Managed Care

and HIV/AIDS

2

FINANCING CARE: FEDERAL PROGRAMSFINANCING CARE: FEDERAL PROGRAMS MEDICAID

Largest payer of direct medical services for PLWH/A FY 1998: $3.5 billion (est) on HIV/AIDS medical services 53% of all people with HIV/AIDS are on Medicaid. 90% of all children

with AIDS are on Medicaid PWA are less than 1% of beneficiaries, 2% of total cost

MEDICARE FY 1997: 1.4 billion- est. 6-20% of PWA (excludes RX)

RYAN WHITE CARE ACT PROGRAMS FY 1998: $1.15 billion

OTHER FEDERAL -SAMSHA, NIH, federal prison, VA, IHS, HUD

3

MOVEMENT TOWARD MANAGED CAREMOVEMENT TOWARD MANAGED CARE Growth in Medicaid Managed Care

As of June, 1997, approximately 47.5% Medicaid recipients in managed care (vs 12% in 1995) ; majority increase in fully capitated plans

States shifting risk from State to MCOs Focus shifting from TANF(AFDC) to SSI (65% of expenditures) WHY?

Control Costs/ Predict Medicaid budget Get out of insurance business- fewer staff?; negotiate with few MCOs

vs all constituent groups Increase Quality & Access- fragmented FFS system; low provider

participation; coordinated care

HOW?- 1915(b)/1115 waivers, State plans (BBA)

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BALANCED BUDGET ACTBALANCED BUDGET ACT

New section 1932(a) of SSA- States submit State Plan amendment to enroll beneficiaries into managed care w/o waivers

exceptions: dually eligibles; special needs children; tribes

REQUIREMENTS: choice of 2 managed care entities (MCEs) disenroll any time for cause in first 90 days; 12 months thereafter HCFA approval of model contracts

subject to new quality assurance, timely payments provisions default enrollment based on prior provider-patient verification

of access to providers info on providers, enrollee, rights, grievances etc in readable

format

5

TRENDSTRENDS

Nearly half of all enrollees in Medicaid dominated plans (more than 75% membership is Medicaid) number of plans serving Medicaid market increased from 166 to 355 b/n 1993-96

Medicaid dominated plans more likely to serve SSI/disabled population

87% enrollees in 16 states: AZ, CA, CT, FL, IL, MI, MN, MO, NJ, NY, OH, OR, PA TN, VA & WA

Newly formed plans dominate new Medicaid plans

6

CHALLENGES OF MANAGED CARECHALLENGES OF MANAGED CARE

State as a purchaser/regulator HIV Provider (social/medical) to

“reengineer” PLWH navigating the new system of care MCOs caring for chronically ill/high cost

population

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CHALLENGES AND CONCERNS OF PLWHCHALLENGES AND CONCERNS OF PLWH Understanding the system Enrollment

Choice of MCO Culturally/linguistically competent materials Disclosure of provider network

Continuity of Care Access to experienced HIV providers

primary care timely & appropriate referrals to specialists access to clinical trials out of network providers

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CHALLENGES AND CONCERNS OF PLWHCHALLENGES AND CONCERNS OF PLWH Access to Pharmaceuticals

Restrictive health plan formularies location of pharmacies

Coordination with Social services Confidentiality of medical information,

enrollment Discrimination Grievance process

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CHALLENGES FORHIV PROVIDERSCHALLENGES FORHIV PROVIDERS

Understanding the system Adapting to change

defining Strategic position changing their mission Using “business” principles

Maintain Continuity of Care for Patients Potential loss of Patients/Revenue

Increase Uninsured

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CHALLENGES FOR HIV PROVIDERS

Development of networks Protecting their “turf”

Upgrading MIS -ability to obtain cost & utilization info

Fair Reimbursement

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CHALLENGES FOR MANAGED CARE ORGS.CHALLENGES FOR MANAGED CARE ORGS.

