1. STEVEN BAILEY, VA DEPARTMENT OF HEALTH ANNE RHODES, VA DEPARTMENT OF HEALTH JOHN FURNARI, NC DEPARTMENT OF HEALTH RW ALL GRANTEES MEETING NOVEMBER 2012 WASHINGTON DC Management of an ADAP Waitlist: Virginia and North Carolina Experiences

2. Background: Waitlist Factors - Virginia Increased Utilization Decreased Funding Increased Costs for ARVs Cap on Medicare Part D Enrollment

3. Waitlist Factors – North Carolina TBD

4. Initial Planning: Late 2010, Virginia Education of physicians on cost of ARV regimens Identification of cost- saving strategies Advisory Committee Projected cost savings from each proposed strategy Identified mechanisms for alternative medication access VDH Formulary Reduction (ARV, OIs, vaccines) Enrollment closure (pregnant, <18, active OI) Dis-enroll clinically stable subgroup (n=204) Actions

5. Waitlist Tracking, Virginia Data Collected Demographics Eligibility Medical Sourced from Physicians, Case Managers, Health Departments and Clients Updates Conducted 6 month recertifications for all clients on waitlist Matched with HIV surveillance, RW service data to obtain updated medical and eligibility information Monitoring Weekly meetings with ADAP leadership team at VDH to examine waitlist and program data, in conjunction with fiscal data Used waitlist data for projections of future scenarios for opening ADAP enrollment

6. Waitlist Tracking – North Carolina TBD

7. Program Monitoring, Virginia Reports

8. Fiscal Monitoring, Virginia Reports

9. ADAP Forecasting, Virginia Capacity (Resources Available) Scenarios (Changing Enrollment Criteria) Change of Program Structure (PCIP) HRSA ERF

10. Capacity Projections, Virginia Total Resources for Program/ Average Cost Per Person for Program Annually MPAP Direct Purchase PCIP

11. Change of Program (include PCIP) Mix of Clients (% eligible for PCIP, when transitioned) Mix of insurance spending (drugs/other) Length of time to reach annual cap (matters for RW year projections) Rebates ???

12. Scenario Projections Elimination of Waitlist Changing of enrollment criteria (different CD4 levels, different FPLs), with or without disenrollment Increase in funding of a certain amount and impact on the waitlist Change in formulary Change in dispensing policy Implementation of TrOOP

13. Projections, North Carolina TBD

14. Moving to Sustainability, Virginia NASTAD decreases in ARV costs Additional Funding Sources (Part A, State, ERF, etc.) Increased Program Revenue (Medicaid Backbilling and Rebates) Increased Recertification and Eligibility Processes Part B Service Reductions

15. ADAP Program Management Increased program efficiencies during 2011  Shifted FY 2011 Ryan White service funds to help cover ADAP medication costs  Improved ADAP client eligibility and recertification processes  Instituted state residency policy for ADAP clients  Addressed inactive clients and intermittent use of ADAP

16. ADAP Program Management Increased pharmaceutical efficiencies  Sustained the 30-day prescription dispensing policy implemented in 2010  Sustained aggressive inventory strategy to monitor pharmacy inventory and daily drug costs at all ADAP pharmacies, including the main State Central pharmacy  Referred patients to PAPs and other medication sources  Pharmaceutical company patient assistance programs (PAPs)  Welvista – central hub for number of ARVs

17. ADAP Program Management Maximizing Use of Other Medication Programs  Increased Medicaid back billing revenue for purchase of ADAP medications, including developing agreements with Medicaid HMOs for backbilling  Used ADAP dollars for Medicare Part D co-payments that are counted as True Out of Pocket (TrOOP) expenses  Secured 340 B Rebate Status allowing VA ADAP to pursue rebates for co-pays for Medicare Part D clients’ drug costs; in 2011, VDH spent $400K in co-pays for ARV medications and received $1.1 million in rebates (a return of $2.84 for each dollar spent)

18. Sustainability, North Carolina TBD

19. Expanding and Sustaining Access, Virginia Virginia ADAP has expanded ADAP enrollment criteria and reduced the wait list over last year:  November 2011: CD4 count at or below 200  December 2011: CD4 count at or below 350  April 2012: CD4 count at or below 500  July 2012: removal of clinical criteria  August 2012: began immediate processing of new applications (no longer placed any new persons on waitlist) Eliminated the wait list as of August 30, 2012.

