New York State Department of Health HIV Uninsured Care Programs

Transcription

1 New York State Department of Health HIV Uninsured Care Programs AIDS Drug Assistance Program (ADAP) ADAP Plus (Ambulatory Care) HIV Home Care ADAP Plus Insurance Continuation (APIC) Lanny T. Cross Program Director Empire Station P.O. Box 2052 Albany, NY

2 New York State HIV Uninsured Care Programs Mission To provide access to care for all New York residents with HIV Dual Goals 1. To empower individuals with access to care 2. To provide a stable funding stream for providers

3 HIV Health Care Funding New York State Medicaid Enhanced Rates Primary Care Acute Care Long Term Care Foster Care Case Management Special Needs Plan (SNPs) Spenddown "Buy-In" Program Medicare HIV Uninsured Care Programs ADAP ADAP Plus HIV Home Care Grants Developmental Infrastructure Clinical Education Support Services Special Populations Corrections Veterans

4 New York State HIV Uninsured Care Programs Key Features Inclusive eligibility criteria User friendly Confidentiality Comprehensive formulary and continuum of ambulatory care Broad network of providers Provider friendly Medicaid compatibility Advisory Workgroup for community involvement Cooperative funding Centralized administration/operation

5 HIV Uninsured Care Programs Eligibility Criteria Residency = NYS Medical Financial ADAP & ADAP Plus = HIV+ Home Care = HIV illness or AIDS, and chronic medical dependency Income < $44,000/year for household of 1 Liquid Assets < $25,000

6 New York State AIDS Drug Assistance Program Formulary (more than 450 drugs as of 12/31/03) Antiretroviral Drugs Nucleoside Analogs -10 NNRTIs - 3 Fusion Inhibitor - 1 Protease Inhibitors - 7 RRI - 1 PCP Prophylaxis & Treatment - 9 Anti-Neoplastics - 16 Treatments for Opportunistic Infections - 45 Treatments for HIV/AIDS Related Conditions - 16 General Medications Antibiotics - 43 Gastrointestional - 15 Analgesics - 21 Insulin and related drugs - 13 Anti-diarrheals/malabsorption - 6 Bronchodilator/Respiratory Inhalants - 22 Psychotropics/anticonvulsants - 60 Hepatitis C - 1 Topical Steroids - 33 Hematology - 4 Sinusitis Medications - 49 Urinary Incontinance - 3 Cardiac Medications - 70 Ophthalmology - 34 Hyperlipidemia - 12 Gynecological - 3

7 UNINSURED CARE PROGRAMS COVERED SERVICES ADAP PLUS Services Comprehensive Medical Evaluation Disease Monitoring - Routine/Intermediate Visits Drug Administration Transfusions Clinic Visits & Physician Visits Primary Care OB/GYN Directly Observed Therapy Neurological Pediatric Ophthalmological Dermatology Specialty Medicine Dental & Oral Surgery Family Planning Oncology Mental Health (24 visits) Nutritional Assessment and Counseling Other Services Ambulatory Surgery Oral Nutritional Supplements Vitamins and Minerals (selected list) Laboratory Services (selected list) Viral Load Test Resistance Test (genotype & phenotype)

8 UNINSURED CARE PROGRAMS COVERED SERVICES HOME CARE PROGRAM Skilled Nursing Home Health Aide Homemaker Service Personal Care Aide IV Therapy Administration & Supplies Nutritional Assessment and Counseling Adult Day Health Care Limited Rehabilitative Therapy Durable Medical Equipment Note: A maximum lifetime benefit of $30,000 for home care services is allowed. EXCLUDED SERVICES Emergency Room Inpatient Services Pharmacy (Drugs not covered through ADAP) Ancillary Services - Any service, lab or procedure not included in the clinic visit. Rehabilitative Therapy (Vocational, Physical, Speech, etc.) Counseling & Testing Substance Abuse & Alcoholism Services/ Methadone Maintenance Case Management/Social Work Psychiatric/Mental Health (Extended visits)

