180 KB - Treatment Action Group
Download
Report
Transcript 180 KB - Treatment Action Group
Given the election results,
how will the ACA and
Medicaid expansion affect
the service delivery mix?
What are the opportunities
to use these mechanisms
to optimize HIV
programmatic success?
Revitalizing the US Domestic HIV/AIDS
Response:
New Science and New Approaches to
Improve Outcomes and Reduce Costs
December 11, 2012
Julia Hidalgo, ScD, MSW, MPH
Positive Outcomes, Inc. & George Washington University
[email protected]
With Contributions From
Naomi Seiler, JD, Katherine Horton JD, Mary-Beth Harty, JD,
Maureen Byrnes
George Washington University
Introduction
The Patient Protection and Affordable Care Act
(ACA), Medicaid expansion, and other health
reforms is impacting the HIV care continuum
through changes in
Coverage
Enrollment mechanisms
Health benefits
Health care system redesign
Payment systems
Information gathering and reporting
Current Opportunities Available Through the ACA
Coverage changes
Expanded Medicaid coverage for childless adults with income up
to 138%, with 8 states expanding coverage
Established Preexisting Condition Insurance Plans (PCIP)
Extended dependent coverage for adult children up to 26 years of
age
Health benefit changes
Prohibited individual and group health plans from placing lifetime
limits on coverage, rescinding coverage, and denying children
coverage due to pre-exiting medical conditions
New health plans must provide
Prevention services with an A or B rating by the USPSTF for
free including HIV screening for individuals at high risk
Insurers must provide free coverage for certain women’s
preventive services such as annual HIV counseling and
screening for all sexually active women
Provides financial incentive to Medicaid programs offering
coverage with no cost sharing for preventive services rated A or
B by the USPSTF
Current Opportunities Available Through the ACA
Health care systems redesign
New Medicaid State option for beneficiaries with chronic
conditions to designate a provider as a medical home, with HIV
added recently as a designated condition
Grants awarded to design person-centered models coordinating
services to Medicaid/Medicare dual eligibles
Payment systems
Medicaid payments to primary care doctors will increase to
100% of the Medicare payment rates
Increased funding for federally qualified health centers
(FQHCs) and planning grants for agencies seeking to become
federally qualified
Opportunities Available Through the ACA in 2014
Coverage changes
Expanded Medicaid coverage for most individuals with incomes up to 138%
of
the FPL, with 100% federal funding from 2014-2016 and step-wise decreases
in 2017 and onward
Creates state-based American Health Benefit Exchanges and Small Business
Health Options Program Exchanges through which coverage can be purchased
Provides refundable and advanceble tax credits and cost-sharing subsidies to
eligible individuals
Prohibits pre-existing condition exclusions in issuing and renewing health
insurance
Prohibits annual limits on the dollar value of coverage
Requires US citizens and legal residents to have qualifying health coverage
and a phased-in tax penalty for individuals without coverage
Health benefit changes
Creates a Basic Health Plan for uninsured individuals with incomes between
138-200% of the FPL who are eligible to receive premium subsidies
Health plans in the individual and small group markets, Medicaid benchmark
and equivalent packages, and the Basic Health Plan must include an essential
health benefits package
Minimum Essential Health Benefits (EHBs)
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services,
including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease
management
Pediatric services, including oral and vision care
Health Care System Re-design: Patient-Centered Medical Homes
“Medical home,” “health home,” and “patient-centered medical home” are
terms used interchangeably
One provider or group of providers is responsible for providing or
coordinating a given patient’s care, with some kind of financial incentive(s)
to do so
Joint Principles of the Patient-Centered Medical Home from the American
Academy of Family Physicians, American Academy of Pediatrics, American
College of Physicians and American Osteopathic Association (2007)
Personal physician for continuous, comprehensive care
Physician directed medical practice, where the physician leads a team of
individuals at practice level who take responsibility for ongoing care
Whole person orientation, where the physician responsible for all of the
patient’s health care needs or arranging care with other qualified
professionals
Care is coordinated and/or integrated across all elements of the health care
system and community (e.g., family, public and private community-based
services)
Quality and safety achieved through accountability, evidence-based medicine,
decision support tools and other mechanisms
