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Issue #166: March 1, 1998
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 Archives of Opthalmology, Philadelphia Business Journal, Philadelphia Daily News, Philadelphia Inquirer, Reuters, Western Journal of Medicine.Study confirms HealthChoices fees "too low"
Pina pleads guilty to Medicaid fraud
Medical care loses out in TPAC priorities
Vision loss linked to use of protease drugs
Study confirms HealthChoices fees "too low"
A state-funded report by the highly-respected accounting firm, Arthur Andersen LLP, has confirmed what advocates have been claiming since the initiation of Pennsylvania's new Medicaid managed care program, HealthChoices, early last year: reimbursement rates for medical care for the people with AIDS and other disabled people are too low to guarantee they will get the care they need.The report, provided to the Pennsylvania Department of Public Welfare (DPW) earlier this month, also said that DPW has failed to set adequate rates to cover most chronically ill people in the Medicaid program.
HealthChoices was developed for residents of southeastern Pennsylvania by Governor Tom Ridge in an attempt to reduce the state budget for Medicaid, which runs to over $2 billion. A similar program in southwestern Pennsylvania, which is expected to be implemented later this year, includes higher rates for care for disabled people, but no action has been taken to extend those increases to the Philadelphia area.
HealthChoices has also been battered by the continuing losses suffered by the four Medicaid managed care companies which have contracts to provide care under the state program. One company, Oxford Health Plans, is expected to soon opt out of the program. Another Oxford affiliated this week canceled its Medicaid contract in Connecticut because it was losing too much money.
Three of the HMOs -- HealthPartners, Oxford Health Plans, and Healthcare Management Alternatives -- have all posted deficits of between $2.9 million and $3.5 million for the first three quarters of their state contracts, which began last February 1st.
Keystone Mercy, the largest Medicaid HMO, has declined to make its financial status public. Keystone Mercy controls about half of the five-county Medicaid market, followed by Health Partners, 24 percent; Healthcare Management Alternatives, 15 percent; and Oxford, 14 percent.
Hospitals, doctors and other caregivers reimbursed through HealthChoices have also complained that even with the low reimbursements, they face significant delays in getting their bills paid. This controversy led several hundred doctors at Temple University Hospital to cancel its contract with HealthPartners, which has the largest number of AIDS patients in its plan. HealthPartners had previously canceled its contracts with Delaware County hospitals and has canceled the expansion of its AIDS-focused "centers of excellence" in the region, blaming the failure of HealthChoices to cover the cost of AIDS services.
Barbara Plager, the longtime director of HealthPartners, is resigning her post at the end of this month.
DPW Secretary Feather O. Houstoun said she intended to ignore the findings of the Arthur Andrersen report because she did not agree with its conclusions.
Houstoun confirmed, however, that adopting the recommendations of the 45-page report would not be too costly to the state, amounting to only $8.9 million -- less than one percent of the $970 million for HealthChoices. She said that a one-year loss for the four HMOs does not necessarily mean that the Medicaid rates are too low.
Houstoun said that the Medicaid HMOs will just have to become more efficient, according to the Philadelphia Inquirer.
Andrew Wigglesworth, president of the Delaware Valley Hospital Council, said that the report highlighted how HealthChoices was not working for the most vulnerable Medicaid recipients.
The Andersen consultants said that the state needs to raise its reimbursement rates for more ill Medicaid recipients by at least 3% for the program to be effective.
Meanwhile, the Philadelphia Business Journal has reported that the state is, in fact, planning to increase reimbursement rates by July, retroactive to January 1st. According to the Journal, rates may increase by as much as 7% in the second year of the three-year HealthChoices contracts.
Peg Dierkers, policy director for DPW, refused to confirm the increase, saying that the state's contracts with the HMOs prohibit her from discussing specific contract terms.
Pina pleads guilty to Medicaid fraud
For the third time in five years, the leader of a major AIDS service organization has been convicted of stealing money -- this time from the state Medicaid program.Stephen Pina, executive director of One Day At A Time, a drug recovery program in with over 30 halfway houses in North and West Philadelphia, Kensington and Germantown, pled guilty to the theft of as much as $151,412 from Medicaid's transportation program this week. In a plea bargain with federal prosecutors, Pina admitted to one count of mail fraud and one count of making a false statement in U.S. District Court.
