published by We The People Living with AIDS/HIV of the Delaware Valley, Inc.
"HealthChoices not ready for PWAs": advocates meet with DPW
HMOs don't work for chronically ill: study
Richman to meet with PWAs on HealthChoices
Advocates meet with DPW
"HealthChoices not ready for PWAs"
An ad hoc group of AIDS service providers, advocates and people living with HIV/AIDS met this week with Carol Ranck, AIDS policy liaison with the Pennsylvania Department of Public Welfare, to request that people with HIV and AIDS be exempted from the state's new Medicaid managed care program until stronger guarantees of quality health care, and access to care, are addressed.
The group has been meeting for several weeks to come to a consensus on the major issues which it feels DPW needs to deal with before it forces an estimated 17,000 people living with HIV/AIDS in southeastern Pennsylvania into HealthChoices.
Under HealthChoices, all people eligible for Medical Assistance will be required to join one of five Medicaid health maintenance plans currently negotiating contracts with the state. Under the current timetable, most people with HIV and AIDS who are eligible for Medical Assistance will be forced into the new plans next July 1st; some, especially women and children in families receiving Aid to Families with Dependent Children (AFDC), will join on January 1st.
The state is still awaiting approval from the federal Health Care Financing Administration (HCFA) to implement the plan in January. A response to a series of questions raised by HCFA to DPW regarding what procedures are in place to assure adequate medical care and access for people living with HIV/AIDS under HealthChoices was delivered by DPW to HCFA earlier this week, but was not available to fastfax at press time.
The five health insurance companies who plan to participate in HealthChoices include They are Keystone Mercy Health Plan, Healthcare Management Alternatives Inc., Oxford Health Plans, Health Partners and PhilCARE Health Systems Inc. QualMed for Health Inc., pulled out of HealthChoices this week, and PhilCARE may not be approved as a participant because of concerns about the involvement of Eugene Newton, M.D., who had previously been charged with Medicare fraud and who has been severely criticized by AIDS advocates and state officials for his reputation for delivering poor quality care at the Philadelphia Nursing Home.
Newton owns 51% of PhilCARE, which is a partnership which also includes a Detroit-based health maintenance organization (HMO). The state is requiring the appointment of a trustee to hold 2% of Newton's ownership, to prevent his having majority control of the company. Several proposed trustees have already been rejected by DPW, according to the Philadelphia Inquirer.
At its meeting with Ranck, the ad hoc group submitted a report which concluded that "enrollment of people living with HIV/AIDS in HealthChoices must be delayed" because DPW is unable to guarantee quality clinical care within the rates it will be paying to the HMOs; no firm standards have been established by DPW requiring quality clinical care, access to new treatments, or availability of experienced physicians throughout the five-county area; no system of coordination has been established linking the physical health services of HealthChoices with Medicaid managed care plans for mental health and substance abuse services, or with the existing HIV/AIDS services system; and no attempt has been made by DPW to overcome a myriad of obstacles to access to care which will be faced by people living with HIV/AIDS once HealthChoices is implemented.
"Low income individuals living with HIV and AIDS are among the most vulnerable in society," the group's report said. "They need on-going access to cost-effective quality health care. HealthChoices does not ensure that adequate access to quality care will occur."
"The health and survival of Medicaid beneficiaries living with HIV and AIDS is dependent upon a health care delivery system which is effective and efficient at the time of implementation," they continued. "The system cannot be perfected at the expense of the chronically ill. DPW must take the necessary steps to prevent mandatory managed care from becoming a health care crisis for people living with HIV/AIDS, their families, and their communities."
The group called delaying the implementation of HealthChoices for people with HIV/AIDS "a logical first step" in addressing these concerns. "A delay would provide DPW an opportunity to study the affect of managed care on the chronically ill and develop a plan providing adequate access to care, while protecting a population from being forced into a health care system that is not presently equipped to serve it," the group said.
People with HIV disease who do join Medicaid HMOs, the group said, should have "the opportunity to opt out of enrollment to avoid an interruption in care, if for instance their doctors or specialists is not available through any of the HMO networks."
Noting that the state is implementing HealthChoices primarily to reduce the cost of Medical Assistance to state taxpayers -- a burden which has increased by 20% over the past three years -- the group said that "as people with chronic illnesses, such as HIV, require more expensive care, HMOs and/or providers must be paid an enhanced rate to provide that care. Without an enhanced rate, every chronically ill member represents a financial risk to the provider and/or the HMO. The result is a strong disincentive to enroll these persons or to deny necessary care, such as referrals to specialists, if enrolled."
The group also noted that many people living with HIV/AIDS -- especially in the suburbs -- already face enormous obstacles in finding physicians which are experienced in the delivery of HIV/AIDS care. They noted that this obstacle exists even for those covered by private insurance plans, as well as those covered by current Medicaid HMO and "fee for service" insurers. "An adequate -- defined as experienced, qualified, and easily accessible -- clinical care provider network, responsible to a clearly defined standard of care -- is essential to ensure access to care."
