The Science: PrEP

Let's talk about Pre-Exposure Prophylaxis (PrEP). When an HIV- negative individual takes HIV meds (Truvada) in order to prevent HIV, we call it Pre-Exposure Prophylaxis. This biomedical intervention can be used by people in serodiscordant relationships (one person is HIV-positive and the other is not), by men who have sex with men at high risk, and even serodiscordant couples who are trying to have a baby.

You probably have questions about PrEP, I know I do. I'm going to share some resources so we can all get good answers. PrEP is still a relatively new tool for HIV prevention and we are still learning how to make it work best for different types of people. There are still lots of questions. But we do know that when taken consistently and correctly PrEP greatly reduces a person's risk of HIV infection.

What's the science?

Research studies comparing PrEP methods have been done in Asia, Africa, North America (including the U.S.) and South America. There are some demonstration projects going on now to see how PrEP works in the real world for real people in the U.S. and other places. If you want a little more detail on the studies you can check out Project Inform's highlights here.

Men who have sex with men and transwomen

So far there has been one major study that tested the effectiveness of PrEP for men who have sex with men (MSM) and transwomen. The iPrEx study included almost 2500 MSM and transwomen in six countries. Participants were assigned to one of two groups: Truvada with comprehensive HIVcounseling, condoms, STI testing and treatment with HIV testing and a group with the same supports and treatment but who were given a placebo (sugar pill). This study was double-blinded, meaning neither the researchers or the participants knew who received the Truvada or the sugar pill. Results showed that adherence to the daily Truvada regimen was the single most important factor for effectiveness of PrEP. Those in the Truvada group who took the drug regularly enough to have measurable amounts of the drug in their blood were protected up to 92% over the placebo group. But those in the Truvada group who did not take the drug as regularly were only protected by 42%. Daily use (as measured in drug blood levels) protected up to 99%.

Heterosexual men and women

Two studies with heterosexual men and women in African countries showed similar results for those who had high adherence to the daily regimen on Truvada: up to 90% protection. These studies were with serodiscordant couples. More than 4500 hetereosexual adults participated in the Partners PrEP study and 1200 in the TDF2 study.

Studies that tested PrEP effectiveness in women were not as successful as those on serodiscordant heterosexual couples. The Fem-PrEP study with 2100 African women was stopped early because there was no difference in protection between the Truvada group and the placebo group. Later follow-up showed that the drug blood levels in most of the women did not indicate use of the drug as directed. Adherence was actually very low, despite women reporting taking the medicine as directed. Another study of women, VOICE,  had similar issues of adherence. 

There are several possible reasons for the women agreeing to be in the study and reporting adherence to the drugs, even while not complying with the regimen, including: free access to health care, access to Truvada for HIV-positive relatives, financial compensation and other benefits of study participation. We also know that research participants may report behavior they think is the desired answer in order to avoid embarrassment, make the researchers feel good, forgetfulness, or reasons other than dishonesty. This is why whenever possible, researchers use biological markers, like drug levels in blood, to determine the real adherence levels in a drug trial.

Intravenous drug users

One study has been completed testing PrEP effectiveness for intravenous drug users (IDU) in Bangkok, Thailand. These results are complicated because the IDU participants may also have been having unprotected high risk sex while in the trial, so it is hard to isolate if Truvada works for IDU HIV exposure. In this study, 2400 self-identified IDU were assigned either to Truvada or a placebo, with access to support like risk counseling, condoms, HIV testing, etc. Overall there was a 49% reduction in HIV infection in the Truvada group, with 74% reduction in the group that had directly-observed treatment (they took the Truvada in front of a researcher on a daily basis). 

Other resources

So that's some of the PrEP science. There's a lot more coming out all the time, including data on risk behaviors, adherence, effectiveness in real life, etc. Stay tuned for more on PrEP but for now here are a few resources to learn more.

My PrEP Experience - firsthand accounts of people who are on PrEP

Project Inform's PrEP videos - videos on making the decision to be on PrEP, PrEP in serodiscordant relationships and more.

My Life on PrEP - series from Frontiers L.A.

C.D.C.'s Q & A on PrEP clinical research

Notes from the Health Reform and Advocacy Workshop

On October 16, 2013 I spent the day with 20 community leaders, learning about health reform and advocacy. We had an extra special guest, Joe Scarborough from the DE HIV Consortium, who shared some of his inside tips on advocacy. Below I'll share some of my visuals and notes from our discussion on the Myths of Health Reform. You can see all the visuals here.

Health Reform Myths - Busted

People are so confused by what they hear from friends, family, politicians and even the news. They have no idea what is fact or fiction. This list will help bust some of the most popular myths about the Affordable Care Act/Obamacare.

Myth #1: Obamacare takes away freedoms.
Truth: Nobody is forced to buy insurance or do anything else. 
There is a requirement to have health insurance, but there are also several exemptions to this rule including financial hardship, religious objections, and not being required to file a federal tax return. If people choose not to sign up for insurance, they may face a penalty. You can learn more about the penalty here.

