published by We The People Living with AIDS/HIV of the Delaware Valley, Inc.
WTP calls for action on HealthChoices
New safe water act seen as improvement
AACO ignores request for change in report
WTP calls for action on HealthChoices
We The People has called on the Philadelphia Health Department and the Philadelphia AIDS Consortium to step up efforts to prepare the AIDS service system for the implementation of HealthChoices, the new state programs which will force all Medical Assistance recipients into managed care plans by next July.
In a letter to city health commissioner Estelle Richman, WTP executive director Joe Cronauer notes that "for several years, members of We The People and other people living with HIV/AIDS, who have participated in the HIV/AIDS planning process, have attempted to convey our urgency with regard to the implementation of managed care plans for residents of the region covered by Medical Assistance.
"We have been deeply concerned," Cronauer wrote, "that the plan for HealthChoices does not pay adequate attention to the special needs of people living with HIV/AIDS." Cronauer said that most of the proposals made by AIDS advocates -- especially We The People, Act Up, the AIDS Law Project, and the Pennsylvania Coalition of AIDS Service Organizations (PCASO) to the Department of Public Welfare (DPW) for enhancements of the regulations and requirements to protect people with HIV/AIDS "have been ignored."
People with HIV/AIDS covered by Medical Assistance will be required to join new Medicaid health maintenance organizations by July, 1997, according to the state welfare department's plan for implementing HealthChoices. HealthChoices is an experimental Medicaid managed care network set to begin in the five-county Philadelphia area beginning next January.
Families with children will be required to join the plans on January 1, 1997. People covered by Social Security Supplemental Income (SSI) and other disability plans will be phased in to the plan next July.
The managed care plan covers Bucks, Chester, Delaware, Montgomery and Philadelphia counties, and eventually is expected to be extended throughout the state.
According to DPW, all individuals and families eligible for Medical Assistance will be required to choose an HMO for their health care from a list of approved companies to be selected by DPW this summer. People who are currently enrolled in a Medicaid managed care plan will have the option of remaining with their current company, or may select a new plan; those who do not choose will be randomly assigned by computer to an HMO.
The DPW HealthChoices plan has been severely criticized by many PWAs and their advocates for lack of sensitivity to the special needs of people living with HIV disease. Advocates asked the state to place new conditions on AIDS care provided under the managed care system, including requiring a specific medical standard of care; allowing people with AIDS to choose infectious disease specialists as their primary care physicians; allowing easier access to "out-of-network" specialty services, since managed care organizations may not always have the specialist care that PWAs need available; and requiring expedited procedures for people with life-threatening diseases to avert the long delays in accessing care that have become common in existing HMO systems.
The DPW plan requires each approved HMO to guarantee that it has sufficient provider participation to assure appropriate care for people with HIV/AIDS, but does not set specific criteria for how that level of appropriateness will be determined. DPW has said, however, that it will monitor plan performance monthly to determine if any access problems have developed.
The implementation of HealthChoices for people with HIV/AIDS next summer may have a significant impact on how HIV/AIDS services are funded in the region. HealthChoices companies will be required to provide specialized AIDS case management services to their participants, according to the standards currently in use in licensing "independent" case managers through the DPW's "targeted AIDS case management" program. HMOs will also be required to guarantee services currently offered under the Medicaid "home and community based waiver" program, which offers a variety of home health and hospice services for people with AIDS.
Since the majority of people living with HIV/AIDS in the region are covered for their health insurance through Medicaid, the requirement that Medicaid HMOs have their own AIDS case managers may mean that funding for AIDS case management currently provided under federal, state and city direct grants may be able to be shifted to HealthChoices reimbursement.
Additionally, most primary medical care services for people with HIV/AIDS are eligible for reimbursement under the HealthChoices system.
The Philadelphia HIV Commission earlier this spring requested the city health department to shift as much AIDS care as possible to other reimbursement sources. With the advent of HealthChoices next year, the impact of Medicaid managed care reimbursement will need to be taken into account in developing funding priorities for the 1997 Ryan White CARE Act allocation.
