Public Financing and Delivery of HIV/AIDS Care Securing the Legacy of Ryan White (2005) / Chapter Skim
Currently Skimming:
5 Options for Financing and Delivering HIV Care
5 Options for Financing and Delivering HIV Care
Pages 141-177
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From page 141... ...
The Committee considered a range of alternative approaches in developing its recommendations for improving the public financing of HIV care. Most of the approaches build on existing financing programs.
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From page 142... ...
The Committee recognizes that the alternatives examined here do not represent the universe of policy options for financing and delivering HIV care. The Committee selected these particular options as broadly illustrative of the alternatives that federal policy makers are likely to explore given the current configuration of federal and state programs described in Chapter 3.
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From page 143... ...
OPTIONS FOR FINANCING AND DELIVERING HIV CARE 143 TABLE 5-1 Alternative Options for Financing HIV Care by Assessment Criteria Benefit Provider Financing Minimum Package Reimburse- Mechanism Integrated and Uniform Meets ment Is Adequate Coordinated Eligibility Standard Is Adequate to Standard Services Rules for of Care to Standard of Care for Fostering Individuals for of Care for HIV/AIDS Accountability Option with HIV HIV/AIDS HIV/AIDS over Time and Evaluation 1: Expand Ryan No No -- No No White CARE Act 2: Medicare Yes No Yes Yes Yes Eligibility for HIV 3A: Medicaid No No No No Yes Budget-Neutral Waiver Expansion 3B: Medicaid No No No No Yes Optional Eligibility, Regular Match 3C: Medicaid No No No No Yes Optional Eligibility, Enhanced Match 4: Block Grant No No No No No to States 5: New Federally Funded, State- Yes Yes Yes Yes Yes Administered Entitlement government could attempt to require state participation in a program responding to a national epidemic, perhaps by conditioning the flow of federal grants-in-aid for highway construction or education upon state participation. However, the Committee believes such an approach does not merit consideration.
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From page 144... ...
The planning process within the Ryan White CARE Act is designed to allow local level flexibility in determining where funding should be directed. Planning councils established under Title I of the CARE Act are charged with monitoring local trends and assessing annual funding needs.
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From page 145... ...
Similarly, CARE Act benefits vary substantially from state to state, for many of the same reasons that eligibility standards vary. Access to lifeextending comprehensive antiretroviral therapy also varies significantly by state.
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From page 146... ...
First, because Medicare is a national program, and because the presence of HIV infection is a standardized medical determination, this approach would ensure coverage of individuals with HIV infection regardless of the state in which they reside. Moreover, this approach would qualify an individual for coverage upon a medical determination of HIV infection, without a waiting period and without a disability determination or a financial means test.
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From page 147... ...
The second major disadvantage relates to Medicare's benefits. As currently configured, Medicare's benefits package does not include a number of services that are essential to the standard of care for HIV/AIDS, including outpatient prescription drugs and case management services.
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From page 148... ...
Expanding the Medicare benefits package to include these services for all beneficiaries would represent a historic program expansion. Restructuring the benefits package just for one group of beneficiaries defined by HIV infection would represent a fundamental break from the Medicare program's long-standing commitment to offering a uniform national benefit to all eligible individuals.
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From page 149... ...
This approach would also allow for the addition of ancillary services such as substance abuse treatment and case management that would not necessarily be offered under a straight Medicaid expansion. In addition, because Section 1115 waivers by definition involve demonstrations, this approach maximizes the opportunity for the comparative evaluation of state coverage initiatives for this population.
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From page 150... ...
. States opting to cover this group may receive federal Medicaid matching funds for the cost of providing to eligible individuals the following defined set of tuberculosis-related benefits: prescribed drugs, physician services, outpatient hospital services, laboratory and x-ray services, clinic services, case management services, and services designed to encourage completion of prescribed drug regimens (directly observed therapy)
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From page 151... ...
Even in those states that elect to cover this optional group, low provider reimbursement rates may constrain provider capacity to meet the standard of care and may limit participation by providers qualified to do so. Moreover, individuals enrolled under this expansion would have access only to those benefits offered under the state's existing Medicaid program, which may not provide coverage for the ancillary services necessary for optimal HIV care.
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From page 152... ...
The federal matching rate available for the costs of treatment is the same enhanced rate available to a state under the State Children's Health Insurance Program, which reduces each state's own-source contribution by 30 percent.
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From page 153... ...
Many states, particularly those hard hit by the epidemic, will have difficulty sustaining their state contribution toward the costs of an eligibility expansion over time, regardless of their relative per capita incomes. Option 4: Federal Block Grant to States for HIV Care Under this approach, the federal government would establish a block grant to states for HIV care modeled on the State Children's Health Insurance Program block grant.
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From page 154... ...
Because of the enhanced federal matching rate, states would be required to contribute a significantly smaller share of the costs of caring for these newly eligible individuals with HIV than the proportion that they contribute to the costs of caring for Medicaid patients with HIV/AIDS. In addition, a state would have broad flexibility to design its own benefits package and to establish its own provider payment levels, allowing for innovation in the design of an HIV delivery system.
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From page 155... ...
In short, this approach would not ensure the use of a benefits package that meets the standard of care for HIV/AIDS and that is uniform for all eligible individuals. In addition, because the new HIV block grant would affect benefits only for low-income individuals not eligible for Medicaid, the benefits available to individuals with HIV/AIDS enrolled in Medicaid would be likely to remain
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From page 156... ...
. Thus, the annual limits on federal funds might or might not be capable of supporting, over time, the eligibility, benefits, and provider payment policies that meet the Committee's criteria for the financing of HIV care.