Myth # 2: It's a government takeover of health care.
Truth: Obamacare helps people afford private insurance purchased through online marketplaces from insurance companies.
 It is not "single payer" federal health insurance like our friends to the North in Canada have. And let's be frank, we already have "socialized medicine", we call it Medicare. 

Myth #3: Obamacare only helps "those people".
Truth: Everyone benefits from a more fair, affordable health care system. 
Most people will experience lower premiums (over time). Insurance companies will not be allowed to discriminate based on gender, age, or health status. No lifetime or annual coverage caps. Wealthy people (making over $200,000/year) will pay more in taxes.

Myth #4: Obamacare rations health care.
Truth: We already have rationed health care, the insurance companies do the rationing in terms of coverage limits, revoking coverage and preapproval policies.
The Affordable Care Act puts an end to discrimination, denials, and protects consumers by limiting out of pocket spending and deductibles. The law also requires all plans to have 10 essential health benefits which include hospitalization, prescription drugs, labs and tests, mental health  and substance abuse treatment, maternity care, and others.

Myth #5: Obamacare is bad for seniors.
Truth: Seniors have a number of protections, including limits on how much more than can be charged for insurance premiums. 
NO DEATH PANELS. The part of the law that some people referred to as "death panels" was actually a provision that would allow Medicare to pay for end of life counseling for seniors and their families. The counseling would have been provided by the patient's doctor, not some government panel. But due to all the controversy that provision was removed from the final law. 
There will be a reduction in the federal subsidy sent to insurance companies who provide the Medicare Advantage plans for seniors. This subsidy reduction may result in changes in benefits, but will not effect essential services. The federal government made this change to reduce spending in Medicare Advantage, which is more than the spending for traditional Medicare and Medicaid combined.

Myth #6: Obamacare means more taxes and higher premiums for everybody.
Truth: Most uninsured people will save money.
Some people, those who make over $200,000 will have to pay a bit more in taxes. Many people will see reductions in their premiums, thanks to getting a tax break to pay for insurance through the health insurance marketplaces. Women will no longer pay higher premiums than men, neither will sick people. Since most people get their insurance through their jobs (about half of Americans), they won't see much changes, except for the regular fluctuations in premiums from year to year. Here's some more info about the tax changes in the ACA.

Myth #7: Congress is exempt from Obamacare.
Truth: Congress has to buy insurance through the insurance marketplaces too. They don't get some secret fancy plans.

The morale of this story: check your facts. Good places to check are Factcheck.org and Politifact.com. And of course, this little old blog right here. 

And there's always our friends the Youtoons.

Q and A from the front lines: What case managers want to know about health reform

Sometimes I get to go out into the world and learn from our amazing HIV community. On September 24th I got a chance to talk with about 30 case managers, social workers and other front line workers from a variety of HIV providers, health centers, and community organizations. It was a lively discussion about how health reform will help people living with HIV (PLWHA). We also covered some basics in communication; how to talk about health reform so people will understand and feel empowered to enroll in new coverage. You can read some about the communication tips here. I'm just going to cover the big topics and provide some links to my go-to health reform resources. You can also read my past posts about health reform here for more background and HIV-specific information.

Basic protections of the law

We started off reviewing the basic protections of the Affordable Care Act (a.k.a. Obamacare or Health Reform) and how they help PLWHA.
1. Insurance companies can't discriminate based on health status. Nobody can be denied coverage or lose coverage because of a new or pre-existing condition or diagnosis. This means no longer can PLWHA be denied coverage because of their HIV status or any other health conditions. This is big!

2. Insurance companies cannot charge women more for insurance. No more discrimination based on biological sex, everybody pays the same.

3. Essential Health Benefits (EHB) include many services either previously not guaranteed under private insurance or not offered by the Ryan White program. These will help fill in gaps of coverage for many PLWHA. You can find out more about EHB here.

4. No more lifetime caps on spending. Whether you cost the insurance company $100 or $10 million, they can't deny you coverage. Pretty awesome for people with complex and chronic health conditions.

Ryan White and health reform

Many people are wondering what health reform means for the Ryan White program. I can't see the future, but what we do know is this: The Ryan White program will continue as is for now. The long term changes and adjustments remain to be seen, and will depend on how PLWHA in different states fair in gaining health coverage, as well as what gaps and barriers remain that prevent PLWHA from access all the care they need to stay healthy. 

This brief is a good resource explaining how the Ryan White Program will interact and be influenced by health reform. I also wrote a blog post about the future of Ryan White earlier this year, so check that out for some more about Reauthorization.

Medicaid and ACA

Half of the PLWHA who receive Ryan White services (in the Philadelphia region) are covered by Medicaid. So for the most part, health reform doesn't really change anything for those individuals. They continue to be covered by Medicaid for many services, and Ryan White services can offer "coverage completion" to fill in any gaps to care. Just like always. 

Now this is where it gets tricky, the health reform law also allows states to expand Medicaid coverage to include low income adults below 133% of the Federal Poverty Line (about $15,000 for a single person). But states can choose not to expand coverage to those adults. Only half the states have decided to open up their Medicaid programs to low income adults. New Jersey has, and you can read more about it here. As of this writing, Pennsylvania has not. PA's Governor Corbett has offered a proposal for some serious Medicaid reforms (which we will dive into in another post), which he calls Healthy Pennsylvania. You can read the concept paper here. He has included expanding Medicaid eligibility to low income adults. We have at least several months to see what happens with Medicaid in PA. 