Pina joins Fran Stoffa, former executive director of Philadelphia Community Health Alternatives, and Carmen Bolden, former director of Congreso de Latinos Unidos, both of whom were convicted in state courts in recent years for thefts from their agencies. PCHA was the first gay community AIDS organization in the city, and Congreso has been the leading AIDS service organization in the city's Puerto Rican and Latino communities since 1987.
Bolden was later arrested again, also for Medicaid fraud, for activities related to a mental health agency she had started after serving her sentence for the Congreso theft.
According to court records, Pina headed a scam involving some residents of ODAAT in charging the state Medicaid program about $58 per month between 1990 and 1992 for transportation services that the residents never used. Under the reimbursement mechanisms in place at the time, most of the reimbursement checks went directly to the residents, making it unclear whether or how much money Pina may have pocketed in the theft.
The admission comes less than a year after Pina agreed with federal tax officials to personally reimburse the Internal Revenue Service for over $120,000 in federal taxes which had not been paid by ODAAT for several years.
The latest incident does not involve ODAAT itself, according to court records. Pina utilized a Medicaid license held by MAPLE Counseling Services, a drug and alcohol outpatient treatment program, to submit the fraudulent bills.
The reimbursements were for transport to counseling sessions that were not held, according to court records.
Pina has disputed the amount of money involved in the fraud, according to published statements by his attorney, Michael Nasuti. If the government's figure is found valid by a judge, Pina could face up to 18 months in federal prison.
Nasuti told the Philadelphia Daily News that Pina should not go to jail for the crime, even though he has pled guilty.
"It's cruel to send somebody to jail who doesn't profit," Nasuti said, noting that the ODAAT residents were the formal recipients of the funds.
According to the Daily News, Assistant U.S. Attorney Mary E. Crawley, the case prosecutor, said Pina falsely claimed to be the director of MAPLE Counseling Services in his submissions for Medicaid reimbursement.
The prosecutor said Pina submitted more than 3,000 false forms, certifying that reimbursable counseling services had been provided and that public transportation was used by residents of ODAAT halfway houses.
Pina has been a controversial AIDS activist for seven years, often disrupting public meetings and AIDS planning sessions claiming that AIDS services were not reaching low-income African Americans in Philadelphia's black neighborhoods. He served for five years as a board member of the Philadelphia AIDS Consortium, and as a leader of the Minority AIDS Project of Philadelphia.
More recently, Pina led an effort with West Philadelphia state senator Hardy Williams to form the Philadelphia EMA HIV African American Planning Group (PEHAAP), a group appointed by Williams to seek control of the city's AIDS funding. PEHAAP negotiated a secret deal with city officials early last year to divert about $200,000 of existing AIDS funds to the group, but that arrangement was nullified when community protests brought it to public attention.
Since that time, Pina and Williams have been demanding that the city's AIDS leadership be removed and that the federally-mandated AIDS planning council, the Philadelphia HIV Commission, be disbanded in favor of PEHAAP.
Pina was the only leader of an African American AIDS organization which supported PEHAAP, which continues to press for control over more than $20 million in federal, state and local AIDS program funding. Virtually all other minority AIDS agencies have condemned PEHAAP's efforts, calling it a "power grab" by Williams and his "cronies" to divert money from needed services to contracts with favored Williams supporters.
Also this week, only days before the deadline for the submission of proposals for over $5 million in federal, state and city HIV prevention funding, PEHAAP has demanded that the process be scrapped because, they say, the application process is too complicated for African American groups.
The city's AIDS Activities Coordinating Office, responding to earlier criticisms of the proposal process, has offered free grantwriting and technical assistance to organizations seeking to apply for the funds, and extended the deadline by several weeks. Pina led a group of about 50 ODAAT residents to a city-sponsored "technical assistance" session on the prevention funding process in late January; the session was eventually ended when Pina and his supporters started verbally abusing other participants.
Pina has also been well-known for his efforts to prevent the involvement of people living with HIV/AIDS in the PEHAAP planning process, and for derogatory remarks about sexual minority African Americans involved in AIDS services. At PEHAAP's first public meeting over a year ago, Pina joined with Williams and his close aide, Barbara Chavous, in forcibly preventing a group of people with HIV from attending the meeting. Chavous threatened to call the police unless the group left the meeting, which was held at Presbyterian Hospital.
