Convergence of the National HIV/AIDS Strategy and the Affordable Care Act: implication for HIV care delivery system in Metro Washington DC

Gregory Pappas, MD, PhDSenior Deputy Director

HAHSTADepartment of Health

District of Columbia

DC Department of HealthMission

• to promote healthy lifestyles, prevent illness, protect the public from threats to their health, and provide equal access to quality healthcare services for all in the District of Columbia.

Overview of this presentation

• The convergence of HIV care and health reform • Current issues for care for HIV, review the

Gardner Continuum for DC• Begin to explain why DC has problems

suppressing viral load• Patient Centered Medical Home• Accountable Community Care and redesign of the

care delivery system• The way forward

Where are we? (1)• Convergence of two great

movements• National AIDS Strategy which

emphasizes suppression of viral load – Treatment is prevention

• Health reform is moving towards establishment of patient centered medical homes for better care of chronic disease– This is happening regardless of

whether insurance mandates continue.

• One point of convergence is an “HIV medical home”

Where are we? (2)

• National leader in fight against HIV and AIDS

• Second highest health insurance coverage in the nation after Massachusetts

• 93% of adults are covered in DC

• 96% of children are covered, number one in the nation!

Where are we? (3)• As an early adopter of

Affordable Care Act, DC can move on to issue of improving the design of the health care delivery system

• DC has shifted over 1000 people off of ADAP onto Medicaid to achieve “treatment on demand”

• Medicaid Expansion– Extends Medicaid eligibility to

every U.S. Citizen with income at or below 133% (tax rate of 138%) of the federal poverty level (FPL)

The National HIV/AIDS Strategy

• Great contribution that has helped focus the field

• The four pillars of the strategy– Reducing HIV incidence– Increasing access to care and

optimizing health outcomes– Reducing HIV-related health

disparities– Achieving a More

Coordinated National Response to the HIV Epidemic

DC is actively scaling up the National Strategy

District of Columbia Continuum of HIV Care*, 2010

*This includes HIV/AIDS cases diagnosed in DC between 2005 and 2009 and living as of December 31, 2010.†Continuous care is defined as having 2 viral load or CD4 test results reported to the DCDOH at least 2-4 months apart. ‡Cases are considered virally suppressed if their last viral load test reported in 2010 was ≤400 copies/mL.

Diagnosed HIV Cases Linked to HIV care as of 12/31/2010

Continous HIV care during 2010†

Virally suppressed during 2010‡

0

1,000

2,000

3,000

4,000

5,000

6,000

4,879

4,172

1,078823

Num

ber o

f HIV

Cas

es

Factors Associated Challenges to Care, NYC

Less Likely to Regular Care*Compared Adj Oddsto Ratio

Blacks Non-Blacks 2.0Ages 13-24Age 50 + 3.0IDU History Non IDU History 2.7

* Regular care ≥1 visit every 6 months

Torian, LV and Wiewel, EW. Continuity of HIV-Related Medical Care, New York City, 2005-2009: Do Patients Who Initiate Care Stay in Care? 2011. AIDS Patient Care and STDS. 25(2):79-88.

Factors Associated Challenges to Care, NYC

More Likely to be Lost to Care*Compared Adj Odds

to Ratio Ages 13-24Age 50 + 1.9Diagnosed at Diagnosed at 1.4Early Stages Later StagesNon-Hospital Designated AIDS1.4Settings Centers

*last visit >6 months before close of analysis

Torian, LV and Wiewel, EW. Continuity of HIV-Related Medical Care, New York City, 2005-2009: Do Patients Who Initiate Care Stay in Care? 2011. AIDS Patient Care and STDS. 25(2):79-88.

Preliminary data in DC on continuous care

• Blacks and persons 13-

19 less likely to be in continuous care

• Black (AOR=1.4, 95%CI: 1.0-2.0 versus White) are less likely to be continuous in care than whites in DC. People age 20-29 years (AOR=0.5, 95%CI:0.2-0.9 versus 13-19 yrs) and 50-59 years (AOR=0.5, 95%CI: 0.2-1.0 versus 13-19 yrs) were more likely to be in continuous care than persons aged 13-19.

District of Columbia Continuum of HIV Care*, 2010

*This includes HIV/AIDS cases diagnosed in DC between 2005 and 2009 and living as of December 31, 2010.†Continuous care is defined as having 2 viral load or CD4 test results reported to the DCDOH at least 2-4 months apart. ‡Cases are considered virally suppressed if their last viral load test reported in 2010 was ≤400 copies/mL.

