Engaging Medicaid Managed Care Plans on HIV

Anna Person: [00:00:11] We are excited to welcome you to the HIV Medicine Association's podcast series, Let's Talk HIV: Why Medicaid Matters. As you'll recall, this podcast series covers the ins and outs of Medicaid, which is the federal health care program that provides care for millions of low-income Americans. I'm your host, Dr. Anna Pearson, an infectious disease doctor at Vanderbilt University Medical Center and an HIVMA member. For this episode in the series, we're going to dive deep into Medicaid managed care plans and how these plans can partner with HIV clinicians to provide quality HIV care and treatment. To do that, we are thrilled to welcome two guests today who are experts in this area. Jenny Babcock is senior vice president for Medicaid policy at the Association for Community Affiliated Plans, or ACAP. ACAP is the national trade association that represents not for profit safety net health plans, including Medicaid managed care plans.

Jenny Babcock: [00:01:18] Hi. Thanks very much for having me, Anna.

Anna Person: [00:01:21] Next, we have Doug Wirth. Doug is the president and CEO of Amida Care, a Medicaid managed care plan in New York that specializes in providing comprehensive health care coverage for Medicaid members with chronic conditions, including HIV and behavioral health disorders.

Doug Wirth: [00:01:37] Thanks. It's great to be with you.

Anna Person: [00:01:39] We're so glad to have you both here. Let's start talking about this topic. Jenny, I want to start with you. We'll start at the beginning. Can you explain to us what is Medicaid managed care and how are Medicaid managed care plans a part of the Medicaid delivery and payment system for HIV care?

Jenny Babcock: [00:02:02] Managed care is, simply put, a health care delivery system that allows for the delivery and the coverage of health benefits and additional services through contractual arrangements. So a state Medicaid agency, in the case of a Medicaid MCO, will have a contractual arrangement with the health plan, otherwise known as an MCO health plan. Under that contract will accept a set dollar amount. What's called it's called a per member per month, or a capitation payment for covering all of those needed services. For people who are eligible. Right now, managed care is the dominant delivery system in Medicaid. The Medicaid program at the moment covers about 83 million people. So it's a vast, a very large program, and that number is always in flux. But about 84% of all of the people who are in Medicaid right now, that's just under 70 million people are in managed care. So you can see how important managed care is to this program at the moment. And it's not just the people, it's the dollars to about 55% of the dollars that are spent in Medicaid flow through managed care plans. In 2021, that was over $400 billion out of about $800 billion. So you can see how big, how big a program it is and how important plans are to how it works.

Jenny Babcock: [00:03:26] There are a lot of requirements for managed care plans that operate under the Medicaid program. There are state requirements, and there are federal requirements that are set in law and regulation. Plans have to do things like cover certain benefits as required by the state and the federal laws. They also have to do things like build networks of providers that are sufficiently robust to give access to all of the people who are in their plan to all of the required benefits and services. They're prohibited by law and regulation from discriminating against people by way of plan, benefit design and lots of other factors as well. But they also have a lot of flexibility. They can cover benefits and services on top of what the state requires. They have control in most cases, I should say they have control over drug formularies, which I think we're going to talk about a little bit later in the program. And we could spend a lifetime talking about formulary development, but essentially it means that the plans get to choose using evidence. You know, what lists of drugs are the most expedient and the most cost effective, and provide that coverage of that list of drugs to their members. And I do want to say to a brand new, newly finalized regulation focused on nondiscrimination in shorthand, it's called 1557, prohibits plans from creating prescription drug formularies that place, um, controls specifically on drugs that treat a particular condition or disease. So it's designed to prevent discrimination by way of the drug formulary development against a subset of people, including people who are impacted by HIV or Aids.

Anna Person: [00:04:51] That's great. That's very helpful. I was listening intently because I really didn't know much about Medicaid managed care prior to this. As an HIV provider, I'm particularly interested in how Medicaid managed care plans are relevant for HIV service delivery. Jenny, is that something you could talk about a little bit for us and fill us in?

