Transcript Ryan White Program

Access to Care and Treatment in the U.S.
Achieving the Goals of the U.S. National HIV/AIDS Strategy:
A Community Perspective
July 26, 2012
2012 International AIDS Conference – Satellite Session
Outline
 Treatment in the United States
– Medicaid and Ryan White
– ADAP
 Opportunities and the Future
– Affordable Care Act
– Ryan White
– HarborPath
Goals of the National Strategy
Reduce New HIV Infections
Increase Access to Care and Improve Health Outcomes
– Increase proportion of newly diagnosed patients linked to clinical
care within three months of their HIV diagnosis from 65% to 85%
– Increase proportion of Ryan White HIV/AIDS Program clients who
are in continuous care from 73% to 80%
Reduce HIV-Related Health Disparities
HIV Treatment in the U.S.
In the United States:
 Nearly 20% of people living with HIV do not they are
infected
 Nearly one-third of people living with HIV continue to
be diagnosed late
– One-third of those progress to AIDS within 12 months of diagnosis
 Approximately half of people living with HIV are in
regular care
 Nearly two-thirds of those in regular care have
suppressed viral loads (28% of people living with HIV)
Also, in the United States:
 HIV disproportionately affects poor people.
 Medicaid eligibility currently limited to individuals who are both
very poor ($698/month) AND disabled, single parents or over 65,
in most states.
 Most people with HIV do not qualify for Medicaid until they are
sick and disabled.
 Even once eligible for Medicaid, significant state variation in
what’s covered and in provider participation.
 Medicare for disabled individuals.
 Therefore, many PLWH rely on Ryan White Program for care
and treatment (70% of Ryan White clients under 100% Federal
Poverty Level – or about $11,000).
AIDS Drug Assistance Programs
(ADAP)
 As of July 19, 2012 – 1,805 individuals in nine states
on waiting lists.
– Most wait-listed clients receive medications from
Welvista or manufacturer patient assistance programs
(PAPs).
 HRSA recently announced $69 million to 25 states
(FY12 funding; including the President’s World AIDS
Day commitment).
– States received all funding they requested.
– Expected to address “current” waiting lists.
– Continued enrollment and fiscal challenges (FY13).
Opportunities to Increase Treatment
Access for PLWHA
Opportunities to Improve
 Science!
 The Affordable Care Act (ACA)
 Increased and improved (more reliable) coverage
 New and diverse payers of HIV care
 Build on Ryan White system of care and
successes (medical home model)
 Ryan White in a post-ACA environment
 HarborPath and Streamlined Access to Patient
Assistance Programs (PAPs)
What’s Ahead
 2012 Election
– Results will affect ACA implementation and Ryan
White reauthorization/extension
 ACA Implementation
– Uncertainty of full ACA implementation
– States may not comply with Medicaid expansion
– Access and health care will vary by state
– Insufficient medical workforce capacity
 Ryan White Program
– Program up for reauthorization in September 2013
The Affordable Care Act
Affordable Care Act
Implementation
What to look for moving forward:
 HHS/CMS will likely release information/guidance about
how they are interpreting the ACA ruling
– Clarify the implications on other pieces of reform
– Answer questions from states, including whether
there will be flexibility around incremental expansion
 Regulations on essential health benefits requirements for
newly-eligible beneficiaries still forthcoming
 If/when will states have to notify HHS/CMS about
whether they will expand
Next Steps
(continued)
The ACA is the Law of the Land, and Implementation Will Continue
The Ryan White Program
Ryan White Extension of 2009
 “Ryan White HIV/AIDS Treatment Extension Act of
2009”
– Authorized the program for four years (FY10-FY13)
– Removed “sunset” provision allowing program to
remain funded at end of authorization period
Ryan White Post-FY13
Options
 Full reauthorization
– Would open up legislation completely for changes
from community and Congress
– Big risk potential as some Members of Congress think
there’s no need for Ryan White post-health reform
 Do nothing
– Since current law does not contain sunset provision it
is possible to do nothing
– Congress can still appropriate funding
– Potentially risky in this fiscal environment
Ryan White Post-FY13
Options (continued)
 Extension with a few minor agreed upon
modifications
– Would allow Congress to weigh-in, but hopefully with
community input on changes
– Would entail much work with community to ensure
modifications were well crafted and virtually noncontoversial
Implementation of ACA:
Short Term Issues for Ryan White
 Far reaching changes of the ACA will not be fully
realized and understood for years after full
implementation begins in 2014.
 Changes must be fully analyzed before making
significant modifications to the Ryan White Program.
 Need to ensure that all critical RW services continue
while clients transition to new sources of coverage.
 Changes made prematurely could be very harmful to
current systems of care for people living with
HIV/AIDS.
