HIV/AIDS News & Information

INTRODUCTION
Managed care appears to be a reality of care delivery in the 1990s. This has had a substantial impact on health care providers and academic medical centers, and is likely to have an even greater impact during the next several years. The Johns Hopkins HIV Care Program was founded in 1983 and has subsequently grown with the epidemic in Baltimore to a program that shows appropriate commitment to the triad mission of academic medical centers for education, medical care and research. During the course of Program evolution, Maryland Medicaid, the major third party payor for HIV care nationally and locally within Baltimore, made the transition from fee-for-service to mandatory managed care in 1997. This represented a steep learning curve for the administration of this program since the consequences were great. We either learned managed care and economic efficiency or the program, its patients, and its faculty would become dinosaurs. This paper reviews this transition and its major messages. Although the focus is on a specific HIV care program at Hopkins, this is seen as representing the consequences of managed care for any chronic, high-cost disease at an academic medical center. generic Levofloxacin online

THE BIG PICTURE AND THE BIG PROBLEM
AIDS, probably more than any other disease, has divided the landscape of patients for third party payors for the haves vs. the have-nots (Table 1). There are approximately 34 million Americans who are Medicaid recipients, representing 13% of the population, and an additional 14% who are uninsured. However, for the approximate 335,000 patients receiving care for HIV infection, about 46% are Medicaid recipients and 20% are uninsured. Thus, approximately two-thirds of all patients with HIV infection in care are either Medicaid recipients or are uninsured. With regard to managed care, about 15 of the 34 million Americans who are Medicaid recipients are in programs that have mandatory managed care with the expectation that most of the balance will be in managed care within the next few years. The implication of these observations is that Medicaid is by far the major third party payor for HIV-infected patients and that most of these patients will be in managed care programs within the next two to five years. As expected, most large HIV care programs serve a relatively large Medicaid population so that Medicaid policies will largely dictate financial reimbursement. omnicef antibiotics online

TABLE 1
HIV Care in the United States

Table 2 summarizes the cost of care for Medicaid recipients according to 1996 reimbursement for patients in various disease categories according to a five-state survey with over 400,000 Medicaid beneficiaries. This shows that the average cost of care among persons with no chronic disease was $l,954/year compared to $22,836/year for patients with AIDS. The average for SSI recipients was $5,834/year. These figures show the enormous differences in cost of care for patients with and without chronic diseases. Medicaid is a state-based program in which there are huge differences between states for reimbursement methods. In general, there are three methods to reimburse for managed care: 1) a blended rate in which historic payments are analyzed to derive an average reimbursement rate for all SSI recipients regardless of associated conditions; 2) a risk-adjusted rate in which reimbursement is based on historic payments for diseases that are categorized in different payment strata, and 3) one of these two methods with a mechanism to adjust payment based on loss/profit, adverse selection, stop-loss provision, reinsurance, or some other adjustment mechanism. The risks associated with these decisions are substantial, particularly for academic medical centers that traditionally have provided care for high-cost chronic diseases and do not have a large stablehouse of low-cost subscribers as seen with many well established HMOs. Quite amazingly, the Medicaid reimbursement rate for AIDS ranges from $98/m/m in Tennessee to $2,800/m/m for New York City. Even these figures do not reveal the true disparity. The Tennessee rate includes all medicines, which average $500-$l,000/m/m compared to New York State, which “carves out” all canadian pharmacy costs for an additional reimbursement. To be fair, TENNCare made a “risk adjustment,” which eventually increased the reimbursement to $606/m/m; nevertheless, this is still substantially below the cost of AIDS care for the current era. The impact of this gross underpayment on academic medical centers in Tennessee was dramatically illustrated in the recent review of adverse selection and its impact on academic medical centers (1). The analysis showed that the number of patients with AIDS was 14-fold higher in academic centers of Tennessee compared to the statewide average so that this, along with other chronic diseases, brought substantial liability to the academic health centers. Thus, in essence, they were harshly punished for developing special programs for complex, expensive conditions. buy Strattera

TABLE 2
Cost of Health Care Expenditures: SSI Averages for Five-State Sample with 400,000
Medicaid Recipients*

