Patient advocacy groups and Medicaid officials sharply disagree on whether HIV/AIDS patients are receiving adequate access to specialists and medications as states increasingly shift this population from traditional Medicaid to Medicaid managed care.
As more HIV/AIDS patients enroll in Medicaid plans, they “are seeing a lot more barriers in terms of access to medications,” said Andrea Weddle, executive director of the HIV Medicine Association, a trade group for providers who practice HIV medicine. Specifically, beneficiaries have been less able to access the drugs they used to get, or get the dosages they were used to getting, he said. “This puts them at risk for not being as adherent to treatment,” he said.
Another recurring issue is that HIV patients who shift to Medicaid plans no longer can claim their infectious disease specialists as their primary-care providers, she said. So they must find a general primary-care provider, then get referred back to their longstanding specialist, assuming that doctor is in the plan's network.
“This is disadvantageous to the client,” said Alexandra Remmel, a health advocate and assistant director at the Gay Men's Health Crisis, a not-for-profit AIDS service organization based in New York City. “Someone who is HIV-positive usually looks at their HIV specialist as their main doctor, and anyone else as white noise.”
But Medicaid plans say HIV/AIDS patients are receiving appropriate care in their networks. "Medicaid health plans are committed to serving the unique health needs of those with HIV," said Jeff Myers, CEO of Medicaid Health Plans of America, which represents Medicaid plans. "States like California, Florida and New York have HIV specialty managed-care plans that provide all the same services as regular Medicaid, as well as those which support wellness like housing, peer support and legal assistance."
“Managed-care plans ensure access to care,” said Wayne Turnage, director of the Washington D.C. Department of Health Care. “Getting a specialist in D.C. as someone on fee-for-service can be awfully difficult.”
He said his department hasn't received any complaints from HIV/AIDS patients on their care in Medicaid managed-care plans. About 1,500 HIV-positive beneficiaries have opted out of managed Medicaid care since 2002, he said. D.C.'s Medicaid program oversees the care for 9,000 HIV-positive people.
Medicaid is estimated to cover half of all people with HIV/AIDS getting care in the U.S., with an enrollment of more than 230,000 beneficiaries infected with the virus as of 2013, according to the Kaiser Family Foundation. As many as 50,000 additional Americans with HIV were expected to join Medicaid as the result of expansion under the Affordable Care Act. Federal Medicaid spending on HIV/AIDS has steadily increased over the past few years, from $4.4 billion in fiscal 2009 to $6.2 billion in fiscal 2014, according to federal data.
States increasingly are transitioning Medicaid beneficiaries with HIV/AIDs from fee-for-service Medicaid to managed-care plans. These patients traditionally were exempted from managed care or given the option to voluntarily enroll in a Medicaid plan because of their complex medical needs.
In California, most of the doctors with HIV/AIDS patients in fee-for-service Medicaid are seeing patients in managed care, and drug benefits continue to be carved out and overseen by the state, ensuring access to prescriptions, said Anne Donnelly, director of public policy for Project Inform, a patient advocate organization.
Other observers say the switch to Medicaid managed care ensures a more holistic care experience compared with fee-for-service. “Managed care is providing folks more comprehensive coverage,” said Amy Killelea, senior manager for healthcare access for the National Alliance of State and Territorial AIDS Directors, a national advocacy group. “They are being connected to both medical and non-medical support.”
But in Washington, where Medicaid managed-care enrollment is optional for beneficiaries with HIV/AIDS, the Whitman-Walker Health, a community health center, steers patients away from managed care. “We do take advantage of that (permission) and opt most of our HIV-positive patients out,” said Erin Loubier, senior director for health and legal Integration and Payment Innovation at Whitman-Walker. “It is easier to be in a fee-for-service model so you are not required to obtain a referral for specialty services.”
One way care could improve in managed care is if there were HIV/AIDS-related quality metrics on which states or the federal government evaluated plans. “While states are looking at outcomes related to diseases like diabetes, they are not looking at HIV quality measures,” said John Peller, CEO of the AIDS Foundation of Chicago. “In many cases, we find that plans aren't paying attention to people with HIV because there are neither incentives nor disincentives for them to do or not to do so.”