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.”

 

Managed care expansion gets a green light in Missouri

Missouri’s option to expand Medicaid managed care became etched in stone when Governor Jay Nixon (D) signed 13 budget bills on May 8, 2015. Missouri currently has some managed care in place, but this law would expand it statewide and affect hundreds of thousands.

Managed care organizations

Contracting with managed care organizations (MCOs) can allow states to reduce program costs and, hopefully, improve quality of health care. In a study of the effect of MCOs in four different communities nationwide, providers seemed to view the organizations as administrative entities with a limited impact on the quality of the delivery of health care to Medicaid enrollees. According to Medicaid Health Plans of America, managed care plans allow for states to better predict Medicaid expenses as opposed to fee-for-service charges. Pennsylvania reported savings of $2.7 billion over five years due to the implementation of Medicaid health plans. About 267 MCOs serve the needs of states that have chosen to contract with them.

Managed care in Missouri

Managed care in Missouri currently covers nearly 440,000 out of 893,000 Medicaid enrollees in the state. Missouri has three MCOs: Centene Corporation, Aetna, and Wellcare. The counties currently using managed care are located along Interstate 70. Individuals who are disabled, elderly, or blind are exempt from managed care and remain exempt despite the expansion, meaning that only 200,000 of those not currently using managed care services will be shifted away from fee-for-service care.

Effects of expansion

One aspect of managed care involves a focus on preventive services to hopefully reduce the number of expensive emergency room visits. This saves money for the MCOs, as they are paid a flat fee for the management services. However, to save more money, some are concerned that companies limit provider networks with an eye on increasing profit margins. According to Missouri Health Care for All, an advocacy group, Medicaid  members in more rural communities may stand to lose access to doctors.

Managed care in other states

Despite Missouri and other states implementing and expanding managed care, it is not always a popular decision. In the year following the implementation of managed care in Mississippi, the president of the Mississippi Academy of Family Physicians told the Governor and state House committee that the program was “wildly unpopular” and felt that it impaired the physician-patient relationship. On the same day Governor Nixon signed the managed care expansion, Iowa Governor Terry Branstad’s (R) managed care expansion plan hit a major roadblock. His Senate passed a budget that placed several caps on his managed care plan. Among the changes included a cap on MCO profits, creation of a commission to oversee moving from fee-for-service to managed care, a ban on cutting provider rates to find savings., and blocking the closing of two state mental health hospitals. As in Missouri, Iowa advocacy groups and lawmakers feared loss of services and a reduction in the quality of care following a switch to managed care. Branstad felt that his plan would result in an estimated $51 million in savings. The Senate estimated that managed care would save over twice that much.

Other budget bills

The managed care expansion was part of the $26 billion state budget that was sent to the governor’s desk two weeks before deadline. According to local news, the Republican majority was steeled to begin overriding line-item budget vetoes, considering that Governor Nixon cut over $780 million in general revenue last June. Representative Scott Fitzpatrick (R) felt that the budget submitted was “pretty reasonable.” Although Nixon did not veto any line items, he plans to keep an eye on state revenue and withhold money if necessary. The budget included a $12 million increase for higher education and controversial cuts to social programs.

Directed ‘HIT,’ the center of the precision medicine bullseye

The Senate Health, Education, Labor, and Pensions (HELP) Committee held a hearing titled “Continuing America’s Leadership: Realizing the Promise of Precision Medicine for Patients.” The hearing discussed the reality that, with innovative approaches, physicians may no longer need to make treatment recommendations based upon outcomes for an average patient. Instead, precision medicine could be utilized to account for individual differences in patients’ genes, environments, and lifestyles in order to enhance the quality and effectiveness of health care. The hearing covered ways that health information technology (HIT) could be advanced to make precision medicine the norm in order to achieve goals like those set out in President Obama’s Precision Medicine Initiative.