Understanding the needs of PLWH & programs Maintain profitability

- risk adjusted rates

Meeting contractual obligations Turnover of Medicaid population Develop delivery networks for PLWH

# of PLWH members vs actual membership

Confidentiality vs assuring care

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CHALLENGES FORMEDICAID AGENCIESCHALLENGES FORMEDICAID AGENCIES

Shift from FFS to managed care limited resources antiquated MIS negotiating contracts Culture

Pressure to control costs/budgets Pressure from “interest”groups

-growth of eligible populations

Fair reimbursement to MCOs

Incentives to MCOs to provide care Assuring quality of care, fair enrollment practices,

overseeing enrollment brokers

13

MARKETINGMARKETING WHO IS RESPONSIBLE? State/local govt’; Contracted MCO; Contracted

CBOs; Health Care Providers; Enrollment brokers

WHERE DOES MARKETING OCCUR? Welfare Offices; Direct Mail (State or MCO); Public Meeting Places; Door to Door

Marketing should not occur in: In non-confidential settings; Emergency Room/ Inpatient Units

WHAT METHOD? Brochures & flyers; group/individual education sessions; enrollment incentives; telephone; media

USING ENROLLMENT BROKERS more states using third party/independent agencies restricts MCO’s ability to market/ Avoids coercive marketing tactics Brokers still must receive training States must ensure brokers provide accurate/sufficient info

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MARKETING AND ENROLLMENT ISSUESMARKETING AND ENROLLMENT ISSUES What categories of Medicaid beneficiaries will be enrolled?

Voluntary or mandatory? Are there any exemptions? How are PLWH advised about enrollment requirements,

exemption options, lock-in periods, changing providers? What is the time period for disenrollment?

Are enrollment materials culturally sensitive and at appropriate reading levels and languages of eligible populations? How will States assure that information on providers and benefits is accurate and includes information on provider specialties/HIV experienced providers?

What is the default assignment algorithm? Can the PLWH be assigned to their traditional provider of care?

Where will enrollment take place and how will patient confidentiality be assured?

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BENEFIT PACKAGESBENEFIT PACKAGES COVERED SERVICES

Must include all services under Medicaid FFS Services must be delivered by network provider

OUT OF NETWORK COVERED SERVICES - Certain covered benefits delivered out of network

NON-COVERED SERVICES PLWH/A require services typically not covered (e.g., residential

care, social services, , hospice care) CARVED OUT SERVICES

Benefit is covered but MCO or provider not at risk and paid FFS OR another entity responsible for benefit (e.g., mental health, dental)

PRESCRIPTION DRUG BENEFITS Use of formularies may restrict access Typically included in capitation but antiretroviral therapy carved

out

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ISSUES ON BENEFIT PACKAGESISSUES ON BENEFIT PACKAGES How will mix of services ( e.g., Medicaid managed care,

Medicaid FFS, grants) be funded? How is medical necessity defined? What is the definition

for emergency services? How will the state ensure that services are coordinated

between MCO gatekeepers and social service providers? Does the defined benefit package include the continuum of

care services for PLWH/A? For carved out services (e.g., dental care, mental health), how will PLWH/A be linked to these services? How will counseling & testing to offered?

How will PLWH/A be given information and access to clinical trials? Will plans be required to cover off-label drugs and experimental treatments?

17

MEDICAID MODELS FOR PLWHMEDICAID MODELS FOR PLWH MAINSTREAM

All eligibles mandated into commercial or Medicaid plans States may or may not have enhanced rate May require MCOs to contract with AIDS “centers of

excellence”

CARVEOUTS People with AIDS remain in FFS Medicaid

SPECIALIZED AIDS PLANS (or SPECIAL NEEDS PLANS) Traditional Providers form HMO for PWH/A

AIDS Health Care Foundation, Johns Hopkins, New York State

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PRIMARY CARE PROVIDERS: GATEKEEPERSPRIMARY CARE PROVIDERS: GATEKEEPERS

Gatekeeper is cornerstone of managed care Experienced physicians is critical for HIV care

Kitahta study found direct relationship between PCP experience w/HIV (treated at least 5 patients) & survival

Inexperienced gatekeepers not only provide poor quality care, but cost more in unnecessary ER visits, hospital admissions etc

Options: Specialist (e.g., Infectious Disease, HIV experienced provider) is

PCP Open ended referrals to HIV experienced provider either in/out

of network HIV experienced provider co-manages patient w/PCP

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PROVIDER CAPACITYPROVIDER CAPACITY Are there an appropriate number of experienced

providers (primary & specialty)? Are they accessible and within reasonable distance to where PLWH/A live? Are providers culturally & linguistically appropriate ?

