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Issue #140: August 31, 1997
FASTFAX is available by fax in the 215 and 610 area codes at no cost, or by mail anywhere for $20.00 per year, by calling 215-545-6868, and by E-mail by contacting and type the message SUBSCRIBE in the message section. Sources for some information in this issue include the Philadelphia Inquirer, the New York Times, and the Washington Post.
HealthPartners reduces more benefits, citing $17m in losses
Protease drugs may not work for 50% of PWAs
Care Committee rejects earlier plan
City plans to re-bid case management, prevention contracts
HRSA names new head of AIDS programs
Village Project seeks prevention staff
SUPPORT WE THE PEOPLE THROUGH THE 1997 AIDS WALK!
HealthPartners reduces more benefits, citing $17m in losses
HealthPartners, the Medicaid HMO believed to be serving the largest number of people living with HIV disease in southeastern Pennsylvania, has announced that it will institute cost-cutting measures as a result of losses of close to $17 million since the state's mandatory managed care program began in February.Most of the financial losses were suffered by the seven area teaching hospitals -- which provide the bulk of HIV care in the region -- who are the owners of HealthChoices.
Last month, HealthPartners stopped enrolling new participants in Delaware County, largely because of the high cost of caring for people with HIV/AIDS at Crozer-Chester Medical Center in Chester. At least three other Delaware County hospitals have already backed out of arrangements with HealthPartners in which they shared financial losses resulting from low HealthChoices reimbursement rates.
HealthPartners, one of four managed care companies participating in the state's HealthChoices program for health care for the poor, had previously announced that it will not expand its planned "centers of excellence" for AIDS care to Delaware County, as a result of the state welfare department's failure to provide adequate reimbursement for the cost of treating people with AIDS and HIV infection. The "centers of excellence" program, planned for fourteen sites in Philadelphia, aims to integrate AIDS specialty care and supportive services in a fashion which encourages high quality primary care as well as cost efficiency.
The company said it will be "reducing significantly the payments to doctors and hospitals in Philadelphia," eliminate coverage of eyeglasses and other optional benefits, and tighten its prescription drug policy, requiring doctors to get permission from the plan before they prescribe certain drugs.
According to published reports, HealthPartners, largely because it is owned by the teaching hospitals, is suffering the most severe losses under HealthChoices. The Philadelphia Inquirer reports that Healthcare Management Alternatives, whose 70,000 members are concentrated in West and South Philadelphia, lost about $1.7 million between April and June of this year, and that Oxford Health Plan, with 63,000 members, lost slightly less than $200,000.
Figures for Keystone Mercy Health Plan, the largest of the HMOs with 220,000 members, were not available. HealthPartners has about 100,000 participants.
AIDS advocates have long predicted that the high cost of AIDS-related care would undermine the ability of the Medicaid managed care system to provide for people with HIV disease, unless the state set higher reimbursement rates for people with HIV/AIDS and other chronic and disabling conditions. They claim that because of the low AIDS reimbursement rates, HMOs will have an incentive to avoid costly AIDS care and seek to avoid enrolling people with AIDS in their plans.
Overall, Medicaid reimbursement rates have been decreased significantly by Pennsylvania Governor Tom Ridge, who claims that the Medicaid program is too costly. Ridge dropped reimbursement rates by 8 percent between 1995 and 1996, and again when HealthChoices began in February. The lower HealthChoices rates have not been made public.
However, the Inquirer reports that DPW is paying an average of $155 per month per member to the HMOs, down from $211 last year, according to financial reports. Some of the reduction is related to the shift of behavioral health services away from the four HMOs under HealthChoices.
State officials have said that HealthChoices is expected to save the state almost $70 million annually.
Peg Dierkers, the former head of the South Central AIDS Assistance Network and now policy director for the Dept. Of Public Welfare, which oversees HealthChoices, told advocates last year that the state would not review the impact of AIDS reimbursement rates on access to care until the three-year contracts with the four HMOs end in 1999.
Protease drugs may not work for 50% of PWAs
Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told the New York Times last week that mounting evidences shows that between 25 and 30 percent of the 150,000 people currently taking protease inhibitors ultimately fail to see a long-term benefit to the therapy, which has been endorsed as the best method for addressing HIV disease.According to the Times report, researchers are unsure why the inclusion of the protease drugs, along with at least two other anti-retrovirals, does not seem to work for a large number of patients. Some of the "failures" are thought to be related to the inability of some patients to keep to the intricate medication schedule usually required by the drug regimen, or the strong side effects associated with some of the drugs.