The alternative payment strategy that is far more attractive for care programs with substantial high-cost users is risk-adjusted rates where reimbursement is based on historic payment according to disease category. This tactic was used in the HealthChoice program in Maryland Medicaid, which was initiated in July, 1997 as a mandatory program with reimbursement based on 12 categories called Ambulatory Care Groups (ACGs). AIDS was a special category wherein the rate was derived by cross-filing the AIDS Registry with Medicaid payments for the first half of 1995. This result was decreased by 10% (for “profit”) and adjusted for inflation to give a final “AIDS rate” of $2,161/m/m for patients who reside in Baltimore City, and $l,812/m/m for Maryland residents outside of Baltimore City. (The difference in AIDS cost for residents of large metropolitan areas compared to other areas is largely unexplained. It is far more dramatic in New York State where the New York City rate is about $2,800/m/m compared to about $1,000/ m/m for residents outside of New York City.) The Maryland rate had a number of exclusions that are important to acknowledge due to their impact on care and reimbursement, including mental health care, protease inhibitors (and other new classes of drugs), patients with hemophilia, and children under 13 years of age. Buy canadian Celebrex

This risk adjustment for AIDS provided adequate reimbursement for patients in this stage of disease. Unfortunately, there was no risk adjustment for patients with HIV infection without AIDS so these patients were assigned to ACGs for reimbursement based on concurrent diseases. As expected, this group brought substantial financial losses, totaling about $1.5 million to the Hopkins programs. This is currently under review for possible reimbursement for this loss and/or the introduction of an HlV-specific rate. generic Imitrex online

THE HOPKINS HIV CARE PROGRAM
The Hopkins HIV Care Program was founded as a subsidiary of the Infectious Diseases Division of the Johns Hopkins University School of Medicine in 1983. In 1990, it was reorganized to include multiple sections, each with a leader, budget, and mission statement. These sections include the Moore Clinic with 24,000 patient-visits/year, the 21-bed inpatient AIDS ward, a 21-bed chronic care facility, a social work program, an education section, community outreach, a clinical research section that included the ACTG, an Internet section that now has eight FTE, a database to longitudinally track cost and outcome, and a managed care section. At present, this Program has 2,500 patients who receive longitudinal care in the Moore Clinic and an additional 1,000 who receive care in satellite clinics throughout the state. There are 30 faculty providing HIV primary care, 12 faculty providing HIV specialty care, a support staff of 170, and a research budget of approximately $7 million/year. These are the components of a typical HIV care unit within an academic center. With regard to third party payors, the distribution among our 3,500 patients was 60% Medicaid, 25% uninsured, and 15% private insurance. buy Skelaxin online. The decision of Maryland Medicaid to pursue mandatory managed care obviously had a great impact on our program, but it was not a novel concept since we had been negotiating for a special Medicaid AIDS rate in meetings with Maryland Medicaid since 1985. Nevertheless, the introduction of mandatory managed care in July, 1997 was a dramatic change associated with a steep learning curve. The following are the major messages of this transition:

1. The best method to get advice is through consultation with someone who has already done it. The initial plan at Hopkins for managed care of AIDS was to create five committees with a total of 102 members that met on a regular basis, but actually accomplished very little. The real forward progress was achieved with a 1.5 day consultation with an expert from AIDS Healthcare Foundation in Los Angeles, an organization that had substantial experience in this transition. A second key message was the necessity of a Project Director, a person with good administrative skills who knew managed care, the Institution, HIV care, and had full-time energy devoted to the transition. Viagra 400 mg

2. HIV care providers have great distrust of, and little interest in, managed care. I served as Director of the program and needed to know the administrative details, working with the Project Director. Nevertheless, the care providers showed virtually no interest so that our messages were generally limited to those issues that were critical to clinical care, and they were delivered by a peer whom they trusted. In general, a medical lecture entitled HIV managed care may possibly attract a crowd, but it will not include care providers. Viagra Professional 100 mg