"Many studies have demonstrated the clear link between survival of a person living HIV and the experience of the treating physician. Under HealthChoices, DPW has not developed an adequate definition of what comprises a physician experienced in HIV care; therefore, the HMOs have no reasonable criteria to guide them when creating their provider networks. The networks must contain an adequate number of both HIV experienced providers and appropriate specialists for HIV care." Neither is guaranteed under HealthChoices at present, the group said.
DPW has also set up no mechanism for measuring the performance of HMOs or particular providers to monitor the care they deliver, they said.
With regard to coordination between HealthChoices and other systems serving people with HIV/AIDS, the group said that there is a "growing recognition of co-morbidity between and HIV/AIDS diagnosis and other medical problems." They said that "DPW must require plans to coordinate appropriate physical health services and make speedy referrals to and between HealthChoices behavioral health companies in each of the five counties of southeastern Pennsylvania, as well as to mental health, alcoholism and substance abuse treatment programs designed for and sensitive to the needs of people living with HIV/AIDS. DPW must develop a practical plan for the integration of existing HIV/AIDS case management programs and other specialized HIV/AIDS programs which have proven effective in assisting people living with HIV/AIDS in addressing their needs. A clear system of accountability and quality assurance to ensure the smooth working of these relationships must be in place and enforced" before requiring PWA/HIV enrollment in HealthChoices, the group said.
Even if progress is made in setting higher standards for HIV care under HealthChoices, the group said, access issues may derail their effectiveness for many people with HIV disease.
"Experienced providers participating in HealthChoices are not presently placed geographically for easy access to all of the people living with HIV/AIDS who will be participating in HealthChoices HMOs," they said. "Especially in suburban counties, historic problems in accessing care from qualified providers will likely be aggravated under HealthChoices without a conscious effort on the part of HMOs to develop creative strategies for making clinical care accessible, and clear, firm, and enforceable direction from DPW requiring their implementation. These strategies must include a capacity to respond to special transportation, child care, and other issues which may inhibit enrollees from being able to fully access HealthChoices services."
In response to complaints about HMO marketing practices under the present experimental Medicaid HMO system set up by DPW in some Philadelphia neighborhoods several years ago, DPW has awarded a contract to Benova, Inc., an Oregon firm, to employ over 700 "benefits counselors" whose job is to provide unbiased information about the various plans and assist Medicaid recipients in making an informed choice on which plan to join.
"Many complex implications arise from the utilization of Benefits Counselors to assist people living with HIV/AIDS in selecting a HealthChoices HMO as well as a Primary Care Physician within the HMO," the group said. "These issues involve confidentiality, the knowledge base of Benefits Counselors with relation to HIV/AIDS care issues, ability of Benefits Counselors to appropriate advise individuals and families with HIV/AIDS on selection of plans and providers, and utilizing the Benefits Counseling process to link individuals and families to related HIV/AIDS services not supported directly by HealthChoices."
"Benefits Counselors need to be appropriately trained in providing these services," they said. "This training needs to range from specific and enforceable guidelines regarding confidentiality issues, in accordance with common sense and applicable law, especially as they pursue their tasks in County Assistance Offices and neighborhood settings; to evaluating the capacity of specific HMOs to provide qualified, accessible HIV care, and a knowledge of how to assist an enrollee in weighing the various options; to a firm understanding of special rules and regulations which may be established which permit an enrollee to obtain services outside the confines of the HMO; to an understanding of how to counsel enrollees on partnerships between behavioral health and HIV/AIDS-specific wraparound and support services, and how to access those services; and to sensitivity issues, to combat both overt and subtle discrimination against enrollees living with HIV/AIDS on the basis of their health status, lifestyles, or histories of unpopular behavior."
"Such training must be provided in a culturally competent manner," they continued, "cognizant of prejudices which may inform both the behavior of Benefits Counselors themselves, and which recognize the context in which the counseling occurs, with regard to race, sexual and drug use behaviors and identities, geographic location, etc."
The group also called for the initiation of "effective, expedited grievance and complaint procedures ... made available in a fashion which makes them obvious, accessible, and clearly understood by enrollees, providers and the HMOs. These grievance procedures must be available in a way which allows for prompt resolution of complaints. Furthermore, information with regard to the nature of these grievances, the speed of response, and outcomes, must be easily available to DPW, HMOs, providers, enrollees and their advocates, to allow for evaluation of the grievance system's effectiveness and to inform efforts to improve the quality of care under HealthChoices."
Finally, the group noted that HealthChoices "does not contain an independent process for consumers to challenge the decisions made by the HMOs. There are no independent fact finders or sources of assistance for the consumer. The consumer living with HIV may need a second opinion to support a request for newly developed procedures and treatments. Without any financial assistance to obtain this opinion, the consumer has no chance to succeed against the HMO."
"Given the current structure of the grievance process, the consumer has no access to an adequate and fair grievance resolution. There is little opportunity for any other effective complaint resolution as years may pass before a Departmental fair hearing is held."