Jenny Babcock: [00:05:12] I would imagine that, and Doug is going to talk pretty soon about his experience with his particular type of Medicaid managed care organization. But I would imagine that all of the health plans we represent, 82 of them across the country, have experience with providing coverage to people with HIV. It is important for those plans to have HIV providers like you in their networks, such that they can provide the right kind of service to people who need it. I did reach out to some of our other health plans, our other health plan members, to see what steps they take in order to make sure that providers are, you know, in their networks or the plans are providing the right kind of services to people who do have HIV. And there were some really interesting answers. So one of our health plans is called Community Health Plan of Washington, or CHBW. It's in Washington state and it's owned by a network of federally qualified health centers. It says that their particular focus, their primary focus, is to provide access to HIV treatment with minimal member abrasion. So that's managed care speak for let's not make it hard for people to get the care that they need. And so they strive to do that by having providers in their network that can provide the right kind of treatment. They also have a broad list of covered HIV drugs and no restrictions on access to those drugs, whether it's by mail or in retail settings. They also develop relationships with their state Medicaid agencies and health and human services agencies and Ryan White agencies. So there are a lot of steps that a plan can take to make sure that people with HIV are getting the right care.

Anna Person: [00:06:43] Thanks, Jenny. That's so great to hear. And we have a really unique opportunity today to pick the brain of someone who runs a Medicaid managed care organization. So, Doug, we'd love to hear a little bit from you about how you look at HIV care delivery.

Doug Wirth: [00:07:00] Thank you for this opportunity. Well, it's an important conversation to have because the complexity here is that the HIV care delivery system providers, community-based organizations, everybody that I know that works in that sector wants to help people become undetectable, get about the business of living their lives. They want to end the HIV epidemic. Health plans rely on network providers to serve their members. So as a managed care organization, we have an essential job to be a partner in ending the HIV epidemic. Medicaid is actually the largest insurer of people living with HIV in the U.S. 40% of people living with HIV right now have Medicaid. In New York, over 85% of people living with HIV will rely on Medicaid during their lifetimes. Now managed care organizations. We need to make sure that we have primary care providers in our networks who are HIV specialists, who are specialists in HIV care. Then we need to spotlight those HIV providers and promote them in our plan directories on our websites. So members living with HIV or at risk for HIV can find those providers and health plans. Ultimately, we want to promote coordination between HIV primary care providers, mental health providers and substance use providers if we do that. If HIV experienced primary care providers work effectively with people living with HIV, we're going to drive up viral load suppression. Viral load suppression means lowering the amount of HIV in the body to the point where it's at an undetectable level that improves health outcomes. It drives down costs and it also reduces new HIV infection. The other thing about paying attention to HIV care delivery. Providers need to pay attention to their patients, and health plans need to listen to their members to get important information about what works for people living with HIV. Otherwise, they're going to be barriers. They're going to be speed bumps. Things are going to get in the way of care. People get frustrated, drop out of care, stop taking medications. And that means that the HIV epidemic will persist. Providers and plans. Patients and members. We've all got our job to do and it means we have to work together.

Anna Person: [00:09:48] Thanks so much, Doug. That's really great and so helpful. I did want to ask a specific follow up question for you, Doug, about just how HIV medication access plays into this and Jenny had touched on this earlier. MCOs, as Jenny mentioned, can often do set their own formularies, and this can mean that MCOs will vary with what drugs they prefer and whether or not there might be something like a prior authorization. Can you tell us a little bit about how an MCO decides whether and how to cover an HIV drug?

Doug Wirth: [00:10:25] There's variability from state to state. Jenny spoke to this. Some states manage the pharmacy benefit outside of the health plan structure, and then other states actually include it in the benefit. And then they tell plans you need to develop your formulary. So from my point of view, managed care organizations have to include pharmacists and HIV experience providers in the decision making. Managed care organizations need to follow and strengthen coverage requirements where it's permitted. So, for example, in New York, when the pharmacy benefit was in the managed care arena, the state actually advanced supplemental rebates on one hepatitis C drug in New York. But that was not the preferred drug for treating hep C in co-infected individuals. So the state goes out, gets a supplemental rebate. They put it on the state's formulary, fee for service formulary. And then the plan sort of adopt the state's formulary problem is the preferred treatment, for people co-infected with HIV, was not on the state's preferred formulary because they didn't have a supplemental rebate. Here's an example where a plan has to go beyond the work that a state does, partner with HIV experienced providers and pharmacists, and then figure out and advocate for putting that new appropriate drug for people co-infected with hepatitis.

