Transcript ADAPs in Context

ADAPS: Ensuring Access to Medications for
Low-income People in the US with HIV/AIDS
Steve Bailey, Assistant Director, Health Care Services, Virginia
Department of Health, May 2008
ADAPs in Context
• Funded through Part B of the Ryan White Program;
58 programs in all states, D.C., and U.S. territories
• Funded at $794.4 million in FY2008; increase of $4.8
million over FY2007
• President proposed a $29 million increase for FY2009;
identified need is increase of $135 million
• Last 4 years have seen insufficient federal increases
ADAPs in Context
• Critical component of safety net for people living with HIV/AIDS
– Reaching about 30% of those with HIV/AIDS in care
– However, IOM estimates 233,000 HIV-positive Americans do not have
consistent access to HAART
– CDC estimates only 55% of people with HIV receiving HAART
• Growing importance of ADAPs over time
– Shifting treatment environment toward early intervention
– Increasing number of people = HIV+ people living longer
• Significant variation in program access/services across the country
• As payer of last resort, changes in other payers of health care
change demand for ADAPs (e.g., Medicaid, Medicare)
Sources: Fleming, P., et.al., HIV Prevalence in the United States, 2000, 9th Conference on Retroviruses and Opportunistic Infections,
Abstract #11, Oral Abstract Session 5, February 2002; HRSA, HIV/AIDS Bureau, Ryan White CARE Act AIDS Drug Data Report, 2002.
“Public Financing and Delivery of HIV/AIDS: Securing the Legacy of Ryan White.” Institute of Medicine, May 13, 2004.
ADAPs in Context
• ADAPs maintained stability in FY2007 due to a number of
factors:
– $294 million in state general revenue contributions
– $39.4 million awarded in FY2007 ADAP supplemental
grants
– Increased drug rebates from pharmaceutical
manufacturers
• ADAP Crisis Task Force saved $150 million; additional
voluntary discounts and rebates from all major
manufacturers of antiretrovirals
– Program savings from the Medicare Part D Prescription
Drug Benefit
National ADAP Budget
Drug Rebates
$262,551,285
(18%)
Other State or Federal
$19,640,632
(1%)
Part A Contribution
$12,265,657
(1%)
Part B ADAP Earmark
$775,320,700
(54%)
State Contribution
$294,071,393
(21%)
Part B Base
$24,583,999
(2%)
Part B ADAP
Supplemental
$39,477,300
(3%)
Total = $1.43 billion
Kaiser Family Foundation and National Alliance of State and Territorial AIDS Directors, National ADAP Monitoring Project Annual Report, April 2008
National ADAP Budget
• Over time, states increasingly contributing to ADAPs
• However, over half the state looking at budget deficits in
FY2009 & FY2010
State Funding, FY 1996-2007
$350
$304.9 $294.1
Millions of Dollars
$300
$252.8
$250
$226.6
$200
$149.6 $160.4
$171.9
$128.8
$117.4 $119.4 $125.5
$150
$100
$50.4
$50
$0
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Kaiser Family Foundation and National Alliance of State and Territorial AIDS Directors, National ADAP Monitoring Project Annual Report, April 2008
8
ADAP Drug Expenditures &
Per Capita Drug Spending, June 2007
All
Other
9%
ARVs
89%
Per Capita Drug Spending
$982
•
Drug spending totaled
$100.1 million
•
ADAPs also spent $8.8
million on insurance
coverage in June 2007;
$74.5 million in FY 2007
•
10 states accounted for most
drug spending (75%);
ranged from $21K to more
than $22 million
"A1" OI
2%
Note: 51 ADAPs reported data. ARVs = Antiretrovirals; "A1" OIs = Drugs recommended ("A1") for prevention and treatment of opportunistic infections (OIs).
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2008.
ADAP Clients, June 2007
• ADAPs provided medications to 101,987 clients
– 10 ADAPs account for 67% of clients served
– 6% increase in clients served over last year
– Among the 47 ADAPs reporting data since 1996, clients
served increased by 226%
• Mostly people of color
– African Americans 33%, Hispanics 35%, others are 6%,
whites 26%
• Very low-income (75% of clients fell at or below 200%
FPL; 43% at or below 100% FPL)
• Most uninsured (15% private insurance; 12% Medicare;
2% Medicaid; 2% duals)
23
ADAP Income Eligibility,
December 31, 2007
NH
VT
WA
ME
ND
MT
MA
MN
OR
WI
NY
MI
SD
ID
WY
PA
IA
NE
NV
IL
OH
IN
CA
KS
OK
AZ
NM
MO
VA
KY
NC
TN
AR
MS
TX
MD
DC
SC
GA
AK
NJ
DE
WV
UT
CO
RI
CT
American Samoa
AL
Federated States of
Micronesia
LA
FL
Guam
Marshall Islands
HI
Income eligibility greater than 300% FPL (25 ADAPs)
Income eligibility between 201% FPL and 300% FPL (19 ADAPs)
Income eligibility at 200% FPL (9 ADAPs)
Not reported (5 ADAPs)
Notes: 53 ADAPs reported data. The 2007 Federal Poverty Level (FPL) was $10,210 (slightly higher in
Alaska and Hawaii) for a household of one.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2008.
Northern Mariana Islands
Puerto Rico
Virgin Islands (U.S.)
Factors Influencing ADAP Budgets
•
•
•
•
Consistent growth into ADAPs
Increased health care costs
People living longer and remaining on ADAPs
New and expensive treatments
– 3 new drugs approved in 2007 and beginning of 2008
• More complex treatment regimens
• Insufficient federal funding
• Increased emphasis on testing
Containment Measures – March 2008
•
•
•
3 ADAPs have 1 or more cost containment measures in
place
1 ADAP has a waiting list (not only reflection of unmet
need)
Other cost containment strategies
– Capped enrollment
– Reduced formularies
– Limiting access to certain medications
– Cost-sharing
– Expenditure limits (monthly or annual)
– More restrictive eligibility requirements (medical,
financial)
Recent Virginia Challenges
• In June 2007, VA served 1,535 clients (over 3,200 clients annually)
• State contribution of $2.6 million represents 11% of total ADAP
budget
• In order to wrap around Medicare Part D implemented a SPAP to
provide services to ADAP clients also eligible for Part D with incomes
between 135% & 300% FPL.
• Initial 35 clients served at projected 1/3 cost of maintaining on ADAP
(which is over $15,600 annually) - Met TrOOP in 2.6 months
• This additional program would not be necessary if ADAP expenses
were allowed to count towards True out-of-pocket costs (TrOOP).