October 3, 2008
In the face of more budget cuts by New York City next week and New York State after the election, AIDS advocates are uniting in plans to fight back and remind government officials that the rise in new HIV infections won't drop just because the stock market does.
"These cuts are going to have some serious consequences on real people's lives," said Manuel Rivera, president of the PWA-driven AIDS Budget Action Coalition. "Our elected officials need to know people with AIDS aren't going to be helpless bystanders as new infections rise and lifesaving support services are cut."
Mayor Michael Bloomberg has asked his deputies to trim the budget 2.5 percent for the rest of the fiscal 2008-09 year, and five percent for the following year by Wednesday, October 8. Deputy Mayor for Health and Human Services Linda Gibbs is in charge of the health budget, and will decide what is on the chopping block. The new danger for AIDS services comes on the heels of devastating cuts in June, including $6 million in cuts to AIDS services, including syringe exchange, testing and prevention last June. In Albany, Gov. David Paterson is cowardly holding off until after the elections to swing his budget axe, and is expected to try to add to the August state budget cuts come November.
Harlem United Deputy Director of Policy and Government Relations Soraya Elcock says that new cuts could jeapordize New York’s AIDS services network. Harlem United has already absorbed a $20,000 cut to its a syringe exchange program.
"The state and the city have been pretty thoughtful about trying to minimize the impact so far," Elcock said. "But particularly looking at the data of Latino and black men who have sex with men, future cuts are going to be counter-productive."
Tracie Gardner, director of state policy at the Legal Action Center said that, like education, HIV/AIDS prevention funding is something that should be held harmless during budget cuts. "
Specifically with HIV prevention, we've been operating on a deficit all along, and have never had the resources to meet the need," she said. "Regardless of the economic situation, people will continue to be at risk, and there are certain things that have to be held harmless. We don't cut schooling, and we can't cut elements of public health. It's a classic situation of penny-wise and pound foolish."
However, Gardner said it is important that HIV/AIDS not be treated as a political issues—including within the AIDS community. "We need to make sure that effective services and programs are funded, while eliminating wasteful spending in our own community as well. There are certain community programs that are considered politically untouchable and we need to be able to point out that politics has no place in this."
Housing Works Vice President of New York Advocacy and Public Policy terri smith-caronia said advocates should treat the city's budget decisions like policy decisions. "We have to let our elected officials know that when they don't back their philosophical support for a program with funding dollars, it is just as harmful as being opposed to it."
September 12, 2008
PATERSON SUCKS BLOOD?
Activists use body bags to protest state budget cuts;
demand meeting with Gov
HIV up! Budget down! Body bags rising! The Gov's not around!" screamed more than 50 activists outside Governor David Paterson's Manhattan office Wednesday, as they threw down black bodies bags reading "Killed by Inaction," and "Budget Cuts Kill." The rally was intended to keep Paterson on the hook for irresponsible cuts to HIV and hepatitis C in the state budget in August, and demand a meeting with Paterson. Aides to the Governor, Carl Andrews and Marco Carrion, said they would get back to activists within 20 days about the possibility for an open forum with the governor.
"It's the first small step of the giant steps needed," said David Golden, a New York City AIDS Network (NYCAHN) board member. Members of CitiWide Harm Reduction and Voices of Community Advocates and Leaders (VOCAL) were also in attendance, some dressed as vampires, in a symbolic gesture of Paterson as a "bloodsucker." Monday, Paterson took heat for calling New York legislators the same thing.
Activists are angry because instead of instituting a millionaire's tax or making strategic budget cuts, the governor opted for across-the-board slashes that affect the state's most vulnerable. Among the sacrificial budget lambs were a 50 percent cut to the state's first and only hepatitis C initiative and a $1 million budget cut to HIV testing, prevention and counseling programs. These hits come on the heels of New York City's $6 million budget cuts to HIV/AIDS programs in June. For a full list of cuts to AIDS and hep C, click here.
Cut back! Fight back!
The rally began with a peaceful march of a dozen protesters into the lobby of the Governor's offices (on 43rd Street and 3rd Avenue). The activists asked to meet with the governor and chanted "Cut back! Fight back!" until a security guard threatened to arrest anyone who remained. I'm going to count to five," he said. The group then started a walking picket outside before heading across the street for a dramatic body bag-inspired protest. Activists lay down the body bags screaming, "Who do budget cuts kill?" The crowd responded with "drug users" and "people with AIDS" as well as "you," and "me."
"Where are people with hepatitis C supposed to go?" Louie Jones of VOCAL asked the crowd. Jones has had HIV for 20 years and was diagnosed with hepatitis C in 1999. "We're dying and no one seems to care."