Last year, Pina was also accused of prohibiting ODAAT residents living with HIV/AIDS from participating in a consumer survey being held by the HIV Commission to help set priorities for federal AIDS funding.
On numerous occasions, Pina has also publicly chastised gay and lesbian African American AIDS activitists for being "out of touch" with black neighborhoods. At one meeting, he was heard to call one gay black AIDS activist a "little faggot," and he got into a shouting match with a leading black gay activitist at the prevention planning meeting in late January.
Others, including We The People executive director Curtis Osborne, have criticized Pina for misinforming ODAAT residents with AIDS about how the AIDS funding process worked, and using them to browbeat city agencies and other community organizations to force them to give in to his agenda.
After issues of We The People's monthly newsletter, Alive & Kicking!, were returned to We The People from several ODAAT facilities, Osborne asked for an apology from ODAAT founder Rev. Henry Wells and condemned what he called Pina's "long history of abuse of people living with HIV in his care." Osborne said that Pina's practice was to "manipulate and threaten people with AIDS who reside in ODAAT houses, forcing them to participate in committees and coalitions without giving them any training or understanding of the issues, but demanding their support with the implied threat of losing their homes and their sustenance unless they did his bidding."
Osborne also criticized Pina's efforts to silence black PWAs and African American AIDS organizations. Pina and PEHAAP have routinely tried to silence criticism of their activities from other people of color, he said, with the argument that the white-dominated AIDS system will take advantage of the division to keep its hold on the lion's share of resources for AIDS services.
"What they really want us to do is cover up their corruption and their incompetence in getting for black and Latino PWAs what we need," Osborne said. "It didn't work before and it's not going to work now. We're not afraid to stand up in our own community, the African American community, and tell the truth. We don't determine our allies by what color they are, but by whether they can do the job. They have already proven they don't know how to get the job done. They've already proven they're not about helping us and we intend to make sure that everybody knows it."
Sources said that Pina was expected to resign from his position at ODAAT in the near future.
Medical care loses out in TPAC priorities
The Philadelphia AIDS Consortium has set priorities for the expenditure of $2.8 million in state and federal AIDS prevention and care funding for the year beginning on July 1st.The funding is provided by the state health department, through its "106" HIV Prevention Program, and Title II of the Ryan White CARE Act. Most of the funding is already allocated to AIDS service organizations in the five-county southeastern Pennsylvania area, but state rules require that it be put out for new competitive bidding at least every three years.
The funding is targeted to services in the city's African American, Latino and Asian communities. Caucuses representing the three communities met over the past several weeks to develop recommendations for the funding.
TPAC had sought to limit participation in the priority-setting process to people living with HIV/AIDS, although some participants said that the African American caucus meeting was dominated by non-PWAs. By the time that controversy over who would participate was resolved, according to several PWAs who attended the meeting, less than 20 PWAs out of a group of over a hundred were actually able to vote on the priorities.
According to TPAC, the largest portion of the funding (31.1%) will be allocated to case management services, including formal case managers and case management assistants. Of almost $900,000 set aside for case management, almost $570,000 will be directed to services in the African American community, with the remainder distributed according to a complicated strategy for Latinos, whites and other groups.
Primary medical care services were given low priority in the TPAC process, even though city officials have been forced to institute significant cuts in care funding in recent weeks. According to TPAC, only 10.2% of the available funding will be dedicated to primary care services, or $292,487. The decision appeared to conflict with the results of a joint consumer survey conducted by TPAC and the Philadelphia HIV Commission last year, which showed that people of color living with HIV/AIDS were much more likely to not have health insurance and also were less likely to have access to protease inhibitors and other promising AIDS therapies.
Other major priorities for the new funding included emergency financial assistance programs, which were awarded $275,000 (9.6%), and food and nutrition programs, which got $242,516 (8.5%). The remainder of the funding is distributed to nine other categories (including complementary therapies, legal services, mental health, transportation, and similar services) and to HIV prevention activities, which were awarded $780,000, the amount of funding available under Section 106 of the state budget.