Can a PLWH/A designate a specialist as their primary care provider?

Are gatekeepers knowledgeable about appropriate referrals for HIV disease?

To what extent do existing plans serve PLWH and what is their experience?

Will States assure that people with HIV receive the appropriate level of health care and support services for each stage of illness?

How and to what extent is the State planning to assure newest treatments, are available and accessible?

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NETWORK DEVELOPMENTNETWORK DEVELOPMENT

Will the State encourage/mandate MCOs to include traditional providers of care, especially Ryan White supported programs in their networks? Will the State give additional points in the RFP process to MCOs that include traditional providers?

How will traditional providers and commercial MCO’s work together to establish an effective and efficient system of care?

Is there sufficient capacity in both the metropolitan epicenters and in more rural areas?

What are the procedures for using out of network providers? Does the plan allow “standing” referrals?

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FULL OR PARTIAL CAPITATION RATESFULL OR PARTIAL CAPITATION RATES States must decide whether to put MCOs on full risk

for defined set of covered services (full capitation) OR Share some of the risk by offering partial capitation

rates and carve out certain services to be reimbursed FFS

Benefits Typically Carved-out: pharmacy, particularly new therapies & mental health/substance abuse treatment

MCOs distribute risk by entering into contractual relationships with providers either on full to partial capitation

Risk related to total cost for providing covered services to enrolled population

22

HISTORICAL RATE SETTING FOR MEDICAIDHISTORICAL RATE SETTING FOR MEDICAID Analyze historical FFS claims data to calculate

monthly cost of providing services for each beneficiary class

Multiply the monthly cost by a discounted percentage (e.g., 95%) to provide state with a savings

Calculate costs to subgroups within beneficiary classes by age, sex or health status (e.g., disabled)

Seek competitive bids from health plans around the calculated rate or pay the calculated capitation to all participating plans

23

ISSUES WITH HISTORICAL STATE MEDICAID RATESISSUES WITH HISTORICAL STATE MEDICAID RATES

Historic provider fees often extremely low

Claims data does not include unreported visits some providers do not submit claims patient confidentiality reduces claims submissions (especially

HIV/AIDS and mental illness) lack of access to care decreases historic utilization rates

All benefits may not be included (e.g., pharmacy, case management)

Does not reflect changing demographics of HIV/AIDS epidemic Does not reflect impact of changing therapies on cost and

utilization of care

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RISK ADJUSTED CAPITATION RATES RISK ADJUSTED CAPITATION RATES

RISK ADJUSTMENT: Adjusting the standard rate to allow for greater intensity, frequency and cost of services for a particular subgroup

TWO APPROACHES: Adopt special rates for HIV/AIDS Institute global risk adjustment for all enrollees (or all

disabled enrollees)

POTENTIAL HIV/AIDS ADJUSTERS: clinical diagnosis, e.g. HIV+asymptomatic, HIV+symptomatic,

AIDS CD4 Count or Viral Load Other co-morbidities (e.g. mental illness, substance abuse, or

factors (e.g. homeless)

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RISK ADJUSTED HIV/AIDS RATES RISK ADJUSTED HIV/AIDS RATES Some states are developing AIDS rates because: High cost of new drug therapies & changing treatment

protocols: Insure access to quality specialized primary and specialty care.

Reduced provider participation without adequate payment

Unpredictability of the state of HIV/AIDS as an illness, and the associated treatment costs.

Concerns that MCOs avoid/underserve PLWH/A, deny treatment, avoid early diagnosis without appropriate reimbursement to cover costs

Potential for poor quality, access, & plan performance with insufficient funding

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CHALLENGES TO SETTING HIV CAPITATION RATESCHALLENGES TO SETTING HIV CAPITATION RATES Difficult to identify claims of HIV+ recipients Historical per capita utilization rates may not predict future

service use because: data unavailable for all planned services based on a small number of patients/heavily influenced by high

or low cost users unable to account for case mix

Historical data on service costs my be: based on inefficiently operated programs offset by other grant funding streams Time allocated for clinical encounters may be insufficient as

complexity of medical management increases Types & combinations of services may change