James Dean has been HIV-positive since 1996, but said he is more worried about how the budget cuts will affect those who aren't already infected. "Without money for prevention, education and care there will be more people infected beside me," he said.
September 5, 2008
State officials finally open up about mandatory managed care for Medicaid recipients with HIV; providers still skeptical
On Wednesday, the State Department of Health met with community-based organizations to provide details about the impending roll-out of mandatory managed care for Medicaid recipients living with HIV and the elimination of fee-for-service care at Designated AIDS Centers. The meeting, attended by some 90 people, brought more questions than answers. Despite specifics about the plan to implement the changes, and the DOH's call for community input, looming questions remain.
The state hasn't set an official date for the roll-out and has yet to receive approval from the Centers for Medicare & Medicaid Services (CMS) or Gov. David Paterson. It's also unclear how people who are unstably housed will be reached, and if HIV special needs plans (SNPs) are going to be prepared for an influx in patients.
State officials were careful to reinforce their position that mandatory managed care is not a budget belt-tightening move. Director of the DOH's division of managed care, Jay Laudato said. "We have not proposed cost savings to the [New York State] Division of the Budget. FOIL us, sue us, do what you have to do."
There are currently 27,500 HIV-positive Medicaid beneficiaries in New York City whose only known exemption from managed care is their HIV status. 9,375 beneficiaries are enrolled in managed care, 3300 in SNPs. Because managed care insurers charge less than fee-for-service insurers, many advocates believe that the state is eyeing the savings to be gained by moving thousands of people living with HIV into managed care.
The Wednesday gathering at St. John's University was intended for CBOs and was invitation-only, but a group of a dozen Medicaid recipients living with HIV/AIDS protesting outside the meeting held up signs reading "Don't force people with AIDS into substandard care." That prompted AIDS Institute director Humberto Cruz to invite them into the meeting to ask questions. Props to Cruz for doing so. While the State has already met with health care plans, Designated AIDS Care Centers and CBOs, it has yet to meet actual Medicaid recipients affected by the policy shift. The State DOH consumer meeting on October 29 and 30 (locations to be determined).
Here are the most critical questions that were asked, and analysis of the answers the State provided.
What is the rationale for mandatory managed care?
"Why do we have to move to managed care at all?" asked a Housing Works client at the meeting. Laudato responded that unlike in managed care, the state has no way of evaluating fee-for-service patients, which means "a lot of people fall into the cracks." Laudato also noted that the three-systems study of Fee-for-Service, Mainstream Managed Care and HIV Special Needs Plans (SNPs) showed better results for managed care than fee-for-service. SNPs had the highest quality of care. He acknowledged that one study is slender justification but said it couldn't be ignored.
As noted in an Update piece by Director of Shubert Botein Policy Associates Ginny Shubert, the three-system study was deeply flawed (and full of its own enigmas). It doesn't look at quality analysis data outcomes, and mostly looks at if services were performed, not at the patient's health outcomes. For example, the study shows if a person is prescribed for ARVs, but not if he is adhering to meds. "Whether or not you billed for that procedure isn't a measure of providing quality care," Housing Works President and CEO King told the Update.
How will the plan roll out?
The State has not decided when the roll-out will begin in New York City and if the process will proceed borough by borough or at random, nor the process for the rest of the state. Jennifer Dean, assistant director of Bureau Planning and Implementation at the Division of Managed Care, explained that about 2,500 Medicaid recipients a months and their providers will receive notices about the new policy. Recipients will have 60 days to choose a plan, and then a three-month grace period before being locked into a plan. HASA case workers, COBRA case managers New York Medicaid CHOICE workers and other providers will be trained to help with the process. Then participants will only be allowed to change plans for nine months if they have a "good cause reason." One such reason, which earned praise from advocates at the meeting, is switching from a mainstream plan to a SNP.
People in homeless shelters will be exempt from choosing a plan, but those in SROs and unstably housed people are not exempt. If someone doesn't receive a letter, then the letter is to be forwarded to the Human Resources Administration, which will try to find an up-to-date address. The clock on the period of time for people to be assigned won't be started until people receive their letters.
Audience participants questioned the short-time period for enrollment. "Why not give six months or some more generous window?" asked Sean Cahill, director of public policy at GMHC. Dean explained, "We've found that after 60 days of not choosing people tend to forget." Still, Cahill told the Update, "I don't understand what the rush is. Unstably house people and people in SROs will not be able to be reached by letters in that time frame."