"There is an increasing percentage of people in whom, after a period of time, the virus breaks through," said Fauci, who directs the federal program responsible for research on AIDS and other infectious diseases. "People do quite well for six months, eight months or a year, and after a while, in a significant proportion, the virus starts to come back."
No one knows the true extent of the problem, but Fauci estimates that when these cases of "viral breakthrough" are accounted for, the failure rate of the new drug cocktails may eventually run as high as 50 percent.
"When the protease inhibitors first came out, everyone was very excited," David Kiviaho, who manages an AIDS treatment hot line for Project Inform, an advocacy group in San Francisco, told the Times.
"We knew this wasn't the miracle cure. But it's frightening to hear the number of people calling and saying, 'What do I do now? I have failed the protease inhibitors. I'm running out of options.'"
Doctors are tinkering with prescriptions, the Times noted, with 11 government-approved AIDS drugs, and other, experimental medicines available for "compassionate use." Some doctors load their patients with six or seven drugs at a time. Others are doing the opposite, encouraging a strategy called "washing out," in which patients whose viral load remains high abandon all their pills, if only temporarily, to see whether there is any point in continuing to take them.
"We are learning as we go along," Dr. Kenneth Mayer, a professor of medicine at Brown University, acknowledged. "People are clearly doing better, but we are not out of the woods. The tricky part with this virus is it ain't over till it's over. And it ain't over yet."
Care Committee rejects earlier plan
The Care Committee of the Philadelphia HIV Commission has rejected an earlier decision to maintain current funding levels for AIDS service organizations and award a 3% automatic raise in provider contracts, instead agreeing to apply its priority formula to all Ryan White CARE Act Title I funding awarded to the Philadelphia region next year.In a highly-controversial decision two weeks ago, the Committee voted that it would only apply new information on unmet needs identified by people living with HIV/AIDS to any new money that might be awarded by the federal government under the Ryan White Act next year, which it hopes will total at least $1.3 million in 1998. That decision would have left intact over $13 million in current funding, without considering whether some of that money would need to be shifted to meet the unmet needs.
Committee workgroups then met to determine percentages of the new funding that they believed should be allocated to almost thirty different service areas which are covered by CARE Act funding.
The HIV Commission this summer conducted a survey of almost 1100 people with HIV/AIDS which indicated that while most were able to obtain AIDS case management and primary care services, over 25% were unable to obtain housing supports and over 30% were in need of emergency financial assistance. An earlier survey, conducted to assess the needs for AIDS-related housing services, showed that the majority of people with HIV/AIDS in the region were trying to survive on incomes of less than $6000 per year.
The earlier Care Committee decision had also come under fire because the committee had allowed people who were not members of the committee to vote on the allocations procedure, an apparent violation of the HIV Commission by-laws. Members of the Commission's Housing Committee were also critical of the decision, saying that their committee had not been consulted by the Care Committee even though consumers had identified housing issues as their top concern.
At a "consensus" meeting on August 23rd -- no votes were taken because the committee was unable to obtain a quorum -- the group decided to apply the percentage allocations agreed to by its workgroups to the entire Title I allocation next year, whether or not there is an increase. While this accommodation was seen as reducing controversy that had arisen from the earlier decision to limit the impact to new funding, others have criticized it, saying that the percentages may have been different if the workgroups had been aware that they were deciding on the whole amount rather than just new funds.
The new percentage allocations agreed to by the Care Committee, which still must be approved by the full HIV Commission on September 3rd, increases the percentage of funding for primary care and medications from 27.5%, up from 27.1% last year, and reduces the allocation for AIDS case management services to 17.9%, down from last year's 19.8%.
Most changes in other categories were very small, usually less than 1%.
Despite the emphasis on housing needs of the Commission's consumer survey, no increase was made in the allocation for housing-related services. The Commission's Housing Committee has asked that whatever housing funds are available be concentrated on providing direct care services to residents of supportive living programs, rather than paying for rents and other housing costs, which are covered by funding available from the Housing Opportunities for People with AIDS (HOPWA) program.
City plans to re-bid case management, prevention contracts
Joseph Cronauer, interim co-director of the city's AIDS Activities Coordinating Office, has announced that the city will issue a request for proposals (RFP) for AIDS case management activities in October, making available approximately $2.5 million in federal and city funding.The action is the first time since the epidemic began that the city is opening up AIDS case management funding beyond the few organizations which received contracts in the 1980s.
