Funded by the Ryan White Program through Baltimore City Health - - PowerPoint PPT Presentation

Funded by the Ryan White Program through Baltimore City Health Department Presented by: Cyd Lacanienta, MSW July 21, 2015

InterGroup Synergy & Planning Collaborative, Inc. for the Greater Baltimore HIV Health Services Planning Council

 Thanks to:

• Members of the PLWH/A Committee, the Continuum
• f Care Committee, and the Comprehensive

Planning Committee

• BCHD Staff
• DHMH Staff
• Panelists
• PC leadership and PC
• PCSO staff

 In 2014, the PLWH/A Committee, the

Comprehensive Planning Committee and the Continuum of Care Committee requested community forums to gather information on how clients are faring with implementation of Maryland health care reform beginning in January 2014.

 Lead committee: PLWH/A Committee  The PLWH/A Committee chose to focus on

the following:

• 1. Ascertaining whether there are barriers to access

to care for PLWH/As in the region

• 2. Providing the community with information on

navigating through the new health insurance landscape

 Lead committees: COCC and CPC  The committees wanted to know:

• The case managers’ perspectives on

 The issues their clients are experiencing related to enrollment in coverage and access to care  The challenges and benefits case managers have encountered in helping clients navigate coverage and care

• The Ryan White administrators’ perspectives on:

 The use of Ryan White funds as the payer of last resort  Client challenges in accessing care

 All attendees were asked to complete a

demographics questionnaire before the start

• f the forum.

 This information provided a baseline of the

population that was participating in the forum.

30 – HIV Positive 65% 16 – HIV Negative 35%

18 – Ages 50-59 7 – Ages 60-69 8 – Ages 30-39 8 – Ages 40-49 5 – Ages 20-29

20 - Male 28 - Female

9 – White, Non- Hispanic 35 – Black, Non- Hispanic 1 – Asian/ Pacific Islander 1 – Multiracial

13 – Live Alone 4- Live with Roommate 21- Live with Family 7 – Live in Funded Housing 1- No Answer

15 – HIV Negative and Not Applicable 29 – HIV Positive and in Care 2- HIV Positive and Not in Care

19 – Yes 31% 27 – No 59%

32 - No 14 - Yes

4 - NA 41 - Yes 1 - No

29 - Excellent 10 - Good 3 - Average 2 - Fair 2 - NA

2 - Yes 41 - No 3 - NA

43 - Yes 3 - NA

 65% of the participants were HIV positive, which

was the intended forum audience.

 Nearly 72% were over the age of 40, and

participants were predominantly black, non-

• Hispanic. This is fairly representative of the EMA.

 More than half of the participants were women.

This is not representative of the epidemic in Baltimore.

 All but two of the HIV positive participants

indicated being in care, but less than half noted having insurance through Medicaid or the Exchange.

 Participants in this session discussed their

experiences with accessing care.

 This particularly focused on trying to get

insurance coverage and problems or challenges with accessing insurance coverage.

 There were 20 total participants in this

breakout group.

1 - NA 19 - Yes

11 - Medicaid 4 - Medicare 3 - MADAP 4 – Private Insurance 2 - Other 2 - NA

Insurance Pre-ACA New Insurance ACA

19 - Yes 1 - NA 3 - Yes 1 - NA 16 - No

3 - NA 15 - No 2 - Yes Access Problems Noted:

• Insurance was flagged

following arrest, and it took

• ver 30 days to obtain

insurance through Maryland Health Connection.

• Application still pending

after 30+ days and there is no way to check status. Lapse in medications and medical coverage. Phone application was faster but is no longer an option.

14 - NA 6 - No

16 - No 3 - NA 1 - Yes

Specialty Care Access Problems Noted:

• Prior authorization is needed

for these services and notification of need is often when client is in specialty care

• ffice.

4 - NA 7 - Yes 9 - No Services Covered by Ryan White as Noted per Respondent:

• 1. Dental, vision, nutrition
• 2. Dental
• 3. Dental
• 4. Dental
• 5. Co-pays
• 6. Co-pays



If they currently have insurance coverage, respondents were asked who helped them get that coverage. No answer options were listed. These are in the respondents’ own words.



Answer by respondent:

1. Case management team 2. Parents 3. Parent, job 4. Myself 5. Employer 6. Case manager 7. Previous employer 8. Employer 9. Case manager 10. Social worker 11. Case manager 12. Social worker 13. Case manager 14. Case manager 15. Social worker

3 – Social Worker 4 - Employer 6 – Case Manager 2 - Family 1 - Self

 Respondents were asked to describe their overall

experience with accessing health insurance to cover their medical needs.

