S T E V E N B A I L E Y, VA D E PA RT M E NT OF H E A LT HA N NE R H O D E S, VA D E PA RT M E N T O F H E A LTHJO H N F U R N A R I , NC D E PA RT M E NT O F H E A LT H

RW A LL G R A N TE E S M E E T I N GNOV E M B E R 2 0 1 2WA S H I NG TO N D C

Management of an ADAP Waitlist: Virginia and North

Carolina Experiences

Background: Waitlist Factors - Virginia

Increased Utilizatio

n

Decreased

Funding

Increased Costs for

ARVs

Cap on Medicare

Part D Enrollme

nt

Waitlist Factors – North Carolina

TBD

Initial Planning: Late 2010, Virginia

• Education of physicians on cost of ARV regimens

• Identification of cost-saving strategies

Advisory Committee

• Projected cost savings from each proposed strategy

• Identified mechanisms for alternative medication access

VDH • Formulary Reduction (ARV, OIs, vaccines)

• Enrollment closure (pregnant, <18, active OI)

• Dis-enroll clinically stable subgroup (n=204)

Actions

Waitlist Tracking, Virginia

Data Collected

DemographicsEligibilityMedical

Sourced from Physicians, Case

Managers, Health Departments and

Clients

Updates

Conducted 6 month recertifications for

all clients on waitlist

Matched with HIV surveillance, RW service data to obtain updated

medical and eligibility

information

Monitoring

Weekly meetings with ADAP

leadership team at VDH to examine

waitlist and program data, in conjunction with

fiscal data

Used waitlist data for projections of

future scenarios for opening ADAP

enrollment

Waitlist Tracking – North Carolina

TBD

Program Monitoring, Virginia ReportsPROGRAM ACTIVITY OVERVIEW: 10/9/2012

Month/Year

Active clients (received prescription in

preceding 5 months) enrolled in ADAP with medication pick-up at a local health department

or MCV

Clients received a prescription in a given month through Central Rx, MCV,

Fairfax, or Alexandria

New clients by Month picking-up

through Central Rx, MCV, Fairfax,

or Alexandria

Active clients enrolled in

Medicare Part D Cost-Sharing Assistance in past 5 months

Clients received a prescription in a given

month through Medicare Part D Cost-

Sharing Assistance

TOTAL CLIENTS WHO

HAVE RECEIVED AN

RX UNDER ADAP IN A

GIVEN MONTH

Value of Dispensed drugs (Direct ADAP Only)

Avg Cost Per Person Per Month (Direct ADAP)

Nov-10 3,577 1,987 68 129 117 2,104 $2,325,257 $1,164.38Jan-11 3,396 1,865 11 193 135 2,000 $1,654,826 $876.96Jun-11 2,679 1,832 8 285 252 2,084 $1,753,214 $956.99Dec-11 2,276 1,724 41 298 242 1,966 $1,584,221 $918.92Jan-12 2,389 1,795 66 303 259 2,054 $1,576,683 $880.34Mar-12 2,574 1,892 87 307 218 2,110 $1,610,127 $851.47Jun-12 2,700 1,961 54 330 255 2,216 $1,663,710 $848.40

Fiscal Monitoring, Virginia ReportsRENEWABLE FUNDING TOTAL EXP/CR BALANCE

RYAN WHITE PART B SUPPLEMENTAL FUNDS BUDGETED FOR MEDS

TOTAL ANTICIPATED RENEWABLE FUNDING -$ -$ -$

TOTAL ONE-TIME FUNDING

-$ -$ -$

PROJECTED NEED THRU 3/31/2013 @ $70,809.87 PER DAYTOTAL AVAILABLE RESOURCES EXCLUDING MINIMUM INVENTORY RESERVE - MEDS

ESTIMATED ADDITIONAL RESOURCESANNUAL ESTIMATE MEDICAID BACK BILLINGANNUAL ESTIMATE ADAP REBATES - MEDICARE PART D GY122011 BASE CARRYOVER, REQUESTED FOR GY20122011 ADAP EARMARK CARRYOVER, REQUESTED FOR GY2012RYAN WHITE PART A CONTRIBUTION - NVRCRYAN WHITE PART A CONTRIBUTION - NORFOLKTOTAL ESTIMATED ADDITIONAL RESOURCES

TOTAL AVAILABLE RESOURCES

OUTSTANDING PHARMACEUTICAL OBLIGATIONSUNOBLIGATED DRUG FUND BALANCE (10/02/2012)VALUE OF AVAILABLE DRUG ON HAND VALUE OF MINIMUM INVENTORY RESERVEINVENTORY - EXCESS (Shortage)

