May 23, 2008
A MEDICAID MOMENT
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Despite some disagreement, Bachrach and King share a laugh post-forum |
A standing-room only crowd of consumers and providers packed the conference room (and the hallway) at the Latino Commission on AIDS Tuesday to hear state officials' and AIDS care providers' spin on how potential changes in Medicaid will affect people with HIV/AIDS.
The system for AIDS care and the general Medicaid system in New York have grown in very different ways. Talk of COBRA case management reform and the possibility of mandatory managed care has created strong concerns that New York's superior quality care for people with HIV/AIDS—which has taken 20 years to develop—will be lost. Currently, $2.3 billion of the $46.3 billion state Medicaid budget is spent on 60,000 to 70,000 poor people with AIDS—more than the entire Ryan White Care Act budget for the entire country.
"We need to learn from the success of AIDS care and bring the rest of Medicaid care up to that level, not the other way around," state Medicaid director Deborah Bachrach said, expressing an idea that was echoed in comments by AIDS Institute director Humberto Cruz and deputy assistant commissioner Ira Feldman. "Can we do it better? Of course. And sometimes doing it better means change. That doesn't mean taking away care." Bachrach also noted that the State Legislature's historic shift of $600 million in Medicaid from inpatient to outpatient care is one way to create positive change to AIDS care.
But Housing Works president and CEO Charles King ,one of the forum's designated "responders," replied to Bachrach, "This is a nuanced conversation, and when we say we're not taking away care, that's not true. These new changes meant people enrolled in ADHCs and COBRAs had to lose access to care." As a cost-saving measure, in August the state announced Medicaid recipients couldn't enroll in both adult day health care programs and COBRA case management, which provides psychosocial case management for low-income people living with HIV/AIDS, even though these programs address different needs.
Other "responders" included Ruben Medina, CEO and president of Promesa Systems Inc.; Eli Camhi, executive director of New York-Presbyterian System SelectHealth; Jose Davila, executive director of Bronx AIDS Services and associate medical director at MetroPlus Sanjiv Shah.
Finally some good news for COBRA
While COBRA had been walking on a funding tightrope lately, on Thursday it received some good news—the U.S. Senate followed the House's lead and voted to delay until April 2009 proposed regulations by the federal Centers for Medicare and Medicaid Services (CMS) that would have caused COBRA to lose all federal funding dollars.
New York is also suing the feds to permanently deny these changes. But COBRA hasn't gotten much love from the state—COBRA providers haven't received a rate increase in more than a decade.
But Bachrach promised that COBRA will not be dissolved. "I'm not eliminating COBRA. I can't be clearer," she told the crowd.
King noted that although there are problems with COBRA, its continuing existence is crucial for poor people with HIV/AIDS. "As providers, we all need to be frank. There's an oversaturation of COBRA providers. Providers have hoarded patients and purposely not recommended them to job training programs because they didn't want to lose a COBRA client," King said. "Still, we don't want to throw the baby out with the bathwater."
SNPs, DACs and other three-letter words
The other big discussion at the meeting was the push to enroll people with HIV/AIDS into mandatory managed care. Currently, PWAs can enroll in Designated AIDS Care Centers (DACs)—hospital-based programs founded in 1986 to provide quality care at a time when people with AIDS were ignored or abused in the typical hospital-based setting; HIV Special Needs Plans (SNPs)—the specialized HIV HMOs founded in 2003 that have served as an experiment in providing good HIV care with experienced providers in a managed care setting; and standard Medicaid HMOs. In 1996, there was a move to put Medicaid recipients in standard HMOs, although people with chronic illnesses were exempt, the belief being that HMOs couldn't adequately deal with chronic health problems. Now the tide in the state has changed. The mentally ill people are the latest class to be forced into managed care, with the process begun in New York City and being expanded to other counties. People with HIV/AIDS are now one of the few exempt groups. (For a full list of exemptions, click here.)
According to one very preliminary health department study, people enrolled in DACs received lower quality care than those in SNPs or HMOs. "We have to take seriously this data," Feldman said. "Almost every population is in? Why not HIV?"
But it's not clear if mainstream HMOs will work in partnership with community-based AIDS care providers to provide high-quality HIV care or whether SNPs are ready for an influx of patients. Currently there the only three SNPs—VidaCare, MetroPlus, and New York-Presbyterian System SelectHealth are based in New York City, and they serve a total of 3,070 people.
Bachrach took pains to say that the switch to Medicaid managed care for PWAs is not inevitable. "Given the preliminary data, this just means we must ask the question," she said.
King noted that even if managed care is proved to bemore successful than SNPs or DACs, consumers should be educated to choose them, but not forced into a plan. "Why, when it comes to poor people in New York, do we force them into a plan, but everyone else can choose?" King said to cheers from the crowd. "Unless we're going to single-payer health care, I don't believe poor people should be treated differently than anyone else."
Shah observed that problems with individual SNPs are expected growing pains. "There are instances where a member enrolled in a SNP doesn't get the care he deserves, but we need to look at that as an individual problem," Shah said. "When there's a bad experience with Medicaid or ADAP, we don't say to get rid of the whole system."
Camhi said that despite all the talk about which care system is best for PWAs, the top priority is increasing the number of people who receive services. "I don't worry about too many resources for HIV. I worry that we don't have enough," Camhi said. "We must recognize that there are a significant number of people not in any care."
Consumers speak up
Although most of the meeting speakers aimed their comments at providers in the room, the consumers were the most vocal. They largely praised COBRA case management and the care they received through SNPs. Sharon Walker, a VidaCare client noted how important COBRA case management was to her success. "The quality of care helps us get to the next level. I need to go to a specialist, someone who understands what I'm going through."
Soraya Elcock, deputy director for policy and government relations for Harlem United, told the Update after the meeting that she was happy to see so much consumer input. "The most important part is the consumers. It's great we got to hear some of them speak." Dennis deLeon, who organized the forum, promised there would be a similar consumer-focused forum in the future.
Paradigm shift?
The Medicaid meeting also brought attention to other looming questions: Should HAART be started earlier for people living with HIV/AIDS? And why are people with HIV more likely to have other chronic illnesses?
"Today the aging population of people living with HIV means we're joined at the hip with doctors that treat other comorbidities," Cruz said.
But King said that aging isn't the only culprit when it comes to comorbidities, evidence that is backed up by a study also released Tuesday in the Annals of Internal Medicine that showed HIV-positive individuals are more likely to have nine non-AIDS-defining cancers as compared with the general population. Anal cancer, for example, is almost 60 times more common in HIV-positive individuals. King also cited Anthony Fauci's July 2007 study that showed infants should be treated with antiretrovirals as early as possible.
"Comorbidities are not the result of an aging population. Within the next couple of years the evidence will become clear that we're starting HAART much too late. It will have a benefit on prevention and inpatient work. But we're too scared to talk about it," King said.
deLeon agreed. "When people start getting comorbidities, they lose a part of their life. We are starting antiretrovirals much too late."
Said Shah, a medical doctor, regarding the question of when to start meds, "There needs to be a paradigm shift."