ADAP and health reform

NASTAD estimates that about 60% of PA's ADAP (AIDS Drug Assistance Program) clients will transition to a Marketplace plan for health care and prescription coverage. Many ADAP clients will transition from uninsured or under-insured to a Marketplace plan with the help of federal tax breaks to pay for insurance premiums. You can learn more about premiums and tax credits here. Those ADAP clients who do not qualify for enrollment in a Marketplace plan will stay on ADAP and continue to access Ryan White services, as appropriate.  People will not be covered by SPBP (ADAP in Pennsylvania) and a Marketplace plan, one or the other.

Helping clients understand options and enroll

Many case managers and social workers are concerned about their ability to assist clients in the health reform enrollment process. The process seems complicated and there is a lot to know. No doubt we will have some bumps on the road to coverage for all, but we can do it by working together. There are a few ways to offer assistance to individuals and families.

One easy option is to partner with a Navigator agency in PA or NJ. More information about those organizations here.

Your organization can apply to become a Certified Application Counselor (CAC) organization and offer help with the enrollment process to your clients. CMS offers an online training course for CACs, however there is no funding attached to these CACs.

Your organization can also become a Champion of Coverage to help share the news about coverage options. This one is easy, provide brochures and posters in your office, post some links on your website, or tell your clients about enrollment support in your community.

All Ryan White service providers are expected to help with outreach and enrollment for the Marketplaces. This is the top priority of the entire Department of Health and Human Services. 

Resources

Here are some of the best sources on health reform I have found. 

Healthcare.gov - the official place to get all your health reform information, find out about your state's Marketplace, enroll in coverage, print brochures, get live online help, and so much more.

HIVhealthreform - webinars, tools, blog posts, issue briefs - you'll find almost everything you need to know about health reform and HIV at this wonderful website. You should definitely sign up for their newsletter.

Kaiser Family Foundation - newly-updated subsidy calculator, interactive health reform timeline, state Marketplace profiles, and lots more.

Notes from the 2013 Pennsylvania Health Access Network Conference

I am grateful to the folks at PHAN for pulling together an informative conference for PA advocates, providers, and public health wonks like me. We mostly talked about health reform and the Affordable Care Act, with enrollment starting on October 1. Here are some of my notes and impressions. I would love to hear from others who attended.

The conference theme of Cover the Commonwealth informed the whole day's programming. We talked and talked about health reform in PA, including Gov. Corbett's proposal to reform (and expand) Medicaid, Healthy Pennsylvania. We also discussed how to talk to people about health reform and new coverage options. I wrote a separate post about communication tips. You can see all the tweets from the conference at #PHAN13

$467M in #pabudget savings in 2014 if PA does #MedicaidExpansion right away, according to PA #IFO: http://t.co/EEaJyGUo8r. #PHAN13 #pagovt
— PA Health Access (@pahealthaccess) September 23, 2013

Navigators and Certified Application Counselors

Every type of community organization and health care provider is encouraged to have Certified Application Counselors on staff to help individuals and families enroll in the Marketplace. You can find out how to become a Certified Application Counselor organization here. Keep in mind that there will be a delay between application and approval from CMS, I have heard 30-60 days. 

Three of the federally-funded Navigator organizations were on hand to talk about their plans to help enroll every eligible Pennsylvanian. They have some big goals and are going to need help to reach them. These organizations want to work with your CBO or community group, so contact them to set up a time for their navigators to come and help enroll your clients/members.

Resources for Human Development is focusing on the 10 PA counties with the most uninsured people. Philadelphia County has the most uninsured of any county (and the most people). 

Pennsylvania Association of Community Health Centers (PACHC) will support all the Navigators and Certified Application Counselors in the state. 

Mental Health Association of Pennsylvania will also have Navigators in the community throughout the state ready to help enroll people in the Marketplace. 

Medicaid

Ann Torregrosa: We really need to give governor our input on 'Healthy PA' Medicaid proposal. Send comments to RA-PWHealthyPA@pa.gov #PHAN13
— PA Budget and Policy (@PBPC) September 23, 2013

In mid-September, Governor announced his Medicaid reform plan, Healthy Pennsylvania. All we know about the reforms are contained in the concept paper, about 10 pages. So the details are unknown. Included in these reforms would be coverage for low income adults, regardless of health or disability status, essentially it is Medicaid expansion by another name. I can share with you my initial impressions and some of what I learned at the conference. Please remember that this is just a proposed plan, not a reality. The Governor must submit a Medicaid waiver application to the federal government for approval, which will take at least several months. At this point in time, Medicaid is going to work as it has, nothing new for the short term.

Proposed Medicaid reforms include requiring working-age, non-disabled recipients to actively looking for employment and/or enroll in a job training program. This kind of requirement is not allowed under current Medicaid law and is a big task to oversee and administer. Some people are thinking this could be a roadblock to federal approval.

Gov. Corbett would like to remove all co-pays associated with Medicaid coverage and start requiring a monthly premium (bill) based on income, no more than $25/month for an individual or $35 for a household. Many people would pay no premium or very little. 