 Responses:

1. So far everything is a green light no problems 2. As a case manager the processes are not smooth 3. I have Medicare 4. No problems or issues at all 5. Great 6. Generally good 7. Excellent 8. I need insurance covering my surgery 9. Good

• 10. Smooth no ripples
• 11. Great
• 12. I am satisfied with my insurance

 All but one respondent had insurance

coverage, and 42% had Medicaid. Few gained new insurance with ACA.

 Largest problem with access to care reported

was amount of time it takes to get coverage.

 For these clients, PAC to Medicaid transition

was smooth.

 Few problems noted once coverage is

• btained.

 Even with insurance coverage, need for Ryan

White is still reported. Particular areas of need for Ryan White noted were with oral health and co-pays.

 Clients rely heavily on the knowledge of their

case managers and social workers to get insurance coverage and access to the services they need.

 Participants in this session discussed their

experiences with medical services.

 This session particularly focused on specialty

care, need for Ryan White and how medical services are covered for clients.

 There were 17 total participants in this

breakout group.

16 - Yes 1 - No

5 - No 12 - Yes

2 – Stomach/ Liver 3 – Physical Therapy 3 - Neurology 7 – Infectious Disease 3- Substance Abuse 1 – Skin Care 6 – Mental Health 2 - Heart 1 - Dietitian 5 - Other

4 - Yes 11 - No 2 - NA Access Issues Noted per Respondent:

• Mental health therapist not

addressing how I learn or retain information.

• Sometimes
• Not enough slots. Insurance

doesn’t cover high co-pay.

• Chiropractor

6 - Yes 11 - No Explanation for Ryan White Access per Respondent:

• Whatever my insurance doesn’t

cover

• In the past
• Co-pays
• Dental and mental health

4 - MADAP 6 - Medicaid 2 – Ryan White 7 – Out of Pocket 2 - Medicare 2 – Private Insurance 1 - Other

4 - Medicare 2 – Ryan White 2 – Private Insurance 6 – Out of Pocket 4 - MADAP 4 - Medicaid 2 - Other

5 – Personal Vehicle 9 – Public Transportation 1 – Family/ Friend 2 – Health Provider 1 - Other

 Respondents were asked to detail positive experiences with

using insurance to cover health care.

 Experiences as noted per respondent:

1. My PCP pays close attention to my needs and addresses them accordingly. 2. Satisfied 3. I can get access to care before it is necessary. 4. My insurance pays for all my medical needs. I struggle to pay co-pays. 5. I get all my meds on time even when I had a red flag on my insurance. 6. Knowledge 7. Insurance follows up with brochures and emails and updates with health care needs. 8. Finances- don’t have to pay for prescriptions. 9. Immunizations are cheaper, along with basics like eye or ear exams. 10. Not very favorable. There are always bills coming in the mail.

 Respondents were asked about their negative experiences

• r gaps with insurance for their health needs.

 Experiences as noted per respondent: 1.

Getting a mental health therapist that is willing to address my needs.

2.

None

3.

When I switched from Medical Assistance to private insurance there was a gap for 5-6 months with no coverage.

4.

It just took too long to get coverage and I was real depressed.

5.

Surgery is needed.

6.

Drug coverage – donut.

7.

Co-pays

8.

My chiropractor. I don’t go any longer.

 94% of respondents have received PMC in

past year, and 71% are seeing specialists. Infectious disease and mental health professionals are the most frequently utilized specialty providers.

 Respondents noted some gaps in insurance

coverage, particularly oral health, co- payments, and mental health.

 29% reported out-of-pocket costs for co-

payments and 25% reported out-of-pocket costs for medications. These are both issues Ryan White can help address.

 Respondent concerns noted once they are on

insurance include gaps in coverage while changing types of insurance, co-payments, and drug coverage. Again, these are instances in which Ryan White can help PLWH/As.

 Participants in this session discussed their

experiences with accessing supportive services, or services the complement medical treatment.

 Particular attention was paid to accessibility

• f these services through insurance and the

need for Ryan White coverage of these services.

 There were 27 total participants in this

breakout group.

27 – Yes

5 - Self 7 – Case Manager 2 – Social Worker 3 - Other 4 - Family 2 - Job

Have Insurance? Who helped you get insurance?