9 ADAP Plus Insurance Continuation APIC Implemented on 7/1/00 Pays the insurance premiums of individuals who: Are unemployed and eligible to continue their insurance (COBRA) Are employed but the premium cost is a barrier to continuation Have self-pay insurance Eligibility: Residency, Financial & Medical = same as ADAP Cost effective insurance policy = individual assessment Premium cost is a barrier = premium versus income test Quality of coverage assessment If employed and eligible for work related insurance coverage: Employer must contribute more than 50% of premium

10 AIDS Deaths in New York State Residents ,000 8,446 8,419 Number of Cases Living 8,000 6,000 4,000 5,215 6,182 6,902 7,229 5,944 3,079 2,000 2,326 2,400 2,305 2,098 1, * 2001* Source: Bureau of Biometrics/NYSDOH *2002 data is provisional

11 Number of Cases Alive With AIDS at the End of Each Year, by Sex, New York State Number of Cases Living * Data as of May 2003 Males Females NYSDOH/BHAE

12 New York State - ADAP Active Enrollment 20 Thousands /96 6/96 7/96 8/96 9/96 10/96 11/96 12/96 1/97 2/97 3/97 4/97 5/97 6/97 7/97 8/97 9/97 10/97 11/97 12/97 1/98 2/98 3/98 4/98 5/98 6/98 7/98 8/98 9/98 10/98 11/98 12/98 1/99 2/99 3/99 4/99 5/99 6/99 7/99 8/99 9/99 10/99 11/99 12/99 1/00 2/00 3/00 4/00 5/00 6/00 7/00 8/00 9/00 10/00 11/00 12/00 1/01 2/01 3/01 4/01 5/01 6/01 7/01 8/01 9/01 10/01 11/01 12/01 1/02 2/02 3/02 4/02 5/02 6/02 7/02 8/02 9/02 10/02 11/02 12/02 1/03 2/03 3/03 4/03 5/03 6/03 7/03 8/03 9/03 10/03 11/ /04 2/04 3/04 4/04 1st day of each month enrollment Month/Year AENBYMO.PRS

13 New York State AIDS Drug Assistance Program Gender by Year of Enrollment 100% 80% 60% 40% 20% 0% MALE FEMALE October December 2003

14 NYS ADAP - Length of Stay Participants Enrolled in % 8% Percent of Enrollees 6% 4% 2% 0% Month Periods Males Females 72% of participants were still active on 12/31/2003

15 ADAP RACE/ETHNICITY Race/Ethnicity By Year of Enrollment 100% 80% 60% 40% 20% 0% October December 2003 WHITE HISPANIC AFRICAN AMERICAN OTHER/UNKNOWN

16 Users by Month - January 1995 through March 2004 Users by Month - Nucleoside Analogs, OI Meds, Protease Inhibitors and All Drugs 14 Thousands Jan-95 Feb-95 Mar-95 Apr-95 May-95 Jun-95 Jul-95 Aug-95 Sep-95 Oct-95 Nov-95 Dec-95 Jan-96 Feb-96 Mar-96 Apr-96 May-96 Jun-96 Jul-96 Aug-96 Sep-96 Oct-96 Nov-96 Dec-96 Jan-97 Feb-97 Mar-97 Apr-97 May-97 Jun-97 Jul-97 Aug-97 Sep-97 Oct-97 Nov-97 Dec -97 Jan -98 Feb -98 Mar -98 Apr -98 May -98 Jun -98 Jul -98 Aug -98 Sep -98 Oct -98 Nov -98 Dec -98 Jan -99 Feb -99 Mar -99 Apr -99 May -99 Jun -99 Jul -99 Aug -99 Sep -99 Oct -99 Nov -99 Dec -99 Jan -00 Feb -00 Mar -00 Apr -00 May -00 Jun -00 Jul -00 Aug -00 Sep -00 Oct -00 Nov -00 Dec -00 Jan -01 Feb -01 Mar -01 Apr -01 May -01 Jun -01 Jul -01 Aug -01 Sep -01 Oct -01 Nov -01 Dec -01 Jan -02 Feb -02 Mar -02 Apr -02 May -02 Jun -02 Jul -02 Aug -02 Sep -02 Oct -02 Nov -02 Dec -02 Jan -03 Feb -03 Mar -03 Apr -03 May -03 Jun -03 Jul -03 Aug -03 Sep -03 Oct -03 Nov -03 Dec -03 Jan -04 Feb -04 Mar -04 Nucleoside Analogs OI Meds Protease Inhibitors NNRTIs Fusion Inhibitors Total All Drugs Formulary Changes: 1/1/96 - Reduction; 7/1/96 - Protease Inhibitors added; 9/1/96 - General Meds restored; 12/1/96 - Restored remaining drugs

