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

May 1, 1997

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.

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

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

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

Study Underway

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

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

The current cohort is 56% male and 44% female. The ethnic makeup is54% African-American, 33% Latino, and 12% Caucasian. Most are between ages30 and 39 (51%), with 9% under age 30 and 40% over age 40. The group includes40% with CD4 cell counts less than 199, 42% with counts between 200 and500, and 18% with counts greater than 500.

Plans Must Provide HIV Drugs

"We hope to show that any managed plan for HIV-infected patientsmust support the unique aspects of this disease as it progresses. The plansshould 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 modelas they develop symptoms and require treatments not usually covered bytraditional managed care programs, he added.

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

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

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