4 - Yes 21 - No 2 - NA New Insurance ACA? Transition Assistance per Respondent:

• Social Worker
• Navigator and housing

services

• My doctor and my case

manager

• Case manager at local

health department

7 - Outreach 9 – Medical Transportation 6 – Psychosocial Support 1 – Referral Services 18 - Housing 9 - EFA 10 – Legal Services 4 – Non-medical Case Management 6 – Food Bank 2 – Treatment Adherence 2 – Substance Abuse Treatment 2 – Health Education 4 - Rehab 3 - Other



Respondents were able to put the supportive services they have accessed in their own

• words. No prompts were given.



Services accessed per respondent: 1. Transitional housing 2. Support groups 3. Rehabilitation services 4. Dental 5. Dental 6. Housing 7. Food bank, EFA, rehabilitation services 8. Now just dentist 9. All 10. Social Services 11. Transportation, food, co-pay 12. EFA financial support, legal services, psychosocial support, medical transportation 13. Medical case management services 14. Health education/risk reduction, psychosocial support, medical transportation 15. Medical transportation 16. Case manager

13 - Yes 9 - No 5 - NA Services Ryan White has Helped Client Access per Respondent:

• Transitional housing
• Dental
• Dental, nutritional, substance

abuse, mental health and legal services

• Prescriptions, dental,

transportation

• Transportation, housing,

support group, case management, dental, EFA, psychosocial, medical transportation, and legal services

• Psychosocial

6 - Yes 17 - No 4 - NA Explanation of Access Issues per Respondent:

• Permanent housing,

psychosocial support

• Chiropractor
• Vision services were not

covered by Medicare

• Specialty services

 Most clients rely on those closest to them and

case managers or social workers for the information they need related to health care.

 PLWH/As have significant need for a variety

• f supportive services, with the most

frequently noted needs being housing, legal services, EFA and medical transportation. 67% noted a need for housing.

 Though they all noted having insurance, 48%

still indicated accessing Ryan White to help meet their needs.

 Respondents noted having accessed Ryan

White for an array of supportive services. Dental services were also frequently mentioned by respondents.

 78% of respondents reported no issues with

accessing supportive services. Many of these same respondents accessed Ryan White for their supportive services needs.

 There is still significant need for Ryan White

following ACA implementation, but the areas

• f need are different than before.

 Most commonly noted core medical services

needs now include oral health, case management, mental health, and co-pay assistance.

 Nearly all respondents were accessing

primary care through insurance.

 The majority of respondents reported some concerns

about payment of medication and/or co-pays. It is important to remember that through ACA and new insurance coverage, many clients are encountering co-pays for the first time.

 Ryan White’s larger role moving forward may be in

providing the supportive services that clients need to complement their medical treatment and keep them engaged in care. Every supportive service offered by Ryan White in this EMA was mentioned as a need at least once.

 50 participants  Representatives from hospital clinics,

community-based organizations, dental clinics, FQHCs, DHMH, local health departments and community

 The gathering was divided into two groups:

• ne for case managers and another for

administrators

 For FY 2016, the Baltimore planning council

PC is likely to seek another waiver from the requirement that 75% of the RW Part A funds be spent on core medical services. With most clients now insured, what needs are you seeing for clients who are newly enrolled in the ACA? Which categories should continue to be funded?

 There are still gaps in health insurance

• coverage. There are often copays, etc., so

patients can still get big bills. Patient costs all add up.

 Issue: youth on their parents’ insurance,

when they have not disclosed their HIV status to the parents.

 Out-of-state college students often have to

stay on their parents’ insurance because they don’t have Maryland residency; can’t get MADAP.

 Many programs have no funding to help

clients with coverage gaps.

 Insurance companies want to discourage

emergency room visits, so charge they charge large emergency-room copays ($200).

 Q2. Are case managers seeing an impact

because of the ACA, e.g., more paper work, more time spent with clients, etc.?

 Reform has resulted in more paperwork and

more time on needed for patient education. Clients are totally reliant of case managers because insurance is too complicated.

 There are long phone waits to talk to

insurers.

 Navigators are useful, but it’s not enough.

Patients tell navigators they understand matters, but really they don’t and then need case managers.

 There is lots of additional care coordination

necessary now; for example, the need to find providers who will accept her patients and who’ll take “after-the-fact” co-pays.

 Ninety-five percent of Medicaid cutoffs are

because of client failure to recertify, but the Maryland Health Connection is vague about what client needs to do.

 Our organization did not realize how much

money would be needed just for all the extra copying and faxing. It’s very expensive.

 There needs to be created a one-stop shop.

Now, there are a thousand different steps. Everything is disjointed.

 There is also an extra burden on clients.

Provider asks clients for loads of extra information, just in case (birth certificates, etc.).

 Q3. How does your program work with young

MSM populations in creating care plans and are any other strategies used?

