Proposed Changes and Revisions to the Ryan White HIV/AIDS Treatment Modernization Act of 2006
It has been 25 years since the first cases of HIV were identified in the United States. Early in the epidemic, an HIV or AIDS diagnosis meant the individual would spend the following 12-18 months losing their strength, their independence, and the ability to care for themselves, making services such as food, transportation, financial assistance and case management essential to ensuring the last days of life were as comfortable as possible. The revolution of the AIDS drug cocktails discovered in the mid-90s transformed HIV from a death sentence into a chronic, but treatable medical condition. Due to this treatment revolution, people are living now for 15-20 years after diagnosis. HIV has become first and foremost a medical issue and the nation’s efforts to fight this epidemic should reflect this fact with the prioritization of medical care and treatment. The numbers make it clear that the nation’s premier HIV-specific program, the Ryan White CARE Act, must maximize its efficiency in the provision of lifesaving care and treatment for the good of the public’s health.
The goals of the Ryan White CARE Act are to:
(1) provide medical care and treatment for Americans with HIV/AIDS; and
(2) eliminate the epidemic by preventing new infections.
According to the CDC:
- Over one million Americans have HIV/AIDS;
- Approximately half of these people are not receiving treatment for their HIV/AIDS;
- Approximately 250,000 of these people don’t even know they have HIV/AIDS.
- Approximately 40,000 new HIV infections occur every year. It is estimated that the majority of these infections are transmitted from people who do not know their HIV status, and/or are not in treatment.
If the Act is to meet its goals, funding has to be prioritized to get all those with HIV to know their status, and to get them into treatment. This is the only way the epidemic can be stopped.
AIDS Healthcare Foundation supports the following changes to the Treatment Modernization Act:
Core Medical Services (Section 104 and related sections)
The bill must seek to address disparities in care nationwide. The minimum drug formulary addresses disparities in access to the necessary therapies available from state to state. The definition of core medical services should also address disparities nationwide. However, anything other than a strict and focused definition of medical services (i.e. services that occur “under the clinic roof”) will allow disparities to continue.
AIDS Healthcare Foundation is concerned that the proposed definition, although it goes very far to prioritize medical care as the central focus of the CARE Act, does not ensure that sufficient funds will be available to provide basic HIV medical care to the 500,000 Americans with HIV/AIDS who are not in treatment, and the 40,000 Americans who contract HIV/AIDS every year.
AIDS Healthcare Foundation has three alternative modifications to the definition:
A. Remove the home health care, mental health services, and substance abuse outpatient services from the list of core medical services; or
B. Insert language limiting the amount that can be spent on home health care, hospice, home and community based health services, mental health services, substance abuse outpatient services, and medical case management to no more than 30% of the total spent on core medical services; or
C. Insert additional language defining mental health services, substance abuse services, and medical case management services as:
1. Outpatient psychiatric services, such services to be utilized only for the purpose of treatment adherence, and only after a determination has been made by a psychiatrist that psychiatric issues are causing non-adherence.
2. Substance abuse outpatient care, such care to be utilized only for the purpose of treatment adherence, and only after a determination has been made by a medical doctor that substance abuse is causing non-adherence.
3. Medical case management directly related to HIV/AIDS infection, performed by trained and licensed medical professionals, such management including treatment adherence services.
Capping Administrative Costs (Section 104 and related sections)
AIDS Healthcare Foundation recommends that the 75% of funds allotted to a grantee that must be spent on core medical services be 75% of all funds, not 75% of funds after government administration has been subtracted. Any funds utilized for government administration should come from the remaining funds. AHF recommends the inclusion of language specifying and clarifying this in the Act.
Coordinating Medicaid Services
AIDS Healthcare Foundation recommends language stating that funds for core medical services may be used to pay for core services for Medicaid recipients, when a state Medicaid program does not cover the core services.
Disease Management (Section 2691)
Disease Management programs for HIV/AIDS is a nurse-driven program for the individual coordination of care that takes place in the patient’s home and in the doctor’s office. Disease management plans provide training and support to both doctor and patient to maximize health outcomes. Doctors and patients are given the expertise taken for granted in more specialized settings. This not only increases health outcomes, but also saves money, as healthier people demand fewer medical services.