AIDS group sues LA county
The California-based AIDS Healthcare Foundation (AHF) has filed a suit against the County of Los Angeles, claiming that County officials cut foundation funding as retribution for a series of foundation demonstrations against the government designed to protest reductions in AIDS services.AHF officials are seeking damages in the amount of $5 million, along with protection from the state government's "retribution" for the Foundation's patient advocacy efforts. "Our suit will stop Los Angeles County from trampling on our rights to advocate for our patients," Michael Weinstein, AHF president said.
The suit also claims that AHF was singled out in June of 1996 by the County's appointed HIV Commission, which passed a series of motions that opposed the AHF's demonstrations. No public notice of the discussions concerning the AHF was given, which the plaintiff claims violates California's open meetings law.
That meeting was taped. AHF representatives cite County law, which bars "...members of the HIV Commission...from discussing individual providers because so many of the commissioners themselves compete for AIDS funds."
Tapes revealed that the Commission had nevertheless "...voted to initiate a series of investigations against AHF."
The suit also charges that the decision to cut the AHF's residential funding by $700,000 was made by the County's AIDS Programs Office Commissioner, who interfered in the competitive bidding process, according to AHF representatives.
Vision loss linked to use of protease drugs
In the February issue of the Archives of Ophthalmology, a multicenter team describes a new syndrome characterized by 'posterior segment intraocular inflammation' that leads to visual impairment in people with AIDS.The condition is associated with signs of immune recovery following antiretroviral treatment with protease inhibitors, along with a history of clinically inactive cytomegalovirus (CMV) retinitis.
Dr. Marietta P. Karavellas of the University of California in San Diego and colleagues conducted a 15-month case-control study of 130 subjects with AIDS and CMV retinitis. The investigators identified five patients with a syndrome consisting of "...symptomatic vitritis and papillitis with cystoid macular edema or epiretinal membrane formation." The patients also had inactive CMV retinitis unrelated to the visual loss and elevated CD4+ T lymphocyte levels as a result of combination antiretroviral therapy that included a protease inhibitor..
A review of the records of 509 patients seen over an 11-year period before protease inhibitors were available did not find any subjects who had had a similar syndrome.
Dr. Karavellas and colleagues were able to treat two of the patients successfully with corticosteroids, which resolved the cystoid macular edema and increased visual acuity.
"It is unclear precisely what factors are necessary to cause the inflammatory response in these patients," they write. They point out that other patients, who also had inactive CMV retinitis, protease inhibitor treatment and partial immune reconstitution, did not develop "immune recovery vitritis."
"Speed" increases HIV risk
The use of oral methamphetamine ("speed") increases the risk of HIV infection, as well as the risk of other sexually transmitted diseases, according to a report in the February issue of the Western Journal of Medicine.The California-based researchers also found that "...methamphetamine use during sex related to risky sexual behaviors regardless of sex, age, race, or ethnicity, or sexual orientation among persons who never injected drugs."
Dr. Richard K. Sun and coinvestigators at the Department of Health Services' Office of AIDS in Sacramento evaluated the relationship between methamphetamine use, sexual behavior and HIV infection. The subjects included more than 258,500 sexually active men and women who were clients at public HIV testing sites in California. All of the subjects denied injection drug use.
Dr. Sun's group found that oral methamphetamine users had more sexual partners than non-users, regardless of gender or sexual orientation. In addition, "[a]mong heterosexuals, a greater percentage of methamphetamine users than nonusers participated in anal intercourse." They also found that methamphetamine use was an independent risk factor for decreased condom use, participating in prostitution, and having sex with a known injection drug user.
On multivariate analysis, methamphetamine use during sex was associated with an increase likelihood of testing positive for HIV., especially among bisexual men. These findings indicate that "...methamphetamine use may contribute to the incidence of HIV infection in the non-injection drug-using heterosexual population."
Dr. Sun's group comments, "By omitting data for IDUs, we were able to show that methamphetamine use is related to sexual HIV infections and that the sexual practices reported for methamphetamine-using IDUs are applicable to non-IDUs, both heterosexual and homosexual." They add that health educators will need to address the problem of methamphetamine use in the design of HIV infection programs.
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