479
Number of Clients
 Client utilization
increased by 2%
between June 2009
and December 2010;
client utilization
decreased by 2%
between June 2010
and December 2010.
ADAP Clients Served, June 2009, June 2010 and
December 2010
June 2009
June 2010
December 2010
ADAP Drug Expenditures
 ADAP drug
expenditures were
$146,457,975 in
June 2010.
ADAP Drug Expenditures and Top 10 States, by Drug
Expenditures, June 2010
$160,000,000
Total = $146,457,975
$120,000,000
 Ten states
accounted for 76%
of all drug
spending; five
states accounted
for 57% of all drug
spending.
$80,000,000
$110,957,891
$40,000,000
$0
June 2010 Expenditures
Average Monthly Cost Per Client
ADAP Average Monthly Cost Per Client, June 1996-2010
Per Capita Expenditures
$1,200
$1,064
$1,024
$991
$1,000
$883
$800
$758
$757
1998
1999
$842
$831
2000
2001
$982
$1,005
$995
$949
$902
$611
$600
$471
$400
$200
$0
1996
1997
2002
2003
2004
2005
2006
2007
2008
2009
2010
ADAP Prescriptions Filled
 In June 2010, the average expenditure per prescription
was $325, compared to $302 in June 2009, representing
an 8% increase.
 Average expenditures per prescription was significantly
higher for antiretrovirals ($491) than non-antiretrovirals
($67 for “A1” OIs and $64 for all other drugs).
 ADAPs filled a total of 451,148 prescriptions in June
2010, representing an increase of 8% compared to June
2009.
ADAP Drug Expenditures and Prescriptions
Filled (Including Drug Purchases and CoPayments), by Drug Category, June 2010
All Other
$9,211,929
(6%)
"A1" OIs
$2,581,031
(2%)
All Other
141,327, (31%)
ARVs
271,503
(60%)
ARVs
$133,379,390
(92%)
Total = $147.2 million
"A1" OIs
38,418
(9%)
Total = 451,148 prescriptions filled
ADAP Drug Expenditures and Prescriptions
Filled (Including Drug Purchases and CoPayments), June 2010
Co-Payment Rx
96,498
(21%)
Co-Payment
Expenditures
$7,289,580
(5%)
Drug Purchases
$139,168,395
(95%)
Total = $147.2 million
Drug Purchases
Rx
354,650
(79%)
Total = 451,148 prescriptions (Rx) filled
ADAP Insurance Coordination
Clients Served and Estimated Expenditures in Insurance Purchasing and Continuation, 2010
$194
120,000
$200
$159
100,000
$160
80,000
$120
$107
60,000
$84
$75
$75
$80
40,000
30,621
$38
20,000
20,960
$30
$19
5,272
7,167
7,277
2002
2003
2004
12,311
13,744
2005
2006
$40
15,843
-
$2007
2008
2009
2010
Fiscal Year Expenditures (in millions)
Number of Clients (June)
110,369
ADAP Insurance Coordination
 In June 2010, 110,338 ADAP clients were served
through insurance coordination.
 Clients served through insurance coordination more
than tripled since June 2009.
 Spending on insurance purchasing/continuation
represented an estimated $139 per capita in June
2010, about 15% of the average monthly cost per
client, based on drug expenditures, in that month
($949).
ADAP Coordination with
Pre-existing Condition Insurance Plans
 As of December 2010, 12 ADAPs reported having the
ability to enroll clients in PCIPs.
 Eleven states had 151 clients enrolled with plans to
continue enrolling additional clients.
 The average monthly cost per client served in a PCIP
was $529 in December 2010, approximately 56% of
the annual average cost per client, based on drug
expenditures ($949) in that month.
ADAP Coordination with
Medicare Part D
 To meet the federal requirements and maintain
appropriate medication coverage for their clients, 53
ADAPs have developed policies to coordinate with
the Part D benefit.
ADAP Policies Related to Medicare Part D, February 2011
44
Number of ADAPs
36
39
36
23
ADAP Pays Part D Premiums ADAP Pays Part D Deductible
ADAP Pays Part D Co-Pays
Standard Beneficiary Clients
Eligible for ADAP
ADAP Provides Medications
During Donut Hole
ADAP Coordination with
Medicare Part D
 Twenty-six ADAPs reported signing a data sharing
agreement with CMS in December 2010 (see Table
13).
 Twenty-three ADAPs, including 9 who do not have a
data sharing agreement with CMS, have a data
sharing agreement with at least one other entity,
including Medicaid, Medicare, private insurance
providers, and other entities (e.g. Pharmacy Benefits
Managers).
Highlights from Module Two
Supplement
ADAP Coverage of Hepatitis B
Treatment, December 2010
ADAP Coverage of Hepatitis C
Treatment, December 2010
ADAP Coverage of Hepatitis A and
B Vaccines, December 2010
Year in Review
The “Perfect Storm”
Heightened national
efforts on HIV testing
and linkages into care
Minimal increases in
federal appropriations
Fluctuations in state
funding
Increased demand due
to unemployment and
other economic
challenges
ADAP
High drug costs
Revised HIV treatment
guidelines
Patient Protection and Affordable
Care Act
 Patient Protection and Affordable Care Act (PPACA) signed into
law in March 2010.