What about people who can't access SNPs
"We can't make a SNP a mainstream plan, and we can't make a mainstream plan a SNP," said AIDS Institute Deputy Director Ira Feldman, noting that SNPs are held to more rigid standards than mainstream plans. There are currently only three SNPs serving 3,300 people in New York State. And it is unlikely that SNPs could handle the massive rollout of patients. People in Staten Island don't qualify for SNPs unless they work in another one of the four boroughs—pretty unlikely for most people who qualify for Medicaid, a provider from the borough noted. "People in Staten Island can't join a SNP even if they wanted to," he said. "We can't say one-size-fits-all when there are disparities between neighborhoods."
What about 'intelligent assignment?'
People who don't respond to a plan within 60 days will be auto-assigned to a plan, which means that people can easily be assigned into plans that don't include their current doctors or care providers. In the past, patients have been auto-assigned into the highest-rated plans, but DOH is toying with the idea of "intelligent assignment," which, based on a patient's current doctors, would try to fit the patient into the best plan. "We're not sure we can do that, but we'll try," Laudato said. He also noted that because so many people with HIV currently see COBRA case managers, HASA case workers or other people who can help with the shift, "we're hoping to minimize auto assignment, but it's a difficult process."
The Legal AIDS Society staff attorney Diane Spicer told the Update that if "intelligent enrollment" actually works, "it would be a huge improvement," compared to the disaster stories when the state shifted SSI recipients to mandatory managed care. "But we have to continue knocking on the door to make sure this happens," she said.
The Update will keep you posted on news of the roll-out and the consumer meetings on October 29 and 30.
August 22, 2008
NYS legislature cuts millions for ADAP, HIV testing initiatives
and other programs
On Wednesday Gov. David Paterson and the state legislature reached an agreement to slash $427 million additional dollars from the New York State budget—making cuts to AIDS funding, social services and other programs that will hit the neediest New Yorkers (without implementing a millionaire's tax or other more equitable solutions). For an in-development list of the cuts that most affect poor people and AIDS services, click here. For a list of all cuts, click here.
"We're outraged that once again it looks like the budget is cutting from the poor and sparing people who can afford it, people who make over a million dollars," Manuel Rivera, chairperson of the newly formed AIDS Budget Action Coalition (ABAC) said. "We're not talking about a job here and a job there. We're talking about real human lives, especially in the black and Latino community where this is an AIDS crisis." ABAC is a consumer-led group formed in response to the city and state AIDS cuts.
Although the state is patting itself on the back for not cutting more than it did, there are still troubling developments. New York's AIDS Drug Assistance Program (ADAP) will be cut by six percent, or $1.5 million. This is the first time the state has stooped so low as to jeopardize access to AIDS medications. No changes in ADAP drug formularies are expected, nor are there to be any waiting lists for medications, but the cuts are a dangerous precedent. "Once the state starts diving into actual medication for spending cuts, they're going down a slippery slope," said terri smith-caronia, Housing Works vice president of New York Advocacy and Public Policy. ADAP was allocated $58.8 million at the beginning of this budget cycle (which began April 1), so the six percent cut will come off of $25 million that has yet to be disbursed.
Cuts to HIV testing and hep C
Advocates are still figuring out where different pots of money will be hit, since the line item cuts were unclear. HIV testing, prevention and counseling will receive at least $1 million less than this year's budget originally allocated. "The state wants to test more people and we want to test more people, but they are cutting testing and other resources that will keep people alive," smith-caronia said.Legislative adds and member items that Paterson slated to cut by 50 percent were spared that heavy blow but still received at least six percent hits. Particularly disappointing is a $390,000 cut—fifty percent of remaining money for the year—in new money for hepatitis C.
"The hepatitis C funding was decimated," said Matthew Lesieur, Director of Public Policy for the New York AIDS Coalition. "It's a short-term fiscal gain for long term consequences to the community."
Other particularly troubling slashes include hits to Medicaid and health care programs, which according to the Albany Times-Union are to "lose almost $500 million over two years through tactics such as a reduction in the grants meant to cover the cost of inflation."
Despite the overwhelming support of the legislature for cutting from the poor, some elected officials deserve props for fighting for their most vulnerable constituents. Cheers to State Senators Bill Perkins (D-Manhattan/Harlem), Martin Connor (D-Brooklyn), Efrain Gonzalez (D-Bronx), Shirley Huntley (D-Queens), Ruben Diaz Sr. (D-Bronx) and Kevin Parker (D-Brooklyn) and Assembly Members Karim Camara (D-Brooklyn), Ruben Diaz Jr. (D-Bronx), Adriano Espillate (D-Bronx), Carl Heastie (D-Bronx), Rhoda Jacobs (D-Brooklyn), Hakeem Jeffries (D-Brooklyn), Jose Peralta (D-Queens), Nick Perry (D-Brooklyn), Philip Ramos (D-Brentwood) and Stephen Saladino (R- Massapequa) for voting "no" on the latest budget cuts.
