Transcript Document

The State of ADAPs
Britten Pund
National Alliance of State & Territorial AIDS Directors
July 8, 2013
Presentation Agenda
 Emerging trends in ADAP
– FY2012 Year in Review
– Looking Ahead to FY2013
– ADAPs and Health Reform
– Expanded Access to Care
 Update on the ADAP Crisis
– ADAP waiting lists
– ADAP cost-containment
 Questions and Answers
Overview of NASTAD

NASTAD is an international non-profit association of U.S. state
health department HIV/AIDS program directors who administer
HIV/AIDS and viral hepatitis programs funded by U.S. state and
federal governments.

NASTAD was established in 1992 as the voice of the states.

NASTAD is governed by a 20 member, elected Executive
Committee charged with making policy and program decisions on
behalf of the full membership.

NASTAD has a Washington, DC headquarters with 38 staff and
field offices/programs in Bahamas, Botswana, Ethiopia, Guyana,
Haiti, Trinidad, South Africa and Zambia with 65 staff.
NASTAD Mission and Vision
Mission
NASTAD strengthens state and territory-based leadership, expertise
and advocacy and brings them to bear on reducing the incidence of
HIV and viral hepatitis infections and on providing care and support
to all who live with HIV/AIDS and viral hepatitis.
Vision
NASTAD’s vision is a world free of HIV/AIDS and viral hepatitis.
FY2012 Year in Review
The National ADAP Budget, by source,
FY1996-FY2012
11%
26%
43%
19%
7%
6%
18%
5%
9%
7%
17%
10%
10%
9%
7%
7%
5%
7%
9%
10%
12%
15%
17%
18%
7%
7%
17%
17%
16%
19%
6%
8%
10%
21%
31%
29%
33%
36%
19%
22%
22%
6%
7%
21%
21%
14%
28%
19%
16%
13%
25%
65%
68%
66%
64%
65%
61%
59%
53%
56%
40%
54%
51%
49%
45%
43%
41%
26%
FY1996
$200 m
FY1997
$413 m
FY1998
$544 m
FY1999
$712 m
FY2000
$779 m
FY2001
$870 m
FY2002
$962 m
FY2003
FY2004
FY2005
FY2006
FY2007
FY2008
FY2009
FY2010
FY2011
FY2012
$1,071 m $1,187 m $1,299 m $1,386 m $1,428 m $1,515 m $1,582 m $1,789 m $1,887 m $2,032 m
ADAP Earmark
State
Rebates
Other
ADAP Crisis
 From FY2008 to FY2012, federal ADAP funding (including
Part B ADAP Earmark, Part B ADAP Supplemental and ADAP
Emergency Funding) increased 24%.
 From FY2008 to FY2012, state contributions to ADAP
decreased 12%.
 From FY2008 to FY2012, estimated drug rebates increased
127%.
ADAP Client Enrollment and Utilization
ADAP Client Utilization, June 1996-2012
160,000
143,941
39%
135,596
140,000
138,173
125,479
120,000
110,047
Clients Served
101,987
100,000
94,577 96,404 96,121
24%
85,825
76,743
80,000
80,035
69,407
61,822
60,000
53,765
14%
12%
11%
15%
10%
43,494
40,000
31,317
8%
8%
7%
6%
5%
4%
2%
2%
-0.3%
20,000
0
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
ADAP Client Demographics
ADAP Clients Served, by Race/Ethnicity, June 2012
American
Indian/Alaskan
Native
<1%
Multi-Racial
5%
Native
Hawaiian/Pacific
Islander
<1%
ADAP Clients Served, by Income Level, June 2012
Other
1%
Unknown
2%
>400% FPL
2%
301-400% FPL
6%
Unknown
<1%
201-300% FPL
15%
Asian
2%
Hispanic
23%
Non-Hispanic
Black/African
American
32%
≤100% FPL
45%
139-200% FPL
19%
Non-Hispanic
White
34%
101-138% FPL
14%
ADAP Client Demographics
ADAP Clients Served, by HIV/AIDS Status,
June 2012
(continued)
ADAP Clients by CD4 Count, Enrolled During
12-Month Period, June 2012
Unknown
10%
CD4 <200
21%
CDC-defined
AIDS
21%
HIV positive,
not AIDS
38%
CD4 > 500
39%
CD4 between
201-350
19%
HIV positive,
AIDS status
unknown
31%
CD4 between
351-500
21%
ADAP Insurance Coordination,
June 2012 and FY2012
50,000
$268
$280
46,653
45,000
Number of Clients (June)
40,000
$227
$200
34,341
35,000
30,621
30,000
$194
$160
$159
25,000
20,960
15,843
13,744
15,000
12,311
$75
10,000
7,167
5,000
$120
$107
20,000
5,272
$80
$84
$75
7,277
$40
$38
$30
$19
-
$2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Fiscal Year Expenditures (in millions)
$240
41,095
ADAP Emergency Funding
 In August 2012, ADAPs received $75 million to address
ADAP waiting lists and other unmet ADAP needs.
 ADAP emergency funding awards were made to 25 states.
 Funding amounts ranged from $74,324 in North Dakota to
$10.1 million in California.
Looking Ahead to FY2013 and
FY2014
Funding Outlook – FY2013
 In FY2013, ADAPs were funded at $886 million, a cut of
$47 million due to sequestration.
– NASTAD estimates this sequester cut could affect over
8,200 clients currently enrolled on ADAP.
– $35 million was transferred to ADAP for emergency relief
funding from other HHS programs, including other parts
of Ryan White.
 This does not affect the sequester cut and it does not
represent an increase in funding for FY2013.
 With the implementation of health reform and continued
fiscal challenges, ADAPs may continue to experience shifts
in state funding allocations, including potential reductions.
Funding Outlook – FY2013
(continued)
 FY2013 also brings changes to the ADAP award formula
calculations:
– Normal shifts of proportion of the country’s living HIV/AIDS
cases
– Only name-based HIV cases reported to CDC will be used
– The hold harmless provision will decrease to 92.5% of
states’ FY2012 award
– FY2013 is the final year of the transitional grant area (TGA)
transfer
 These funding shifts have not yet been realized by final
FY2013 awards are just being received by states.
Funding Outlook – FY2014
 If sequestration is not fixed, it will continue each fiscal year
until FY2021:
– Discretionary spending caps for fiscal years 2012-2021
for $984 billion in savings over 10 years or $109 billion
annually
– $350 billion less over 10 years than in 2013 for nondefense discretionary programs
– These cuts will be made through the appropriations
process or through across-the-board cuts
Funding Outlook – FY2014
(continued)
 President Obama’s budget was released on April 10, 2013
and includes:
– $20 million increase for Ryan White Program, including
$10 million increase for ADAP
– $35 million Emergency Relief Funding continued
– Eliminates the sequester
Funding Outlook – FY2014
(continued)