Diagnosed HIV Cases Linked to HIV care as of 12/31/2010

Continous HIV care during 2010†

Virally suppressed during 2010‡

0

1,000

2,000

3,000

4,000

5,000

6,000

4,879

4,172

1,078823

Num

ber o

f HIV

Cas

es

J O H P E C B0

10

20

30

40

50

60

70

80

90

10099 98

84 83

77 77

53

Difference between DC clinics for percent patients virally suppressed among those on in care and prescribed

RW-funded Clinical Care Providers in DC: reported by clinics

Perc

ent P

erfo

rman

ce

Average: 86%

Percentage of clients on ART, aged 13 years and older, with a diagnosis of HIV/AIDS with a viral load <200 copies/ml at last test between September 2010 and August 2011. Denominator includes clients that had at least two medical visits during the measurement year with at least 60 days between each visit; were prescribed antiretroviral therapy for at least 6 months; and had a viral load test during the measurement year.

13

Patient Centered Medical Home

• Long history traced back to Altamy Declaration

• Barbara Starfield a pioneer

• Emerging as a key strategy in health reform to address chronic disease quality and cost of care

Elements of Patient Centered Medical Home

• There are four core functions – Accessible– Comprehensive– Longitudinal, and– Coordinated care in the context of families

and community.” (National Academy of Sciences, 1996)

Appropriate coordinated care

• The increases in complexity may overwhelm informal coordinating functions requiring a care team that can explicitly provide coordinated care and assume responsibility for the coordination of a particular patient’s care (National Academy of Sciences, 1996). “When you have a home and you don’t make it

home to dinner some one calls you.”

CMS definition of the medical home

17 criteria for medical homes emphasizing written care plans, written protocols to ensure appointments, electronic medical records, referral networks and much more.

http://www.acponline.org/running_practice/pcmh/demonstrations/two_tier.pdf.

CMS Definition

Work in DC is proceeding to better define an HIV medical home

• Building on the basic model• Needs to be clinical expertise

in HIV• Need support services with

HIV expertise• Needs community outreach

customized to HIV infection populations

• Places with low prevalence may need medical home with HIV emphasis versus an HIV medical home A debate in the medical home literature involves the role of specialty care.

Rittenhouse, Shortell, and Fisher. N Engl J Med 2009

Ryan White: An Unintentional Home Builder

• Convergence with long standing work by HRSA (Ryan White) to improve quality of HIV care and the medical home

• HIV has a lot to contribute to medical home particularly related to patients role

Saag, AIDS Reader. 2009;19:166-168

Redesign Needs Investment

• Payment systems driving redesign alone may not be enough to get it right

• Investments to help clinics and CBOs come together may be need

• Local tax dollars in DC “Effi Barry Program” will be used to encourage this redesign

Berensen et. al Health Affairs 2008

What CBOs need to consider

• Strategic alliances with clinics

• Mergers• Performance measures

that demonstrate contribution to care

• Participation in care teams• Contractual agreements

that provide money for services rendered to clinical centers

Medical Home is not a panacea• Risk of becoming a fad and cannot

solve health care’s cost and quality challenges.

• Accountable Care Organizations also being discussed, redesign of larger units than the home.

• Substantial payment redesign, overall health system reorganization, and much more also needed.

• More research on medical home needed– team-based care,– full patient engagement, – optimal use of electronic records – Best way to implement

Kilo and Wasson, Health Affairs 2010Redesign of the health system an important role for the future of public health.

Three kinds of people*

Series10

20

40

60

80

100

120

Some people are excellent patients and have high controlMe and most others. I need a lot of support maintaining my healthMultiple serious prob-lems, serious mental health problems, addic-tion, homelessness

*This is my common sense understanding of different types of patients and levels of care they need.

…

Accountable Care Communities: the missing link?

• Contribution to health reform literature out of University of Akron

• White paper emphasizes need for community based organizations to play role in improving health care quality

• http://www.faegrebdc.com/webfiles/accwhitepaper12012v5final.pdf

Indicators of Adherence to Antiretroviral Therapy Treatment

• Clinical supervision of community based programs increases adherence and viral load suppression

• Without clinical supervision, no improvement

Indicators of Adherence to Antiretroviral Therapy Treatment Among HIV/AIDS Patients in 5 African Countries. Etienne et. al Journal of the International Association of Physicians in AIDS Care, 2010

The mission of the JACQUES Initiative (J.I.) program is to provide a holistic care delivery model that provides

long-term treatment success for urban populations infected with HIV.

Our focus is to decrease the morbidity and mortality associated with HIV illness through care delivery

while providing early intervention services through activities such as testing, outreach and linkage to

care. We are committed to providing a “safe place” for our

clients through delivered services and providing access to clinical research for all. We accomplish this

mission through the Journey To Wellness.

Summary• To reach the potential of

“treatment as prevention” we must improve the care delivery system in coordination with community support.

• The medical home provides a useful model to achieve continuity and comprehensive care.

• Redesign of the health care delivery system should be a top priority for research in DC.