Implementation of ACA:
Long Term Issues for Ryan White
 RW will still be needed to address gaps in covered services
and populations along with enabling and support services
– There is unmet need for current RW services – ACA will help
but won’t address all.
– Medicaid reforms and private insurance reforms are being left
to the states. Scope of coverage will vary.
– States that “opt-out” of Medicaid expansion may continue to
have very limited programs. People under 100% FPL hurt –
no subsidy to buy insurance.
– Undocumented individuals will not be eligible for either
Medicaid coverage or private insurance through exchanges.
Patient Assistance Programs (PAPs)
And HarborPath
The Role of HIV PAPs
 PAPs operated by pharmaceutical manufacturers
play a small, but very important role in the U.S. health
system for delivering medications to people living
with HIV/AIDS (PLWHA).
 PAPs operate in the context of a patchwork health
care system:
– A drug coverage safety net for the public safety net
programs.
– In an environment where ADAPs and other programs
restrict access to medications, PAPs are critical.
The Role of HIV PAPs
 All 8 companies that manufacture HIV antiretroviral
medications in the U.S. operate PAPs.
– One additional PAP for a two company/combination
drug.
 Varying eligibility levels (most 500% FPL), application
processes and medication distribution methods.
 Each company has worked to simplify their PAP
enrollment, eligibility and distribution processes:
many successes are noted.
Challenges Accessing PAPs
 PLWHA, providers and case managers often report
these programs can be difficult for individuals to
access:
– Multi-drug regimens (from multiple companies)
require multiple applications with varying
requirements.
– Lack of knowledge of PAPs.
– Confusing and/or challenging application and income
verification requirements that vary by company.
– Delays in eligibility processing (vary by company and
on a case-by-case basis).
Challenges Accessing PAPs
(continued)
 PLWHA, providers and case managers often report
these programs can be difficult for individuals to
access for a number of reasons:
– Communication about status of application.
– Inconsistent eligibility requirements (eligible for some
but not all PAPs).
– Differing time frames and locations for receiving
medications.
– Differing re-certification time frames.
HarborPath: Overview and
Purpose
• To implement a “single portal” for uninsured or
under-insured people living with HIV in the United
States to simplify access to medications from PAPs.
• A collaborative undertaking between NASTAD,
Clinton Health Access Initiative (CHAI), donors and
pharmaceutical companies, government agencies,
and advocacy groups.
• Advisors include NASTAD, CHAI, Congresswoman
Barbara Lee, Jeff Crowley and AKA Health.
Actions to Optimize the Safety
Net Provided by PAPs
1
Develop a common application form (HHS)
All PAP enrollment forms serve the same purpose; BUT there are differences in:
• type and amount of data requested for the same purpose
• requirements for supporting paperwork
• the number and types of signatures required
2
Streamline eligibility determination
• Simplify and standardize income determination/verification
3
Improve prescription fulfillment
• Single pharmacy with delivery options, refills and medication assistance that
meets patient and care manager needs
A Common PAP Form PLUS a
Cooperative Entity
Current State
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Multiple pharma manufacturers
Multiple PAP vendors
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Multiple phone numbers and websites
Multiple applications
Multiple sets of criteria
Approval of some meds, not others
Fulfillment of some meds at one time; other
meds at another time
Fulfillment of various meds to different
locations
Patient, prescriber and case manager must
contact multiple PAPs for status
Need to contact each supplier for refills
Single portal model for access
to donated drugs
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Multiple pharma manufacturers
PAP access through web-based portal
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One phone number and website
One application
One set of criteria
Approval of all meds at one time
Fulfillment of all meds at one time; safety
checks on multi-drug regimens
Fulfillment of all meds to one location
Patient, prescriber and case manager are
notified of status in one database
One contact for all refills
The HarborPath Single Portal
 Provides case managers with a single portal and one
time data entry for completion of all PAP forms
The HarborPath Single Portal
(continued)
The HarborPath Single Portal
(continued)
 Case managers most important needs are to simplify
eligibility documentation and to track status.
HarborPath Pilot Program
Common
form
defined
April
6
4
2
May
June
System &
infrastructure
build
July
August
5
3
1
Expansion to
broader
audience
Pilot at
selected
sites
Obtain Pharma
approvals of
HarborPath
Formal
announcement
September
The Way Forward
The Way Forward –
Turning the Tide
People living with HIV in the U.S. need:
 Full funding and support for effective implementation
of the Affordable Care Act.
 A sustained federal commitment to Medicaid and
Medicare Programs.
 A continuing, robust Ryan White Program to fully
address the HIV public health crisis.
 Partnerships among all organizations and agencies
working to serve their needs.
Murray Penner
Deputy Executive Director
[email protected]
www.NASTAD.org