The House and Senate have very different FY2014 budgets:
– The House allocation for Labor, Health and Human Services,
Education, and Related Agencies is $121.8 billion, which
represents an 18.6% cut from FY2013.
 If applied universally, ADAP could be funded at $721
million, a $164 million cut.
– The Senate’s budget funds at much higher levels than the
House budget and eliminates the sequester

It is highly possible that FY2014 will result in a continuing
resolution and probable sequestration causing prolonged fiscal
uncertainty for ADAP.
Ryan White Program Reauthorization
 The Ryan White Program authorization ends on September 30,
2013.
– The authorization does not contain a sunset clause and can
continue through appropriations.
 The Ryan White Program may not likely to see legislative
action this year.
– Administration will not push for reauthorization
– Need better understanding of changes to health system
due to health reform before making major changes
 Long term visioning and planning for reauthorization is
underway with the HIV advocacy community
 Potential for language to be introduced by the House or Senate
in the appropriations process that could affect how the Ryan
White Program continues.
ADAPs and Health Reform
ACA Timeline
Using the ACA to Tackle the Treatment
Cascade
ADAP in a Reformed Health System
 What will ADAP “look like” after January 1, 2014?
– Traditional ADAP
 Full payment of medications for those not eligible for
coverage under the Affordable Care Act
– Insurance purchasing/continuation
 Wrap-around of Medicaid and Medicare
– Including Medicaid expansion and non-expansion
states
 Insurance purchasing – purchasing of a new policy
– Including policies purchased through the Exchange
 Insurance continuation – payment for an existing policy
– Including policies purchased through the Exchange
ADAP in a Reformed Health System
(continued)