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OTHER RISK METHODOLOGIESOTHER RISK METHODOLOGIES Some states are moving toward a comprehensive

risk adjustment system based on groups of diagnosis to predict risks (disability payment system)

Some states provide rate adjustment to MCOs with disproportionate number of HIV/AIDS patients

Some states use stop loss/reinsurance: Establishes an upper limit on payment of claims for an

individual member (catastrophic insurance)

Some states using risk corridors -establishes a ceiling & floor of risk for the MCO or provider

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EXAMPLESEXAMPLES

AIDS RATES: MD $1,812/ 2,161 - excludes PIT, VLT MA $2,300/ 2,998 for active/advanced AIDS CA $1,100 - 1,200 to AHF excludes inpatient NY - rates being developed for Special Needs

Plans

GLOBAL RISK ADJUSTMENT Implemented: CO, MD Planned: MI, MN, OR, WA

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FINANCIAL ISSUESFINANCIAL ISSUES How will your state reimburse health plans? Does

it propose to use risk adjustment methods? If so, what variables will be used?

What services will be carved out of the capitation? Will protease inhibitors and other new pharmaceuticals be excluded?

Does your state plans to use other risk adjustment mechanisms such as stop loss or risk corridors?

How will participating providers be paid? How will MCOs protect participating providers from caring for PWA?

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INTEGRATING MANAGED CARE INTEGRATING MANAGED CARE APPROACHES INTO THE APPROACHES INTO THE HIV CARE CONTINUUMHIV CARE CONTINUUM

INTEGRATING MANAGED CARE INTEGRATING MANAGED CARE APPROACHES INTO THE APPROACHES INTO THE HIV CARE CONTINUUMHIV CARE CONTINUUM

CORE CORE SERVICESERVICE

SSCARE ACT CARE ACT PROVIDERPROVIDER

S SUB-S SUB-CONTRACT CONTRACT

WITH WITH MCOs TO MCOs TO PROVIDE PROVIDE

SOME SOME CORE CORE

SERVICES, SERVICES, BEAR BEAR SOME SOME RISKRISK

FFS FFS AGENCIES AGENCIES

BEARING NO BEARING NO RISK RISK

PROVIDE PROVIDE WRAP-WRAP-

AROUND AROUND SERVICES SERVICES THROUGH THROUGH LINKAGE LINKAGE

AGREEMENTAGREEMENTSS

CORE CORE SERVICES SERVICES

CAPITATED, CAPITATED, MCO BEARS MCO BEARS

RISKRISK

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PLAN SELECTION CRITERIAPLAN SELECTION CRITERIA

Established provider network Geographic coverage Sufficient capacity & accessible services Acceptable marketing, enrollment, grievance &

disenrollment procedures Established quality assurance program Fiscal Solvency Established administrative & governance structure Meets State managed care licensure criteria

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PLAN SELECTION AND CONTRACTING PLAN SELECTION AND CONTRACTING What criteria will be established for plan

selection? cost, contracted providers, geographic access

Will there be an RFP program or bidding process?

Will capitation be lowest bidder, ranges or set amount?

How will state certify MCO’s operational readiness to provide care to PLWH/A?

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QUALITY MANAGEMENT AND MONITORINGQUALITY MANAGEMENT AND MONITORING Health care services are available, accessible, and

acceptable Participating providers meet established credential criteria Inpatient, ambulatory, and emergency services meet

defined standards and parameters for medically appropriate care; and

Health outcomes are monitored and meet established criteria

Critical for PLWH/A because of incentives to deny care, cost, complexity of meeting HIV/AIDS health care needs, rapidly changing standards, and MCO’s limited experience in serving PLWH/A

HEDIS only has test measures on prevention for HIV/AIDS

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STATE QUALITY ASSURANCE ACTIVITIESSTATE QUALITY ASSURANCE ACTIVITIES