Federal officials have recommended that the city make available its AIDS funding through competitive bidding process every few years to assure that new programs have an opportunity to obtain funding.
Included in the RFP process will be funding awarded to the city under Title I of the Ryan White CARE Act for programs in southeastern Pennsylvania and southern New Jersey, as well as city general funding which is available only to city agencies. Since 1988, only ActionAIDS, the state's largest AIDS case management agency, has been a recipient of city case management funds.
Minority case management agencies have criticized the city for limiting its funding to only one organization, claiming that the generally less restrictive regulations associated with city funding have allowed ActionAIDS to grow while they have been hampered by the more heavily-regulated and more limited federal funds. For many years, the debate over allocation of case management funding has been mired in racial issues, with former ActionAIDS executive director taking the lead in efforts to limit funding for minority AIDS organizations.
Kevin Conare, who replaced Littrell as the organization's director last year, has been credited with increasing minority staff and leadership at Action AIDS over the past year, as well as for strengthening ActionAIDS' community presence through sites in West and North Philadelphia. The board of directors of ActionAIDS also now is comprised of mostly people of color, according to city officials.
Cronauer also announced that the city will, in the spring, bid out most of its HIV prevention and HIV counseling and testing funding, in keeping with a plan developed by the HIV Prevention Community Planning Group two years ago. This RFP process will also be the first time that HIV counseling and testing services will be subjected to a competitive bidding process, with most current contracts having been awarded in 1988.
HRSA names new head of AIDS programs
The federal Health Resources and Services Administration -- which is responsible for administering funding under the Ryan White CARE Act for direct care services for people with HIV/AIDS, has named Joseph O'Neill, MD, as head of its Bureau of HIV/AIDS.O'Neill replaces Eric Goosby, MD, who has been responsible for the AIDS programs while HRSA reorganized its AIDS efforts over the past year to form the new AIDS bureau. Goosby had obtained some notoriety in Philadelphia, when State Sen. Hardy Williams claimed that Goosby supported an effort to divert $200,000 in AIDS funding for a group Williams was forming to gain control over the city's minority AIDS organizations.
The Ryan White programs -- which have an annual budget of more than $1 billion and subsidize the cost of drugs and medical care for HIV-infected people -- had previously been scattered through five different parts of the agency.
AIDS experts and community activists were enthusiastic about the consolidation of programs and about O'Neill's appointment. Both come at a time when the success of new combination therapies for HIV and a resultant increase in demand for care have created intense pressure on the Ryan White programs.
O'Neill's experience as an AIDS doctor "makes a huge difference," said John Bartlett, director of the infectious diseases division at Johns Hopkins University School of Medicine in Baltimore. "There's a big difference between people that manage AIDS from behind a desk and people that manage AIDS in a clinic."
Bartlett said appointing a bureaucrat with no experience on the front lines of AIDS care to run the Ryan White programs would be like asking a person who has never driven a car to design the country's automobiles.
Claude Earl Fox, HRSA's acting administrator, said consolidating the Ryan White programs within the agency will reduce paperwork and duplication and should make the funds go farther. HRSA's HIV/AIDS programs serve an estimated 300,000 people each year.
O'Neill has been responsible for directing HRSA's policies on HIV/AIDS since 1995. For one half-day each week, he also volunteers at Johns Hopkins University's Moore Clinic, which serves people with HIV/AIDS.
From 1992 to 1994, he worked at Chase Brexton Health Services, a Baltimore community AIDS clinic similar to Washington's Whitman-Walker Clinic. There, he ran Maryland's largest HIV counseling and testing program, administered a program to recruit inner-city patients into research trials, and treated AIDS patients at the clinic, in hospices and in their homes.
O'Neill, who received his medical training at the University of Washington in the late 1980s, said he saw his first AIDS patient as a medical resident. The man died of Pneumocystis pneumonia, a lung infection that doctors can successfully treat today without admitting patients to hospitals. "At no time in the epidemic has it been so clear that high-quality health care makes a tremendous difference in how well and how long people with HIV live," he said.
He said he has seen the obstacles that poor people have to surmount to get health care -- some of which have been created by the federal bureaucracy, including his own agency.
"There are specific things that I learn," he said, like "what it means to take three or four buses to get to the clinic. What it means to a woman [being treated at one clinic] to have a sick child who has to go to a different clinic" because federally subsidized treatment for adults and children with HIV is not available in one place.