Believe it or not, this week's cuts aren't as horrendous as previously expected. Matching funds for local jurisdictions were spared, a relief for city-funded groups such as the Injection Drug Users Health Alliance (IDUHA), which was already affected by big cuts in June. Some credit for staving off the worst reductions must go to ABAC.
The group staged a raucous protest attended by 150 people across the street from Paterson's Manhattan office last Friday. On hand were delegations from a host of community groups such as Positive Health Project, VOCAL, NYCAHN, Housing Works, GMHC, Hispanic AIDS Forum, CHAMP, Bronx AIDS Services, Harm Reduction Coalition, The Black Men's Xchange and many others, as well as high-profile civil rights lawyer and Giuliani foe Norman Siegel. Siegel told the crowd, "You have to have stamina. You have to outlast the bastards." The protest was covered by NY1 and the New York Daily News' politics blog. Also look for an article in today's New York Blade.
According to ABAC Secretary Joseph Sellman, last week's protest was just "a warm-up." He said, "Elected officials in the city and the state are going to realize that they are going to be held accountable."
Indeed no one should be resting easy. Depending on how Wall Street performs, we should brace for more late-breaking cuts as the year continues.
August 15, 2008
PROTEST AGAINST AIDS BUDGET CUTS TODAY AT 2PM!
Fed-up New York ASOs are circling the wagons
as Paterson threatens Medicaid
It's been one piece of bad news after another lately. In late June (on LGBT Pride Day no less), New York City announced a budget deal that decimated HIV/AIDS services by $6 million. Last week, State Medicaid Director Deborah Bachrach made it clear that she wants to force poor New Yorkers with HIV on Medicaid into managed care. This week, Gov. David Paterson announced he wanted to cut another $1 billion from an already trimmed State budget and that $506 million of those cuts would come from Medicaid spending.
Galvanized and angered by the CDC's recent report that 40 percent more Americans get HIV year every year than previously estimated, New York City and State AIDS groups are ready to push back.
The AIDS Budget Action Coalition is organizing hundreds of people living with HIV/AIDS, their supporters, and representatives of dozens of New York City AIDS service organizations for a rally outside of Paterson's New York City office today. Housing Works, GMHC, Positive Health Project, Bronx Pride, Bronx AIDS Services, Harlem United, New York AIDS Coalition, Harm Reduction Center, Hispanic AIDS Forum and dozens of other groups will be in attendance.
“Many legislators may not be afraid to make these cuts because of who they affect: poor people, people of color, drug users and other at-risk groups. This rally and other actions will show them that we hold them accountable,” said Housing Works President and CEO Charles King.
Protest location: Gov. Paterson's New York City office at 633 Third Avenue between 40th and 41st St.
Ralliers are calling for 1) a restoration of HIV/AIDS funding cuts to the State Budget 2) no further cuts and 3) an in increase in funding for services to those living with HIV/AIDS.
Despite the fact that federal Ryan White funding reductions loom, New York City and State are chipping away large chunks of our AIDS infrastructure. The City cut $750,000 for housing for homeless people with HIV, $700,000 for syringe exchange programs and $1 million for rapid HIV testing. Meanwhile, Paterson's proposed cuts to Medicaid could be devastating to New Yorkers living with HIV/AIDS. That population relies on Medicaid more than any other program for health care. Cuts will imperil services upon which they depend.
Come tell Paterson to show his commitment to New Yorkers living with HiV/AIDS—and put his money where his mouth is!
For more information on today's rally, contact terri smith-caronia at email@example.com.
HASA slashes rental assistance to pioneering SSI invisibility plaintiff; Housing Works sues for retaliation, obtains injunction
Last Thursday, Housing Works filed a lawsuit on behalf of Zoraida Melendez, charging that the HIV/AIDS Services Administration (HASA), the Human Resources Administration (HRA) and the New York State Office of Temporary and Disability Assistance (OTD) retaliated against her when it reduced her monthly rental assistance last May from $1,350 to $810. The reduction in Melendez's housing benefits would have resulted in her family's eviction from their home.
When Housing Works filed the lawsuit on Thursday, it also obtained a temporary restraining order on the city's marshal, staving off the eviction of the Melendez family.
Melendez's lawyer, Housing Works staff attorney Matthew Carmody, believes that the city and state government agencies are retaliating against Melendez because of her role as lead plaintiff in Melendez v. Wing. Melendez's victory in that case, which went all the way to the State's highest court, established the right of all HASA clients to exclude family members with SSI income from their household budget calculation. SSI invisibility, as the exclusion is known, saves families over $500 each month, money that can go to the care and support of their disabled family members. Melendez v. Wing was relied on heavily by the Appellate Division in Doe v. Doar, a sister case that restored SSI invisibility budgeting to all eligible public assistance recipients in New York State. Doe v. Doar cost New York State tens of millions of dollars in retroactive benefits.
