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HIV
Managed Care in the Maryland Health Choice Program [Bartlett
JG and Moore RD. IDCP 2001;10:S25] This
is an analysis of the Maryland Medicaid Health Choice Program, one
of the first Medicaid capitated AIDS programs in the U.S., which
was initiated in July 1997. The capitated rate applies only to patients
with CDC-defined AIDS. The initial rate was $2,161/member/month
based on Maryland Medicaid payments for patients with AIDS in 1995
minus 10% (for Medicaid savings), with a carve out for protease
inhibitors and NNRTIs as "new technology." Sequential
analysis of payment showed minimum variation through 12/31/00 so
rate adjustments were maintained at $2,111 to $2,168/m/m from July
1, 1997 through December 31, 2000. With regard to the Johns Hopkins
Hospital experience, the analysis was provided for Priority Partners
for calendar year 1999 since this is one of two HMOs that serve
the Moore Clinic as well as other care sites within the Hopkins
system. Analysis of data for 11,169 member-months showed that reimbursement
was adequate for patients with AIDS, but the lower rate, which was
based exclusively on co-morbidities for persons with HIV infection
without AIDS, resulted in a $3,259,000 loss.
| Priority Partners
Experience, 1999 |
|
Member-months
|
Revenue
(x $1000)
|
Expense
(x $1000)
|
Difference
(x $1000)
|
| AIDS |
3,805
|
$7,784
|
$7,777
|
+$7
|
| HIV without AIDS |
7,364
|
$4,427
|
$7,693
|
-$3,266
|
| Total |
11,169
|
$12,212
|
$15,470
|
-$3259
|
A third analysis in this report concerned the Moore options program,
which is the Moore Clinic component of the Medicaid Health Choice
program. Analysis of claims for 243 patients with AIDS showed that
14% of patients account for about 50% of all payment claims. Analysis
of these 14% shows a number of comorbidities that contributed to the
high cost, including injection drug use, mental health problems, hepatitis
C co-infection and renal failure. Particularly striking in this group
was the paucity of patients receiving HAART for a variety of reasons
that were medically sound.
Comment: This report provides the three-year follow-up for the
Maryland Health Choice program, which was widely acclaimed as perhaps
the most progressive in terms of risk-adjusted rates at the time of
its inception in 1997. With regard to HIV, the capitated rate was
provided for patients with AIDS, but there was no risk-adjustment
for HIV-infection without AIDS, and this accounted for substantial
losses. This assessment has resulted in the decision to now provide
a risk-adjusted rate for this category as well, a policy that was
implemented July 1, 2001. Despite the enthusiasm at program inception,
the current status is that the Maryland Medicaid Program is about
$150 million in debt, and several of the contracting HMOs have declared
either bankruptcy or their intent to discontinue or limit this service
for purposes of financial survival.
posted
1/18/2002
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