17 Government and Community Partnership on Drug Pricing Fair Pricing Coalition Treatment advocates and government payors Engage senior management of drug companies in pricing discussions Primary focus on initial pricing of new drugs and price freezes ADAP Crisis Task Force 10 ADAP/AIDS Directors representing 70% of the buying power of ADAPs Negotiated pricing concessions with all eight antiretroviral drug manufacturers $60M - $65M savings to ADAPs nationally from first round All ADAPs benefit equally Coordinate efforts with the Fair Pricing Coalition and other advocacy groups Continuation and expansion of efforts to secure the best possible price for ADAPs

18 NRTIs & NNRTIs - By FDA Approval Date $450 $400 $350 $300 $250 $200 $150 $100 $50 $0 RETROVIR VIDEX EC HIVID ZERIT EPIVIR VIRAMUNE RESCRIPTOR SUSTIVA ZIAGEN VIREAD EMTRIVA AWP-12% Net Cost

19 Protease & Entry Inhibitors by FDA Approval Date $4,000 $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $500 $0 FORTOVASE NORVIR CRIXIVAN VIRACEPT AGENERASE KALETRA FUZEON REYATAZ LEXIVA AWP-12% Net Cost

20 $60 Millions New York State ADAP Expense by Quarter of ADAP Costs Period April 1996 through March 2004 $50 $40 $30 $20 $10 $0 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q NA PI NNRTI Fusion Inhibitors All Other Protease Inhibitors added on 7/1/96 Non Nucloeoside Reverse Transcriptase Inhibitors (NNRTI) added 9/1/96) Fusion Inhibitors added 5/15/03

21 Primary Care Users by Month 6000 Number of Users Jan-95 Feb-95 Mar-95 Apr-95 May-95 Jun-95 Jul-95 Aug-95 Sep-95 Oct-95 Nov-95 Dec-95 Jan-96 Feb-96 Mar-96 Apr-96 May-96 Jun-96 Jul-96 Aug-96 Sep-96 Oct-96 Nov-96 Dec-96 Jan-97 Feb-97 Mar-97 Apr-97 May-97 Jun-97 Jul-97 Aug-97 Sep-97 Oct-97 Nov-97 Dec-97 Jan -98 Feb -98 Mar -98 Apr-98 May-98 Jun-98 Jul-98 Aug-98 Sep-98 Oct -98 Nov -98 Dec -98 Jan -99 Feb -99 Mar -99 Apr -99 May -99 Jun -99 Jul -99 Aug -99 Sep -99 Oct -99 Nov -99 Dec -99 Jan -00 Feb -00 Mar -00 Apr -00 May -00 Jun -00 Jul -00 Aug -00 Sep -00 Oct -00 Nov -00 Dec -00 Jan -01 Feb -01 Mar -01 Apr -01 May -01 Jun -01 Jul -01 Aug -01 Sep -01 Oct -01 Nov -01 Dec -01 Jan -02 Feb -02 Mar -02 Apr -02 May -02 Jun -02 Jul -02 Aug -02 Sep -02 Oct -02 Nov -02 Dec -02 Jan -03 Feb -03 Mar -03 Apr -03 May -03 Jun -03 Jul -03 Aug -03 Sep -03 Oct -03 Nov -03 Dec -03 Month-Year Updated: 04/12/04

