Transcript Puerto Rico`s AIDS Crisis Update

Anselmo Fonseca
VP / Co-Founder
Pacientes de SIDA pro Política Sana
ADAP CRISIS SUMMIT
July 5-7 2010
Washington, DC
The State allowed their 8 Epi-clinics to become in
disarray and unsafe for working while
providing less than standard quality of care,
and provide life saving drugs in a rationed
manner with a very high probability even
expired.
Some CBOs and Service Providers were forced to
severely reduce and eliminate services while
some even closed an office or two in other
regions.
SJ-EMA Part –A:
2006 - 2008 SJ-EMA Part-A and HOPWA some
payments were 90-120 days late, others 6-9
months.
 Patient dumping from SJ-EMA to the PR-DoH
Part-B helped foment a waiting list.
 * FBI, HHS, OIG, IRS- Raided four municipal
offices including the San Juan AIDS Clinic, this
investigation ongoing and out-come still
pending.
PR-DOH Part–B:
2006 – 2008 PSPS, along with CBOs and CPTET clinic director had indentified over
500 persons waiting for initial and change of TX and charts for 6-9 months were
hidden lock in an office pending approvals. Along with the Project Officer a
waiting list was confirmed and officially constituted, seeing how the PR-DoH
Secretary would not recognize the existence of a list. Hundreds of patients
migrated to other states, While others felt forced to get into clinical trials in order
to guarantee continuity in treatment, many were persons with Private Insurance
that were not able to cost the high Co-Pay and Deductibles.
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The PR-DoH had no ADAP Co-Pay System in place, so ADAP was
paying 100% of TX of PLWHA w/ Private Insurance since 1996.
The OIG continuously found violations against the grantee for
mismanagement of ADAP funds hence having to return $48 millions to
HRSA for FY 2002 – 2004, (Other audits pending). As of 2007 the state
would pay 100% of ADAP TX to persons instead of Co-Pay and
Deductable from the state’s ordinary operating funds.
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“The State attempts against the health and lives of the Patients from the
8 State Epi-Clinics” sited local press.
All the while failing to comply with the proposed plans for the
HIV/AIDS patients in the entire island as findings highlighted in
an OIG audit # A-02-08-02003.
The audit “Review of the Puerto Rico AIDS Drugs Assistance
Program's Controls for Accounting for and Safeguarding Drugs”
from 2004-2006 for these years the PR-DoH received $75,332,082
for life saving drugs for persons living with HIV/AIDS.
PR-Doh Admits to canceling contracts of delivery company which
were tasked with picking and drop-off prescription for 200
patients to and from the PR-DoH Central Pharmacy Warehouse.
Additional findings:
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Contrary to local and federal regulations the DoH did not
secure the proper dispatch of drugs under the supervision
of a licensed pharmacists.
That three Epi-clinics did not have and adequate inventory
of drugs.
That expired drugs were not disposed of, nor credit
requested and that expired drugs found on those shelves
were very likely dispatched to patients jeopardizing there
regiment and health.
Florida/Caribbean AETC-PR
Global findings of Patient Chart reviews to Detect the
Educational Needs of the State Clinics for the Prevention and
Treatment of Transmittable Deceases
IntroductionDuring fiscal 2006-2007 the Florida/Caribbean AETC realized 8
visits to the Epi-Clinics of the P- DoH. It’s objective was to
identify the educational needs, training nad consulting of the
clinical personnel which provide services to person with
HIV/AIDS. The methodology used in this needs assessment was
the revision of patients clinical charts.
In the process a total of 198 charts were reviewed, of these 61%
corresponded to males and 39% females. 62% of the males
were less than 50 years of age and 38% were older than 50. In
the female group 68% less than 50 years of age and 32% were
older than 50.
The revision of charts was realized using an instrument
which gathered information on 6 clinical management
aspects of the patient. Following are the most significant
findings according to the most recent guidelines for
Treatment of Adults and Adolescents suggested by the
Federal Department of Health at the time that these visits
were conducted.
Global Findings
Laboratories:
61% of the charts reviewed showed that patients with a good
CD4 count were in control of their illness (CD4 >350) and 62% of
the charts revealed that patients a viral load of <1,000.
Both indicators were consistent with patients in good control of
their illness. These lab results (CD4 y Viral Load) are both done
every 3-4 months as suggested by DHHS guidelines.
When changing ARV therapy it is necessary to repeat the Viral
Load every 2-8 weeks and although close to 63% of the clinics
did this, 26% did not.
Although other important laboratories works is best for the
management of the infected patient these getting done varied.
In 70%of the charts reviewed the CBC and Lipid profiles were
done every 3-4 months as suggested by the guidelines.
However less than half of the charts reviewed showed that
these had not been done after a change in therapy.
The tests for Toxoplasmosis (78%), Chlamydia (93%) and
Gonorrhea (95%) were not routinely done in the majority of the
charts.
Even though a baseline VDRL had a high percentage (67%) in all of
the charts reviewed, only 23% continued to get done annually as
recommended.
The test to detect Hepatitis A y B were only done in half of the
charts reviewed, contrasting with the Hepatitis C test done in
65% of the cases.
Vaccines- In the majority of the charts reviewed, the administration of
vaccines were not routinely done. This finding was consistent in all
of the Epi-Clinics.