AIDS Healthcare Foundation supports continued study and expansion of disease management programs as a way to improve HIV/AIDS expertise in rural and emerging communities, and to further reduce costs and increase health outcomes. AIDS Healthcare Foundation proposes that SPNS grants include grants for the establishment of disease management programs, and recommends that the following language be inserted as Section 2691(a)(3):
The Congress finds that disease management programs have been particularly effective in addressing the needs of special populations, including minority communities and individuals and families living with HIV disease in rural communities and in developing essential community-based service delivery infrastructure. Therefore, notwithstanding any other provision of this section, the Secretary shall use up to one third of the amount set out in subsection (a) to administer a special projects of national significance program to award direct grants to public and nonprofit private entities including community-based organizations to fund disease management programs for the care and treatment of individuals with HIV disease.
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AB 1894 Krekorian –Insurance Coverage of an HIV Test
AHF is sponsoring AB 1894, authored by Assembly member Paul Krekorian, which would require all group or individual health insurance plans to pay for an HIV test in emergency care departments of hospitals, regardless of whether the testing is related to a primary diagnosis. Under current law, health plans and insurance carriers provide coverage for an HIV test when determined to be medically necessary.
When a private provider bills for an HIV test, insurance plans will cover the test but if a person receives an HIV test in the emergency care department of a hospital, health care plans will refuse to pay based on the test not being considered part of the final diagnosis or reason for the emergency room visit. This lack of reimbursement becomes a disincentive for hospitals to develop HIV screening protocols based on the recommendations of the CDC from 2006 calling for routine screening of the general population. If hospitals know they won’t get paid for an HIV test, they won’t be inclined to offer it.
As dictated by law every health insurance benefit mandate goes through an independent analysis to scrutinize it’s medical, financial and public health impact. The California Health Benefits Review Program (CHBRP) did an analysis of AB 1894 and determined that while allowing for the potential of more people accessing testing there would be no direct or immediate public health impact and that the mandated benefit of HIV test coverage would generate an overall annual cost increase of $554,000 which translates into a 0.0007% increase to health plan members or less than one cent.
We agree with the CHBRP analysis that the implementation of AB 1894 in and of itself, would not directly have an impact on public health or increase capacity to any great extent, but it would increase the rate of HIV testing by 3% and it certainly clears the way for increased capacity as hospitals develop more vigorous programming for HIV screening.
Last years successful bill AB –682-Routine Screening relaxed the previously high standard for consenting to an HIV test making it easier for people to access testing and moved California closer to the CDC recommendations for routine HIV screening. AB 1894 is another small step to making those recommendations a public health reality.
AB 2899 Portantino- Counseling Reform
Sponsored by AIDS Healthcare Foundation and authored by Assembly member Anthony Portantino this bill would require the State Department of Public Health to develop an HIV counseling program by July 1st, 2009 that would provide for flexibility in the counseling of persons testing for HIV.
When testing for HIV became available over 20 years ago, counseling of test subjects became an essential part of the testing protocol. However, best practice models of HIV counseling have not kept pace with the changes in the HIV/AIDS epidemic. Counseling of persons getting an HIV test continues to take a “one size fits all” approach.
An increasing number of test subjects are persons at low risk for exposure to HIV and serial testers who are tested on a regular basis. In addition, the public’s knowledge and awareness of HIV is much greater than it was in the mid-1980s. Current counseling employs the same tactics regardless of the test subject’s need for pre-test counseling and whether the test subject is at low or high risk of exposure or is a serial tester.
Some testing organizations cannot test all the people who wish to be tested because the counseling protocols demand unnecessary attention to low risk and serial testers.
The objective of a successful HIV testing policy must be to test as many people as possible while focusing the counseling resources on those who need them most, i.e. those who test positive for HIV.
In 2006, an agreement was reached with the Office of AIDS to conduct two pilot projects that would reform the counseling model. One pilot has been completed and the other is just beginning. Early signs are encouraging that the counseling model is ready to accommodate the changes that were envisioned in 2006.
Guidelines developed by the department will allow testing site counselors to determine the degree of counseling that is appropriate for each person seeking a test. A person will be given the option to decline counseling but if counseling staff determines that the person would benefit from counseling they will be encouraged to accept it. No person will be denied counseling if they request it. The “one size fits all” approach to HIV testing is outdated and needs to change.
AB 2899 codifies those changes that testing organizations need to conform their practices to current needs and to facilitate the swift introduction of this new counseling model by the Office of AIDS.
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