britten pund national alliance of state & territorial aids directors august 4, 2014 the state of...
Post on 02-Jan-2016
218 Views
Preview:
TRANSCRIPT
Britten PundNational Alliance of State & Territorial AIDS Directors
August 4, 2014
The State of ADAPs
Presentation Agenda
Emerging trends in ADAP– FY2013 Year in Review– Looking Ahead to FY2014 and FY2015– ADAPs role in public health
Update on the ADAP crisis– ADAP waiting lists– ADAP cost-containment
Questions and Answers
Overview of NASTAD
NASTAD is an international non-profit association of U.S. state health department HIV/AIDS program directors who administer HIV/AIDS and viral hepatitis programs funded by U.S. state and federal governments.
NASTAD was established in 1992 as the voice of the states.
NASTAD is governed by a 20 member, elected Executive Committee charged with making policy and program decisions on behalf of the full membership.
NASTAD has a Washington, DC headquarters with 38 staff and field offices/programs in Bahamas, Botswana, Ethiopia, Guyana, Haiti, Trinidad, South Africa and Zambia with 65 staff.
NASTAD Mission and Vision
Mission
NASTAD strengthens state and territory-based leadership, expertise and advocacy and brings them to bear on reducing the incidence of HIV and viral hepatitis infections and on providing care and support to all who live with HIV/AIDS and viral hepatitis.
VisionNASTAD’s vision is a world free of HIV/AIDS and viral hepatitis.
The National ADAP Budget, by source, FY1996-FY2013
FY1996 $200 m
FY1997 $413 m
FY1998 $544 m
FY1999 $712 m
FY2000 $779 m
FY2001 $870 m
FY2002 $962 m
FY2003 $1,071
m
FY2004 $1,187
m
FY2005 $1,299
m
FY2006 $1,386
m
FY2007 $1,428
m
FY2008
$1,515 m
FY2009 $1,582
m
FY2010 $1,789
m
FY2011 $1,887
m
FY2012 $2,032
m
FY2013 $2,010
m
26%
40%
53%
65% 68% 66% 64% 65% 61% 59% 56% 54% 51% 49% 45% 43% 41% 39%
25%
28%
22%
18%17% 17% 17% 16%
19%19% 22%
21%21%
14% 19%16%
13%11%
6%
5%
6%
7%7% 7% 9% 10% 12% 15% 17%
18% 21%
31% 29%33%
36% 40%
43%
26%19%
11% 9% 10% 10% 9% 7% 7% 5% 7% 7% 7% 6% 8% 10% 10%
ADAP Earmark State Rebates
Other (includes Part B ADAP Supplemental, Part B Base directed to ADAP, Part B Supplemental directed to ADAP, ADAP Emergency Funding, Part A directed to ADAP)
ADAP Client Enrollment and Utilization
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
0
50,000
100,000
150,000
200,000
250,000
128,465 133,572 134,128 141,856 145,799 151,200 168,707
179,009 179,988195,001
210,411
4%
0%
6%
3%4%
12%
6%
1%
8% 8%
ADAP Client Enrollment, June 2003-2013
Cli
en
ts E
nro
lled
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
31,31743,494
53,76561,822
69,40776,743 80,035 85,825
94,577 96,404 96,121 101,987110,047
125,479135,596 138,173 144,509
152,48739%
24%
15%12% 11%
4%7%
10%
2%0%
6% 8%
14%
8%
2%5% 6%
ADAP Client Utilization, June 1996-2013
Cli
en
ts S
erv
ed
ADAP Client Demographics
Non-Hispanic Black/African
American34%
Non-Hispanic White33%
Hispanic27%
Asian2%
Native Hawaiian/Pacific Is-lander<1%
American Indian/Alaskan Na-tive<1%
Multi-Racial1%
Other1%
Unknown2%
ADAP Clients Served, by Race/Ethnicity, June 2013
Male78%
Female21%
Transgender<1%
Unknown<1%
ADAP Clients Served, by Gender, June 2013
ADAP Client Demographics (continued)
<12 Years<1%
13-24 Years4%
25-44 Years41%
45-64 Years50%
>64 Years4%
Unknown<1%
ADAP Clients Served, by Age, June 2013
≤100% FPL43%
101-138% FPL10%
139-200% FPL15%
201-300% FPL13%
>400% FPL1%
ADAP Clients Served, by Income Level, June 2013
301-400% FPL 4%
Unknown 13%
ADAP Insurance Coordination,June 2013 and FY2013
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 -
10,000
20,000
30,000
40,000
50,000
60,000
$-
$40
$80
$120
$160
$200
$240
$280
$320
$360
$400
5,272 7,167 7,277
12,311 13,744
20,960
15,843
30,621
34,341
41,095
46,653
52,568
$19 $30 $38
$75 $84
$75
$107
$159
$194
$268 $227
$397
Clients Served and Estimated Expenditures in Insurance Purchasing and Continuation, 2013
Nu
mb
er
of
Cli
en
ts (
Jun
e)
Esti
mate
d F
iscal
Year
Exp
en
dit
ure
s (
in m
illi
on
s)
Congressional Outlook
The 113th Congress has grown increasingly partisan, resulting in very little accomplishment.– Have passed only 126 laws since January 2013; lowest level of
productivity in many years
In the 107th Congress (2000-2001), the Senate and House were controlled by different parties and still managed to enact 200 new laws.
