Public Financing and Delivery of HIV/AIDS Care Securing the Legacy of Ryan White (2005) / Chapter Skim
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6 Recommendations
6 Recommendations
Pages 178-212
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From page 178... ...
In this chapter, the Committee puts forth its vision for an improved public financing and delivery system for HIV care and examines the cost and health implications of such a program. For expository convenience, the Committee has named its proposal the HIV Comprehensive Care Program (HIV-CCP)
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From page 179... ...
As a direct result of receiving HAART, the Committee predicts that premature deaths among this cohort of individuals would fall over a 10-year period by more than half (55.9 percent)
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From page 180... ...
Recommendation 6.7: The new program should coordinate closely with the Ryan White CARE Act, which should be refocused to meet the needs of low-income individuals who are not eligible to be served by the new program. The Committee acknowledges that the group of recommendations it makes to redesign the way HIV care is financed and delivered is a bold response to its charge.
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From page 181... ...
Program Eligibility and HAART Gain for the HIV-CCP Using the federal poverty level of $8,860 for an individual in 2002, and extrapolating from the HIV Cost and Services Utilization Study (HCSUS) 2This assumption underlies the Committee's base case analysis and results.
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From page 182... ...
. The result equaled 71 percent of the total population that the Committee estimates is publicly insured or uninsured and aware of their TABLE 6-2 HIV-CCP by Eligibility, Enrollment, and Care Status, HAART Need and HAART Gain Eligibility, Enrollment, and Care Status HIV-CCP Individuals eligible to enroll in program 400,975 Individuals predicted to enroll in program and remain in care 285,503 Individuals enrolled and in care who need HAART 222,681 Individuals who will receive HAART through the program 181,848 Individuals receiving HAART through the program who received HAART 123,151 prior to enrolling in the program Individuals who will continue to receive HAART through a public 44,499 program such as Medicaid or ADAPa Total gain in HAART use as a result of the program 58,697 aThese individuals represent a small percentage of individuals in public programs who may not transition into the new program because of imperfect outreach and awareness of the program, imperfectly implemented enrollment procedures, or personal choice.
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From page 183... ...
. Health Benefits of the HIV-CCP Although the increase in HAART use is one measure of the benefit of implementing the Committee's policy recommendations for public financing of HIV care, it is an intermediate outcome that relates to but is not a direct measure of the likely impact of the Committee's recommendations on life expectancy or the quality of life of those living with HIV.
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From page 184... ...
If no changes are made to the current system of public financing of HIV care, some of the initial cohort of 58,697 individuals who would not otherwise be on HAART at the time they would qualify for the program recommended by the Committee would eventually receive antiretroviral therapy as a result of a worsening in their disease status and/or finances.
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From page 185... ...
The Committee estimates that the incremental cost of providing antiretroviral therapy to 58,697 individuals for 10 years in 2002 dollars is $2.65 billion, discounted. Adding in the cost of the complete benefits package (including case management, substance abuse treatment, and mental health care services)
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From page 186... ...
The program modeled by the Committee provides for comprehensive care and therefore has substantial costs and benefits beyond the costs and life-expectancy gains associated with HAART. For example, the Committee recommends that case management, substance abuse treatment, and mental health services be provided as part of the packet of services to which beneficiaries are entitled in order to support the goal of early entry into care, retention, and adherence.
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From page 187... ...
. Investments that are significantly more expensive than implementation of the Committee's recommendations for public financing of HIV care are annual mammography (versus clinical breast exam)
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From page 188... ...
b This reflects state spending on individuals with HIV who remain in the Medicaid program as well as incomplete adjustment for dual Medicaid and Medicare eligibility. cThis excludes the cost of care provided by the Ryan White CARE Act, which is included in "care for the uninsured".
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From page 189... ...
The Committee would like to stress that any reduction in the funding allocation for the Ryan White CARE Act must be undertaken with utmost care and deliberation, as the individuals served by the CARE Act after the implementation of the HIV-CCP program would remain the most vulnerable population with HIV/AIDS. In fact, since the Committee believes that
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From page 190... ...
, Titles I and II of the CARE Act cover a variety of support services, including housing and food assistance, transportation, and advocacy and outreach services. The need for these services among the populations served by the CARE Act would not be eliminated by the implementation of the HIV-CCP.
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From page 191... ...
Title I Health care $272 Case management $74 Support services $161 Medications/ADAP $43 Administration, planning, evaluation, $68 and program support Title II Health care $117 Case management $78 Support services $68 Medications/ADAP $664 Administration, planning, evaluation, $68 and program support Title III $194 Title IV $71 Dental assistance $13 AETCs $35 SPNS $25 Total $1,261 $690 as savings within the Ryan White CARE Act. Compared to the estimated savings for care of the uninsured in Table 6-7, no more than $602 million of the estimated $880 million would be realized within the CARE Act.