3. Most HIV care providers know almost nothing about cost of care and efficiency of care delivery. For example, we queried the care providers regarding cost issues listed in Table 3 and never found one, either at Hopkins or at multiple national presentations, who had more than one correct answer. With regard to efficiency, the Hopkins Department of Medicine guideline for outpatient care was one point/half hour with one point for a return visit, two points for acute walk-in care, and three points for a new patient evaluation. Analysis of clinic performance showed enormous differences between providers for performance by this guideline, and the care providers aggressively fought any plan to introduce this as a performance standard for evaluation. viagra canadian pharmacy

TABLE 3
Hopkins Managed Care: Queries About Cost

Query: What is the most expensive drug used in the outpatient department (1994-95)?
Usual answers: AZT, generic fluconazole,
Correct answer: G-CSF (only 18 patients took G-CSF, but the cost was >$250,000)
Query: What is the most expensive drug in the HIV inpatient service? Usual answer: ganciclovir, foscarnet
Correct answer: IVIG (This reflects the requirement to increase platelet counts to >50,000/mm3 as a contingency for invasive tests.)
Query: What service charges professional fees that are similar in magnitude to the pro-fees of those providing primary care? Usual answer: ophthalmology, neurology, or surgery
Correct answer: radiology
Query: What HIV complication results in care costs that average >$75,000/year for the rest of the patient’s life? Usual answer: dementia, wasting, CMV
Correct answer: CMV

4. Standards of care: A decision was made early in the evolution of this plan to limit the important, but often offensive, strategies of managed care designed to reduce care. Thus, we have an open formulary, there is no preauthorization required for admission, and there is no restriction on laboratory tests, consultations, or radiology services. These rules have continued to apply, but they are possible only because the risk-adjusted rate provides adequate reimbursement. order cialis professional

5. Financial status: Economic performance for patients with AIDS has shown modest losses that total about 2% of the net reimbursement. In assessing this balance sheet, it is important to recognize the financial implications of Medicaid managed care even with a risk-adjusted rate. The rate is based on historic payments minus 10%, but there is an additional 10% loss for administration that was previously done by Medicaid and is now done by the MCO, and we required approximately 10 FTE to deal with the mandated quality assurance program. Thus, the challenge for us was to provide HIV care at a rate that was 30-35% lower than the reimbursement during the fee-for-service period. With regard to patients with HIV infection who have not progressed to AIDS, the financial losses were anticipated and totaled approximately $1.5 million the first year. This represents the cost of providing service to a high-cost user population with adverse selection comparable to that encountered by academic medical centers in Tennessee, but for us it was limited to only a segment of our total population. cheap levitra

6. Medicaid negotiations: Medicaid reimbursement strategies are state-specific and largely dependent on the extent of AIDS activism within the state. Thus, states with a loud HIV voice will have the best Medicaid programs in terms of reimbursement for HIV care. These include New York State, Massachusetts, and Maryland. States with virtually no AIDS activism will usually have poor reimbursement with the following examples: Tennessee, Utah, Georgia, and Michigan. Academic medical centers may be well rewarded for establishing a dialog with Medicaid in an effort to influence decisions regarding reimbursement, but to do this there needs to be a good source of data to support positions and an understanding that precedent established by other Medicaid programs is critical. female pink viagra

7. Internal assessment of the program showed some surprising features that may account for the financial experience. Analysis of individual records showed 38 patients (14% of the total enrollment) accounted for 50% of the payments. Subset analysis of this group failed to reveal any clear risk factors to account for the high cost. There was a suggestion that the following comorbidities were contributing factors: hepatitis С was noted in 70% of enrollees and accounted for 13% of hospitalizations. There are high rates of mental illness which, although separately funded, contribute substantially to medical care costs. Surprisingly, injection drug use was not a contributing factor. Use of protease inhibitors reduced costs by an average of $383/m/m, but these drugs were rarely used in this high-cost subpopulation. With regard to other factors, analysis of records indicated that an average of 25% of enrollees were disenrolled at any point in time. The reason for disenrollment was failure to re-enroll and our inability to find these patients despite assiduous and sometime heroic efforts. The obvious impact is a 25% reduction in income. An analysis of patients who are in this plan compared to those in the rest of the Moore Clinic population showed that Medicaid enrollees had lower CD4 cell counts, reduced response to antiretroviral therapy, and higher costs. Thus, we had adverse selection even within our own program. cymbalta online