 Some portions of reform that will impact ADAPs specifically are:
– Medicaid eligibility expansion (2014);
– Increase in the number of individuals covered by insurance plans
(2014);
– ADAPs’ Medicare Part D expenditures counting toward True Out
Of Pocket (TrOOP) expenditures (2011);
– Narrowing and closing of the Medicare Part D “doughnut hole
(ongoing);”
– An increase in the Medicaid rebate amount for purchased drugs;
and (2010)
– 340B pricing transparency.
Pharmaceutical Partners
Contributions
 In May 2010, pharmaceutical partners augmented
current agreements with ADAPs including:
– Providing deeper discounts;
– Increased rebates; and/or
– Price freezes to ADAP.
 Pharmaceutical partners expanded the reach of
Patient Assistance Programs (PAPs) and participated
in Welvista for waiting list clients.
ADAP Waiting Lists
 Over the course of 2010, 19 ADAPs reported a
waiting list.
 Several ADAPs decreased income eligibility
requirements and disenrolled clients from ADAP in
order to address shortfalls.
 In FY2010, some ADAPs began transitioning clients
off of ADAP and onto PAPs as a means of costcontainment. These clients were directed to seek
access to medications through PAPs.
ADAP Waiting Lists and
Cost-containment, as of May 2011
ADAP Waiting Lists,
as of June 30, 2011
8,615 individuals in 13 states*
Alabama: 73 individuals
Arkansas: 40 individuals
Florida: 3,562 individuals
Georgia: 1,630 individuals
Idaho: 20 individuals
Louisiana: 824 individuals**
Montana: 29 individuals
North Carolina: 292 individuals
Ohio: 485 individuals
South Carolina: 810 individuals
Utah: 25 individuals
Virginia: 817 individuals
Wyoming: 8 individuals
*As a result of ADAP emergency funding, Hawaii, Idaho, Iowa, Kentucky, South Dakota, and Utah eliminated their waiting
lists; Idaho reinstituted a waiting list in February 2011 and Utah reinstituted a waiting list in May 2011.
**Louisiana has a capped enrollment on their program. This number represents their current unmet need.
ADAPs with Cost-containment,
as of April 13, 2011
Arizona: reduced formulary
Arkansas: reduced formulary, lowered financial eligibility to 200% FPL
(disenrolled 99 clients in September 2009)
Colorado: reduced formulary
Florida: reduced formulary, transitioned 5,403 clients to Welvista from
February 15, 2011 to March 31, 2011
Georgia: reduced formulary, implemented medical criteria,
participating in the Alternative Method Demonstration Project (AMDP)
Idaho: capped enrollment
Illinois: reduced formulary, instituted monthly expenditure cap ($2,000 per
client per month)
Kentucky: reduced formulary
Louisiana: discontinued reimbursement of laboratory assays
North Carolina: reduced formulary
ADAPs with Cost-containment,
as of April 13, 2011 (continued)
North Dakota: capped enrollment, instituted annual expenditure cap,
lowered financial eligibility to 300% FPL (grandfathered in current clients
above 300%FPL)
Ohio: reduced formulary, lowered financial eligibility to 300% FPL
(disenrolled 257 clients in July 2010)
Puerto Rico: reduced formulary
South Carolina: lowered financial eligibility to 300% FPL (grandfathered in
current clients above 300% FPL)
Utah: reduced formulary, lowered financial eligibility to 250% FPL
(disenrolled 89 clients in FY2010)
Virginia: reduced formulary, transitioned 207 clients onto waiting list and
PAPs, only distributing 30-day prescription refills
Washington: instituted client cost sharing, reduced formulary (for uninsured
clients only), only paying insurance premiums for clients currently on
antiretrovirals
Wyoming: reduced formulary, instituted client cost sharing
Coordinated Strategy to Save
America’s ADAPs
 Secure additional resources for ADAP from the
federal government:
– The HIV/AIDS community is advocating for an
increase of $106 million for ADAPs for a total funding
of $991 million in FY2012.
 Maintain, restore and increase resources for ADAPs
from state governments.
 Continue agreements between ADAPs and
pharmaceutical manufacturers to provide financial
stability and augment existing agreements, when
possible.
The Outlook for the Future
 A bridge to 2014 is slowly being built and will require
much construction before ADAPs can fully take
advantage of health reform provisions.
 Weathering the current storm to reach 2014 will take
collaboration from all stakeholders involved in the
administration of the program.
Questions and Answers
Resources
 For an electronic copy of the 2011 National ADAP
Monitoring Project Annual Report, please visit
www.NASTAD.org.
 For more information about the National ADAP
Monitoring Project or the ADAP Crisis, please
contact Britten Pund at [email protected].
Contact Information
Britten Pund
Manager, Health Care Access
NASTAD
Phone: (202) 434.8044
[email protected]
www.NASTAD.org