In his letter to Richman, Cronauer said that efforts of local AIDS advocates to "convince those responsible for the direction of HIV/AIDS planning that HealthChoices would have important implications for both AIDS care and the allocation of federal, state and local AIDS resources have mostly fallen on deaf ears."
"The lack of planning for HealthChoices is a cause of increasing distress to us," Cronauer said, "as we are only ten months away from its formal application to people living with HIV/AIDS."
Cronauer noted that the Philadelphia AIDS Consortium, as the Ryan White CARE Act Title II planning council, last week agreed to begin to recognize these issues, and an ad hoc committee has established by the Board of Directors to begin to discuss these matters. The new TPAC committee is the third attempt over the past four years to construct managed care planning process for the AIDS service system, each of which has faded away as other priorities engaged HIV/AIDS planners.
Cronauer said that "the minimal efforts that had been part of Title I planning when it was located at TPAC have not been continued by the HIV Commission, and neither the Commission nor AACO staff seem to be particularly knowledgeable about the potential impact of HealthChoices either on AIDS care or their own system coordination or resource allocation functions."
Cronauer requested Richman to "join with us to assure that existing AIDS planning and resource allocations processes are fully educated and informed about the requirements of the new HealthChoices program."
He noted the following specific areas of concern to people living with HIV/AIDS:
-- how will HealthChoices impact on AIDS-specific care and access to AIDS drug treatments?
-- how does the Department of Public Welfare intend to monitor and evaluate the delivery of care to people living with HIV/AIDS?
-- what standards will be used HealthChoices managed care companies and DPW to assure the an appropriate standard of care is in place for the treatment of HIV infection and AIDS?
-- how DPW and the HMOs will guarantee access to care from providers knowledgeable and experienced in HIV/AIDS care?
-- what special mechanisms, if any, will be in place to assure timely referrals to qualified providers?
-- what mechanisms are being established to assure coordination of care between HealthChoices managed care organizations and the services which will be offered through Community Behavioral Health?
-- what impact will HealthChoices reimbursement for primary medical care and AIDS case management services have on priorities for allocation of Ryan White CARE Act and state and city general funds for HIV/AIDS services in the region?
-- what role will the AIDS Activities Coordinating Office play in monitoring the outcomes of Medicaid managed care for people living with HIV/AIDS, or in quality assurance activities?
-- what relationship does HealthChoices have to the HRSA-mandated quality assure mechanism which is supposed to be established for CARE Act-funded agencies this year?
-- what efforts are planned by AACO in assisting its funded agencies to prepare for HealthChoices, or to encourage partnerships between existing AIDS service organizations and the Medicaid HMOs?
Cronauer said that the Philadelphia Health Department, "as the public health authority for our region, and the lead agency with regard to HIV/AIDS planning and funding" should take a leadership role in helping the HIV/AIDS service system understand and prepare for the advent of this fundamental change in how Medical Assistance services are paid for."
"We also expect that the allocation of federal, state and city general funds will be approached in a way which avoids duplication of funding for HealthChoices-eligible services, and establishes a safety net for people who may fall through the cracks as a result of the activation of the HealthChoices system," Cronauer wrote.
Cronauer also noted that some AIDS service organizations have already begun to negotiate arrangements to collaborate with HMOs in the region likely to be participating in the HealthChoices program, and that some have even obtained the Health Department's support for their efforts.
"Unfortunately, as in the past, the concentration of direct service AIDS funding in large, center city based organizations has once again provided those organizations with a stronger ability to become ready for managed care reimbursement, and they have appropriately sought to build on that framework to assure that their services are relevant in the new reimbursement scheme," Cronauer said.
"However, organizations run by and serving primarily low-income people and people of color outside of center city are again being shunted to the side because they have not been supported in any meaningful way to prepare for the fundamental changes in financing that are headed our way. Neither the HIV Commission nor the AIDS Consortium have taken any action to help them. While virtually every other segment of the health delivery system has received assistance in planning for Medicaid managed care in some way -- from informational sessions about HealthChoices to the provision of hands-on technical assistance to become 'managed care ready' to active advocacy efforts in Harrisburg -- AACO and TPAC have been silent."
