A contentious switch in contractors approved by the
California Department of Health’s Office of AIDS (CDPH/OA) in 2016 has had
several negative consequences, including two lawsuits from the previous
contractor, lost applications, dropped coverage, a broken application system,
and wrongly denied coverage for California ADAP clients. In other words, it is
a complete mess in California.
The AIDS Drug Assistance Program (ADAP), Part B of the Ryan
White CARE Act (RWCA) is designed to be the “payer of last resort” for patients
living with HIV/AIDS whose incomes fall near enough to the Federal Poverty Level (FPL) to make
affording the cost of care prohibitive, if not entirely unaffordable. As such,
ADAP clients come to rely upon the uninterrupted delivery of those services in
order to effectively treat their HIV infection, address co-morbidities, and
achieve and maintain the viral suppression that makes transmission of the virus
highly unlikely. By those measures the state of California has abjectly failed
the charges whose health the ADAP program was intended to address.
The process that resulted in California’s dereliction of duty
began in October 2015, when the initial Request for Proposal Process (RFP) was
sent out. The initial RFP followed state guidelines using a 1,000-point
allocation system to award the bid to contractors. Consistent with government
regulations, the actual monetary bid for the contract (“Cost Calculation”) was
weighted at 75% (750 points) and “Technical Calculation” requirements were
weighted at 25% (250 points), with a contract term of three years with two
one-year extensions for a total of a five-year contract (
Hews,
2016).
Using this state-mandated RFP, the then-existing contractor,
Ramsell Corp (Oakland, CA) submitted a bid of $900,000 per year, with no
increases over the five-year period, for a total of
$4.5 million for the Enrollment Benefits Management (EMB) part of
the program – the process where clients apply for coverage and maintain
enrollment in the program. A competing bid was submitted by Michigan-based A.J.
Boggs & Co., Inc.: $4,699,585 for the first year, $2,212,563 for the
second, $2,208,767 for the third, $2,211,532 for the fourth, and $2,235,012 for
the fifth and final year, totaling
$13,567,459
– a bid roughly
$9.067 million higher
than Ramsell’s (
Hews).
Under the terms of the RFP, point allocation to the lowest
bidder – Ramsell – would have been 750 points, while Boggs would have received
296 points, using the state-mandated formula.
That was the case, until CDPH/AO Procurement Officer, Jeffrey Mapes,
changed the terms of the RFP on December 03, 2015, reversing the calculations
so that the Technical Calculation became weighted 75% and the Cost Calculation,
weighted by 25% (
Hews).
Mapes’ actions, along with simple math
miscalculations, led the Boggs being awarded the new contract on March 04,
2016.
Ramsell, unaware of these changes
and miscalculations, submitted a Freedom of Information Act (FOIA) request for
all documents related to the Boggs bid – a request whose fulfilment was delayed
and incomplete.
Realizing the errors in the process, Ramsell submitted a
protest on April 06, 2016, from which the following excerpt comes:
We are concerned that the amount of
time that has been allotted for system beta testing and enrollment worker
training is not adequate. The Office of AIDS has notified us that the new
system is still being developed, beta testing has not yet begun, and enrollment
worker training will not begin until just weeks before the July 1st transition. Further, the system is transitioning from one
to three contractors which will require additional coordination to effectively
serve clients. In order to ensure a seamless transition, we believe additional
time is necessary to adequately beta test the new system, train enrollment
workers, and ensure time for feedback on what works properly and what needs
improvement (Otiko,
2016).
In June 2016, Ramsell Corp filed two separate suits related
to the EBM and the Pharmacy Benefits Management (PBM) contract awarded to Magellan
Rx Management, LLC. The EBM suit alleges
that:
…after Ramsell complained about
major defects in the unfair procurement, CDPH cancelled the award to Boggs, and
then gave them an illegal, sole-sourced contract only days later in violation
of the requirements of the State Contracting Manual. The lawsuit also notes
that the Boggs’ bid was about three times higher ($9 million more) than the
Ramsell bid (Allen
& Barajas, 2016).
