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New York Leads the Way in Getting HIV Medicaid Patients into HMOs

New York Leads the Way in Getting HIV Medicaid Patients into HMOs

BUFFALO, NY--The Medicaid Managed Care Act of 1996 and the pending 1115B waiver in New York State would mandate that all Medicaid recipients be transferred to managed health care plans. (Such transfers are currently voluntary.) In New York State, more than 65% of persons with HIV are either in Medicaid or are Medicaid-pending.

"New York will be implementing a program of managed care for persons with HIV disease that is unparalleled by any other pending or existing program in the country. We estimate that there are 100,000 to 140,000 potential enrollees once managed care is mandatory," David Jemiolo said at the HIV, Cancer & the Family conference, sponsored by Roswell Park Cancer Institute.

Similar plans for HIV managed care programs in Los Angeles, Boston, and Maryland will be enrolling substantially fewer numbers, said Mr. Jemiolo of the AIDS Institute, Division of HIV Health Care, State of New York Department of Health

Study Underway

The enrollment of HIV Medicaid recipients into managed care has promoted the creation of a Special Needs Plan (SNP). To create a working SNP model, the AIDS Institute is coordinating a multifaceted study. One phase will attempt to determine HIV-disease-related costs to create a capitation schedule and another will examine patients and their needs during their illness progression.

Currently, 424 patients are included in the cohort. They have been selected to be studied as they transfer from fee-for-service to managed care, and will be interviewed about their access to care, quality of care, and quality of life.

The current cohort is 56% male and 44% female. The ethnic makeup is 54% African-American, 33% Latino, and 12% Caucasian. Most are between ages 30 and 39 (51%), with 9% under age 30 and 40% over age 40. The group includes 40% with CD4 cell counts less than 199, 42% with counts between 200 and 500, and 18% with counts greater than 500.

Plans Must Provide HIV Drugs

"We hope to show that any managed plan for HIV-infected patients must support the unique aspects of this disease as it progresses. The plans should provide or create access to services specific to HIV treatment, including new and experimental drugs," Mr. Jemiolo said.

People in earlier stages of the disease may most benefit by this model as they develop symptoms and require treatments not usually covered by traditional managed care programs, he added.

In 1995, outpatient Medicaid claims among HIV patients averaged $2,084 per patient versus $27,727 for inpatient claims.

According to data from the New York State AIDS Institute, the costs of treating HIV are driven by a few high-cost patients. Dr. Jemiolo said that 50% of the HIV population accounted for only 13% of the total HIV Medicaid inpatient dollars spent in 1995 while, at the other extreme, 3.3% of the HIV inpatient population (ie, those utilizing over $100,000 in health care cost per year) accounted for 15% of the HIV Medicaid monies available that year.

"HIV is a drastically different disease at different stages of the disease," Mr. Jemiolo said. "The bulk of the money supports the patients with low CD4 levels. We will need to closely monitor enrollment to ensure that this is a fiscally sound program and to maintain the quality of care."

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