Enhanced access to care
Payment that appropriately recognizes the added value provided to patients
Application of the PCMH Model
About half of States Medicaid programs are currently
implementing medical home initiatives of some form
New or revised payments to primary care providers to
function as PCMHs
Case management fees, performance payments, payments to support shared
teams or networks, support for transformation to PCMHs
Some, but not all, states require PCMH accreditation by the
National Committee for Quality Assurance (NCQA) or another
national accrediting body
CMS and HRSA fund the FQHC Advanced Primary Care
Practice Demonstration (500 FQHCs)
Three-year demonstration to evaluate the effect of the advanced primary care
practice model, in improving care, promoting health, and reducing the cost of care
provided to Medicare beneficiaries served by FQHCs
Monthly care management fee of $6 each eligible Medicare beneficiary attributed
to their practice
CMS’s Comprehensive Primary Care Initiative
Multi-payer- Medicare works with commercial payers and State plans
Primary care providers in selected markets
Monthly care management fee ($20 PMPM for two years, then $15 for two years)
After two years, possibility of sharing in regional Medicare savings
Medicaid Health Homes in the ACA: Definition
CMS requires States that provide this optional benefit, and
the health home providers with which the State collaborates,
to operate under a “whole-person” philosophy – caring not
just for an individual’s physical condition, but providing
linkages to long-term community care services and supports,
social services, and family services
Eligible Medicaid beneficiaries include individuals with
at least two chronic conditions, OR
one chronic condition and at risk for another, OR
one serious and persistent mental health condition
States can target specific diseases or regions, and may set
more restrictive criteria, but may not exclude dual-eligibles
A chronic condition can be a mental health condition,
substance use disorder, asthma, diabetes, heart disease, or
being overweight (BMI >25), or HIV
Entities serving as a health home include designated
providers, a team of health care professionals, or a health
team
Medicaid Health Home Services
Enhanced federal match is offered for services that provide
the glue to coordinate care
Comprehensive care management, care coordination, and health
promotion
Comprehensive transitional care from inpatient to other settings, including
appropriate follow-up
Patient and family support
Referral to community and social support services
Health information technology to link services
States receive 90% federal match for 8 consecutive quarters
All other services (underlying medical services, etc.) matched
at usual Federal Medical Assistance Percentages (FMAP)
States can do more than one health home state plan
amendment, or can do a geographic expansion of an
amendment to new enrollees
But states can only receive eight quarters of enhanced match for
any individual enrollee
After 8 quarters, the state may continue to provide health
home services at usual FMAP
Managed care enrollees must be permitted to enroll in health
homes if offered in their area and otherwise eligible
Key Considerations for the HIV+ Community In Implementing the ACA
HIV is not the foremost concern of State policy makers, health
exchange panels, Medicaid program staff, and insurers
HIV community must organize and mobilize to ensure that HIV+
beneficiaries’ need are met
There will be significant variability in state-level coverage, benefits,
and payment systems
Will States build, buy, or borrow HIV care?
Systems-level changes will be swift and hard to monitor accurately
at the federal level
People will be confused, and will need to be educated
Many HIV+ individuals and their family members will need
significant help in choosing the insurance plan that best meets their
needs
Managed care service delivery and payment models are likely to be
adopted
Many HIV programs are likely to be unfamiliar with these models,
may not participate in insurance plans, and their staff may not be
sufficiently credentialed to serve as providers
Key Considerations for the HIV+ Community In Implementing the ACA
HIV clinical and support providers must learn to market their
services to ensure they have a role in HIV care delivery
The essential HIV benefit package is likely to vary considerably
geographically and by public and commercial systems, insured
population, by insurer, and by service delivery systems (e.g., fee for
service or managed care)
Payment models are also likely to vary considerably
The impact of the ACA on HIV surveillance systems is unclear
Surveillance systems will likely rely on lab reporting
Ensuring access to HIV screening, medication education, treatment
adherence, access to PrEP, and HERR will be challenging unless
financial incentives are in play
