Public Financing and Delivery of HIV/AIDS Care Securing the Legacy of Ryan White (2005) / Chapter Skim
Currently Skimming:
3 Current Financing and Delivery of HIV Care
3 Current Financing and Delivery of HIV Care
Pages 73-106
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(see Figure 3-1) .1 Programs such as the Ryan White Comprehensive AIDS Resources Emergency (CARE)
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74 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE Medicare 6% Private 31% Medicaid 43% Uninsured 20% FIGURE 3-1 People living with HIV/AIDS in regular care: estimated insurance coverage, 1996. SOURCE: Bozzette et al., 1998.
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States have broad flexibility in designing their Medicaid programs, and consequently there is significant variation in eligibility, benefits, provider payments, and other aspects of the program at the state level (Westmoreland, 1999; Kaiser Commission on Medicaid and the Uninsured, 2001)
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SSA determines disability by inability to work; thus, a person with symptomatic HIV infection who can still work may not be eligible for disability (SSA, 2004)
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Medicaid coverage of prescription drugs includes all FDA-approved highly active antiretroviral therapy (HAART) drugs, but coverage of these drugs is at state option and subject to amount, duration, and scope limits (e.g., limit on the number of prescriptions)
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, and coverage of prescription drugs. Eligibility Most Americans ages 65 and older are entitled to Medicare as soon as they are eligible for Social Security payments.
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Ryan White CARE Act Administered by the Health Resources and Services Administration (HRSA) , the Ryan White CARE Act was designed to address the gaps in financing care for people with HIV/AIDS and to provide financial support to cities that were bearing a disproportionate burden of the cost of care.
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As a result, there is significant variation in state funding, eligibility, services, and other aspects of CARE Act programs across the country. Other Ryan White CARE Act Programs That Provide Care Although much smaller in scope, three additional CARE Act programs provide funding for care services: Title III-Early Intervention Services, Planning and Capacity Grants (Title III)
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. In addition to these programs, two additional Ryan White CARE Act programs are designed to assist in improving the quality of care provided by the Ryan White programs and to assist community providers in improving the delivery of care.
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. Data from this tracking project indicate that the CARE Act served a much higher proportion of HIV-infected, African-American women than women from other racial/ethnic categories at these sites and that clients who received medical care services from Ryan White CARE Act providers were more likely to have no insurance coverage and less likely to have private insurance than clients who did not receive medical care from CARE Act providers.
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Case management 12 11 11 06 12 05 12 08 Support services 23 12 23 06 27 05 26 07 Medications/ADAP 07 46 12 67 07 71 07 68 Administration, 09 07 10 10 10 09 11 07 planning, evaluation, and program support aThe most recent data available is for 2001 (Personal communication, Dr. Richard Conviser, HRSA, December 23, 2003)
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Consortia membership includes agencies with expe 9As part of the Ryan White CARE Act Reauthorization in 2000, Congress directed that the Title I and Title II formulas incorporate data on cases of HIV as well as AIDS in order to target funding to more accurately reflect the HIV/AIDS epidemic. The use of such data could take effect in FY 2005.
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In conducting their work, consortia members must also demonstrate that they have consulted with people affected by the disease, the public health agency providing HIV/AIDS-related health care, at least one community-based AIDS service provider, other CARE Act grantees, and Title I planning councils. Private Coverage for HIV/AIDS Care Private insurance represents a significant source of coverage for individuals with HIV/AIDS.
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Additional blood samples have been collected from a majority of HCSUS respondents, and virological analyses are being initiated. Supplemental studies are examining HIV care delivery in rural areas, prevalence of mental and substance abuse disorders, oral health of HIV-positive individuals, and issues related to HIV-infected persons over 50 years of age.
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A recent analysis of HCSUS data found that private insurance covered 42 percent of individuals with HIV infection in the early asymptomatic stage of the disease. Medicare, Medicaid, or a combination of the two programs provided coverage for 31 percent of those with asymptomatic disease, and the remaining 26 percent of individuals were uninsured.
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Eight broad areas of standard care surfaced that capture the critical components of HIV care. These critical components of HIV care
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Highly Active Antiretroviral Therapy As noted in Chapter 2, access and adherence to life-sustaining comprehensive antiretroviral therapy is the cornerstone of HIV care. Without it, patients experience a rapid death.
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. Similar guidelines for the use of antiretroviral agents for the treatment of pediatric HIV infection were developed by the Working Group on Antiretroviral Therapy and Medical Management (WGATMM)
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First, adherence to antiretroviral treatment may be undermined by co-occurring substance abuse and mental illness and could lead to the development of drug resistance. Second, the clinical management of HIV-infected individuals must take into account the impact of substance abuse and mental illness and their treatment on the expression of symptoms, the development of drug interactions, progression of HIV disease, the utilization of care services, and high-risk HIV behaviors (see Box 3-4)
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While the psychiatrist might argue that her drug use must be stabilized first, the drug treatment provider might insist that her untreated bipolar disorder compromises successful drug treatment. The HIV clinician might fear poor adherence to HAART and forego treatment until both the mental illness and substance abuse are controlled.
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Alcohol use by patients with HIV has been shown to alter drug metabolism and to increase the risk of drug-induced hepatotoxicity, especially in patients co-infected with hepatitis C Similarly, prescribed medications used in the treatment of substance abuse and mental illness can produce drug interactions with the medications used in the treatment of HIV infection.
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As noted in Chapter 2, HIV-infected individuals who abuse substances or are mentally ill are at a higher risk of transmitting HIV infection to others. For some, substance abuse and mental illness placed them at risk for becoming infected with HIV.
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. Two federal programs that focus on this population, the HIV set-aside in Substance Abuse Prevention and Treatment Block Grants and the CARE Act, are mandated to seek collaboration between substance abuse treatment providers and medical care providers and to seek to establish service linkages between the two systems (CSAT, 1995)
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Many medical providers of HIV services prefer models in which case management services are closely related to primary care, so that these services can directly support treatment adherence. Case management service visits account for the largest number of visits made by Ryan White CARE Act clients under Title I and Title II non-ADAP services (HRSA, 2002j)
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HRSA, under its CARE Act SPNS program, has two studies underway exploring prevention with HIV-infected persons seen in primary care settings and a demonstration project on prevention for HIVpositive persons (HRSA, 2003a)
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A primary care services approach to managing the complexity of services and providers who provide care to people with HIV infection has been an important foundation of the CARE Act and the federal Medicaid program. Generally, primary care is understood as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community (IOM, 1996)
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to cover their non-reimbursed costs of providing oral health care to individuals with HIV. Where HIV/AIDS Patients Receive Care The most comprehensive source of information on the delivery of HIV care comes from the HIV Costs and Service Utilization Study.
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· The standard of care for HIV/AIDS includes HAART, other drug therapies that prevent complications and that support retention in care, obstetrics and reproductive health services for HIV-infected women and pedi atric care for infants with HIV, primary care services, substance abuse and mental illness treatment, case management services directly related to clinical care, and HIV prevention services. · Two-thirds of HIV care takes place in physician offices, community hospitals, and clinics.
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2000. Who receives Ryan White CARE Act Services?
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2000. Ryan White CARE Act: Opportunities to Enhance Funding Equity.
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2002j. Ryan White CARE Act Annual Administrative Report 2000: Title I, Title II, AIDS Drug Assistance Program, Health Insurance Program.
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Paper prepared for the Committee on Public Financing and Delivery of HIV Care, Institute of Medicine. Wash ington, DC: Kaiser Family Foundation.
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:722. SAMHSA (Substance Abuse and Mental Health Services Administration)
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WGATMM (Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children)
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