The House is scheduled for 12 working days between now and then
Congress New Laws Enacted
113th (2013-2014) 125
112th (2011-2012) 140
111th (2009-2010) 198
110th (2007-2008) 260
Congressional Outlook(continued)
Many “must address” issues:
– Veterans’ Affairs health care access– Unaccompanied Immigrant Minors – Highway Trust Fund– Surface Transportation Bill– Tax Extenders– Terrorism Risk Insurance Act– Export‐Import Bank reauthorization– Foreign Affairs– 12 Appropriations Bills
FY2014 Funding
In FY2014, ADAPs were funded at $900.3 million, a $14 million increase. Part B Base was funded at $414.7 million, a $9.5 million increase
– Increases were due to the alleviation of sequestration
FY2014 was the first year without the hold harmless provision, which shifted allocations of funding awards
FY2015 Funding
The Bipartisan Budget Act of 2013 established spending caps and reduced sequestration for FY2015
The FY2015 302b allocations for the Labor, Health and Human Services bill are similar to FY2014, however there are increasing funding needs for other programs
The debt ceiling will expire in March 2015
FY2015 Funding(continued)
President Obama’s budget included flat funding for ADAP and Part B Base
The Senate LHHS Subcommittee mark included a $5 million increase for ADAP and flat funded Part B Base
– The proposed bill also redistributes SPNS funding throughout the Ryan White Program parts instead of a separate funding line
FY2015 Funding(continued)
The House and Senate Appropriations Committees have no plans to mark up a LHHS bill until after the November election
There will be a continuing resolution (CR) through November, possibly January – House is readying a CR for vote before the
August recess
Awards will potentially be delayed
FY2016 Funding
President Obama’s last full fiscal year in office
Potential changes in House and Senate
Sequestration will impact FY2016 funding– Budget cap for non-defense discretionary funding
is $494 billion, an increase of $1.6 billion from FY2015
– Appropriators will have to allocate funding at this level to avoid across-the-board cuts
Low chance of another “grand bargain”
Ryan White Next Steps
Ryan White still critical despite ongoing implementation of the Affordable Care Act
Part B and ADAPs continue to see growth in programs and strive to address unmet need:– From 2003 to 2013, enrollment in ADAPs increased by
64%. Forty-four ADAPs used funds for insurance purchasing and
continuation in 2013 Part B programs necessary to address gaps in covered
populations and services and to ensure that clients receive all support necessary to access and maintain new coverage options (both in premium and co-pay assistance and support services)
Ryan White Next Steps(continued)
AIDS Healthcare Foundation (AHF) has introduced the “Ryan White Patient Equity and Choice Act” (HR 4260)o Introduced by Rep. Renee Elmers (R-NC), Bennie Thompson
(D-MS) and Eddie Bernice Johnson (D-TX). Bill proposes:
o To ensure that funding to jurisdictions under Part B and Part A does not varyby more than 5% (calls for Secretary report on how to do that);
o Requires ADAPs to have pharmacy network that includes specialty pharmacies;
o Tightens up cover medical services and waiver processo Bill is not getting traction in Congress
The Future of Ryan White: Congressional & Community Conversations
NASTAD and majority of community still feel it is best to not seek a reauthorization at this time
Congressional staffers have said we need “at least one year of data on ACA implementation” before moving forward
Changes ahead could potentially complicate situation– Leadership changes to Committees of jurisdiction