In late April 2007, Melendez, her husband and child were approved by HASA to move into an apartment with a rent of $1350 a month. In late April, HASA paid the security deposit, first month's rent, and brokers fee, all at the actual rent amount, $1,350. In early May, however, just a few days later, the agency inexplicably reduced Melendez's rental supplement to $810, the bare minimum required by law."In the 10 years I've been practicing HIV law in this city, I've never seen HASA approve an apartment and subsequently not use the actual rent as the basis for the family's shelter allowance," Carmody said. "HASA moved the family in and paid the full rent, then days later informed the family that their rental assistance would be cut by hundreds of dollars. That left the family on a collision course with eviction."
Carmody has obtained affidavits from four leading HIV/AIDS attorneys saying that they, too, have never seen a circumstance in which HASA budgeted rental assistance for less than a client's actual rent.
Carmody said that New York State is essentially attempting an end run around Melendez v. Wing: "Since HASA can't put Ms. Melendez's child's SSI benefits on her budget directly because of the Melendez v. Wing decision, the State is, effectively, attempting to force her to pay rent with those benefits." Those benefits are earmarked to meet the needs of Melendez's disabled daughter, as Melendez v. Wing established. "The family is faced with an impossible choice: Use their subsistence benefits to make up the difference in rent, or use the subsistence benefits to meet the family's survival needs," said Carmody.
After trying to recoup Melendez's rent payments through administrative means, Housing Works filed a lawsuit against HRA/OTDA, which oversees HASA. The City has already signaled that it will move to dismiss the case, with papers due in mid-September.
Study justifying mandatory HMO enrollment for HIV-positive Medicaid recipients deeply flawed
Editorial by Ginny Shubert
Earlier this month, the New York State Department of Health (DOH) issued a press release innocently titled "Comparison of Fee-for-Service, Mainstream Managed Care and HIV Special Needs Plans (SNPs) Shows Better Quality in Managed Care." The comparison study is, in fact, the State's key piece of evidence in justifying a cost-saving move to force tens of thousands of Medicaid recipients living with HIV/AIDS into HMO plans.
The Department of Health should be applauded for attempting an evidence-based approach to health policy decisions. There is nothing more important to the lives of New Yorkers living with HIV than the delivery of health care. Any change to HIV health care delivery systems can only be justified by clear, strong evidence that the change will result in improved access, continuity, and quality of care.
The DOH's study comparing three health care systems for people with HIV/AIDS on Medicaid—Special Needs Plans (SNPs), fee-for-service care and mainstream managed care (HMOs)—may be a beginning in our understanding of how existing health care systems are working, but the reported results simply do not support policy change. As the DOH acknowledges, in order to save money and get quick results, the study was limited to billing and encounter data, which tell us nothing about clinical outcomes, the true test of health care. Since only one year of administrative claims data were examined, the study period is too short to tell us anything meaningful about continuity of care. These major weakness aside, the preliminary results included in the press release raise more questions than they answer.
Numbers don't add up
It's not easy to evaluate the results of the DOH's comparison study, since so little information has been provided in the press release. Some major problems with the study are acknowledged in the press release—false positives, insufficiently detailed claims data and incomplete encounter data—and the fact that reporting requirements for fee for service, managed care and the SNPS differ. Other methodological questions and gaps in the data are not explained.
The state must have data available that would help refine the study results and answer some pressing questions.
The study also measures averages in health care delivery, not the best measure in a study of this kind. The numbers here are large (21,745 patients). Averages are often skewed by groups of patients that are doing much better — or much worse — than the majority. That's why "median" is more often used in rigorous research of this kind. At the very least, one would need to know the range of results for each measure, and the standard deviation from the average.
Problems all around
Putting aside the major methodological problems in the comparison study, its findings do not support pushing people living with HIV/AIDS on Medicaid into managed care. Some results for all three health care delivery systems are disheartening: Only 40 to 55 percent of patients on antiretroviral medications are getting regular viral load tests. Forty percent off all persons studied used emergency rooms for care during the study period.
While SNPs appear to be marginally better than fee-for-service and mainstream managed care on each measure reported, there aren't significant differences among the three systems of care. For example, the statewide average of patients prescribed antiretroviral medications is 73.7 percent, compared to 73.9 percent for fee-for-service patients, 76.3 percent for SNPs, and 69.2 percent for mainstream managed care.