Cronauer said that We The People was asking Richman to "work with us to develop a plan through which the Department can help the AIDS service system confront the HealthChoices challenge" prior to its implementation for people with HIV/AIDS next July 1st. He asked for a meeting with Health Department officials to " discuss further our concerns in this area, as well as potential strategies for confronting these issues forcefully and constructively."
New safe water act seen as improvement
Originally drafted as an extreme deregulatory measure which would have allowed states and localities to opt out of many of the most important provisions protecting the purity of drinking water, the final version of the Safe Drinking Water Act (SDWA) actually improves on the original legislation, according to the AIDS Action Council.
"This is especially true with regard to protections for vulnerable populations including people living with HIV/AIDS," the group said in its weekly AIDS Action Alert several weeks ago.
One provision of the act includes requiring water systems to supply consumer right-to-know reports with substantive information on the content, quality, and source of their drinking water. These reports will empower individuals, especially those with weakened immune systems, with the information they need to decide if they need to find alternatives to tap water. Another provision is the establishment by CDC, NIH, and EPA of waterborne disease surveillance studies, health effects research on microbial and chemical contaminants, and research into the identification of contaminant sources. This research will be especially important in identifying and providing guidance on cryptosporidiosis and giardia.
AIDS Action noted that Congress passed the bill two hours after a statutory deadline had expired that would have freed a $725 million appropriation for a state revolving fund to assist communities to meet the requirements of the Act. The availability of this revolving fund could prove especially crucial for small communities whose water revenues are insufficient to employ new technologies. When Congress returns, they will have to act affirmatively to reauthorize this fund.
Now reports crypto infections
AACO ignores request for change in report
The quarterly AIDS epidemiology report issued by AIDS Activities Coordinating Office director Jesse Milan and AACO epidemiologist Erica Gollub again ignores requests from PWA advocates, including We The People and representatives of black gay organizations, that it report AIDS cases clearly by risk factor and race.
The existing report format has been criticized for implying that most AIDS cases in the gay and bisexual communities have occurred in whites, when in fact most cases among "men who have sex with men" have been in the African American and Latino communities.
Gollub's report has consistently reported this level of detail by gender, but she has ignored requests to provide the data as clearly for men who have sex with men.
Almost two years ago, Gollub agreed to incorporate changes to the report based on feedback from community organizations which use the data in planning their AIDS prevention and service activities, but few changes have been made. AACO director Jesse Milan told We The People last fall that the format would be revised by the end of last year.
By reporting AIDS epidemiological data for the gay and bisexual male community "by race and risk factor," a table in the report implies that over 72% of cases of AIDS among men who have sex with men (MSM) are white.
In fact, a more sophisticated analysis of the AACO data indicates that 60% of AIDS cases since 1981 have occurred in men of color who have sex with men: African Americans (54%, or 2,531 reported cases), Latinos (5%, or 239 cases), and Asians (less than 1%, or 14 cases). Since 1981, 1,862 White MSM cases have been reported, comprising 40% of the total.
The AACO report says that over 70% (8,642) of the total of 12,263 AIDS cases reported through June 30, 1996 in the Philadelphia area have occurred in the city of Philadelphia. Camden County in New Jersey has the second highest number of cases (8%, or 958 cases); followed by Delaware County, PA (6%, 712); Montgomery County, PA (4%, 514); Bucks County, PA (4%, 445); Burlington County, NJ (4%, 433); Chester County, PA (2%, 266); Gloucester County, NJ (2%, 203); and Salem County, NJ (1%, 90).
Responding to concerns raised last summer at detectable levels of cryptosporidium in city water supplies, the new AACO report does include new data on the incidence of cryptosporidium infection in people living with HIV/AIDS in the city. In its June 30th AIDS epidemiology report, AACO noted that the city health department had received 138 reports of AIDS-related cryptosporidiosis since January of 1990, with only three cases being reported so far in 1996. The report said that by this time last year, twelve cases had been reported to the health department.