Energy & Commerce: Rep. Waxman retiring; Rep. Pallone (NJ) likely to replace him (although Rep. Dingell (MI) is a possibility) as Ranking Member
Health, Education, Labor & Pensions (HELP): Sen. Harkin retiring; Sen. Murray (WA) likely to become Chair
The Future of Ryan White: Congressional & Community Conversations
(continued)
Possible complicating changes (continued):– 2014 Congressional elections; Republicans will retain
control of House and Democrats will likely retain control of Senate (Senate is more up in the air)
– Community already worrying about implications of 2016 Presidential election and its impact on legislation
Unknown appropriation levels in near-future Focus on drug pricing with new ADAP Crisis Task Force
negotiations Focus on 340B program overall – Congressional and
regulatory efforts– Part C and D RW community push
The Future of Ryan White: Congressional & Community Conversations
(continued)
Messages from Congressional staff at FAPP RW Work Group meeting:– Many priorities in 2014
Medicare “doc fix” Authorization bills with sunset provisions Beginning to look at discretionary health bills with
ONLY medical component– Need to have state “case studies” showing how
allocation of funds changed after ACA implementation Both Medicaid expansion & non-expansion states
– Need to have data to describe the ongoing importance of both “core medical” & “support services”
340B and ADAP
The Office of Pharmacy Affairs (OPA) intended to release a “mega-regulation” on 340B this summer and the rule on ADAP rebates in December
In May, a judge ruled that on OPA’s orphan drug rule and found that OPA does not have the authority to make rules
This has postponed the original timelines for rule release. OPA is currently working on rereleasing the orphan drug rule and then will address the “mega-regulation” and ADAP rebate rules
NASTAD released a Best Practice for Shared ADAP and 340B Drug Pricing Program Clients earlier this month
25,000 ADAP Clients Transitioned to Medicaid Expansion and Qualified Health Plans (QHPs)
AL
ARGA
ID
IL IN
KY MO
MT
NV
NH
OH
SC
SD
TX
VA
WY
OK
ME
MD
NJ
NY
OR
AK
CO
LA
UT
CAKS
MS
FL
HI
NMAZ
ND
MN
IA
WIMI
NE
WA
PA
NCTN
WV
VT
DE
CT
DC
Medicaid QHPs Total12,004 13,129 25,133
Challenges and Priorities
Challenges• Availability of plan information• Formulary gaps• High cost sharing/co-insurance• Political environment in many states made
it difficult for state employees to participate in ACA implementation activities
• Many clients remain ineligible because their state has not expanded Medicaid
Priorities/Solutions• Advocate for Medicaid expansion• Increase Ryan White capacity to assist
clients with costs• Identify work-arounds to obtaining
insurance information• Advocate with federal government, state
government, and insurers about importance of formulary coverage for ALL ARVs
• Continue to educate clients about ACA and prepare for continued enrollment efforts in November
ADAP and Affordable Care Act
QHPs have extremely high cost sharing and co‐insurance costs.
QHP formulary issues – commonly prescribed single-tablet regimens being left off.
Pharmacy and provider networks do not include Ryan White Program providers or ADAP pharmacies.
24 states are not expanding Medicaid.– 68% of ADAP clients in non-Medicaid expansion
states have an income below 138% FPL.
Some ADAP clients have remained ineligible for ACA.
ADAP and Affordable Care Act (continued)
Looking Forward:
– Mitigating churn between Medicaid, QHPs and other forms of coverage
– HRSA is examining if ADAPs can cover any costs when reconciling the Advance Premium Tax Credits
– States may not disenroll clients who do not transition to new coverage options
ADAP’s Role in Public Health
ADAP remains the safety net provider for many people living with HIV.