With these reforms, Gov Corbett argues the state would be able to include more people in Medicaid, including low income adults. These newly-eligible recipients would be enrolled in the insurance Marketplace and given state/federal subsidies to pay for insurance just like other Pennsylvanians buying insurance through the state marketplace. These individuals/families would also be required to pay a monthly premium based on income. The will also have a choice to select a Marketplace plan or the Health Choices plans. 

Other items in the concept paper include a penalty of $10 for "inappropriate use" of the Emergency Room, reduction in the number of benefit packages offered to different categories of Medicaid enrollees from 14 to 2, and no changes to children's benefits under Medicaid/CHIP.

http://t.co/VtDfTvwjpN is a good resource for Pennsylvanians to learn more about coverage options #PHAN13
— Nicole Johns (@PublichealthNDJ) September 23, 2013

I encourage you to sign up for the PHAN newsletter to keep up to date on all the training and events they offer. They will be a great resource for health reform in PA. A member of PHAN will come to your organization to educate your clients or staff. You can also participate in webinars and conference calls.

Big Picture - September 2013

This post is part of a monthly series. It provides an overview of themes and topics from the general meetings and committee meetings of the Ryan White Planning Council and HIV Prevention Planning Group. To view meeting materials and presentations, please visit www.hivphilly.org or check out our SlideShare account.

Ryan White Planning Council (RWPC)

First off, the RWPC's Needs Assessment Committee has new leadership!  Tre Alexander is a first-time co-chair for the committee, and Gerry Keys has returned as a co-chair once again.  During their meeting, the group continued its previous discussions on the current processes used to link newly-diagnosed people living with HIV/AIDS to medical care.  They developed a list of questions for AACO on these processes. 

Meanwhile, the Positive Committee opened nominations for one of its co-chair positions in September.  An election will take place at the October meeting, which will be held on Monday, October 7.  (Both October and November's Positive Committee meetings have been moved to the first Mondays in those months, due to city holidays.)  They also continued talking about their World AIDS Day project recognizing the efforts of local heroes.

The Ryan White Planning Council also opened nominations for one of its co-chair seats this month.  Rich Lampkins' current term as co-chair is coming to an end, and we'll be taking nominations for his position until the October RWPC meeting.  Any nominee has to be a current RWPC member who has been in good standing for at least a year.  The nominee also has to accept the nomination.  You can email me at briana@hivphilly.org if you'd like to throw someone's hat in the ring.  They also approved a 10% increase budget to include with the grant application to the federal government.  We don't expect to actually receive a 10% increase, but it doesn't hurt to ask.  Plus, I gave a short presentation on Pennsylvania's Sunshine Act.

Thanks to the efforts of the RWPC Nominations Committee, the Ryan White Planning Council will welcome several new members in October.  They approved sixteen applications in total, eleven of which were current members that were reapplying for membership.  The new members will go through orientation on October 10, and we're looking forward to having them!

HIV Prevention Planning Group (HPG)

The new HIV Prevention Planning Group (HPG) is still getting their feet wet with community planning until they have their locally-adapted HIV Planning Boot Camp that will be provided by the National Minority AIDS Council next month.  Their September meeting started off with a basic presentation on us, the Office of HIV Planning.  They also watched a CDC Grand Rounds webcast on high-impact prevention, which is part of a series of webcasts the CDC has been doing on public health.  This provided the new HPG members with necessary background information that will help them in months to come.

Points of Integration Workgroup

The Points of Integration Workgroup kept on with its discussion of linkage to care tools for Philadelphia.  They talked about current risk assessments used by HIV testers, and how they might include questions to assess a newly-diagnosed client's readiness to enter HIV care into the whole testing process.  They also had a discussion on partner services, including their place in linkage to care.  They'll finalize the readiness for care tool and determine their next steps during their October meeting.


It's always a great time to get involved in community planning for the Philadelphia area. To learn more, follow the links in this post, attend one of the meetings listed on our calendar, or email info@hivphilly.org to find out how to get involved. If you have questions, you can also call us at 215-574-6760.

What to say when you talk about health reform

Everything I am about to say comes from the great work of Enroll America. Those folks have done the research and pulled it all together so we can use it to make sure all Americans have the affordable quality care they need. So check out all of their resources for everything you need to plan your outreach and enrollment work.

The health reform law is so confusing and complicated. It doesn't surprise me that so many people feel like its just too much to understand, let alone do anything. So I'm going to try to break it down into some simple messages for you to share with people you want to encourage to sign up through the Marketplaces. (If you don't know what a Marketplace is, then start with this fun and simple video.

Some things to keep in mind when talking to people about health insurance:

1. Share personal stories about the uninsured and how health reform helps them be healthy and more secure.
2. Keep it simple and concrete.
3. Make sure the message is targeting the individual. Single people don't identify with messages about families and vice versa.
4. Share your values, like "security", "family", "fairness". Financial and health security are the biggest motivators for the uninsured to seek more information about the Marketplace.
5. There is deep confusion and skepticism among consumers, due to lack of experience with insurance or bad experiences. Be prepared for it.
6. Most people (91%) think that health insurance is necessary or very important.
7. Cost and affordability are the top barriers to coverage for most people.
8. Use examples and dollar amounts whenever possible, rather than percentage or other abstract concepts.