The PBM suit alleges that:
…in procuring the new contracts,
CDPH: (1) failed to follow its own rules as set forth in the Request for
Proposals (RFP); and (2) conducted the procurement in a biased manner that was
slanted in favor of the out-of-state companies (Allen &
Barajas).
Despite these lawsuits being filed, CDPH/OA continued the
transition to the three new vendors, which also included Pool Administrators
Inc. (which covered the Health Insurance Premium Payments (OA-HIPP) and
Medicare Part D premium payment programs), effective July 01, 2016 (
Grimes,
2016). Since that transition
occurred, ADAP clients, healthcare providers, clinics, pharmacies, and AIDS
Service Organizations (ASOs) have experienced numerous problems accessing
coverage.
Clients have been turned away at pharmacies, forced to
postpone medical procedures, and some have been dropped from the program,
altogether (
Gorman,
2017).
Additional complaints from
patients and caseworkers allege that reimbursement claims have been repeatedly
rejected (
Allday,
2017) and patients have been dropped from the health insurance because ADAP
failed to send premium payments to the correct address (
Gorman).
Dr. Karen Smith, director of California’s
Public Health Department, stated in a letter to state Senator Scott Wiener
(D-San Francisco) that:
Shortly after [the department
switched to new contractors in July 2016], …CDPH received a letter from
constituents expressing concerns that there were issues for some clients
receiving medications. …As you note, the
ADAP portal was unexpectedly unavailable for ADAP enrollment worker and client
use as of November 29, 2016, due to information security vulnerabilities in the
system. …To ensure uninterrupted client access to medications, we have extended
client eligibility to their next reenrollment or recertification date occurring
after June 30, 2017 (Hemmelgarn,
2017).
 |
| California State Senator Senator Scott Wiener; Gloss Magazine |
Dr. Smith noted that her agency identified two separate
breaches of information, and that impacted clients were notified. Those breaches, however, led to the online
portal, where patients could register, re-enroll, and re-certify, being taken
offline indefinitely on November 29, 2016. As of January 23, 2017 – just seven days short of the January 30
extension deadline – that online portal has not been replaced. This failure on the part of Boggs forced
patients and caseworkers to register for ADAP by fax – a process that took
weeks, due to a shortage of both fax machines and customer service workers to
handle the load (
Allday).
In response to patients being unable to access pharmacy
services due to complications with PBM contractor, Magellan, the staff at
Magellan were authorized by the state
…to provide real-time, 24 hours a
day, seven days a week authorizations to pharmacies for a 30-day supply of
medications for ADAP clients with active eligibility who experience access
issues at the pharmacy (Hemmelgarn).
While this step is a nice quarter-way measure to ensure that
active patients – those who have not
been erroneously dropped or unable to enroll or certify – can gain access to
their lifesaving HIV medications, it in no way serves as a long-term solution
to address the myriad disasters that this ill-advised contract switch has
created. For those patients, providers,
and caseworkers who have been unable to successfully register clients, process
claims, pay premiums, or be successfully reimbursed, this disastrous transition
is entirely unacceptable.
Further frustrating already harried caseworkers and providers
is that this transition from one California-based, minority-owned contractor
(Ramsell) to three out-of-state contractors, one of which is inexperienced in
the arena, could and should have been
entirely avoided, had the CDPH/OA complied with the state-mandated RFP process
and properly calculated the points, even within the new calculation. That Ramsell Corp, a company that had
successfully provided services to California’s ADAP program for nearly twenty
years, was summarily dismissed and their bids rejected in what appears to be
retaliation for filing a formal protest in response to the procurement process
is foolish behavior on the part of the CDPH/OA.
CDPH/OA’s failure to follow even the most basic statutes
indicates the need for a new Procurement Officer, as Jeffrey Mapes’ unexplained
and potentially illegal (
Hews)
actions indicates that he is unfit for the position.
California’s patients deserve better, and
until there is a permanent fix in place, it is incumbent upon all California
residents, advocates, caseworkers, and providers to keep the pressure on the
CDPH/OA.
According to sources, the Health Resources & Services Administration (HRSA) at the U.S. Department of Health & Human Services is aware of the situation and monitoring it.
Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.