 The biggest barrier is getting people in the

door to meet a case manager for the first

• time. The clients need to trust the case

managers before we can get them to walk in. Ideas? Maybe queer outreach workers would

• help. Outreach workers should know what’s

going on in LGBT community. We need to focus on young MSM venues.

 Care plans must be fluid. We must be ready

to change it day to day. And we must keep on empowering clients.

 It’s a good idea to have at least one

achievable goal in a care plan. We should permit achievable low-hanging fruit in the plan.

 Q4. How can we establish a maximum

number of clients per case manager?

 We have stopped taking referrals from

• providers. A case manager left and the

remaining ones could not keep up. But many case managers have snuck in extras. It is very difficult to set limits, as a practical matter. We can’t say no.

 A maximum number of clients per case

worker is a good idea. I have 150 clients and that’s too much. People are falling through the gaps.

 Different organizations have different case

management methods, so one-size-fits-all caseload limits may not be suitable for all

• rganizations.

 An organization’s design is important to take

into account. But right now case managers are burning out.

 Average case load ranged from 50 to 400

depending on the organization being represented.

 Could case management programs benefit

from having peer navigators, e.g., PLWH/As?

 I have a peer advocate on staff. Very useful,

especially for support groups, transportation, etc.

 We have to carefully define the roles of peer

navigators.

 It’s important to debrief with the peer

• navigators. You may have to help them set up

barriers between their professional and personal lives because they may know a number of the clients. But it’s a good job

• pportunity for them.

 Do your program case managers work with a

multi-disciplinary team or do you use other approaches?

 We are part of only a small group so it’s quite

easy to set up. The group is composed of doctors, case managers and others.

 We’re moving to “something more

integrated.”

 A third of our case management caseload

goes to the in-house clinic.

 Does your program have down time to catch

up on your paperwork?

 NO

 Should we employ a measurement unit for

Ryan White case managers e.g. 30 minutes and below = 1 unit?

 Should we employ a measurement unit for

Ryan White case managers e.g. 30 minutes and below = 1 unit?

 Provider documents the length of phone calls.

It should be easy to implement a measure. It would be a good idea.

 Who would do the administration to

document all this stuff? It’s a nice idea, but it would be difficult to implement without giving case managers even more work.

 The irony is that we would need more time to

spend time on documenting this stuff. “I don’t have the time to have the time.”

 Clients spend so much time signing waivers

and releases that is very little time for productive case management.

 For FY 2016, the Baltimore PC is likely seek

another waiver from the requirement that 75% of the RW Part A funds be spent on core medical services. With most clients now insured, how do we continue to show the need for RW funds for medical and non- medical services? Which services should continue to be funded? How do we ensure funds are spent?

 Case management is important, particularly

for those who are disenrollment. We have patients who lose their coverage because they do not respond to the re-enrollment.

 Oral health needs; 99% not covered.  Pediatric services, particularly those unstably

housed.

 Co-pays and premiums  RW case management  Low reimbursements for Medicaid

 With insurance coverage, clients now have

healthcare portability, so how do we adapt the RW system to keep clients in care?

 Not completely portable  New concept for some consumers  Covering costs for youths aging to adults  Co-insurance payments  Deductibles  Co-pays  Fortunate to have MADAP  Adherence counseling  There has to be the barebones staff; the

backbone staff

 Health literacy 

 Across the country, we continue to hear that

for many providers about the administrative burden of RW funds. Do you have suggestions on streamlining the RW system in the Baltimore metropolitan area?

 50% who were uninsured were medical

assistance interruptions

 Medicare part B issues  Targeted case management  Possible solutions: a clearinghouse for

eligibility

 Line item for data – 10% indirect cost

 All RW Parts will likely see a decrease in funds

within the next few years. How do you see this affecting services that your organization provides?

 Definitely affects oral health  transportation will go  outreach will go  Already having a hard time with Part D. Half

the money for case management will disappear.

 Innovative stuff like social media  linkage rates will go down  programs will tank  increased transmission

 Some agencies will decide whether this is a

business decision

 Providers are not able to generate enough

revenue to provide services

 Making decisions of deferring until insurance

is covered

 This perpetuates the high rates we can

charge

 An important task for the PC is to plan for

those living with HIV who do not know their status and are not in care. This means that many of those clients will likely be identified

• utside the current RW system in Baltimore.

How do RW organizations connect with providers and clients who are outside the system and bring them into it? (e.g., from a business perspective, this requires a willingness to have formal or informal agreements outside the system such as private practice sites, non-RW hospitals and clinics, etc).

 We start at the academic institution by

educating future private clinicians

 Have agreements with outreach programs