What is the potential change in ADAP utilization between FY2013 and
FY2014?
– Client migration to Medicaid in a non-expanding state
 Presumption that clients would not move
– Client migration to Medicaid in an expanding state
 Potential for clients to shift coverage to Medicaid
– Client migration to Exchanges
 Potential for clients to gain access to insurance for the first
time, however ADAP may remain the payer for the policy (i.e.,
premiums, deductibles, and co-payments)
– Clients remaining on ADAP
 Individuals who are categorically ineligible for federal
programs
 Individuals needing wrap-around coverage for an existing or
new insurance policy
 Individuals who churn
 Individuals who do not enroll
Expanded Access to Care
Current Initiative
 Analyzed three current options for increased access to
care for under and uninsured individuals living with
HIV – ADAP, pharmaceutical patient assistance
programs (PAPs) and Welvista.
 In collaboration with HHS/HRSA and the Clinton
Health Access Initiative, NASTAD has worked to
develop a standardized PAP enrollment process and
application.
 This effort, in conjunction with industry and federal
partners, will bring HIV/AIDS care and treatment for
the under and uninsured to a new era.
Common PAP Process
 Working toward reaching consensus on a common
application and eligibility/fulfillment process.
– Step One: simplifying and streamlining access to PAP
medications (HHS Common Form)
– Step Two: streamlining eligibility and prescription
fulfillment distribution (HarborPath)
 Reduce burden for providers, case managers and PLWH.
Common Patient Assistance Program
Application
Common PAP Application
 Working with industry and NASTAD, HHS/HRSA developed
and announced the common form during the
International AIDS Conference in July 2012
(www.NASTAD.org/CommonPAPForm).
 Form “went live” on September 12, 2012
Instructions for Completing the
Common PAP Application
 Individual or case managers completes the online form
– Form only needs to be completed once for all
medications for which individual is applying.
 Print out the completed form for the companies from which
the individual needs medications.
 Sign the form (most need an original signature).
 Attached necessary documentation.
 Submit to companies – each company has a separate
fulfillment process (e.g., mail order, pharmacy, etc.).
Common PAP Application
(continued)
 In April 2013, all companies accepting the common form
convened for a consultation to discuss the use and
usefulness of the form.
 Updates are being made to the form to ensure its efficacy
and it will be relaunched in summer 2013.
HarborPath
HarborPath
 NASTAD and the Clinton Health Access Initiative (CHAI)
launched HarborPath (HP) to streamline PAP enrollment,
eligibility processing and prescription fulfillment.
 HP is a collaborative undertaking between pharmaceutical
partners, NASTAD, donors, government agencies, and
advocacy groups.
 There are currently two prongs of HarborPath:
– Online portal
– ADAP waiting list program
HarborPath: Online Portal
 HP has completed software development for the common
portal and can process PAP forms as well and ADAP waiting
list forms.
 Gilead Sciences, Merck and Co, and ViiV Healthcare are
supplying medications to the HarborPath online portal.
 Discussions continue with AbbVie, Bristol-Myers Squibb,
and Janssen Therapeutics.
 The HarborPath online portal is currently in a pilot phase
in seven states and Washington, DC (AL, FL, GA, NC, SC,
TX, WA).
Instructions for Using HarborPath:
Online Portal
 The HarborPath online portal is for clinics/case managers
(requires an agreement between clinic and HarborPath).
 Case managers enter all application data (stored).
 HarborPath determines eligibility and then transmits
shipping information to mail-order pharmacy.
 Clients receive one shipment containing all medications
available on HarborPath formulary.
 Other medications not available require print out of
company form based on data inputted into portal.
HarborPath:
ADAP Waiting List Program
 In May 2013, the ADAP waiting list program was transferred
from Welvista to HarborPath.
 AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen
Therapeutics, Merck and Co, and ViiV Healthcare are
supplying medications to the HarborPath ADAP waiting
list program.
 The HarborPath ADAP waiting list program is licensed
in all states and currently available in all states that have a
waiting list.
Instructions for Using HarborPath:
ADAP Waiting List Program
 ADAP coordinators or ADAP case managers, on behalf of new
patients on ADAP waiting lists wishing to access the
HarborPath ADAP waiting list program, should complete and
certify a HarborPath ADAP Waiting List Program Enrollment
Form, including prescriptions, and submit these to HarborPath
in order to ensure the dispensing of available medications.