Indeed, on all the measures presented in the press release, fee-for-service is equal to or above the statewide average in every area except health screenings, where both managed care and SNPs show substantially higher percentages. This may reflect a difference in billing and encounter data, or the fact that reporting these preventative procedures is mandated in managed care (which makes it curious that only 53 to 55 percent receive them).
It's also important to note that given a large sample such as this one, extremely small differences can be found to be "statistically significant," but statistical significance says nothing about the practical significance of the difference. Again, it would be helpful if the DOH would share their findings on the "confidence intervals" calculated for the reported differences.
What we do know through years of experience and research is that an unacceptable number of HIV-positive New Yorkers remain outside or marginal to health care. Recent findings from the CHAIN study show that 39 percent of people living with HIV/AIDS in care had delayed initial entry into care and/or reported one or more periods of dropping out of care. Persons living with HIV/AIDS who are not receiving medical care are significantly more likely than others to have multiple non-medical needs (three quarters reported a housing need, for example). There are proportionately more chronic homeless and seriously mentally ill among the currently unconnected.
What is needed urgently are innovative interventions to increase engagement and consistent utilization of HIV care. This requires a multipronged approach to reach and engage those who are unconnected to care, and to maintain those in care who are marginally connected. Innovative outreach approaches are needed for persons at different stages of engagement with the health care system. We also know that consumer choice and patient-provider communication are important factors impacting engagement in care. We need to remove barriers to initiating and maintaining care among persons with multiple needs—not create new ones.
Ginny Shubert cofounded Housing Works and the consulting firm Shubert Botein Policy Associates (Shubertbotein.com).
On September 11, 2008, GMHC will host a meeting for people living with HIV/AIDS, AIDS advocates and others to strategize about mandatory HMO enrollment at 3:30pm in the 12th floor cafeteria. For more information, contact Matthew Lesieur at the New York AIDS Coalition: firstname.lastname@example.org; 212 629 3075 x108
August 8, 2008
State Medicaid director lays out plans for mandatory HMO enrollment for HIV-positive Medicaid recipients; advocates mobilize
After weeks of angry speculation about New York State's plan to force HIV-positive Medicaid recipients into managed care, State Medicaid Director Deborah Bachrach publicly confirmed that mandatory HMO enrollment was in the works. In an interview with the Update this week she said, "We have recommended mandatory enrollment, but the Department of Health has not made a decision. We expect it in the next few weeks."
For the first time, Bachrach also publicly laid out some of the plan's specifics:
Currently, HIV-positive Medicaid recipients can get health care from fee-for-service insurers, or choose a SNP or standard HMO plan. Mandatory HMO enrollment, which Bachrach says will start in January and gradually roll out over a 12 month period, has Medicaid and AIDS advocates, including Housing Works, up in arms.
First and foremost, advocates are fearful that mandatory HMO enrollment will cause a disruption in care for HIV-positive Medicaid recipients. Diane Spicer, an attorney with the Legal Aid Society's Health Law Unit, says her organization has seen "unending problems" for Medicaid recipients who also receive SSI. (SSI recipients--without other exemptions--were forced into HMOs in 2005.) Those problems include interruptions in home care, failure to notify recipients of their auto-assignment to an HMO, and finding a plan that includes all of the specialists required by people with serious, chronic illnesses.
Bachrach denies that the mandatory enrollment of SSI recipients was a disaster. " We did get calls about a handful [of problems], but in each case we resolved them. People who go to Legal Aid, by definition it means something went wrong. We can't draw conclusions from the people who went to Legal Aid," Bachrach said. She also cites the results of a DOH survey of SSI recipients on Medicaid released last week showing, according to Bachrach, "incredibly favorable" feedback.
Spicer scoffs at the survey, detailed results of which have not been posted on the DOH site, and the idea that Legal Aid cases are isolated. "You'd have to have a 12 th grade reading level and no reading impairment or developmental disability to participate in this survey," Spicer says, referring to the fact that many SSI recipients are severely physically and mentally disabled. "This is the population that didn't understand mandatory enrollment in the first place! I think the problems we're having are representative."
Denise Soffel of Medicaid Matters called Bachrach "a little disingenuous," referring to her speculation that SSI recipient complaints were isolated. "We know that many people are reluctant to complain and especially file formal complaints," she said. "Many people just shake their heads and say, 'I can't fix this.'"
'Not a financial decision'
Some in the AIDS community believe that Bachrach is moving ahead with mandatory enrollment simply to save the state money because HMOs will provide care at a much lower cost than fee-for-service insurers. Bachrach says no way. "This is not a financial decision. We did no financial analysis. The data shows that both managed care plans and SNPs do better than fee-for-service [care]. And the data shows that SNPs and managed care plans have more case managers and specialists," she said referring to a comparison study on HIV-positive Medicaid recipient health services.