HIT

Dr. Karen DeSalvo the National Coordinator of the HHS Office of the National Coordinator for Health for Health Information Technology (ONC) testified before the Senate committee that “health information technology is the foundation required to bring precision medicine to operational life.” To achieve broad utilization of precision medicine, DeSalvo testified that the nation needs to continue to move forward with plans like the ONC’s interoperability roadmap. To develop the HIT infrastructure, the ONC believes three goals need to be met: (1) develop consistent use of applicable standards for application programming interfaces, health care terminology, implementation, and security; (2) foster an environment of trust and security around individual’s data; and (3) incentivize interoperability.

Testimony

Jeffrey Shuren, Director, Center for Devices and Radiological Health (CDRH) at the FDA, testified that technology will also play a key role in precision medicine through technological medical advancements like Next-Generation Sequencing (NGS). According to Shuren, “An NGS test is capable of detecting the billions of bases in the human genome, and in doing so identify the approximately 3 million genetic variants an individual may have.” As a result, a single use of an NGS test could help diagnose and even predict patient’s risks for countless conditions. Francis S. Collins, the Director of the National Institutes of Health (NIH) added that technology can increase biomedical understanding through “widespread adoption of electronic health records, the recent revolution in mobile health technologies, and the emergence of computational tools for analyzing large biomedical data sets.”

Senators

Senator Lamar Alexander (R-Tenn) criticized what he called the “failed promise” of the EHR incentive program as a barrier to the advancement of precision medicine. Alexander said that the $28 billion drive to increase EHR utilization has not been worth the effort due to complaints of disrupted workflow. Alexander did say that interoperability should remain a goal. Senator Patty Murray (D-Wash) commented that Republicans and Democrats need to work together and invest in “priorities like the President’s precision medicine initiative.” Murray added that while it is important to promote precision medicine, the protection of privacy needs to remain a top concern in light of “serious security breaches impacting families’ personal health information.”

Highlight on North Dakota: Pharmacists take four more steps to provider status

Four new laws are giving pharmacists greater authority in the North Dakota. Republican Governor Jack Dalrymple signed four pieces of legislation, all of which include language granting pharmacists limited provider status.  The North Dakota Pharmacists Association (NDPhA) is celebrating the passage of the legislation as a victory for the profession and practice of pharmacists in the state.

Collaborative practice

Under the status quo in North Dakota, pharmacists have limited provider status when undertaken under a collaborative practice agreement with a physician in accordance with the state’s collaborative practice law. The requirements of a collaborative practice agreement will change under S. 2173, which expands a pharmacist’s role by eliminating the institutional requirement, allowing pharmacists to practice under a collaborative agreement regardless of practice setting. The bill also allows pharmacists to initiate and modify certain drug therapies.

Medication Therapy Management

Another bill, S. 2320, allows pharmacists to conduct medication therapy management (MTM) for Medicaid beneficiaries. The bill specifically considers pharmacists as providers who may provide MTM services in person or via telephone for Medicaid reimbursement. The MTM law will go into effect on January 1, 2016.

Status and prescription authority

The other two bills also grant pharmacists provider status under certain circumstances. Under H.R. 1102, pharmacists have provider status for the purposes of pain programs and services provided under the state’s worker’s compensation law. The last bill, S. 2104, gives pharmacists provider status and limited authority to prescribe naloxone rescue kits, which are used to prevent deaths resulting from drug overdoses.

Testimony

To get the bills passed, pharmacy organizations like the NDPhA banded together to raise awareness about the benefits of increased provider status for pharmacists. Shelby Monson, a 2015 PharmD candidate at North Dakota State University and NDPhA intern, supported the cause by testifying before the North Dakota Health and Human Services Committee. In addition to highlighting the perspective of future pharmacists, Monson testified regarding the role that pharmacists could play in the management of cholesterol-lowering medications, which typically require that a patient have a lipid panel done 4–12 weeks prior to the start of the medication.  Monson explained that “instead of going to the doctor’s office for an appointment and lab tests, the patient would be able to come into the pharmacy and have their cholesterol, LDL, and HDL checked at a pharmacy—and if necessary, the pharmacist could adjust the medication and assess for drug-related effects and [adherence] as well.”