 Patients who are prescribed medications not listed above
(primarily from Boehringer Ingelheim Pharmaceuticals) will
need to apply through the applicable patient assistance
program (PAP).
 Clients receive one shipment containing all medications
available on the HarborPath: ADAP waiting list program
formulary.
ADAP Waiting Lists
Factors Leading to Implementation of Costcontainment Measures
 ADAPs reported the following factors contributing to
consideration or implementation of cost containment
measures:
– Higher demand for ADAP services as a result of
increased unemployment
– Level federal funding awards
– Increased demand for ADAP services due to
comprehensive HIV testing efforts
– Escalating drug costs
– Budgets cuts in state Medicaid and other state programs
 Demand for ADAP has not dwindled.
Access to Medications
 Case management services are being provided to clients on
ADAP waiting lists through:
– ADAP
– Ryan White Part B
– Contracted agencies
– Other agencies, including other Parts of Ryan White
 ADAP waiting list states confirm that ADAP waiting list
clients are receiving medications through other
mechanisms.
NASTAD Process for Updates
 Weekly updates
– Monday-Thursday – connect with ADAPs anticipating
cost-containment and waiting lists to check on current
program status
– Friday – e-mail requesting an updated number of
individuals currently on each states ADAP waiting list, as
of that date
– Monday – compile information received and release
ADAP waiting list update
 Process aligns with ADAP waiting list reporting to HRSA.
NASTAD Reporting Process
 ADAP waiting list update contains individuals who have:
– Completed the application process for their state ADAP
– Been deemed eligible for the ADAP in their state
– Been placed on the states ADAP waiting list or unmet
need list
 Information captured each week at the same point in time
(all states provide an updated number based on a date
provided by NASTAD)
What the ADAP Watch
Does Not Capture
 Individuals who have not presented to ADAP
 Individuals who have presented but were not eligible
 Individuals who may have been disenrolled
 Individuals who have “fallen out” of ADAP (e.g., no longer
taking drugs, moved, obtained other coverage)
 Individuals who may be in one or more of the above
categories and accessing a PAP for medications
ADAP Waiting List Update
ADAP Waiting Lists
(227 individuals in 3 states),
as of June 20, 2013
State
Number of
Individuals on
ADAP Waiting
List
Percent of
the Total
ADAP
Waiting List
Increase/Decr
ease from
Previous
Reporting
Period
Date Waiting
List Began
Alabama
210
93%
+114
April 2012
Idaho
0
0%
0
October 2012
South Dakota
17
7%
0
August 2012
Waiting List Organization and
Access to Medications
 Waiting List Organization: Waiting list clients are
prioritized by one of two models:
– First-come, first-served model: placing individuals
on the waiting list in order of receipt of a completed
application and eligibility confirmation (3 ADAPs).
– Medical criteria model: based on hierarchical medical
criteria based on recommendations by the ADAP
Advisory Committee (0 ADAPs).
 Access to Medications: All three ADAPs with waiting lists
confirm that case management services assist clients in
obtaining medications through the HarborPath ADAP waiting
list program or pharmaceutical company patient assistance
programs (PAPs) while clients are on the waiting list.
ADAP Cost-containment Measures
Factors Leading to Implementation of
Cost-containment
 As of June 11, 2013, ADAPs reported the following factors
contributing to consideration or implementation of cost
containment measures:
– Reduced or insufficient federal ADAP funding (9 ADAPs)
– Increased clients/demand due to job loss/unemployment
(9 ADAPs)
– Escalating drug costs (7 ADAPs)
– Increased utilization from already enrolled clients (6
ADAPs)
– Increased insurance/Medicare Part D wrap around costs
(6 ADAPs)
ADAPs and Cost-containment
ADAPs with Other Cost-containment Strategies
(since April 1, 2013, as of June 11, 2013)
Enrollment Cap
•
•
•
•
Alabama
Idaho
Indiana
Utah
Financial
Eligibility
Expenditure Cap
•
•
•
Illinois
(monthly)
New Mexico
(monthly)
South Dakota
(annual)
•
Illinois
Formulary
Reduction
•
•
•
•
•
Alabama
Alaska
Illinois
Louisiana
Maine
Other
•
Georgia:
cap on
insurance
premiums
ADAPs Considering New/Additional Cost-containment Measures
(before March 31, 2014)
Expenditure Cap
Waiting List
Other
Arizona
(annual)
Arkansas
Utah
Wisconsin
Questions and Answers
Resources
 For an electronic copy of the 2013 National ADAP
Monitoring Project Annual Report, please visit
www.NASTAD.org.
 For more information about the National ADAP Monitoring
Project or the state of ADAPs, please contact Britten Pund
at [email protected].
Contact Information
Britten Pund
Senior Manager, Health Care Access
NASTAD
Phone: (202) 434.8090
[email protected]
www.NASTAD.org