Four messages about health reform that will reach most uninsured people:

1. All insurance plans will have to cover doctor visits, hospitalizations, maternity care, emergency room care, and prescriptions.

This refers to the 10 Essential Health Benefits. You can learn more about them here.

2. You might be able to get financial help to pay for a health insurance plan.

People with income between 100% FPL and 400% FPL (Federal Poverty Line) will be eligible for tax breaks to pay for premiums. There is also help for some people to cover co-pays. You can learn more about ways to make health coverage affordable here.

3. If you have a pre-existing condition, insurance plans cannot deny coverage.

Health insurance companies cannot discriminate against anyone based on health status or pre-existing conditions, including HIV, cancer, diabetes, or any other chronic condition or infectious disease. More on these protections here.

 
4. All insurance plans will have to show the costs, and what is covered in simple language with no small print.

The health care law requires all coverage information to be simple, clear and comparable. So you can compare plans for the different services, doctors, and limits. No small print allowed.

Healthcare.gov is the place to go to learn about the Insurance Marketplaces and how to access insurance. Here's a great place to start to figure out what kinds of information you need to enroll and how to compare your options.

The (PA) State of HIV Planning: A report back from the September 2013 PA HPG meeting

This week, I had the privilege of attending the PA statewide HIV Planning Group (HPG) meeting.  Pennsylvania has a new integrated planning body that includes both HIV prevention (for all counties except Philadelphia) and HIV care (for the whole state).  This overlaps with our local care planning for the five counties in Southeastern PA.  You can read a little more about this, plus get the meeting schedule, on the PA HPG's website.




PA HPG meetings take place outside of Harrisburg.
Photo Credit: JasonTromm via Compfight cc

Members of the PA state HPG are from all over Pennsylvania, so the group conducts its business over the course of two-day meetings held every other month.  This cuts back on travel time and expenses, and gives the group a lot more time to work together.  These meetings include sessions with the entire body, as well as smaller breakout task groups each day to dive into meatier issues.  I live-tweeted the PA HPG meeting. If you're interested in a play-by-play, you can search hashtag #PAHPG over on Twitter.

The first day started off with reports back from each of the three task groups: one that deals with membership issues, another dealing with priority setting and resource allocations, and a third that plans needs assessments.  Note: This structure will shift in January, but that's what it looks like for now.
 
After updates, we broke into task groups.  I sat in with the priority setting and resource allocation group on the first day.  Their requirements are a little bit different from what I'm usually involved with, because the care funding comes through Ryan White Part B.  For Part A funding (what we get in the Philadelphia Eligible Metropolitan Area, or EMA), the planning body is required to both set service priorities and allocate/budget money for these services.  (You can get a refresher on the Philadelphia EMA Part A process here.)  On the state, Part B level, the planning body does not have to make the budget, so the task group focused largely on the priority setting process.  They had an extensive conversation on the type of data and information the PA HPG would need in order to make its decisions, planning out almost a year's worth of presentations.  They also briefly discussed the process itself, which will have some parallels to the Philadelphia EMA's process.
 
Later on, the whole PA HPG reconvened to talk about their new protocols, which were similar to what we call bylaws for our planning bodies here.  HPG members were asked to review the protocols for changes.  The HPG also got an introduction to the three new HIV data managers at the Department of Health.  These new positions include one data manager each for care, prevention, and the Special Pharmaceutical Benefits Program (SPBP). 
 
Last on the HPG's agenda was concurrence for the statewide HIV prevention 2013 interim progress report and 2014 grant application.  This document gets sent to the CDC, and the CDC then uses the document to decide how much prevention money the state will receive.  It includes changes, successes, and challenges to prevention services and the planning process itself.  It also includes special projects and relatively detailed budgets.  The document is 62 pages long, with around 72 pages of appendices.  I actually read the whole thing - the most notable part for me was about a special demonstration project called Project Silk.  Project Silk is a drop-in program geared toward minority LGBTQ ball youth in Pittsburgh, and has had some pretty remarkable results.  They've managed to reach a challenging population, and they are using a peer navigator program.  I'm looking forward to hearing more about the project at future meetings.  The PA HPG did ultimately concur (or agree with) the application after hearing a very thorough presentation, and that was the last item on the first day's agenda.

Day two was much shorter, and we broke almost immediately into task groups.  On the second day, I decided to move over to the needs assessment group.  If you're not familiar with the term "needs assessments," it just refers to ways that we can figure out what people need, like surveys, focus groups, town hall meetings, and other similar activities.  The task group wants to look particularly at people who are "late-testers," meaning that they aren't diagnosed with HIV until they're already sick, so they're diagnosed with AIDS at the same time.  They also want to find out more about provider capacity - essentially, whether the providers have room for more clients.  Plus they're planning to gather as much data as possible from sources like SPBP and partner services to help them plan their needs assessments.  We're going to be sharing our data with them to help with this process.