Ranck, who pledged to bring the group's concerns to the attention of DPW officials responsible for the implementation of HealthChoices, asked for additional information which might support the advocates' contention that a delay in enrollment for people living with HIV/AIDS might be justified. Kiyoshi Kuromiya, of Critical Path AIDS Project, noted that a new national study is being conducted, which includes Philadelphia, which will better define the cost of HIV care and which should be utilized by DPW in determining the payment rates it will be offering the HMOs.
The group agreed to develop a more detailed report on its concerns for submission to DPW by October 4th.
Meanwhile, Rhonda Goldfein, an attorney with the AIDS Law Project of Pennsylvania, said that she had received a commitment from presidential AIDS advisor Patsy Fleming that HCFA officials would come to Philadelphia later this month to hear directly from people living with HIV/AIDS and their advocates on these and other concerns regarding Medicaid managed care in Pennsylvania.
HMOs don't work for chronically ill: study
Older and sicker patients tend to fare worse in HMOs than under fee-for-service (FFS) medicine, according to a study published in a special managed care issue of the Journal of the American Medical Association (JAMA).
AIDS advocates hailed the study as confirming their contentions that HMO plans are not able to guarantee quality clinical care to those with chronic illnesses, since the financial incentives offered to HMOs lead them to seek care options that are cheaper and less effective for sicker participants.
The four-year study followed 2,235 patients between the ages of 18 and 97 who had at least one of five medical problems: hypertension, non-insulin-dependent diabetes, recent heart attack, congestive heart failure or depression. Slightly more than half of the study participants were women (54%) and 22% were at or below 200% of the federal poverty level. The study is part of the Medical Outcomes Study, an observational study tracking the differences in health outcomes for FFS and HMO patients in Boston, Chicago and Los Angeles.
According to the authors, "Patients who were elderly and poor were more than twice as likely to decline in health in an HMO than in a FFS plan." Fifty-four percent of the older HMO patients "reported a decline in physical health," while only 28% of the FFS patients experienced a decline. Thirty-three percent of low-income, ill patients experienced a decline in health status under HMOs, compared to five percent of those in FFS.
However, the study did find that patients who were "younger, relatively healthy, and relatively well-off financially did at least as well in HMOs as in the FFS plans."
The study also found average mental health outcomes "did not favor [one] system over the other."
The American Association of Health Plans (AAHP) released a statement saying that the study "seems to be at odds with a number of other studies from that period, as well as more recent studies showing the care for the chronically ill elderly and poor in HMOs to be as good as or better than care in fee-for-service settings." According to the AAHP, one possible reason for the differences could be that "the JAMA study focuses only on one measure -- whether or not patients believed their health improved, stayed the same or worsened. In most scientific studies of this nature it is typical to use more than one measure when analyzing health outcomes." Health and Human Services Secretary Donna Shalala said, "We shouldn't over interpret this study." However, she said, "We're going to be very tough minded. If companies aren't producing, we ought not to be either recommending them, contracting with them, or doing any kind of business with them."
With more than half of all states moving to Medicaid managed care, and with both the Republicans and the Democrats having introduced plans last year for revamping Medicare that would have made it easier for older people to join an HMO, the study's author says that politicians have to "keep the chronically ill in mind."
Speaking at a seminar for reporters in San Francisco, JAMA editor Dr. George Lundberg called the study a "'red flag' that should prompt additional research on the subject." Lundberg and Dr. Paul Ellwood co-authored an accompanying editorial to the study in which they called managed care a "work in progress." They said it was "unrealistic" to expect a return to the old FFS style of medicine and said, "We should expect a more integrated, selective, epidemiologic data-dependent, and consumer-driven health system." They add, "The new American health system works. It has contained costs ... and, on the whole, it has not yet jeopardized quality." However, they call for "Principles of Accountability to the Public for Health Quality" in order to ensure that progress toward a consumer-oriented system continues."
Richman to meet with PWAs on HealthChoices
Health Commissioner Estelle Richman has asked We The People Living with AIDS/HIV to convene a public meeting of people living with HIV/AIDS to help them better understand the implications of HealthChoices to their care.
Joe Cronauer, executive director of We The People, said that the meeting would be scheduled for Wednesday, October 23rd, at 6:30 p.m. A location had not been decided by press time, he said.
Richman also plans to invite regional HIV/AIDS service providers and consumers to a meeting earlier in the month to help the HIV/AIDS system begin planning for the implementation of HealthChoices in 1997. Many HIV/AIDS service providers will have to work out new arrangements to provide their services to clients in HealthChoices, Cronauer said, because HealthChoices establishes new mechanisms for obtaining HIV/AIDS case management and other services for its clients.
Richman also told We The People that she is planning on convening a meeting with the chief executive officers of the HealthChoices HMOs with a small group of HIV/AIDS advocates to initiate communication between the companies and their HIV/AIDS enrollees.