O'Neill said that on dozens of occasions, he has returned to his Rockville office after working at the clinic with ideas about how to make the Ryan White programs work better. He said his staff at HRSA is eager for such suggestions. "People are really hungry for that contact with the outside. They say, 'Is what we're doing in here really making a difference ?' "
The move to consolidate the various Ryan White programs under one manager should reduce competition among the programs, which has been a problem in the past, said Cornelius Baker, executive director of the National Association of People with AIDS.
He applauded O'Neill's appointment to head the new bureau. "He's not just an abstract administrator in Washington," Baker said. "He's worked in one of the hardest-hit cities in the country."
Village Project seeks prevention staff
The Village Project, the first major collaboration among AIDS service organizations to provide individualized "HIV prevention case management" to sexual minority men of color at high risk of HIV infection, is seeking a supervisor and four Prevention Case Managers for the program, to begin in October.We The People has received a $244,000 annual grant from the U.S. Centers for Disease Control for a three-year program aimed at working directly with individual gay men of color to help them address behavioral or other issues that may result in their being infected with HIV. The program promises to provide counseling and risk reduction education and link individuals to social and health care services they may need to address problems leading to high-risk behaviors.
While We The People will manage and supervise the project, Prevention Case Managers working for the four organizations serving gay men of color in Philadelphia -- The Colours Organization and Unity, Inc., serving African American men; the Gay and Lesbian AIDS Education Initiative, serving Latino men; and AIDS Services in Asian Communities, serving Asian and Pacific Islander men -- will each have an on-site case manager to provide direct services.
We The People and the four organizations are seeking a Prevention Case Management Coordinator, who will work for We The People, and a Prevention Case Manager to work for each of the four collaborating organizations.
For more information on applying for the positions, contact We The People at 215-545-6868 or any of the collaborating groups.
Meanwhile, Intercultural Family Services has also received a CDC grant for an HIV awareness program targeted to Asian and Pacific Islander communities, and is seeking a coordinator for the effort. For more information, call 215-386-1298.
Corrections
In last week's fastfax, we incorrectly reported, based on information provided to us by members of the HIV Commission Care Committee, that a motion to maintain current priorities and expenditures for Ryan White Title I money had been made by Dorothy Mann, executive director of the Family Planning Council. In fact, the motion was made by Anna Katz, executive director of the South Jersey Council on AIDS, and Ms. Mann's statements were made in support of that motion. We sincerely regret and apologize for this error.Also, the same article implies that the HIV Commission is responsible for setting priorities for the allocation of $25 million in federal AIDS funds for the region. In fact, the Commission's responsibilities are limited to over $13 million in Title I funding and $3 million in federal prevention funding. The Philadelphia AIDS Consortium remains responsible for the priorities and allocation of about $6 million in Title II and other state funding through a process independent of the Philadelphia HIV Commission.
SUPPORT WE THE PEOPLE THROUGH THE 1997 AIDS WALK!
The annual Philadelphia AIDS Walk takes place on Sunday, October 19, 1997 and is a great opportunity for everyone to raise money to support and fund AIDS services in the Philadelphia region.We The People Living with AIDS/HIV of the Delaware Valley would love it if you would join our team, whether you're a member of We The People, a friend of people living with HIV/AIDS, or just someone who'd like to help.
The AIDS Fund, which sponsors Philadelphia's annual AIDS Walk, last year raised $35,000 for We The People's LifeSavers Fund, which provides emergency assistance to people living with HIV/AIDS, and another $55,000 for our ongoing support services for low-income and homeless people with HIV disease. Over a million dollars was raised for over sixty other critically-needed AIDS services in the Philadelphia region as well.
Won't you help? We're Team #33, and you can register NOW at We The People's Life Center, 425 South Broad Street, or on the web at http://www.CritPath.Org/aidsfund/indreg.html.
And if you can't walk, please make a donation anyway. Checks can be written to the "AIDS Fund" and sent directly to the AIDS Fund office at 1227 Locust Street, Philadelphia, PA 19107. Please remember to mention We The People or Team #33 on your check.
If you do want to walk, the event starts (rain or shine) at the Eakins Oval on the Ben Franklin Parkway in Philadelphia. Sign-in and Opening Ceremonies begin at 9 AM; the Walk starts promptly at 11 AM.
Register NOW to walk and raise money to fight AIDS and support people with HIV or AIDS! For more information, call 215-545-6868 or email aidsfund@critpath.org or wtp@critpath.org.
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