After long delays, Hopkins offers AIDS managed care
Non-capitated AIDS programs face disaster’
Nearly 10 years after the head of the Johns Hopkins University AIDS program began propounding the benefits of treating AIDS patients under a managed care model, the program is finally about to offer a capitated rate structure for the state’s Medicaid population. Although Hopkins joins only a handful of providers offering capitation for AIDS care, experts say the move toward putting Medicaid patients under managed care could be disastrous if rates are capitated.
Hopkins began working with the Maryland Department of Health and Mental Hygiene and a health maintenance organization more than a year ago to put together its managed care program, called Moore Options. The program had planned to enroll patients in February but was delayed when the state required that the program obtain patients’ signatures on an agreement form stating that their enrollment is voluntary and that the state would be gathering information on them.
"It has been a difficult and rather long process," says Patricia Engblom, RN, MA, administrator for Moore Options. "People weren’t really sure about the program, and managed care had a negative connotation to people on the advisory board. But now they are starting to buy into the concept of specialty care and managed care programs for AIDS patients.
After years of making AIDS treatment a part of primary care, the pendulum is swinging back toward specialized care. The movement has been fueled by studies in the past year showing that patients treated by specialists survive longer than those treated by primary care physicians. At the 4th Annual Conference on Retroviruses and Opportunistic Infections in January, researchers presented evidence that specialized treatment for HIV using combination therapy is more cost-effective than nonspecialized care without the new drugs.1
So far, 17 states already have enrolled all or part of their Medicaid patients in managed care plans. Maryland will soon join six other states Arizona, Delaware, Oregon, Tennessee, Utah, and Virginia in providing managed care for its disabled Medicaid recipients as well. As more states seek managed care waivers, consumer advocates and providers must be involved in the process to assure that the managed care programs for AIDS patients provide quality care and adequate reimbursement, says Amy Anderson, policy associate for AIDS Action Council in Washington, DC.
"The capitated system is increasingly going to be the care delivery system of choice, so we as advocates must make sure we are part of that process," she says.
Anderson and other advocates warn that other states may not be as willing as Maryland to carve out AIDS care from a Medicaid managed care program. Without capitation, programs are reimbursed at the regular Medicaid rate of about $150 per month, compared to the $2,160 per month rate set up for the Hopkins program.
"Other states are not carving out AIDS and that is the big difference," says John Bartlett, MD, chief of the division of infectious disease at Johns Hopkins and the initiator of the Moore Options program. "I don’t know why people aren’t screaming about this. If you have a good AIDS care program you are going to be a financial disaster."
Concerns over getting specialty care
In addition to adequate reimbursement, advocates are concerned that managed care programs won’t provide patients access to specialists who have expertise treating the disease. As one of the country’s leading AIDS research universities, Johns Hopkins doesn’t have that problem, having experience treating a quarter of the state’s 3,000 Medicaid AIDS patients since 1983. At the same time, its team of specialists, which includes infectious disease experts, ophthalmologists, and gastroenterologists has decreased hospitalization of AIDS patients by 10%. Length of stay for program patients is 5.9 days, compared to an 8-day average for other hospitals in the state.
"One of the strong reasons for this program being finally viable is the efficiency and cost-effective care that clinicians at Hopkins have been providing," Engblom says, adding that the university’s hospital not only has a dedicated AIDS unit but has a skilled-nursing facility dedicated to HIV patients.
Moore Options is one of five projects funded by the Ryan White CARE Act’s Title V program known as Specials Projects of National Significance (SPINS). The grant allows Hopkins to track cost-effectiveness and other patient outcomes, and share its findings with other states or health care systems considering managed care for AIDS. Another SPINS recipient, the AIDS Healthcare Foundation of Los Angeles, was the first managed care AIDS program in the nation and helped design the Hopkins program.
Under the Moore Options plan, one or more HMOs will subcontract with Hopkins to provide AIDS care for Medicaid enrollees. The state has agreed to pay $2,160 a month for patient medical costs, including prescriptions, dental care, and home care. The capitated rate doesn’t include protease inhibitors or viral-load testing, both of which will be reimbursed on a fee-for-service basis, Engblom adds. The reason for the exclusion is that the state set its capitation rate before protease inhibitors were approved. Without more experience with the new therapies, it has no historical data on which to base a rate for those services, she says, adding that this may change when the contract is renewed after the first year.
Protease inhibitors and viral-load testing also are not capitated for enrollees in the AIDS Healthcare Foundation program, says Peter Reis, plan administrator for the foundation’s capitation program, which covers 400 of its 3,000 patients. Currently, California lawmakers are trying to determine what pool of funds will pay for viral-load testing. One possibility is to make it part of the Ryan White funding pool that pays for drugs for uninsured patients, he says.
Whatever the outcome, one of the advantages of a capitated program is the flexibility it offers as treatment and treatment costs change, Reis says.
"The nice thing about capitation is that it allows the money to reside with the caregiver," says Reis. "We consider ourselves experts in the management of this disease, so we can shift costs and move resources as the disease changes."
Both Hopkins and the AIDS Healthcare Foundation are exploring the possibilities of expanding capitation coverage to include patients before they develop AIDS. With the push for earlier treatment and the successes of viral suppression, managing treatment from the start could lead to greater cost savings.
"It would be smart to consider care across the entire progression of disease," Engblom says. "We are not sure how we would price such a product, but it might be a tiered approach."
Reference
1. Ruane P, Ida J, Zakowski P, et al. Impact of newer antiretroviral therapies on inpatient and outpatient utilization of healthcare resources in patients with HIV. Presented at the 4th Conference on Retroviruses and Opportunistic Infections. Washington, DC; 1997. Abstract # 262.
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