New York AIDS Coalition's Matthew Lesieur is skeptical. By the measures of the comparison study, SNPs were the best care providers. "If you're going to rely on the conclusions [of the comparison study], why not enroll everyone in SNPs? If you want to put your money where your mouth is, everyone should be auto-enrolled in SNPs," Lesieur said.
"I find it difficult to believe that they are making decisions without worrying about the financial ramifications. Bachrach's job is to manage Medicaid, which includes controlling costs," said Housing Works President and CEO Charles King, who adds, "The comparison study doesn't show that managed care is that much more effective than regular fee-for-service insurance plans." Lesieur agrees that the comparison study is flawed. "The study tells you about viral load tests, but it doesn't give you health outcomes. What were the viral loads? What were the CD4s? It's widget counting."
Money-related distrust between AIDS groups and Bachrach is a far cry from what was supposed to happen when Gov. Eliot Spitzer was in office and the state's finances weren't looking nearly so grim. "Spitzer's Medicaid reforms were supposed to result in all these savings, which were going to be used to expand care. Now we hear that money is going to fill budget gaps," said King.
Last but not least on the minds of AIDS groups is the fact that Bachrach assured community groups that she would ask for community input on the plan before making any decisions. Bachrach feels that she's kept advocates in the loop all along. "I don't know what to attribute [people's anger] to. This has been under discussion since we rolled out Special Needs Plans four years ago," Bachrach said. Bachrach added that September meetings about enrollment in managed care for HIV-positive Medicaid recipients are in the works.
Responding to the crisis
NYAC, Housing Works, the Legal Aid Society, Medicaid Matters, GMHC and other groups have begun to organize a response to mandatory HMO enrollment. A community sign-on insisting on a meeting with Bachrach to discuss problems with mandatory HMO enrollment will be circulated next week. On September 11, 2008, GMHC will host a meeting for people living with HIV/AIDS, AIDS advocates and others to strategize about mandatory HMO enrollment at 3:30pm in the 12 th Fl cafeteria. Lesieur also says that a coalition of groups will be reaching out to Sen. Tom Duane and Assembly Member Dick Gottfried for help in crafting a response to the state Medicaid changes.
King, who thinks state government has no right to force people into choosing one health care plan over another just because they are poor, said, "The Department of Health should focus on expanding the idea of all-inclusive care. Then they can educate consumers to the benefits that care affords."
Soffel thinks a little well-promoted outreach would go along way. "It's something that the DOH has been inconsistent about, but when they do outreach, the response is always tremendous," she said. "They had a stakeholder meeting upstate and were stunned when 75 people showed up because consumer advocates put the word out. Those kinds of things make a huge difference."
August 1, 2008
READY OR NOT...
AIDS Advisory Council call makes clear Medicaid managed care on its way,
even if DOH won't confirm
During a New York State AIDS Advisory Council call last Wednesday, the Department of Health (DOH) discussed logistics of the switch for people with AIDS on Medicaid to mandatory managed care. DOH hasn't made an official announcement, but sources who were on the call say that despite lip service to community input, Medicaid managed care is going to happen, possibly as early as January 2009. The DOH had long said that any such shift would happen one borough a year for five years.
"It was all kind of a surprise that they are moving so quickly," said Dr. Lambert King, Director of the Department of Medicine at the Queens Hospital Center, who is on the AIDS Advisory Council and was one of the few members able to make the hastily arranged call. King said that the DOH indicated on the call that it would come up with a plan this week or next week and would solicit community input.
The DOH also stated on the call that they have been working on a mandatory enrollment proposal for people with HIV since 1994. And that's true, but the plan was halted after Housing Works issued several reports on poor enrollment practices when the majority of people on Medicaid were forced into the mainstream plans. At a Medicaid community meeting in May, state officials said they have learned from these experiences and have also learned from the more recent mandatory enrollment of SSI recipients in the plans.
So far DOH has been less than forthcoming about their plans. Neither State Medicaid Director Deborah Bachrach nor AIDS Institute Director Humberto Cruz would comment for the Update. Key pieces of government information have yet to be made public, including a "three system analysis" that looked at outcome indicators for people living with HIV/AIDS enrolled in the current mainstream plan, those enrolled in HIV Special Needs Plans, and those remaining in the fee-for-service system. The DOH said it is working to get out data before the end of the week.