PROBLEM SOLUTION
The tabulation above shows a steep learning curve. It occurred to us at the inception of the program that the transition from fee-for-service to mandatory managed care in Maryland was a model that was to be repeated in multiple additional states since this is part of a global objective for Medicaid over the next two to five years. Our experience indicated that there were clear messages, there was a need to systematically collect data, there needed to be continuous negotiations with Medicaid using other stakeholders in Maryland, and multiple other HIV care providers were experiencing similar problems. Nevertheless, there is no group or organization that is taking any responsibility for teaching this transition, not academic medical centers, HCFA, managed care organizations, or anyone else. In March, 1997 we sent a letter to 130 directors of HIV care programs in the U.S. to determine possible interest in forming a network to deal with this issue. The query included a request to indicate enthusiasm for the plan on a 10-point scale. Of the 130 mailings, we received 148 returns indicating some had shared the document. Nearly all wanted this association, and the mean enthusiasm score was 9.4. cialis super active

The HIV Managed Care Network was founded in the summer of 1997. This has subsequently grown to over 600 member organizations involving care providers for approximately 50% of all patients with HIV infection in the U.S. who are receiving medical care. There are three major identified functions of the Network:

1. Technical assistance and education: The Network is funded by Health Services Research Administration (HRSA) to collect state-specific information about HIV managed care with emphasis on the variations in state plans, quality assurance programs, and other data relevant to this issue. The major emphasis is on Medicaid, but information from the private sector is also being collected. The goal is to make this information available to those who request it, including providers, representatives of Medicaid, and others. There is also an attempt to educate providers and Medicaid personnel regarding efficient service delivery, methods to collect data, quality assurance based on care standards from DHHS and other scholarly resources, and tracking and publicizing new developments in this field. Major mechanisms of communication are by conferences, broadcast e-mail, the Internet, and publications. Amoxycillin 500mg

2. Establishment of a database for 16-20 centers to determine cost and resource utilization: This component of Network activity is funded by grants from HRSA and the Agency for Health Care Policy and Research (AHCPR). These data will be used to examine the cost of HIV care correlated with numerous variables such as CD4 cell count, risk category, service delivery model, co-morbidities, impact of pharmacy, etc. It is assumed that such data will be useful for defending the position of risk-adjusted rates.

3. Public policy review: The goal here is to establish a dialog with policy makers to effectively implement reimbursement and health care strategies that are justified on the basis of information from the database and to target this information to states that are viewed as problematic. cheap antidepressants

To our knowledge, the HIV Managed Care Network is a relatively unique organization in terms of its mission, plans for establishing a database to examine resource utilization, cost and outcome, and its goal to educate providers in managed care. Given the potential consequences for care of HIV infection and other chronic conditions, we are surprised that there have not been organizations or societies that have attempted to fulfill this obvious gap. buy cialis professional

SUMMARY
Approximately one-half of all patients with HIV infection who are under care have Medicaid as the third party payor. Unlike Medicare, Medicaid is a state-specific program that has huge variations in reimbursement strategies. Multiple studies have shown that care for persons with AIDS is about $20,000/year, but reimbursement through various state Medicaid programs varies about $100/m/m to $2800/m/m despite the fact that expectations for care are identical. Hopkins has a major commitment to persons with HIV infection with a program that now includes 30 faculty members and a support staff of 170. With the introduction of mandatory managed care for Medicaid recipients in July, 1997, we were confronted with the issue of substantial downsizing with abandonment of over half of our patients, or learning the transition to managed care. This has been a steep learning curve involving negotiations with the state Medicaid office, reorganization of our clinic, careful scrutiny of our database regarding resource utilization and cost, education of providers, and longitudinal collection of new information and integration of the rapid changes in the field. In the process of this transition, we learned that there are precious few resources to provide guidance and that there is a perceived need for assistance by HIV providers throughout the country. Consequently, we have now established the “HIV Managed Care Network” with substantial funding from diverse sources to support education, data collection, and public policy review. It is premature to evaluate performance since most of these activities have just begun, but we expect that this Network will serve as a demonstration model for methods to deal with chronic diseases under managed care.