Restricted Access to Care under Insurance Network Narrowing

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

One community that the Affordable Care Act ("ACA") has served particularly well is people living with HIV/AIDS. The law has led to the elimination of pre-existing condition barriers, lifetime limits on the amounts insurers have to pay, and the prescription drug “donut hole” under Medicare Part D, to name only a few. Expanded screening for HIV-infection is also an important feature of the law. That said, new barriers now face many people living with HIV/AIDS trying to access care and treatment. Among the most troubling is insurance network narrowing.

The ADAP Advocacy Association hosted a roundtable discussion on the "Restricted Access to Care under Insurance Network Narrowing" in Birmingham, Alabama earlier this month. The practice of narrowing networks is a cost-savings tool utilized by insurers, but patients find fewer doctors and hospitals in their network...or pay more to use a provider of choice. The practice has taken on a life of its own under the ACA.[1]

Photo Source: California Broker

The issue isn't going away, which is prompting advocates to combat it. The forum in Birmingham included an in-depth policy discussion on insurance network narrowing with the following panelists:

• David Poole, Legislative Affairs, AIDS Healthcare Foundation
• Wendi Clifton, President, WL Clifton Political Consulting
• John Dunnam, Positive Leadership Council, AIDS Alabama
• William Arnold, President & CEO, Community Access National Network

L-R: B. Arnold, J. Dunnam, W. Clifton, and D. Poole

One consistent theme emerging is consumer choice -- including among people living with HIV/AIDS -- is indeed "narrowing." In Georgia, numerous changes to the marketplace plans have resulted in no Platinum Plans being offered...and costs are increasingly being shifted to the patient. One problem for patients, such cost-containment tactics yield a "push-pull" paradigm with rising drug costs versus insurance carriers mitigating risk. The end result is the same, and that is both contribute to access to care and treatment barriers.

For example, Grady Health System in Georgia provides over $200 million in indigent care because over half the population experience insurance-related barriers. This figure is problematic for people living with HIV/AIDS considering that the Peach State is one of the leading states in new HIV infections.

Patients in Florida are experiencing similar challenges, too. Summarized David Poole, Director of Legislative Affairs for AIDS Healthcare Foundation, "Narrow networks are forcing Floridians to access providers who they do not know, do not have an existing trusting relationship and often times are not experienced as HIV providers. The treatments have become highly effective and are much more simple regimens but the disease state remains very complex."

The problem with insurance network narrowing is compounded by the "balance billing" practice by insurers. Healthcare.gov characterizes balance billing as, "When a provider bills you for the difference between the provider’s charge and the allowed amount."[2]

(Editor's Note: Additional barriers to care and treatment were outlined in our previous blog, "Future of ADAP in Medicaid Non-Expansion States")

As the ACA continues to unfold, growing pains will certainly remain and none probably more frustrating than insurance network narrowing. People living with HIV/AIDS -- just like any patient -- should be afforded the opportunity to visit the provider of their choice, especially for specialty services such as infectious disease care and treatment.

The ADAP Regional Summit in Birmingham, Alabama was held in partnership with the AIDS Alabama, AIDS Healthcare Foundation (AHF) and the Community Access National Network (CANN). To learn more, visit http://adapadvocacyassociation.org/events.html#arsba.

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[1] Ableson, Reed, The New York Times, "More Insured, but the Choices Are Narrowing,"May 12, 2014; last viewed online at http://www.nytimes.com/2014/05/13/business/more-insured-but-the-choices-are-narrowing.html?_r=0. 

[2] Healthcare.gov, "Balance Billing," 

Future of ADAP in Medicaid Non-Expansion States

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

On April 15th, access to care and treatment took center stage in Birmingham, Alabama as the ADAP Advocacy Association hosted a roundtable discussion on the "Future of ADAP in Medicaid Non-Expansion States." It is an issue with deep rooted concerns among people living with HIV/AIDS, especially since the Affordable Care Act ("ACA") was designed to expand both. According to Families USA, there are currently 19 non-expansion states...mostly situated in the South, and rural states in other parts of the country.

Photo Source: Families USA

One of the most troubling unintended consequences of the ACA has been exacerbated health disparities in the South, evidenced by only three southern states having expanded their Medicaid programs (Arkansas, Louisiana, and West Virginia).  Yet the South is arguably the area of the country that needs greater access to care and treatment, and not less.

The forum included perspectives from Alabama, and Florida -- both Medicaid non-expansion states. At issue was navigating how to advocate around the new ACA-led healthcare world increasingly driven by an insurance model, rather than a service-delivery model. For example, new barriers have emerged preventing some people living with HIV/AIDS from obtaining medications that may have been previously more accessible to them.

Aside from Alabama and Florida, other non-expansion states represented at the forum included Georgia, North Carolina, and Tennessee. The forum included an in-depth policy discussion with the following panelists:

• Joey Wynn, Community Relations Director, EmpowerU
• Michael J. Mugavero, MD, MHSc, Professor of Medicine, University of Alabama at Birmingham
• Alex Smith, Director of Policy and Advocacy, AIDS Alabama
• Warren Dates, Sr. Peer Linkage Specialist, Alabama Department of Public Health

L-R: A. Smith, Dr. M. Mugavero, W. Dates, and J. Wynn

Florida has learned to leverage its existing programmatic structure and wrap-around services under Ryan White to minimize clients falling through the cracks. In many cases, clients have experienced fewer barriers to care and treatment by receiving their medications via the AIDS Drug Assistance Programs (ADAPs), as compared to what is unfolding in some Medicaid expansion states. Florida could very well be the exception, though.