The prevention with positives paradigm may be unsustainable in a
new financing and delivery system
Access to HIV-experienced providers may be decreased
Medication benefits may not be sufficiently covered
Key Considerations for the HIV+ Community In Implementing the ACA
Physical and behavioral service payment systems may
implemented separately
Access to HIV care in rural areas will continue to be limited
HIV clinical providers are likely to insufficiently reimbursed for their
services unless Ryan White (RW) Program funds are used for
balanced billing
STI, TB, family planning, and other public health systems will
experience significant pressure to integrate in the broader health
care financing system
Roles for community-based organizations may be available, but will
need to defined and marketed to health care plans and insurers
Linkage from testing to treatment, patient navigation, and peer
coaches
The ACA is unlikely to reduce HIV stigma and concerns about
disclosure and discrimination
Violations of ACA protections are likely and must be documented
The ACA does not address the need for equity and transportability
of health insurance benefits when HIV+ individuals move to another
state
Key Considerations for the HIV+ Community In Implementing the ACA
Some HIV+ individuals will not be included in expanded coverage
The District of Columbia is addressed as a state in the ACA
Puerto Rico and other territories will not enjoy benefits comparable to
states
Application of HIV quality measures and improvement processes to
public and commercial health insurance systems will be
challenging
Significant data granularity will be lost as we rely on insurance
claims systems
It will be very difficult to measure the impact of the ACA
implementation on HIV+ individuals and the HIV care continuum
Caution should be used in making a business model or cost saving
rationale for HIV prevention and treatment
Meanwhile in the RW HIV/AIDS Program
Results of efforts to reauthorize the RW Program are unclear
Transition of core services from RW Program grant-based
budgeting to public and commercial payment systems,
including fee for service reimbursement and prospective
capitation payment
Increased monitoring of HAB and the RW Program’s grantees
and providers to ensure adherence to statutory requirements
(e.g., payer of last resort, client charges)
Balanced billing in which RW Program funds are used to supplement
insurance payments likely to be eliminated
Demand for RW Program-funded health insurance premium,
co-payment, and deductible assistance is likely to increase
sharply as HIV+ individuals enroll in health insurance
As medication costs are shifted to insurers, ADAPs’ revenue
from rebates will decrease sharply
Many ADAPs use rebates to support services or employees
Meanwhile in the RW HIV/AIDS Program
Demand for RW Program-funded health insurance premium,
co-payment, and deductible assistance is likely to increase
sharply as HIV+ individuals enroll in health insurance
An increasing number of RW Parts A and B grantees will seek a
waiver from the 75% core / 25% support service requirement
RW client-level data systems vary highly in maturity
Much critical accurate data are missing
It is important to acknowledge that the RW Program has some
profound limitations, the quality of clinical and support
services vary considerable, and we have limited capacity to
demonstrate the direct impact of the RW Program
Our failure to convert the “cascade effect” to a “golden pond
effect” must be acknowledge by the HIV prevention and care
community
Efforts to help transition HIV+ individuals into insurance
systems must be spear headed by RW-funded Programs
Design Used to Assess Eligibility Determination (ED)
Activities Funded Five Part A Grantees
Key Facts
Grantee 1
Grantee 2
Grantee 3
Grantee 4
Grantee
5
Region
Southwest
Northeast
South
South
South
Service Area
Large urban,
and adjoining
rural areas
Suburban, and
adjoining rural
counties
Moderate
urban, and
adjoining
rural counties
Large urban
Large urban, and
adjoining rural
areas
Providers
1 hospitalbased HIV
clinic, 2
FQHCs, 1 CHC
2 ASO, 2
hospital-based
HIV clinic2, 1
FQHC, 1 county
health dept
3 ASOs (1 colocated in HIV
clinic), 1
county health
dept
Centralized Part
A ED Unit
3 ASOs, 2
community ID
practices, 1
county health
dept
Assessment
Design
Chart review
Chart review
Chart review
Electronic
records
Chart review
Chart
Review Tool
# Charts
Reviewed
Tool measures attainment of HAB and grantee monitoring standards, and assesses key
components of RW Program and third party insurance eligibility
285
407
325
144
493
Findings of ED Quality Assessments Among
Providers Funded by Five Part A Grantees
Grantee 2
Grantee 3
Grantee 4
Average
Error Rate
Grantee 1
Grantee
5
Region
Southwest
Northeast
South
South
South
Average
Household
Size
Not
Assessed
38%
58%
Not Assessed
Not Assessed
Household
Income
Not
Assessed
74%
77%
35%
Not Assessed
Health
Insurance
32%
39%
27%
11%
44%