20. Medical Model for Waitlist Reduction, VA Clients with CD4 counts <200 are often diagnosed late and/or enter medical care late and have shorter survival times (Schwarcz, 2006) and higher costs of care than those with higher CD4 counts (Krentz, 2004). Clients with CD4 counts under 350 who are not on antiretroviral therapy have been found to be less likely to survive over time and more likely to be lost to care (Franke et al, 2011) Current public health guidelines emphasize having all those with CD4 counts under 500 on antiretroviral therapy

21. Initial Opening of Enrollment, November 2011

22. CD4 Count ≤ 350, December 2011

23. CD4 Count ≤ 500, April 2012

24. All CD4 Counts, August 2012

25. VA ADAP Wait List Removals

26. VA ADAP Waitlist Removals: Reasons Each client removed from waitlist was assigned reason for removal Those with CD4 counts under 200 often had other payer sources

27. Waitlist Trends, North Carolina TBD

28. Enrollment Expansion Process, VA Sustainability New projections done prior to each expansion to show capacity Enrollment monitored weekly and prescriptions filled monitored monthly Methodology Complete eligibility done before enrollment, including regimen, next fill date, other payer sources Contact process – if no client follow up in 30 days, client removed from waitlist Challenges Did not always have client signature on file Clients sometimes resistant to changing from PAPs Rx often lagged significantly behind enrollment, making projections difficult

29. Enrollment Expansion, Education Community education plan familiarized stakeholders with PCIP/ADAP enrollment criteria. VDH planner met with consumers, physicians, case managers, client advocates, consortia, and others to present VDH plan and answer questions Regional calls held before each expansion to explain change and receive input from stakeholders

30. VA ADAP: Persons and Cost, 2010-2012 Source: VA-ADAP database, Division of Disease Prevention, Virginia Department of Health, August 2012

31. Restructuring the Model for Medication Access, VA Strengthening and improving the eligibility processes for all HIV services Moving toward a model of insurance coverage  Transition of eligible clients to coverage under the Pre-Existing Condition Insurance Plan (PCIP)  PCIP is cost-effective and covers services and medications  Acquired Pharmacy Benefits Manager (PBM) to handle Medicare Part D and PCIP programs

32. Cost Effectiveness of PCIP: Direct Purchase ADAP vs. PCIP Costs Annually for a Client Costs &Revenue Full medication purchase through ADAP PCIP purchase through ADAP (Revenue in green) Net Savings From PCIP Monthly Premium (varies by age) $0$168 Monthly HAART Regimen $944$1,347 (until max out of pocket is reached) Annual Max Out of Pocket NA$4,000 (reached at 3-4 months) Annual Premiums$0$2,016 Annual Rebates$0$(3,000) Annual Totals$11,328$3,016$8,312 * Avg. client is 40 years old on a common protease inhibitor regimen

33. Program Sustainability & Increases in Demand Expected increases in client demand from increased testing efforts and linkage to care efforts  Expanded Testing efforts  SPNS Systems Linkages & Access to Care 4-year grant (NC and VA)  CDC Grant to HIV Prevention for increased linkage activities New HIV Treatment Guidelines promoting a “test and treat” philosophy  Treatment lowers amount of virus in the body and keep patient healthier  Treatment reduces transmission of virus to others

34. Stakeholder Involvement, Virginia Consumers  Outreach and contact efforts  Currently forming a consumer advisory board for SPNS project that we hope will serve for ADAP as well Providers  ADAP Advisory Committee Consortia Part A Planning Councils Virginia legislators and policy makers

35. Lessons Learned, Virginia Gather insurance eligibility information (PCIP) Involvement of ADAP Advisory Committee Proactive approach with agency administration Improvements in tracking clients Stakeholder involvement critical Rebates will support program sustainability

36. Lessons Learned, North Carolina TBD

37. Conclusion VA ADAP has expanded enrollment criteria through aggressive program, fiscal, and pharmaceutical efficiencies VA ADAP is monitoring increases in client demand from testing and linkage to care efforts Sustained funding from federal and state resources will be necessary to support sustained and increased client demand