Highlight on New York: Governor, task force plan to end AIDS by 2020

On June 29, 2014, Governor Andrew Cuomo announced an initiative with an ambitious goal: to end the AIDS epidemic in the state by the end of 2020. He appointed a task force of 63 members and charged it to develop a plan to make it happen.

The targets:

  • reducing the number of new AIDS cases per year to 750, about the same as the number of new cases of tuberculosis;
  • reducing deaths from AIDS to zero; and
  • ending discrimination against people with HIV.

The three points of Cuomo’s initiative, called “Bending the Curve,” were:

  • identifying people with undiagnosed HIV and connecting them to health care;
  • connecting those diagnosed as HIV-positive with treatment, including antiviral therapies to suppress the virus and stop the transmission of the disease; and
  • providing access to pre-exposure prophylaxis (PrEP) to individuals at high risk for AIDS to keep them HIV-negative.

 Previous progress

At the peak of the epidemic, in 1993, there were 14,000 new diagnoses in New York each year. In 2014, there were about 3,000. The number of New Yorkers living with AIDS has grown—from 112,000 in 2002 to 132,000 in 2012—because the number of AIDS-related deaths has declined. Because medication has been made available, between 44 percent and 51 percent of infected New Yorkers have suppressed the virus, meaning that it is no longer at a detectable level.

Nationally, the number of new infections per year has remained stable at about 50,000, and only about 25 to 30 percent of people with HIV have reached suppression.

Related actions taken

Routine screening for HIV and targeted screening of individuals at risk are key to detection and treatment, but it has been necessary for the state to remove legal obstacles in recent years. In 2014, the law requiring written consent to HIV testing was amended to require only verbal consent, as is standard for other laboratory tests. Some prosecutors and police departments have forsworn or limited the practice of confiscating condoms for use as evidence in criminal cases involving prostitution.

The task force believes that transgender individuals are at higher risk for AIDS, so that legal protections against discrimination and coverage of their unique health care needs are helpful in the achievement of the goal of minimizing the spread of the disease. Therefore, the state Department of Health has adopted regulations requiring Medicaid to cover the treatment of gender dysphoria, including medically necessary gender reassignment surgery. The legislature also is considering bills that would ban discrimination based on gender identification. Both Medicaid and most private insurers will cover daily medication that prevents the transmission of the virus to the partners of HIV-positive individuals.

The task force and the blueprint

The task force formed four committees, each with its own focus: care, prevention, housing and supportive services, and data. They held public listening sessions and considered some 300 recommendations submitted to them. They then formulated 44 recommendations and tied each to at least one of the three elements of the Bending the Curve initiative.

The blueprint was presented to the governor in late April, 2015. The recommendations go beyond the goal of reducing new infections to 750, with the aim of reaching zero by 2025. An essential part of the plan is continuous monitoring to identify the populations currently most affected or at greatest risk of contracting HIV, and, as well, those most affected by “systemic health, economic, and racial disparities that act as catalysts for new infections.”


Kentucky Hospital Association calls ‘code blue’ over $7B in cuts

In what it termed a “code blue,” the Kentucky Hospital Association (KYHA) released a report warning that health reforms implemented under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) will significantly contribute to $7 billion in federal cuts to Kentucky hospitals by the year 2024. The report acknowledged that the uninsured rate in Kentucky dropped by 50 percent as a result of the ACA, but maintained that Kentucky hospitals will lose more in revenue than they gain through the expansion of the covered population, amounting to a net loss of $1 billion by 2020.

According to the report, the ACA reduced the number of uninsured Kentucky residents by 50 percent, with over 400,000 individuals gaining health insurance, including through Kynect, the state’s health insurance marketplace. Kentucky was the only southeastern state in the United States to expand its Medicaid under the ACA. However, the KYHA warns that the expansion comes at a cost to Kentucky hospitals that will face $7 billion in federal cuts which will cause layoffs and reductions in available services, especially to those in rural areas.

Kentucky Hospital Association President Mike Rust has been reported as stating that while the expanded coverage of the uninsured has provided additional money to hospitals, there is a significant downside to the changes in the health care system and that the report, “provides the real picture” of the challenges faced by Kentucky hospitals.

The report blames the expected federal cuts to Medicare and Medicaid payments, with many of the newly insured in Kentucky qualifying for the expanded Medicaid services. The report also cited Medicare payments that are lower than cost of inflation, readmission penalties, hospital acquired condition penalties, cuts to disproportionate share hospital (DSH) payments, and problems with Medicare Managed Care Organizations (MCOs), such as slow, reduced, or denied payments. Additionally, it noted that hospitals are facing reductions in funding unrelated to the ACA, including across-the-board federal cuts.

As a result, Kentucky hospitals have resorted to reducing staff, benefits and wages, and programs and services, according to a survey conducted by KYHA. The survey stated that over three quarters of hospitals reducing programs and services were located in rural areas.

Kentucky Governor Steve Beshear, however, defended the state’s Medicaid expansion. According to the governor’s website, the Medicaid expansion will have a $15.6 billion impact on the state’s economy in the coming years and will create 17,000 new jobs.