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From page 192... ...
Thus, the total population that we estimate would receive ongoing prevention counseling through the program is 199,852. An average HIV transmission rate of 4 percent per year (i.e., four new HIV infections per 100 infected individuals per year)
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From page 193... ...
The cost includes current use of ancillary services, but not the cost of added ancillary services such as substance abuse treatment received as a result of being enrolled in the program. The predicted cost reflects the fact that many individuals with early HIV disease are unaware of their infection.
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From page 194... ...
Recommendation 6.1: The federal government should establish and fully fund a new entitlement program for the treatment of low-income individuals with HIV that is administered at the state level. As discussed in Chapter 4, the current public financing programs do not adequately address the barriers to HAART for low-income Americans with HIV.
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From page 195... ...
These ranged from incremental approaches building upon the existing Ryan White CARE Act, Medicare, and Medicaid programs, to the establishment of new federal programs. As explained in Chapter 5, the Committee concluded that the approach that best fit the criteria for effective public financing of HIV care for low-income Americans was a federally funded, state-administered program (Option 7)
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From page 196... ...
In a classic Catch-22, people diagnosed with HIV cannot get Medicaid coverage that would enable them to access care that would prevent the costly onset of AIDS, which Medicaid does recognize as a basis for eligibility. In contrast, eligibility for the Ryan White CARE Act program is usually based on HIV diagnosis rather than the onset of AIDS.
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From page 197... ...
The Ryan White CARE Act program uses less restrictive standards. Reflecting the high costs of HAART, eligibility for the AIDS Drug Assistance Program (ADAP)
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From page 198... ...
The Committee does not believe that any useful public purpose would be served by excluding these individuals from the new federal program if they are willing to contribute toward the costs of this coverage. The Committee therefore recommends that individuals with HIV who cannot purchase adequate private insurance coverage (either through their employers or in the individual insurance market)
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From page 199... ...
Because of their income and their HIV status, these individuals are less likely to have private insurance coverage. In these circumstances, screening all applicants to identify those individuals would unnecessarily complicate the application process.
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From page 200... ...
The Committee therefore weighed in favor of following current Medicaid policy rather than reopening this debate. However, the Committee expects that a strongly refocused Ryan White CARE Act program will include these populations in care.
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antiretroviral therapy and other medications, including those that prevent complications and support retention in care; 2. obstetric and reproductive health services; 3.
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Title IV of the CARE Act addresses the specified needs of women, infants, and children and youth living with HIV. It covers primary and specialty medical care, psychosocial services, logistical support and coordination, and outreach, and case management (HRSA, 2002)
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From page 203... ...
However, a public program that relies on Medicare payment principles and rates is much more likely to succeed in attracting sufficient qualified providers than is a program that pays providers less. Recommendation 6.5: To ensure that the new program is a prudent purchaser of drugs used in the treatment of HIV/AIDS, Congress should implement measures that lower the cost of these drugs such as applying the Federal Ceiling Price or the Federal Supply Schedule price currently used by some major federal programs.
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From page 204... ...
The incremental cost of providing antiretroviral therapy alone would be in the range of $2.65 billion over the next 10 years. At this projected level of expenditure, simple fiscal prudence requires that the new program use mechanisms currently in use by other federal purchasers to
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From page 205... ...
. The Committee takes this matter seriously: after all, research and development of antiretroviral therapies by pharmaceutical manufacturers have made fundamental contributions to our understanding of HIV and the dramatic change in the clinical course and outcome of HIV infection brought about by HAART.
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From page 206... ...
Positive evaluation results would provide support for a wider dissemination of the model and the possibility of incorporating other responsibilities such as research to improve care delivery. Recommendation 6.7: The new program should coordinate closely with the Ryan White CARE Act, which should be refocused to meet the
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From page 207... ...
Current grantees include community and migrant health centers, hospitals or university-based medical centers, and city and county health 7For a discussion on the new program's budget impact on the Ryan White CARE Act, please see the earlier section of this chapter.
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From page 208... ...
These populations require additional outreach and support, services which the CARE Act system provides. In addition, these programs are a means to provide voluntary counseling and testing that enables individuals to be made aware of their infection at an earlier disease stage and to enter care.
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From page 209... ...
2000. AIDS Drug Assistance Pro gram Cost Containment Strategies.
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From page 210... ...
2003b. Measuring What Matters: Allocation Planning and Quality Assurance for the Ryan White CARE ACT.
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From page 211... ...
2001. Characteristics and trends of newly identi fied HIV infections among incarcerated populations: CDC HIV voluntary counseling, testing, and referral system, 19921998.
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