ADAPs and the rest of the Ryan White Program provide more comprehensive services than QHPs and Medicaid.
Health insurance does not replace public health.
ADAP in a Reformed Health System
ADAP structure, pre- and post-health reform implementation– Traditional ADAP
Full payment of medications for those not eligible for coverage under the Affordable Care Act
– Insurance purchasing/continuation Wrap-around of Medicaid and Medicare
– Including Medicaid expansion and non-expansion states
Insurance purchasing – purchasing of a new policy– Including policies purchased through the Exchange
Insurance continuation – payment for an existing policy– Including policies purchased through the Exchange
ADAP in a Reformed Health System (continued)
What is the potential change in ADAP utilization between FY2013 and FY2014?– Client migration to Medicaid in a non-expanding state
Presumption that clients would not move – Client migration to Medicaid in an expanding state
Potential for clients to shift coverage to Medicaid– Client migration to Exchanges
Potential for clients to gain access to insurance for the first time, however ADAP may remain the payer for the policy (i.e., premiums, deductibles, and co-payments)
– Clients remaining on ADAP Individuals who are categorically ineligible for federal programs Individuals needing wrap-around coverage for an existing or
new insurance policy Individuals who churn Individuals who do not enroll
Factors Leading to Implementation of Cost-containment Measures
ADAPs reported the following factors contributing to consideration or implementation of cost containment measures:– Higher demand for ADAP services as a result of
increased unemployment– Level federal funding awards – Increased demand for ADAP services due to
comprehensive HIV testing efforts– Escalating drug costs– Budgets cuts in state Medicaid and other state programs
Demand for ADAP has not dwindled.
Access to Medications
Case management services are being provided to clients on ADAP waiting lists through:– ADAP– Ryan White Part B– Contracted agencies– Other agencies, including other Parts of Ryan White
ADAP waiting list states confirm that ADAP waiting list clients are receiving medications through other mechanisms.
ADAP Waiting Lists (35 individuals in 1 state)
as of July 24, 2014
StateNumber of
Individuals on ADAP Waiting List
Percent of the Total ADAP Waiting List
Date Waiting List Began
Utah 35 100% February 2014
Waiting List Organization and Access to Medications
Waiting List Organization: Waiting list clients are prioritized by one of two models: – First-come, first-served model: placing individuals on
the waiting list in order of receipt of a completed application and eligibility confirmation.
– Medical criteria model: based on hierarchical medical criteria based on recommendations by the ADAP Advisory Committee (1 ADAP).
Access to Medications: Utah ADAP confirms that case management services assist clients in obtaining medications through the HarborPath ADAP waiting list program or pharmaceutical company patient assistance programs (PAPs) while clients are on the waiting list.
Factors Leading to Implementation of Cost-containment
Implementation of the Affordable Care ACT
Increase in clients/demand due to job loss/unemployment
Increase in clients/demand due to neighboring state's cost-containment measures/waiting list
Increased drug costs
Increased HIV testing leading to higher client enrollment
Increased insurance/Medicare Part D wrap around costs
Increased utilization from already enrolled clients
Reduced contribution from Part A into ADAP
Reduced contribution from Part B into ADAP
Reduced or insufficient federal ADAP funding
Reduced or insufficient state funding
State Medicaid or other state program budget cuts
3
2
2
5
2
3
2
1
2
8
6
1
ADAPs and Cost-containment
ADAPs with Other Cost-containment Strategies (since April 1, 2013, as of July 15, 2014)
Enrollment Cap Expenditure Cap Financial
EligibilityFormulary Reduction Other
Indiana
Utah
Arizona: monthly
Illinois: monthly
South Dakota: annual
Illinois Alabama
Alaska
Illinois
Louisiana
Maine
Georgia: cap on insurance premiums
Montana: service reductions in place
Resources
For an electronic copy of the 2014 National ADAP Monitoring Project Annual Report, please visit www.NASTAD.org.
For more information about the National ADAP Monitoring Project or the state of ADAPs, please contact Britten Pund at bpund@NASTAD.org.
Contact Information
Britten PundSenior Manager, Health Care Access
NASTADPhone: (202) 434.8090
bpund@NASTAD.orgwww.NASTAD.org
top related