It was reported that the governor issued a statement defending the changes to the Kentucky health care system and stated, “We are very aware of the challenges that medical providers face in Kentucky.” He added, “Rather than trying to turn back the clock and return to old business practices, we are working directly with providers to help them develop new strategies for better, more efficient, quality health care delivery.”

Lingering recession impact slowing health spending growth rate

Although health care spending is continuing to grow, the rate of growth has slowed dramatically. U.S. News & World Report has created a new interactive Health Care Index highlighting spending trends in specific health areas. This index hopes to offer a better understanding of the economic effects of spending and shifting payment responsibility. The index’s base year is 2000, and information is available through 2013.

Affordable Care Act

The indexed data ends before the implementation of major components of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). These include individual and employer health insurance mandates as well as state Medicaid expansion. The budget sequester of 2013, which resulted in automatic cuts to government spending, is not accounted for in the index. Experts expect that data will show that the ACA had a mixed impact on overall spending, with premiums rising for the young and healthy but lowering for those who are economically disadvantaged, elderly, or in poor health.

Why the decline?

U.S. News blames much of the slowdown in spending growth, particularly between 2009 and 2013, on the lingering effects of the recession. The trends in the rates of health insurance spending are a prime example. The number of people covered by private plans has decreased since 2000, while enrollment in Medicare and Medicaid has increased. Much of this effect can be blamed on the large amount of jobs lost during the recession, as people lost health benefits and enrolled in Medicaid or remained uninsured.

The index also points to the aging population causing a large shift in coverage. Up to 77 million seniors have moved from private plans to Medicare in recent years. However, this influx of new enrollees lowered the average age of Medicare participants and their overall healthier status caused the rate of Medicare spending to slow. As this group of seniors ages, spending is expected to increase again.

Other trends

As the health care landscape continues to shift, private insurance is making adjustments as well. Those with private insurance have had to contend with higher out of pocket costs, as employers require employees to contribute more to offset expenses. In 2002, less than half of private insurance plans had a deductible. Fast-forward over a decade, and over 80 percent of these plans had a deductible in 2013. Experts warn that the trend of citizens becoming more responsible for their own health care costs will likely continue. The government’s involvement in health care is expected to continue to grow as well.

Is hospital’s success with bundled Medicare payments a sign of things to come?

Baptist Hospital System in San Antonio made a deal with Medicare that changed how it provided care for hip and knee replacements by departing from its old payment system and replacing it with a bundled payment approach, which appears to have lowered costs and shortened hospital stays, according to recent reporting by Kaiser Health News.

Pursuant to the bundled payment deal, Medicare made one payment to Baptist Hospital for knee and hip replacement surgeries to cover all providers for the entire episode of care. If the hospital and the surgeons could lower the costs and maintain quality, they could retain a portion of the savings, thus incentivizing everyone involved to keep costs down. Baptist Hospital and its surgeons took responsibility for the care of the patient for the entire month surrounding the surgery, including rehab. A preliminary study seems to indicate that such bundled payment method resulted in substantial increase in savings, shorter hospital stays, and lower costs for aftercare facilities like nursing homes.

The bundled payment system arises from the Patient Protection and Affordable Care Act (ACA)(P.L. 111-148). As part of the ACA, the Medicare and Medicaid Innovation Center was created for the purpose of testing “innovative payment and service delivery models to reduce program expenditures …while preserving or enhancing the quality of care” for those individuals who receive federal health program benefits. According to Kaiser Health News, the center has a $10 billion budget to launch experiments throughout the country to test methods to fix the Medicare and Medicaid payment systems.

In January of 2013, CMS announced the health care organizations selected to participate in the Bundled Payments for Care Improvement initiative, (BCPI), which was created to test out a new payment model. Under the BCPI, physicians, hospitals and other providers arrange to share a single payment for an entire episode of care, which is a departure from the current Medicare system of providing separate payments for the services furnished by each provider. The bundled payment makes the providers jointly accountable for the patient’s care. It also allows providers to achieve savings based on effectively managing resources as they provide treatment to the beneficiary throughout the episode.

The CMS website details the Bundled Payments for Care Improvement Initiative, which is being tested in the United States. Users can access the data to see where such bundled payment models are being tested.

In the Baptist Hospital example, the first step was to educate providers as to the true costs associated with services and devices they order. As reported by the Kaiser Health News, a participating surgeon, Dr. Sergio Viroslav, doctors commonly do not know of the costs associated with their patients’ care, “The public is like, ‘Wow, you guys have no idea what that costs.’ We never really did.”

Many of the surgeons were unaware that some hardware cost more than others and, thanks to the bundled payment incentives, were more likely to be cognizant of the costs. Also, half of the costs associated with the surgeries were attributable to post-surgery physical therapy, nursing visits and nursing home stays. Now, home rehab is ordered more frequently and any nursing home visits are coordinated in the attempt to avoid hospital readmission. The added incentives resulted in a savings of over $1 million in the first year, according to Michael Zucker, Baptist Hospital’s Chief Development Officer.

It is yet unclear whether this model would work on more complex surgeries, like heart transplants or other types of medical cases, or if it can even be implemented on a larger scale basis. As NPR recently reported, other experiments in coordinating care have seen mixed results. However, the Baptist Hospital experience may offer support for the application of the bundled payment model on a smaller level to individual surgeries or types of services.