PROFILE OF PEOPLE LIVING WITH HIV/AIDS
IN THE WESTERN REGION OF PUERTO RICO
AND THE EVALUATION OF SERVICES
PROVIDED TO THEM
“The
needs reported by the PLWHA were economic
support, housing, psychological services, medication,
medical treatment, and transportation. Regarding
symptoms, 98.1% of PLWHA showed indicators of
clinical depression”
2005- Harvard Enhancing Iniciative
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* 2003 “La Reforma” (PR-SHIP) State Health
Insurance Plan, was implemented in the San
Juan Metro area, where three of the states EpiClinics with the highest incidence rates of HIV
and STDS cases are registered, (San Juan,
Bayamón, Carolina).
During this year the ADAP Program paid 100%
for all PLWHA at these clinics 100% of their
medications at an estimate of $17,000,000, when
in fact “La Reforma” was suppose to pay for all
regular and AVR drugs except PIs
Audit (A-02-06-02000)
09-29-2008
Review of the Puerto Rico Health Department's Compliance With the Ryan White CARE Act
Payer-of-Last-Resort Requirement
Executive Summary
“For grant years 2002-2004, we estimated that Puerto Rico claimed $24.3 million in unallowable Federal
funds under Title II of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of
1990. These claims did not comply with the payer-of-last-resort requirement that Title II funds not
be used to pay for HIV/AIDS drugs or services that are eligible for coverage by other Federal, State,
or private health insurance. The CARE Act, which is administered by HRSA, funds health care and
support services for more than 500,000 individuals each year who have HIV/AIDS and who have no
health insurance or are underinsured. Of the 100 prescriptions that we sampled, 57 prescriptions
were incorrectly claimed for patients who had other health insurance that would have covered the
drugs.
We recommended that Puerto Rico refund $24.3 million and develop procedures to bill HIV/AIDS drugs
to the Federal, State, or private health insurance plans with primary payment responsibility. Puerto
Rico did not directly address our recommendations but disputed some of our error determinations.
Based on additional documentation provided to us, we revised four of our original error
determinations and the refund amount.”
Complete Report
Download the complete report (PDF)
Their are at least 2 more audits pending to be made public, each in large part will consist of similar findings.
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2008 -2010 The PR- DoH and Advocates sought that HRSA approve the
use of $2 million for Co-Pays.
The states’ proposal for FY ‘08-‘09 included implementing a Co-Pay
System but locally it got put on hold, 3 DoH Sec. were not confirmed.
Advocates were not sitting idly and kept complaining to HRSA and
ONAP and were successful in getting the funds to carried-over for ’09-’10.
* 2010 - 2011 Currently those patients from the clinical trials have ended
and are now again faced with an ADAP system that is still not capable of
complying with conditions of award. Since the part– B: Co-Pay program
is still not working, Case workers keep telling patients to get on the Sate
Health Insurance Plan and drop their private plans.
The DoH now says that for 9/2010 the Co-Pay System will be in place and
will begin providing that service fulfilling their contractual obligations to
the affected population for whose health care these funds were granted.
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Harvard Enhancing Iniciative finding:
2010 – Very little improvement in services but
basically still the same unmet needs, (Current
Needs Assessment)
2009 - 2010 SJ- RW-EMA Part- A and HOPWA
are paying reasonably as grantee.
Ponce will still be an EMA, Caguas will
continue to be TGA.
* 2010-2011 State HOPWA Contracts w/ ASOs
are 5-6 months in rears.
2008- 2010 Other Current Events:
22,000 – 24,000 public and private employees laid-off,
thousands were health related professionals.
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110 Emergency Room medical staff were laid-off of which 53
were specialized doctors.
Doctors contracted with the state providing services at the
islands’ main medical complex, (“El Centro Medico”) and
EPI-clinics were being forced to accept a cut of 15% for
their services, while the CBOs were cut 12% last year and
15% this year.
2008- 2010 Other Current Events:
National Quality Center
“Since 2008 the PR-DoH has been participating in improving
quality of care within all RW programs.
However this endeavor has been faced with much resistance from
within by the very same entrenched mediocre staff.
The implementation of Client level Data entry has had its
obstructions but is progressing at a snail pace. However the
Central Pharmacy Distribution Center still has not intergrated
it's inventory system with the clinics. So client databases were
populated in reverse from prescription activities rather then
clinical.
2008- 2010 Other Current Events:
Part-B Planning Body
Since 2008 the PR-DoH had to reconstitute at HRSA insistence
Finally there is a needs assessment and comprehensive plan.
However they reiterate what we have known all along, services
delivery is poor, little or none is some regions and the nneds
are the same as 10 years ago or even worst.
Buy-in from some DoH leadership has been minimal or none. Add
to that the constant turn-over of long-time key stakeholders
and it only further impide steady progress.
2008- 2010 Other Current Events:
Local Legislature pending:
“Mi Salud” new version of the local State Health Insurance Plan,
somewhat in-line with the federal reform, but with a single
payer.
Merge 6 state oversight and citizens protection agencies into 1
Ombudsman, i.e. Patients, Womens, Elderly, Veterans,
Disabled, Consumers. “The most vulnerable populations will
be denied independent advocacy and oversight”.
Contact Information
Anselmo Fonseca
787-948-8890
[email protected]
[email protected]