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From page 157... ...
Option 5: New Federal HIV Entitlement Program Administered by States The final approach the Committee considered is the implementation of a federally funded, state-administered program for the coverage of HIV/ AIDS care. Under this option, the federal government would establish eligibility requirements, specifications for benefits, and standards for provider reimbursement designed to ensure that individuals with HIV and family incomes at or below 250 percent of the FPL receive the services needed to meet the standard of care for the treatment of HIV infection.
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From page 158... ...
Advantages This approach has a number of advantages. First, of all the approaches considered by the Committee, this approach has the greatest likelihood of ensuring that all individuals with HIV and family incomes below 250 percent of the poverty level have coverage for services that meet the standard of care for HIV/AIDS, regardless of the state in which they reside.
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From page 159... ...
Second, because the federal government would finance the entire cost of covered services for all eligible individuals in participating states, it would have purchasing leverage that could be used to generate considerable efficiencies in the purchase of prescription drugs used in highly active antiretroviral therapy (HAART)
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From page 160... ...
The role of Ryan White Planning Councils, in particular, would be reduced, and the program would likely require the redistribution of dollars in ways that may reduce funding for certain community-based services. IMPROVING THE DELIVERY OF HIV CARE In addition to considering options to improve the public financing of HIV care, the Committee was asked to consider what improvements could be made
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From page 161... ...
The complexity of HIV disease -- lifelong need for treatment and prevention, coordination of medical treatment with social support and mental health and substance abuse services, and chronic care management requirements -- calls for the development of an improved HIV/AIDS care delivery structure. This is essential if the goals of preventing death and disability associated with HIV infection, controlling the epidemic spread of HIV, and improving quality of life for those affected by the disease are to be achieved.
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From page 162... ...
, substance abuse treatment (Turner et al., 2001) , mental health services (Ashman et al., 2002; Davis, 2002)
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From page 163... ...
Lessons learned from the broader chronic care management literature highlight five important elements of chronic care programs. These elements include evidenced-based planned care, a multidisciplinary team approach, systematic approaches to providing patient information (counseling, education, information feedback)
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From page 164... ...
These challenges include redesigning care processes based on best practices; making effective use of information technologies; managing clinical knowledge and skills; developing effective teams; coordinating care across patient conditions, services, and settings over time; and incorporating performance and outcome measurements for improvement and accountability. The Committee on the Public Financing and Delivery of HIV Care fully embraces the principles of quality and strategies for quality improvement as outlined in the previous IOM reports and believes that publicly funded programs of HIV care should support delivery system redesign in order to
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From page 165... ...
In particular, HRSA's HIVQUAL Continuous Quality Improvement Program seeks to improve quality of care for people with HIV by building knowledge, skills, and capacity through system improvement, information management, and performance measurements (New York State Department of Health, no date)
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From page 166... ...
4) care Policy continuous consistency 2)
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From page 167... ...
More specifically, the system should be made up of entities capable of · identifying highly qualified, experienced providers of HIV-related services and entering into contracts with those providers for the provision of care to a defined set of patients; · managing patients' clinical information (i.e., medical records) and making that information available as needed to the range of health care providers involved in patient care; · measuring and monitoring access to care, quality of care provided, and outcomes of care, and reporting that information to the public entities providing funds for HIV-related services; and · receiving and managing public funds allocated for HIV/AIDS care and distributing those funds to individual providers and provider organizations in exchange for services rendered.
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From page 168... ...
The Medicaid program has some experience with disease-focused CoEs, but not with CoEs for HIV care. The state of New York, however, has been experimenting with the CoE concept since 1986 through its Designated AIDS Center Program (DACs)
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From page 169... ...
Models can range from highly integrated systems exemplified by the VA or Kaiser Permanente to very loosely structured organizations in which there is no central administrative entity. In the former model, a single organization provides the entire range of medical and support services and receives payment for that entire range of services.
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From page 170... ...
In some instances, the entire range of medical, mental health, substance abuse, and social services will be available at a single physical facility; in other instances, the organization may have multiple physical facilities that are closely linked in terms of medical records, appointments, and billing systems. In the latter model, the CoE concept comes to life primarily through a process of selecting only high-quality, experienced providers to participate in the public financing system.
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From page 171... ...
Each designated CoE would be responsible for assuring that individual providers meet ongoing quality and service standards to maintain their individual eligibility to participate in the CoE. The designated CoE organization, itself, would receive compensation from the state Medicaid agency to support network management, quality management, and network care coordination expenses required to assure long-term efficacy and cost effectiveness of care services.
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From page 172... ...
to better performing organizations and financial disincentives (e.g., no return of "withholds") for poorer performing organizations or individual providers.
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From page 173... ...
A mechanism through which patients can be reassigned from one CoE to another as a consequence of poor performance (or if patients are allowed to choose among competing CoEs) can provide a strong incentive for improvement in poor-performing organizations.
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From page 174... ...
It is conceivable that in some regions, with large metropolitan areas that cross state boundaries, the federal government could encourage individuals to seek care in one state rather than another and allocate funds accordingly, but the Committee views this as not being feasible. SUMMARY The Committee is convinced that implementing a redesign of the HIV delivery system would result in an improved system of HIV care based on the chronic care model and driven by the six aims for health system improvement: safe, effective, patient centered, timely, efficient, and equal.
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From page 175... ...
2000. Ryan White CARE Act: Opportunities to Enhance Funding Equity.
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From page 176... ...
2001. Developing a performance management system for a federal public health program: the Ryan White CARE Act Titles I and II.
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From page 177... ...
2000. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection.
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