Perspective: Information, Inspiration and Advocacy for People Living with HIV/AIDS

Medicaid anage Car

and in general to avoid adding single new
drugs one at a time to a failing regimen.
The old expanded access programs, in effect, encourage such improper use of
therapy by limiting access only to those
people who have reached some arbitrary
and often dangerously low level of CD4+
cells (or high viral load), and who are failing all existing regimens. In effect, the current system provides the drug only when it
is likely to be too late to be of benefit and
when it can't be used properly.
New proposals are calling for elimination
of CD4+ cell and viral load limits as entry
criteria for expanded access. Instead, the
recommended criteria will be to make the
new drugs available to anyone who needs
the drug to construct a viable treatment
combination, as defined in the Federal
Guidelines for the Use of Antiretroviral
Therapy. In addition, the proposals will
strongly encourage collaboration between
programs so that people who need multiple
new drugs can get them at the same time.
By simplifying the entry criteria to these programs, the goal is to make it easier for
people and their physicians to use the new
drugs wisely, at a time when the patient is
able to benefit most and when the drugs
can be combined with one or two other new
drugs the patient hasn't previously used.
Critics who fear that such a program might
be too broad frequently don't understand
that this design still imposes limits. For
example, anyone who hasn't tried many of
the available combinations would still be
denied access because by definition, such
people don't really need the new drug to
create a viable combination. But the new
program model would not deny the new
drug or drugs to anyone who has cycled
through the available combinations, regardless of CD4+ cell and viral load levels.
Despite wide community support, it is not
clear at the time of writing whether the FDA
has sufficiently advanced its own thinking
to permit this approach. *
Expanded Access
Program Numbers: "

Medicaid Managed Care:: A System in Transition
* Medicaid is the nation's primary health care safety net for low
* income people. Although Medicaid budget increases have slowed
dramatically, the program's total operating cost for 1995 was. $156.3 billion, making it a large target for cuts by policy makers and government officials seeking a "balanced budget."

The worst of the proposed reforms have
been defeated this year, but the future of
Medicaid remains a major concern because
* it is one of the most important care pro* grams for people with AIDS. Roughly half. of adults with an AIDS diagnosis and more
than 90% of children with HIV depend on
Medicaid. People with AIDS (and other
chronic and life-threatening illnesses) need
a high level of expert care. Medicaid recipients have had difficulty accessing that care
in the past. If Medicaid fails to meet HIV
health care needs, many people will suffer
and fail to benefit from the recent advances
in AIDS treatment research.
In addition to policy and funding changes,
one of the most daunting challenges in ensuring appropriate HIV care is the rapid
move into managed care. Ironically, this
drive to lower costs by moving to managed
care settings is occurring at the same time
as the development of improved, but more
expensive anti-HIV therapy. These treatment regimens not only cost more, but they
also require more time, support and knowledge on the part of the healthcare provider. and the patient. Complex needs are more
* difficult to meet in a managed care environment where monetary considerations
often restrict access to expensive therapies. and minimize the time healthcare profes* sionals can spend with their patients. As a
result, people with HIV may not be getting
the appropriate diagnostic tests and may
not get adequate information on drug adherence and potential drug interactions.. Mvement
into IMedicaid
Managed Care. Enrollment in Medicaid managed care is
* growing rapidly. Between 1993 and 1996,
* enrollment increased 170%, 33% of that
growth happening between 1995 and 1996.
* As of June 30, 1996, 13 million Medicaid
beneficiaries were enrolled in managed care
* plans, 35% of all Medicaid recipients.. Forty-eight states offer some form of managed care (often called Health Maintenance
Organizations or HMOs); some states have
been able to use the savings to expand their

Medicaid programs. As of 1996, Hawaii,
Illinois, Kentucky, Minnesota, Ohio, Oregon, and Tennessee had received approval
to enact Medicaid managed care programs
that would mandate inclusion of people
with AIDS.
Some HMOs have a good reputation for
HIV care, and some physicians say they are
able to provide quality HIV care in an
HMO environment. However, this is not
always the case and the incentive to deny
access to care or to limit services has also
resulted in many horror stories about managed care. At least one study has shown
that people living with chronic or life-threatening illness do not fare as well under managed care, compared to in fee-for-service arrangements. For people living with HIV/
AIDS the details and methods of implementation of their managed care program can
mean a difference both in quality, and
length, of life.
Since most HMOs are profit-oriented businesses rather than non-profit enterprises,
their goal is to provide adequate service at
the lowest possible cost. The lowered costs
allow HMOs to "sell" health care packages to employers and government for a
lower fee. Competition between HMOs to
offer cost advantages is intense. Consequently, HMOs have a strong incentive to
either carefully limit the number of high
risk/high cost patients they accept, or to
carefully constrain the amount of money
spent on such patients. This makes people
with HIV and other life-threatening illnesses
a problem for most HMO's. Conversely, it
also creates problems for people with HIV
who must get their health care through
HMO's and find themselves constantly confronting the drive to limit costs. Cost is understandably the last thing on the mind of
a sick or dying person.
In the movement to Medicaid managed care
there are both promises and challenges. The
promises are largely directed to the employers and groups who purchase the service
and to the stockholders, while the challenges
are felt mostly by the patients. In theory,
Medicaid managed care could provide more

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