DDP YEAR END SWEEP - GENERAL FUNDS FOR MEDS

TOTAL BUDGETED FUNDS FOR DRUG PURCHASE

REBATES - MEDICARE PART D GY12

RYAN WHITE ADAP SHORTFALL RELIEF BUDGETED FOR MEDS

ONE-TIME FUNDINGOEPI-DDP SFY12 GENERAL FUNDS BUDGETED FOR MEDSSFY12 GENERAL FUND AGENCY ALLOCATIONOEPI YEAR END SWEEP - GENERAL FUNDS FOR MEDS

RYAN WHITE PART B ADAP DIRECT SERVICES FUNDS BUDGETED FOR MEDSRYAN WHITE PART B BASE FUNDS BUDGETED FOR MEDSRYAN WHITE PART B BASE FUNDS BUDGETED FOR VACSRYAN WHITE PART B ADAP SUPPLEMENTAL FUNDS BUDGETED FOR MEDSMEDICAID BACK-BILLING RECOVERIESFAIRFAX MEDICAID BACKBILLING

ADAP Forecasting, Virginia

Capacity (Resource

s Available)

Scenarios (Changing Enrollment Criteria)

Change of Program Structure

(PCIP)

HRSA ERF

Capacity Projections, Virginia

Total Resources for

Program/ Average Cost Per Person for

Program Annually

MPAP

Direct Purchas

ePCIP

Change of Program (include PCIP)

Mix of Clients (% eligible for PCIP, when transitioned

)

Mix of insurance spending

(drugs/other)

Length of time to reach

annual cap (matters for

RW year projections)

Rebates ???

Scenario Projections

Elimination of WaitlistChanging of enrollment criteria (different

CD4 levels, different FPLs), with or without disenrollment

Increase in funding of a certain amount and impact on the waitlist

Change in formularyChange in dispensing policyImplementation of TrOOP

Projections, North Carolina

TBD

Moving to Sustainability, Virginia

NASTAD decreases in

ARV costs

Additional Funding

Sources (Part A, State, ERF, etc.)

Increased Program Revenue

(Medicaid Backbilling and

Rebates)

Increased Recertificatio

n and Eligibility Processes

Part B Service

Reductions

ADAP Program Management

Increased program efficiencies during 2011

Shifted FY 2011 Ryan White service funds to help cover ADAP medication costs

Improved ADAP client eligibility and recertification processes

Instituted state residency policy for ADAP clients

Addressed inactive clients and intermittent use of ADAP

ADAP Program Management

Increased pharmaceutical efficiencies

Sustained the 30-day prescription dispensing policy implemented in 2010

Sustained aggressive inventory strategy to monitor pharmacy inventory and daily drug costs at all ADAP pharmacies, including the main State Central pharmacy

Referred patients to PAPs and other medication sources Pharmaceutical company patient assistance programs (PAPs) Welvista – central hub for number of ARVs

ADAP Program Management

Maximizing Use of Other Medication Programs

Increased Medicaid back billing revenue for purchase of ADAP medications, including developing agreements with Medicaid HMOs for backbilling

Used ADAP dollars for Medicare Part D co-payments that are counted as True Out of Pocket (TrOOP) expenses

Secured 340 B Rebate Status allowing VA ADAP to pursue rebates for co-pays for Medicare Part D clients’ drug costs; in 2011, VDH spent $400K in co-pays for ARV medications and received $1.1 million in rebates (a return of $2.84 for each dollar spent)

Sustainability, North Carolina

TBD

Expanding and Sustaining Access, Virginia

Virginia ADAP has expanded ADAP enrollment criteria and reduced the wait list over last year: November 2011: CD4 count at or below 200 December 2011: CD4 count at or below 350 April 2012: CD4 count at or below 500 July 2012: removal of clinical criteria August 2012: began immediate processing of new

applications (no longer placed any new persons on waitlist)

Eliminated the wait list as of August 30, 2012.

Medical Model for Waitlist Reduction, VA

Clients with CD4 counts <200 are often diagnosed late and/or enter medical care late and have shorter survival times (Schwarcz, 2006) and higher costs of care than those with higher CD4 counts (Krentz, 2004).

Clients with CD4 counts under 350 who are not on antiretroviral therapy have been found to be less likely to survive over time and more likely to be lost to care (Franke et al, 2011)

Current public health guidelines emphasize having all those with CD4 counts under 500 on antiretroviral therapy

Initial Opening of Enrollment, November 2011

17%

83%

CD4 Count Distributionof VA-ADAP Waitlist as 10/1/11

N = 1,010<200201 and above

CD4 Count ≤ 350, December 2011

11%

19%

21%

49%

200 or less201 to 350351 to 500>500

CD4 Count Distributionof VA-ADAP Waitlist as 12/1/11

N=1,104

CD4 Count ≤ 500, April 2012

1%

15%

84%

< 200201 to 500> 500

CD4 Count Distributionof VA-ADAP Waitlist as 4/19/12

N=864

All CD4 Counts, August 2012

0.5% 4.5%

95.0%

< 200201 to 500> 500

CD4 Count Distributionof VA-ADAP Waitlist as 8/2/12

N=489

VA ADAP Wait List Removals

40544

40575

40605

40640

40668

40696

40725

40756

40787

40817

40848

40878

40909

40940

40969

41000

41030

41061

41091

41123

41153

0

200

400

600

800

1000

1200

Num

ber

of C

lien

ts

Virginia AIDS Drug Assistance Program Waitlist2011 to 2012

Data Source: AIDS Drug Assistance Program Waitlist DataDivision of Disease Prevention, Office of Epidemiology, Virginia Department of Health, August 24 2012