Monitor voluntary disenrollment Consumer/enrollee satisfaction

surveys enrollee hotlines ombudsman programs consumer focus groups

Performance Measures/Contract Compliance financial audits medical record reviews

Specialized Studies Most State QA activities targeted for “typical” beneficiary &

often do not consider HIV/AIDS issues

35

GRIEVANCE PROCEDURES AND DISENROLLMENTGRIEVANCE PROCEDURES AND DISENROLLMENT

Grievance procedures often not timely delays for PLW/A could be life-threatening some states moving toward expedited reviews

for referrals (e.g., within 24 hours of denial and/or retrospective review)

Disenrollment with cause - no restrictions without cause - typically within 30 days then

every 6 months or 1 year thereafter

36

QUALITY MANAGEMENT CONTRACT COMPLIANCEQUALITY MANAGEMENT CONTRACT COMPLIANCE

How will the state monitor health plan compliance for state & federal requirements?

How will the state review member satisfaction, disenrollment, and grievances? Will they conduct consumer satisfaction surveys? Will PLWH/A to oversampled to assure representation?

What performance measures has the state developed and how will they monitor them?

How will the data collect data on: primary care encounters, specialty referrals, prescriptions, laboratory testing, counseling & testing?

37

HAB MANAGED CARE STRATEGIC PLANHAB MANAGED CARE STRATEGIC PLAN

Enhance the capabilities of HIV providers to participate in managed care

Improve HAB’s knowledge base about MC and HIV, especially with regard to various financing and reimbursement methodologies

Educate people with HIV/AIDS about managed care to improve their ability to access services

Assure quality care for HIV/AIDS members enrolled in managed care

Collaborate Efforts with HCFA, States and Other Key Stakeholders

38

HAB TECHNICAL ASSISTANCE AND TRAININGHAB TECHNICAL ASSISTANCE AND TRAINING

Strengthen the infrastructure within individual states for RW programs to participate in managed care by providing customized, state based training & TA

Build collaborative relationships between key stakeholders including MCOs, State Medicaid agencies, HCFA and RW funded programs

Up to $20,000 in JSI TA monies can be used for training, TA from individuals/groups of consultants, facilitated meetings between key stakeholders, data analysis, or other activities requested by the State

7 States participated in pilot: CT, NJ, PA, MD, FL, IL, WA 9 States applied for FY 98/99 funds: OR, VA, WV,AL, AZ, RI, NM, TX, OK

HAB Staff training, Project Officer Guide, Resource List

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HAB TECHNICAL ASSISTANCE: EXPAND KNOWLEDGE BASEHAB TECHNICAL ASSISTANCE: EXPAND KNOWLEDGE BASE Expert Panel on Risk Adjustment

addressed policy, development and implementation; proceedings published as TA document

1115 Waiver Study examined capitation rates, benefits, eligibility & enrollment

requirements related to HIV service delivery in 9 States (OSE)

Evaluation Studies (Center for Managed Care) impact on Medicaid Managed Care on providers (Mathmatica) &

safety net providers (IOM)

Managed Care SPNS Grantees Updated Medicaid Guide (AIDS Action)

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HAB TECHNICAL ASSISTANCE: CONSUMER EDUCATIONHAB TECHNICAL ASSISTANCE: CONSUMER EDUCATION

Joint Project with National Association of People with AIDS

consumer resource guide to help PWH/A navigate the system-diary to record information and “what to ask for”

Spanish & English Available early 1998

Train the Trainers plan to identify consumers to become trainers of

managed care in key states

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HAB TECHNICAL ASSISTANCE:QUALITYHAB TECHNICAL ASSISTANCE:QUALITY

Purchasing Specifications contract with GWU Center for Health Policy Research modules for contracts between State Medicaid

agency & MCOs to assure access to care for PLWH coordination with CDC model contract project

“White Papers” on quality of care Guide for federal/state officials, purchasers of

care, advocacy organizations on best practices

42

HAB TECHNICAL ASSISTANCE: STAKEHOLDERSHAB TECHNICAL ASSISTANCE: STAKEHOLDERS

Federal Agencies HCFA - cross trainings, waiver reviews, review guidelines DHHS Managed Care Forum - AIDS Workgroup

National Association of State Medicaid Directors 4 regional meetings- Chicago, Sante Fee, Austin, Boston HRSA program directors (MCH, PCA, AIDS) & Medicaid

Directors

American Association of Health Plans National Association of State Health Policy Officials National Association of Insurance Commissioners