In Alabama -- where Blue Cross Blue Shield yields a monopoly on the state's insurance market -- efforts continue to focus on prioritizing services for people living with HIV/AIDS. On a positive note, ADAP waiting lists have been completed eliminated and client advocacy has become more specialized by focusing on related issues (i.e., housing and transportation).

In addition, Alabama’s Insurance Assistance Program (AIAP) was launched in 2015, providing cost- effective health insurance to eligible clients. This approach to linking clients to timely, appropriate care and treatment is paying dividends with outcomes, too. According to the State of Alabama AIDS Drug Assistance Program (ADAP) Quarterly Report, "The majority of clients actively served by ADAP reported viral suppression (i.e., viral load ≤ 200 copies/mL) at the last viral load test collected during the preceding 12 months. However, the level of viral suppression varied by service category with MEDCAP reporting the most virally suppressed clients (89 percent), followed by AIAP (79 percent) and ADAP (56 percent). As only fifty-six percent of active ADAP clients are virally suppressed, this indicates a need for improved adherence to antiretroviral therapy (ART) and retention in care in this service category."[1]

Ironically, Alabama and Florida are experiencing different challenges related to the marketplace plans. In Alabama, there are not enough plans available to people living with HIV/AIDS (only 12), whereas in Florida too much time is spent "policing" the plans because there are so many.

The discussion also provided an opportunity to share lessons learned, and the implementation of successful strategies aimed at increasing access to care. Among them, local agencies leveraging 340B rebates to expand services and supports in critical areas, and the deployment of telemedicine networks.

Medicaid expansion will undoubtably remain an issue with profound repercussions on people living with HIV/AIDS, especially considering the uneven way it happening across the country. In the meantime, partnerships between care providers will grow in importance, as well as leveraging existing dollars to promote better health outcomes.

The ADAP Regional Summit in Birmingham, Alabama was held in partnership with the AIDS Alabama, AIDS Healthcare Foundation (AHF) and the Community Access National Network (CANN). To learn more, visit http://adapadvocacyassociation.org/events.html#arsba.

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[1] Alabama Department of Public Health, Division of HIV Prevention and Care, "State of Alabama AIDS Drug Assistance Program (ADAP) Quarterly Report," March 31, 2016; last viewed online at http://adph.org/aids/assets/ADAP_QuarterlyReport_Q1_2016.pdf. 

ADAP Directory & ADAP Formulary Database Link Stakeholders to Important Tools

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

On March 15th (2016), an important resource was once again made available by the National Alliance of State & Territorial AIDS Directors (NASTAD). NASTAD released its 2016 Online AIDS Drug Assistance Program (ADAP) Formulary Database and accompanying User’s Guide. The Database complements the patient-centric ADAP Directory, which is the ADAP Advocacy Association's flagship program.

NASTAD describes the provider-focused Database as "an online, searchable, publicly available resource detailing state-by-state ADAP coverage of medications both individually and by drug class including HIV antiretroviral (ARV) treatments, “A1” Opportunistic Infections (A1 OI) medications, treatments for hepatitis B and C, mental health and substance use treatment medications, and various vaccines and laboratory tests."[1]

Key findings from the 2016 ADAP Formulary Database include:[2]

• 3 ADAPs have “open formularies” in which all FDA-approved medications are included, excluding designated exceptions
• 38 ADAPs cover one or more hepatitis B treatment medication
• 33 ADAPs cover one or more hepatitis C treatment medication
• 19 ADAPs cover one or more of the curative direct acting antiviral (DAA) hepatitis C (HCV) treatment medications
• 9 cover daclatasvir (Daklinza)
• 17 cover dasabuvir, ombitasvir/paritaprevir/ritonavir (Viekira Pak)
• 19 cover ledipasvir and sofosbuvir (Harvoni)
• 8 cover ombitasvir, paritaprevir and ritonavir (Technivie)
• 12 cover simeprevir (Olysio)
• 17 cover sofosbuvir (Sovaldi)
• 43 ADAPs cover one or more of the most frequently prescribed mental health treatment medications
• 14 ADAPs cover one or more substance use treatment medication 

The ADAP Directory – launched in 2014 with ongoing support from AbbVie, Gilead Sciences, Janssen Therapeutics, Merck, ViiV Healthcare, and Walgreens – ensures that people living with HIV-infection have access to the information and resources they need to live healthy and productive lives. The ADAP Directory consolidates useful ADAP-related information from all 50 states and 6 territories into one convenient location for:

• easy access to ADAP resources organized by state and territory;
• updated, current information for all 56 state ADAPs -- including drug formularies; and
• uniform presentation of ADAP information for effective advocacy and easy dissemination.

The “Perfect Storm” that had ravaged the cash-strapped ADAPs between 2008-2010 exposed some very real deficiencies in the amount and quality of information made readily available to patients living with HIV/AIDS. Today, patients...and in fact, all community stakeholders...have much more user-friendly information at their disposal.

Aside from the interactive map, which allows users to navigate all 56 ADAPs, other important resources and tools are available at the ADAP Directory. Among them, patient medication assistance programs and pharmaceutical patient assistance programs.

To learn more about the ADAP Directory, visit http://adap.directory. To learn more about the NASTAD Formulary Database, visit https://www.nastad.org/sites/default/files/2016-ADAP-Formulary-Database-Users-Guide.pdf.
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[1] National Alliance of State & Territorial AIDS Directors (NASTAD), "Update: 2016 ADAP Formulary Database," March 16, 2016.

[2] National Alliance of State & Territorial AIDS Directors (NASTAD), "Update: 2016 ADAP Formulary Database," March 16, 2016.