VA ADAP Waitlist Removals: Reasons

Each client removed from waitlist was assigned reason for removal

Those with CD4 counts under 200 often had other payer sources

13%

10%1%1%

60%

12%

4%

ANOTHER PAYER SOURCE FOR MED-ICATONSINELIGIBLE FOR ADAPDECEASEDDECLINED ADAP SERVICESENROLLED INTO ADAP REMOVED FOR NON-CONTACTCONTACTED, PENDING EN-ROLLMENT

Source: VA ADAP Waitlist database, Division of Disease Prevention,Virginia Department of Health, October 1, 2012

Waitlist Trends, North Carolina

TBD

Enrollment Expansion Process, VA

Sustainability•New projections done

prior to each expansion to show capacity

•Enrollment monitored weekly and prescriptions filled monitored monthly

Methodology•Complete eligibility

done before enrollment, including regimen, next fill date, other payer sources

•Contact process – if no client follow up in 30 days, client removed from waitlist

Challenges•Did not always have

client signature on file•Clients sometimes

resistant to changing from PAPs

•Rx often lagged significantly behind enrollment, making projections difficult

Enrollment Expansion, Education

Community education plan familiarized stakeholders with PCIP/ADAP enrollment criteria. VDH planner met with consumers, physicians, case managers, client advocates, consortia, and others to present VDH plan and answer questions

Regional calls held before each expansion to explain change and receive input from stakeholders

VA ADAP: Persons and Cost, 2010-2012

Janua

ry 20

10

March

2010

May 20

10

July

2010

Sept 2

010

Nov 20

10

Janua

ry 20

11

March

2011

May 20

11

July

2011

Septem

ber 2

011

Novem

ber 2

011

Janua

ry 20

12

Mar-12

May 20

120

2

4

6

8

10

12

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

Number of Active Persons Total Cost Per Month

Clie

nts

Mill

ion

of D

olla

rs

Source: VA-ADAP database, Division of Disease Prevention, Virginia Department of Health, August 2012

Restructuring the Model for Medication Access, VA

Strengthening and improving the eligibility processes for all HIV services

Moving toward a model of insurance coverage Transition of eligible clients to coverage under the

Pre-Existing Condition Insurance Plan (PCIP) PCIP is cost-effective and covers services and

medications Acquired Pharmacy Benefits Manager (PBM) to

handle Medicare Part D and PCIP programs

Cost Effectiveness of PCIP: Direct Purchase ADAP vs. PCIP Costs Annually for a Client

Costs &Revenue

Full medication purchase

through ADAP

PCIP purchase

through ADAP(Revenue in green)

Net Savings From PCIP

Monthly Premium(varies by age)

$0 $168

Monthly HAART Regimen

$944 $1,347 (until max out of pocket is reached)

Annual Max Out of Pocket

NA $4,000 (reached at 3-4 months)

Annual Premiums

$0 $2,016

Annual Rebates $0 $(3,000)

Annual Totals $11,328 $3,016 $8,312* Avg. client is 40 years old on a common protease inhibitor regimen

Program Sustainability & Increases in Demand

Expected increases in client demand from increased testing efforts and linkage to care efforts Expanded Testing efforts SPNS Systems Linkages & Access to Care 4-year grant (NC

and VA) CDC Grant to HIV Prevention for increased linkage

activities

New HIV Treatment Guidelines promoting a “test and treat” philosophy Treatment lowers amount of virus in the body and keep patient

healthier Treatment reduces transmission of virus to others

Stakeholder Involvement, Virginia

Consumers Outreach and contact efforts Currently forming a consumer advisory board for

SPNS project that we hope will serve for ADAP as wellProviders

ADAP Advisory CommitteeConsortiaPart A Planning CouncilsVirginia legislators and policy makers

Lessons Learned, Virginia

Gather insurance eligibility information (PCIP)

Involvement of ADAP Advisory CommitteeProactive approach with agency

administrationImprovements in tracking clientsStakeholder involvement criticalRebates will support program sustainability

Lessons Learned, North Carolina

TBD

Conclusion

VA ADAP has expanded enrollment criteria through aggressive program, fiscal, and pharmaceutical efficiencies

VA ADAP is monitoring increases in client demand from testing and linkage to care efforts

Sustained funding from federal and state resources will be necessary to support sustained and increased client demand