Later on, the whole PA HPG got back together for task group reports.  While I was with the needs assessment group, the priority setting and resource allocation task group continued talking about the tool in the context of the whole process.  They also further refined their presentation schedule for 2014, and talked about having a more unified priority setting process that would get input from many local consumer groups.  I offered to speak with our own Positive Committee about the process when they had more information.  Then we heard from the membership task group, which plans to have an ongoing orientation process that includes mentorship.  They requested that the Department of Health have the application materials translated into Spanish.  They're also looking for more HIV-positive consumer members.



The new Kenneth McGarvey fashion line


Last on the agenda was the final approval of the HPG protocols, including any updates.  Once that was taken care of, there was a small surprise.  Ken McGarvey, the director of the HIV/AIDS Division of the PA Department of Health (DOH), created a model of the care continuum that pops its head into many of the DOH's documents.  At the end of the meeting, there were surprise t-shirts immortalizing the famous "McGarvey HIV Service Model."

A steering committee meeting followed the main meeting, but it was time for me to head back to Philadelphia.  I'm looking forward to attending the next PA HPG meeting, and excited for increased collaboration between our planning bodies and the PA statewide group!

Big Picture - August 2013

This post is part of a monthly series. It provides an overview of themes and topics from the general meetings and committee meetings of the Ryan White Planning Council and HIV Prevention Planning Group. To view meeting materials and presentations, please visit www.hivphilly.org.

Ryan White Planning Council (RWPC)

As you might remember, the Ryan White Planning Council hosted its annual regional allocations meetings in July.  Each of the three regions in the eligible metropolitan area (EMA) did some contingency planning for the 2014 - 21015 fiscal year.  (See each region's plans in last month's Big Picture.)  In August, the Finance Committee and then the RWPC took a look at those plans and voted to approve them.  Once we receive the actual grant award from the federal government, the RWPC will use those plans to decide how to allocate the money.  You also might remember the service priority list that the RWPC approved in July, and how the RWPC agreed to go back and look at the list again.  After reviewing the new Part A manual, the Comprehensive Planning Committee updated the factors used for the priority setting list and ran the numbers again.  The RWPC ultimately approved the new service priority list for the 2014 fiscal year.  Last, but not least, the RWPC decided to eliminate term limits for RWPC members in order to ensure continuity through changes related to the Affordable Care Act.  RWPC members were previously limited to serving three consecutive two-year terms.  Current members are still required to reapply for membership every two years.

Some of the committee-level work has already been discussed.  The Comprehensive Planning Committee also talked about the potential need for technical assistance (in other words, training and support) for HIV providers, specifically about health reform.  In addition, they discussed family planning, and permanently moved their meeting date to the third Thursday of the month at 2 p.m.  Meanwhile, the Needs Assessment Committee continued its work on a provider survey on linkage to and retention in care for newly-diagnosed clients.  They've also had vacancies for both committee co-chair positions; in August, Tre Alexander and Gerry Keys were nominated, and elections will be held in September.  The Positive Committee talked about World AIDS Day projects, and will continue working on those throughout the fall.  (Note: The Positive Committee moved its September meeting to Monday the 16th at noon.)  Finally, the Nominations Committee talked about membership vacancies, committee attendance, and updates to the RWPC application.

HIV Prevention Planning Group (HPG)

The newly-formed HIV Prevention Planning Group held its second meeting in August.  Concurrence was major item on their agenda for the month.  "Concurrence" refers to a process required by a CDC, as a part of Philadelphia's prevention grant.  Basically, the HPG was asked to vote on whether Philadelphia's HIV prevention plan reflected the current HIV prevention system, and whether prevention resources were being spent in the geographic areas and on the populations of greatest need.  The HPG voted to concur with the plan.  They also talked about potential dates for a special training from the National Minority AIDS Council.

Points of Integration Workgroup

The Points of Integration Workgroup's discussion on linkage to HIV care for those newly diagnosed with HIV continued in August. They talked about the group's purpose and work plan for the coming months, and reviewed a draft treatment readiness tool that could be used by HIV testers and then provided to linkage coordinators.  They also learned that the previously-discussed Anti-Retroviral Treatment and Access to Services (ARTAS) model had been included in the new Philadelphia prevention system Request for Proposals (RFP).



This is a great time to get involved in community planning for the Philadelphia area. To learn more, follow the links in this post, attend one of the meetings listed on our calendar, or email info@hivphilly.org to find out how to get involved. If you have questions, you can also call us at 215-574-6760.

Quick Notes on the Uninsured

I was lucky enough to be a part of a 2-day training on health reform (Affordable Care Act/Obama Care) earlier this month and got some great information and resources that I will be sharing with you faithful readers over the next few blog post. Most of the information I'll share is collected and provided by Enroll America, a nonprofit dedicated to making sure every uninsured American knows about the increased coverage options under the ACA. You can find all sorts of community and consumer education materials at Get Covered America. Let's start off with understanding who are the uninsured and how we can reach them.

Guess how many uninsured Americas know about the expanded coverage options under health reform (ACA, Obama Care)?

22%. 78% of uninsured Americans have no idea of their expanded coverage options under health reform. They have no clue. We have to change that.

