NASTAD has a Washington, DC headquarters and field ... Adherence counseling and support. ⢠Health .... via Medicaid to
PrEP and Prevention Sustainability A Health Systems Integration Approach
Edwin Corbin-Gutierrez, Manager, Health Equity & Prevention Amy Killelea, JD, Director, Health Systems Integration National Alliance of State and Territorial AIDS Directors (NASTAD)
Presented at the 2015 Gay and Lesbian Medical Association Conference, Portland, OR
Outline: 1. 2. 3. 4.
Who We Are The Changing Landscape PrEP financing: Insurance Basics PrEP in Action: Collaboration Opportunities: • • • • •
Influencing Payers and Health Care Systems PrEP Assistance Programs Insurance Enrollment and Health Plan Navigation Task-sharing and PrEP clinic models Outreach opportunities
5. Assessing the cost of providing PrEP for providers
Who We Are
3
About NASTAD • NASTAD is an international non-profit 501(c)(3) association of U.S. state health department AIDS 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 (EC) charged with making policy and program decisions on behalf of the full membership • NASTAD has a Washington, DC headquarters and field offices/programs in Bahamas, Botswana, Ethiopia, Haiti, Mozambique, South Africa, Trinidad, Uganda and Zambia
Health Systems Integration and PrEP: Financing and Operations • Care and prevention provider collaboration and sustainability
• Research: Understanding needs and models
• Public and private insurance coverage and access
• Technical assistance and capacity-building
• Leveraging claims and surveillance data
• Federal advocacy and national coalitions
The Changing Landscape
6
Health Systems Transformation and the Role of Public Health Programs
The Triple Aim
The Need to Change The Changing Science
New Attention to Population Health by Medicaid and Insurance
The Coverage Landscape 16.4 million people have gained health insurance coverage through the ACA
A Math Problem • CDC and HRSA do NOT cover PrEP (the medication) • We cannot fight an epidemic with discretionary funding alone
The Key to Sustainability and Innovation: Partnerships
ADAP/RW Insurance Expertise and Infrastructure
Medicaid (state program, MCOs)
Insurance (state commissioner, plans)
PrEP Program Hospitals
Private physicians FQHCS
PrEP Financing: Insurance Basics
10
Comprehensive PrEP Program Elements Comprehensive PrEP Services • PrEP medication access • Primary care visits (LGBT health) • Linkage to social support services • Mental illness & substance use/abuse services • Adherence counseling and support • Health insurance enrollment and plan navigation • HCV, HIV and STI screening • HIV Risk Reduction Counseling
Evaluating Scope of Coverage: Prescription Drug Formulary • EHB Standard = same number of drugs per U.S. Pharmacopeia (USP) category/class as state’s benchmark plan USP USP Category Class
Anti-viral
NRTIs NNRTIs Protease inhibitors Anti-Cytomegalovirus (CMV) agents Anti-hepatitis agents
Other
Truvada is included! May require prior authorization depending on the plan
Qualified Health Plan: Cost Challenges
Putting It Together: Comparing Costs Across Plans John • Makes ~$17,000 per year (150% FPL) • Gets $202/month in APTC • Prescribed Truvada
Bronze Plan
Silver Plan (with CSR)
Gold Plan
Individual premium contribution (after tax credit)
$13/month
$53/month
$130/month
Annual OOP cap
$6,600
$2,100
$6,600
Cost sharing
Tier 2: 30% ~$385/mo.
Tier 2: 20% ~$257/mo.
Tier 2: $35
Deductible
$6,600
$2,000
$500
Industry Co-pay Assistance Programs Can Help
Health Systems Reform and New Opportunities for Community-based Services
Payment and Delivery Reforms:
Health Care Systems and Payers
• Point of care testing to test people in community settings • Peer support services and community health workers • Linkage services to find people and link them to care • Care coordination services to link people with housing, social, and health care services and keep them retained in care
Health Department and Provider Collaborations
16
1) Insurance Enrollment and Health Plan Navigation Colorado
o Developed Biomedical Intervention Coordinator positions o Medication & Adherence Counseling o Financial Navigation Services o Primary Care Medical Home & PrEP Provider Placement
Tennessee • Supporting new patients navigate the clinical process o CBO-based PrEP navigators use HIV prevention behavioral skills
• Building provider capacity o Practice site champions o Continuing education credits and academic detailing o Providing adherence support o Augmenting state lab services
PrEP Coordinators, Nurses and Benefits Management Task-sharing PrEP Navigator at Howard Brown Health Center • PrEP education, engagement, patient navigation and adherence counseling • Focus on community involvement, outreach, and providing targeted health education through outreach • Ensure that participating clients receive relevant HIV/STI-related education and services, sexual health information, and appropriate care and wellness referrals
“These services will be geared toward persons most at-risk for HIV within the Chicago-land area, including but not limited to cisgender/transgender women who have sex with men, and cisgender/transgender men who have sex with men.”