22 Home Care Users by Month Number of Users Jan-95 Feb-95 Mar-95 Apr-95 May-95 Jun-95 Jul-95 Aug-95 Sep-95 Oct-95 Nov-95 Dec-95 Jan-96 Feb-96 Mar-96 Apr-96 May-96 Jun-96 Jul-96 Aug-96 Sep-96 Oct-96 Nov-96 Dec-96 Jan-97 Feb-97 Mar-97 Apr-97 May-97 Jun-97 Jul-97 Aug-97 Sep-97 Oct-97 Nov-97 Dec-97 Jan-98 Feb-98 Mar-98 Apr-98 May-98 Jun-98 Jul-98 Aug-98 Sep-98 Oct-98 Nov-98 Dec-98 Jan-99 Feb-99 Mar-99 Apr-99 May-99 Jun-99 Jul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 Jan-00 Feb-00 Mar-00 Apr-00 May-00 Jun-00 Jul -00 Aug -00 Sep -00 Oct -00 Nov -00 Dec -00 Jan-01 Feb-01 Mar-01 Apr-01 May-01 Jun-01 Jul-01 Aug-01 Sep-01 Oct-01 Nov-01 Dec-01 Jan-02 Feb-02 Mar-02 Apr-02 May-02 Jun-02 Jul-02 Aug-02 Sep-02 Oct-02 Nov-02 Dec-02 Jan-03 Feb-03 Mar-03 Apr-03 May-03 Jun-03 Jul-03 Aug-03 Sep-03 Oct-03 Nov-03 Dec-03 Month-Year Updated: 04/12/04

23 HIV UNINSURED CARE PROGRAMS ACTUAL EXPENDITURES by QUARTER/YEAR 1996-Present $60 Millions $50 $40 $30 $20 $10 $0 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q HOME CARE ADAP PLUS ADAP APIC HUCPEX97

24 New York State ADAP Cost Containment Principles Do the least clinical harm Maintain HIV health care infrastructure Consistency with Program Principles - whenever possible Spread the Pain Reversible measures if fiscal situation changes Tiered approach for phased implementation Administrative Factors = Ease, speed and cost of implementation Avoid unintended consequences

25 New York State ADAP Cost Containment Contingency Plan Developed by Clinical Subcommittee 7 $5 M/Tier for Phased Implemenation Tiers 1 to 4 recommended by Steering Committee Restrictions and Elimination of Drugs and Services Reduced Payments to Providers Restrictions on Eligibility

26 New York State ADAP Cost Containment Contingency Plan (continued) Tier 1 - Implementation date = 02/15/03 Limit number of clinic and dental visits per year Limit refills to 5 per prescription, and encourage participants to avoid unnecessary filling of prescriptions Mandatory generics Begin restructuring of coverage of nutritional supplements by restricting daily quantity limits. Eliminate certain high cost drugs, where there are less expensive alternatives Encourage participants to apply for other coverage (Medicaid, Medicaid Spenddown, Family Health Plus, etc.)

27 New York State ADAP Cost Containment Contingency Plan (continued) Tier 2 Tier 3 Tier 4 Reduction in payments to pharmacies and health care providers Further restructuring of nutritional coverage, and Elimination of coverage of lower priority drugs and categories of drugs Further reductions in payments to pharmacies and providers Further reduction and restriction of formulary, and Restrictions on coverage of participants with partial insurance Major reductions to formulary and covered services

28 New York State AIDS Drug Assistance Program Regained financial stability Program Status 4/1/04 Deferred implementation of the remaining cost containment tiers Expanded the formulary and covered services in high priority areas: New antiretrovirals - Fuzeon, Emtriva, Reyataz and Lexiva Hepatitis C - pegylated interferon and ribavirin, viral load and genotype tests Voriconazole for fungal infections Testosterone gel (Androgel and Testim) for wasting syndrome New psychotropics - aripiprazole, escitalopram, ziprasidone HCL New anticonvulsant - oxcarbazepine

29 New York State AIDS Drug Assistance Program Future Continued growth in enrollment with: Inclusive eligibility criteria Comprehensive outreach program Further refinement of drug and service coverage to address emerging HIV related conditions Unknowns Medicare Prescription Coverage Medicaid Reform Federal Funding Ryan White CARE Act Reauthorization