"Managed care has a mixed history for people with chronic illnesses, and there ought to be a full discussion of quality of care issues," said Jeffrey Reynolds, Public Affairs Advisor for the Long Island Association for AIDS Care. Reynolds, who is on the NYS Advisory Council but was unable to participate in last week's conference call, added, "I'm concerned about how this relates to the governor's talk about the fiscal position of the state. I'm sympathetic, but it shouldn't come at the expense of our clients."
Currently, PLWHAs on Medicaid have three health care choices: Fee-for-service care, including Designated AIDS Care Centers (or 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 (or SNPs, specialized HIV HMOs created in 2003 as an experiment in providing HIV care with experienced providers in a managed care setting); and standard Medicaid HMOs. While people can currently shift between plans if they are dissatisfied, a shift to mandatory managed care would lock consumers into a plan after three months for the rest of the year.
Housing Works is a part owner of VidaCare, which could stand to benefit significantly from implementation of mandatory managed care. Nonetheless, Housing Works strongly opposes coercion of people with HIV into managed care systems. Housing Works President and CEO Charles King has stated publicly that even if the concerns regarding capacity, access and quality of care are all addressed, Housing Works remains opposed to mandating this mode of care.
"Low income people living with HIV and AIDS act in their best interests based on the information they have. People with AIDS and HIV would be better served if the Department of Health focused on expanding the concept of all-inclusive care and then educated consumers to the benefits that care affords," King said.
July 25, 2008
GUV'S OFFICE LIKELY TO APPROVE MANDATORY MEDICAID MANAGED CARE FOR PEOPLE WITH HIV/AIDS
Possible rollout as soon as January 2009
Despite the fact that state Medicaid Director Deborah Bachrach told the Update in May that mandatory managed care for people with HIV/AIDS on Medicaid was not a done deal, talk within the Department of Health, the AIDS Institute and the Governor’s office suggests that we could see mandatory enrollment begin as soon as this coming January. On Wednesday, state officials presented the proposal to members of the New York State AIDS Advisory Council.
If the State's plan goes through, current regulations will be changed and New Yorkers on Medicaid who are living with HIV/AIDS will be forced to enroll in a managed care plan. Mandatory HMO enrollment will undoubtedly save the state money, but it's unclear if health outcomes will improve. Key pieces of government information have yet to be made public, including a "three system analysis" that looked at outcome indicators for people living with HIV/AIDS enrolled in the current mainstream plan, those enrolled in HIV Special Needs Plans, and those remaining in the fee-for-service system. Bachrach and AIDS Institute Director Humberto Cruz claim that the data from this and other departmental reviews indicate that mandatory enrollment would improve quality of care.
Currently, PLWHAs on Medicaid have three health care choices: Fee-for-service care, including Designated AIDS Care Centers (or 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 (or SNPs, specialized HIV HMOs created in 2003 as an experiment in providing HIV care with experienced providers in a managed care setting); and standard Medicaid HMOs.
It’s not clear that current managed care programs have the network capacity to meet access standards required for people living with HIV/AIDS. It’s also not clear if mainstream HMOs will be required to 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.
The only three existing SNPs—VidaCare, MetroPlus, and New York-Presbyterian System SelectHealth—are based in New York City. In May 2008, they served 3,070 people. (Ironically, while the SNPs were set up in anticipation of the possibility of mandatory enrollment, the AIDS Institute has determined that it would be a breach of confidentiality to auto-assign HIV-positive Medicaid patients to the SNPs. Consequently, those most in need of the intensive care that the SNPs provide are least likely to find their way into that system.)
Opposing mandatory enrollment
Housing Works is a part owner of VidaCare, which could stand to benefit significantly from implementation of mandatory managed care. Nonetheless, Housing Works strongly opposes coercion of people with HIV into managed care systems. Housing Works President and CEO Charles King has stated publicly that even if the concerns regarding capacity, access and quality of care are all addressed, Housing Works remains opposed to mandating this mode of care.
“We have invested in VidaCare because we strongly believe that the type of all-inclusive care that a SNP has the potential to provide is the best care for many people. But if managed care is so good, we shouldn't have to force people into it," King said. "Low income people living with HIV and AIDS act in their best interests based on the information they have. People with AIDS and HIV would be better served if the Department of Health focused on expanding the concept of all-inclusive care and then educated consumers to the benefits that care affords."
Housing Works' opposition to mandatory enrollment has been long-standing, including issuing several reports on poor enrollment practices when the majority of people on Medicaid were forced into the mainstream plans. State officials say they have learned from these experiences and have also learned from the more recent mandatory enrollment of SSI recipients in the plans. "Why, when it comes to poor people in New York, do we force them into a plan, but everyone else can choose?" King said at a May meeting on Medicaid in New York, earning cheers from attendees. "Unless we're going to single-payer health care, I don't believe poor people should be treated differently than anyone else."
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