Targeted Outreach Activities • Identifying high risk HIV-negative PrEP candidates o o o o
‘Data to Prep’ from STD clinics ‘SNS-like’ program targeted to high-risk MSM CBO-based counseling and testing programs Social marketing campaigns
An Integrated Care and Prevention Approach to PrEP Access HIV Community Services support use of anti-retroviral medications for PrEP and HIV treatment.
PrEP Access: It Takes a Village WASHINGTON STATE DEPARTMENT OF HEALTH BUSINESS DEVELOPMENT APPROACH FOR PrEP
•
WA State Office of the Insurance Commissioner – Prioritizing PrEP / multisite GC testing as preventive services within Essential Health Benefits OR identify mechanisms to reduce PrEP-related costs (i.e., medical, lab, rx)
•
WA State Office of the Insurance Commissioner – Joint advocacy to encourage PrEP inclusion as A or B recommendation via US Preventive Services Task Force
•
WA State Medicaid Medical Director – Partnering to identify opportunities via Medicaid to promote End AIDS WA, including PrEP
•
Medicaid managed care plans – medical directors from WA State managed care plans to discuss public health value / influence plan coverage
•
State Health Care Authority (Medicaid) –Participating in the development and ongoing implementation of CMMI state innovation grant (Healthier WA)
•
Accountable Communities of Health – Participating in the ongoing roll-out (passive increasingly active)
3) PrEP Drug Assistance Programs: Washington and Colorado • CO: Cover medical deductibles, co-insurance and co-pays related to initiating and monitoring PrEP therapy. Also cover medication deductibles for insured patients after pharmaceutical and other patient assistance programs are accessed
• Programs maximize state staff, regional prevention contractors and AIDS Service Organizations
• WA: Cover medication only, not medical visit or lab costs. The program purchases insurance plans for a limited number of uninsured clients
• Use ADAP Pharmacy Benefits Management and medical payments contractors
• Braided funding dedicated to public and private health insurance enrollment services for High Risk HIV-negative clients
22
Comprehensive PrEP Program Feasibility Assessment 1. Inputs 2. Outputs 3. Strengths and weaknesses of the assessment
STD TAC: Cost/Benefit Analysis Workbook
STD TAC: Revenue Estimates
NASTAD’s PrEP Financing and Operations Learning Lab
Informal group checkins Guest expert video conferences
Resource bank
Discussion board
Intro webinar
Wiki Sustainability Encyclopedia
NASTAD’s PrEP Financing and Operations Learning Lab
Resources • National Alliance of State & Territorial AIDS Directors (NASTAD), www.NASTAD.org o Amy Killelea,
[email protected] o Edwin Corbin-Gutierrez,
[email protected] o Xavior Robinson,
[email protected] Health Systems Integration resources • Guttmacher Institute, Medicaid Family Planning Eligibility Expansions, May 2015, http://www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf • HIV Health Reform, http://www.hivhealthreform.org/ • Treatment Access Expansion Project, www.taepusa.org • HIV Medicine Association, www.hivma.org • HRSA/HAB ACA and Ryan White Resources, http://hab.hrsa.gov/affordablecareact/ • Health Care Reform Resources o Center on Budget and Policy Priorities, Beyond the Basics, http://www.healthreformbeyondthebasics.org o State Refo(ru)m, www.statereforum.org o Kaiser Family Foundation, www.kff.org o Healthcare.gov, www.healthcare.gov PrEP Billing and Operations resources: • PrEP Facts: prepfacts.org • Project Inform: http://www.projectinform.org/pdf/PrEP_Flow_Chart.pdf • Association of Nurses in AIDS Care: http://www.nursesinaidscare.org • Cicatelli: http://caiglobal.co/j_cba/index.php/available-cba-services
THANK YOU!