Graphic from Enroll America Presentation Materials.

Who are the uninsured?

Minorities in America are more likely to be uninsured than are Whites/Caucasians. Men are more likely to be uninsured than women. People living in poverty are more likely to be uninsured than those with more income, with an exception being those working but earning low income, who earn too much for safety net programs and not enough to make health insurance affordable. These low income workers also often work jobs part time or their employers do not offer health insurance. Most people who are uninsured are not uninsured by choice. They do not health insurance either because they can't afford it or because they are excluded because of a previously diagnosed health condition (diabetes, heart disease, HIV, cancer, etc.). Many have been uninsured for more than 2 years (67%).

How do people feel about insurance?

Almost all the people surveyed by Enroll America thought health insurance is important (91%). Cost and affordability are the biggest barriers to health insurance for people. Many of the uninsured have shopped for insurance in the individual insurance markets, outside employer offered insurance (44%). They found this experience stressful, confusing and frustrating. They want health insurance, for financial and health security, but have no real options under the current system.

How do we reach the uninsured?

People have some misconceptions about the uninsured, one might be that they are not online because of affordability or access to technology. We can see by the graph below, that the uninsured are using the internet and smart phones just like other Americans. We can use social media and technology to reach different segments of the uninsured to get the word out about enrollment and insurance coverage options. 

But even well-connected and savvy internet users prefer to do somethings offline. Shopping for and enrolling in insurance is one thing many prefer to have in-person assistance with, rather than to go it alone online. According to Enroll America's survey, 75% of uninsured people who are newly eligible for coverage would prefer in-person assistance for enrollment.  So this is where Certified Application Counselors, Navigators and other in-person assisters are going to be key to getting all eligible Americans enrolled in health insurance.

In our next installment we will explore the messages that will work best to help people get informed and enrolled. 

 

Quick Notes: HRSA webinar on outreach and enrollment and policy clarifications

This webinar was one of a series by HRSA to offer clarifications on how the ACA (health reform) affects Ryan White grantees, consumers and providers. The focus of this webinar was on how Ryan White programs can support outreach and enrollment for the state Marketplaces, and the two policy clarifications released earlier this summer on Ryan White consumer certification (13-02) and Ryan White eligibility of Medicaid-eligible clients (13-01). I encourage you to take the time to listen to the whole webinar (less than an hour), because these are my key take-aways. You may find other points more relevant or important.

Ryan White is the payer of last resort. Always. 

Ryan White providers and grantees are expected to help clients review eligibility and enroll in appropriate health insurance coverage (Medicaid, Marketplace plans, etc.)

• HRSA expects grantees to "vigorously pursue" enrollment in insurance for their clients.
• Ryan White grantees and planning councils should reconsider their priorities and allocations to include support for ACA-related outreach and enrollment activities.
• Outreach education, enrollment and benefits counseling can be provided under several Ryan White service categories: medical case management, early intervention services, care outreach, non-medical case management, health education and referral for health care and support services. More details from HRSA can be found here and here.  

Ryan White will continue to offer "coverage completion" and "wrap around services" for Medicaid eligible consumers. 

• Includes those currently eligible (covered) and those who will become eligible through the expansion of Medicaid eligibility in some states.
• Ryan White funds can cover services not covered or partially covered by third-party payers (Medicaid, private insurance, etc.). This means services, not money. If a provider can bill a third party for a service, then that is the reimbursement for that service. Ryan White cannot be billed for the same service. If the client's coverage has limits on the number of visits/units or specific activities, then Ryan White funds can pay for the services/activities not covered (the underinsured). The amount of third-party reimbursement does not affect "payer of last resort" requirements.
• Medicaid should be back-billed for eligible services. Any reimbursement received from Medicaid for services previously paid for Ryan White should be applied to HIV programming.

Clarifications about Ryan White client certification and re-certification requirements.

• Ryan White clients must be certified for eligibility for Ryan White services, with re-certification no less than every 6 months. 
• Criteria for certification include low income as defined by the grantee and HIV+ status.
• Information required for certification process include: residency, HIV status, income, and insurance. HIV status does not need to re-confirmed after initial certification. Once a year a client can be re-certified without producing documented proof of income, residence, insurance status. However, any changes in status should be documented. 
• Grantees should make an effort to align certification processes with Medicaid eligibility re-certification processes to reduce burden on clients and providers.
• More info on HRSA and CMS collaboration can be found here.
• More info on Ryan White client eligibility determination can be found in HRSA policy clarification 13-03

The Big Picture - July 2013

This post is part of a monthly series. It provides an overview of themes and topics from the general meetings and committee meetings of the Ryan White Planning Council and HIV Prevention Planning Group. To view meeting materials and presentations, please visit www.hivphilly.org.

Ryan White Planning Council (RWPC)

The Ryan White Planning Council had an action (item)-packed meeting in July.  They started off the meeting by approving their allocations (budget) for the fiscal year, since the eligible metropolitan area (EMA) finally received its grant award - even though the fiscal year started on March 1.  Their first order of business was to approve budgets for the rest of the year.  Then they updated a couple of formal processes, starting with the resource allocation process.  The RWPC used to make advance plans in case the EMA got level funding, a 5% decrease, or a 10% increase.  But, given everything happening in Washington, D.C., they decided to stop planning for a 10% increase, and starting planning for a 10% decrease instead.  They also changed their reallocation process, which is what they use when a service can't spend all of its budgeted money.  The AIDS Activities Coordinating Office (AACO) has to follow the budget set by the RWPC, but they've always been able to move up to 5% of the money in a service in or out without clearing it first.  In July, the RWPC increased this to 10%, since there are so many changes happening.  Then, after all of that, the RWPC voted on the draft list of service priorities that was created by the Comprehensive Planning Committee.  The RWPC approved the list, but there were still some questions about the priority setting tool.  Everyone agreed to talk about the list again at a future meeting.

Most of the work at the committee level in July was spent preparing for that one busy RWPC meeting.  The Comprehensive Planning Committee met to go over their priority setting list and process; the Finance Committee voted on FY2013 allocations and updated the two process documents that they presented to the RWPC.  The Finance Committee also talked about the upcoming regional allocations meetings to plan for FY2014 - more information on the decisions from those meetings can be found below.  The Needs Assessment Committee didn't meet, and the Positive Committee got an update on everything happening at the RWPC meetings.  They also learned more about the allocations process so they could better participate in those meetings.

 

Allocations Meetings

Every summer, the RWPC hosts three regional allocations meetings.  The Philadelphia EMA is made up of nine counties - four suburban PA Counties (Delaware, Chester, Montgomery, and Bucks), four New Jersey Counties (Gloucester, Salem, Camden, and Burlington), and Philadelphia itself.  The RWPC knows that each of these three regions has different needs, so they all budget separately.  These allocations meetings are held far in advance - the July 2013 meetings were for planning for the fiscal year starting on March 1, 2014.  This way, when the EMA finds out how much money they're actually getting from the federal government, there's already a plan in place.

This year, each region planned for what they would do if the EMA received level funding (the same amount as last year), a 5% decrease, or a 10% decrease.  They also have the option to provide instructions to the grantee (AACO).  The RWPC will vote on these plans and any instructions at their August 8, 2013 meeting.  The decisions from the meetings are here:

Philadelphia
Level-funding budget: Philadelphia chose to fund services at the same level under a level-funding budget.

5% decrease budget: Philadelphia chose to spread a 5% decrease proportionally across all service categories (based on their level-funding budget).

10% decrease budget: Philadelphia chose to fund supportive services at the same level as the 5% decrease budget, spreading the decrease proportionally across all other service categories.

Instructions to the grantee: Philadelphia would like the grantee to investigate the non-Part A funding streams available to each service category.

PA Suburban Counties
Level-funding budget: Due to funding shifts within the EMA, the PA Counties would receive an increase if the EMA received level funding.  The PA suburban counties chose to spread the increase proportionally across all service categories.

5% decrease budget: The PA suburban counties chose to spread a 5% decrease proportionally across all service categories (based on their level-funding budget).

10% decrease budget: The PA suburban counties chose to spread a 10% decrease proportionally across all service categories (based on their level-funding budget).

Instructions to the grantee: None.

New Jersey Counties
Level-funding budget: The New Jersey counties chose to keep all services funded at the same levels in the case of level funding, with the exception of medical case management.  Due to funding shifts within the EMA, New Jersey would receive an additional $43,463 if the EMA received level funding.  The New Jersey counties agreed to place the entire amount of this increase in medical case management.

5% decrease budget: The New Jersey counties chose to spread a 5% decrease proportionally across all service categories (based on their level-funding budget).

10% decrease budget: The New Jersey counties chose to spread a 10% decrease proportionally across all service categories, with the exception of legal services, which would not receive a reduction (based on their level-funding budget).

Instructions to the grantee: None.

HIV Prevention Planning Group (HPG)

The new HIV Prevention Planning Group (HPG) met for the first time in July.  Welcome to the first twelve members!  The HPG took the place of the PPG, and will focus on gathering community input on Philadelphia's plan for HIV prevention.  For their first meeting, the new HPG got a presentation on Philadelphia's HIV prevention plan from AACO's Coleman Terrell.  Jen Chapman also talked about the concurrence process, explaining that the HPG would have to vote to either concur with the plan, concur with reservations, or not concur at all.  The HPG also voted to keep former PPG community co-chair Jen Chapman in her position on the new HPG.

Points of Integration Workgroup

Members from both the care and prevention planning bodies come together for the Points of Integration Workgroup.   In July, they continued their conversation about how to improve linkage to HIV care for those newly diagnosed with HIV.  They talked about programs in other areas, including Washington state and Lousiania, which were addressed in a webinar by the HIV Prevention Justice Alliance.  They also talked about the Anti-Retroviral Treatment and Access to Services (ARTAS) model.  One of the major points from the meeting was a need to develop clear and consistent messages so that people being tested for HIV would know that they could access free care at their choice of provider if they found out they were positive.



This is a great time to get involved in community planning for the Philadelphia area. To learn more, follow the links in this post, attend one of the meetings listed on our calendar, or email info@hivphilly.org to find out how to get involved. If you have questions, you can also call us at 215-574-6760.