Doug Wirth: [00:12:10] We did that. We added HARVONI® to our formulary because that was the preferred treatment for people co-infected, and over 2000 of our members living with HIV were cured of hepatitis C. That means plants can't do this alone. Most plans have a pharmacy and a therapeutics committee that involve clinical pharmacists, medical directors, HIV clinicians. Sometimes representatives from their pharmacy benefit manager can also participate. So one of the things that impacts formulary development by MCOs is the adequacy of the Medicaid rates, the dollars that a state Medicaid program pays to the health plans, and sometimes providers don't really understand the complexity of that. They think, well, why isn't the plan putting this drug on their formulary or why do they have prior auth? Very often it's because of inadequate Medicaid rates. Now here's a great opportunity for HIV experienced and knowledgeable providers to work with health plans, to advocate with state Medicaid authorities to make sure that Medicaid rates are adequate, and also that drug formularies are comprehensive enough in order to treat not only HIV, but other comorbid conditions with the right drug for people co-infected with HIV. There's a bigger partnership role for plans and HIV experience providers to play in doing the right thing for members and patients.

Anna Person: [00:14:00] Oh, I love it. I love a good call to advocacy. Thank you so much. It gets me fired up. So you raise a really important point, and I want to get into that a little bit more. And Jenny, I want to ask your opinion about this. So obviously not every plan is going to be based in New York. And not every plan will have a Doug Worth at the helm, unfortunately. And Doug, you raised this tension about plans providing access to care and treatment, but the need to work within constrained budgets. So Jenny, how do you see this playing out in other states and how are plans balancing this tension?

Jenny Babcock: [00:14:39] Thank you. Yes. And first of all, I'd like to say that we would like to replicate Doug. We would like him to be in every state. The world would be a different place and it would be a better place. So Medicaid, it's not just at the state level, like Medicaid budgets are being fought over all the time at every possible level of government. But at the beginning of the segment, I did mention that states pay health plans a set monthly amount for each person on Medicaid, and if it works right, that amount should be Actuarially sound, more managed care speak. It should be calibrated appropriately to the person's needs. Now, with tight budgets, budget pressures, sometimes it doesn't always work out that way. But the bottom line is that in a publicly funded program like Medicaid that spends 800 plus billion dollars per year, all eyes are on it, and there is a constant tension between providing the highest quality, you know, the best possible health care, which I think our health plan members, as evidenced by Doug here, really try to do versus the cost, right? There are a lot of pressures here. I know there's been a ton of interest for the past several years, including the concept of utilization management and prior authorization, and how it's used as a cost controlling tool. We get that, and we're always keeping an eye on what's being said about this, and also trying to figure out from our plans how are you using this not just as a cost controlling tool, but as a tool that helps you provide the best possible care? You know the right care at the right moment.

Jenny Babcock: [00:16:06] I did reach out, as I mentioned, to several of our other health plan members, and discovered that at least some of them do require a prior auth for some HIV medications. But ultimately all of those medications are covered by the plan if the right approvals are made. The cost issue, though, gets back to something else that Doug already touched on, and our other plans told me too, that they think about their efforts to work on viral load suppression among their members living with HIV. It's a quality issue. It's a health care issue. It's a health status issue. It's all of the things that Doug mentioned, and it's also a way to control cost in Medicaid. I don't think that that's necessarily more important than making sure that person has good health, but it is part of of the role. And our plans take extraordinary and important and innovative steps to work with their Ryan White providers and their departments of health in their states to make sure they have the right data, to make sure they're partnering on the right outreach, to make sure that people aren't lost to care, and that they are encouraged to adhere to their medication regimens to get to that point of viral load suppression. So there's so much good work that is happening and can happen so that it's sort of a win win win situation.

Doug Wirth: [00:17:22] You know, Jenny, I love what you're saying. We talk about this at ACAP between plans. And it's not just HIV. This could be about behavioral health conditions too. When plans don't spend enough money on medications and primary care, if you really pay attention, what you'll see is that plans will end up paying more for hospitalizations, nursing homes, and other inpatient settings. When you're serving people with chronic conditions like HIV, serious mental illness, substance use disorders, what keeps me up at night, is people who are not getting enough outpatient care, because I know it's just a matter of time before they go into the ER or get admitted. Fundamentally, providers, the HIV care delivery system and plans have this unique opportunity to advocate, together with their state Medicaid authority, for adequate Medicaid funding and risk adjustments to those rates to address the needs of people living with HIV and behavioral health conditions. What's further complex is that not every state expanded Medicaid. So one state's Medicaid program is not as robust as another state. And that means that you actually also have to involve the Ryan White systems, or the federal and the epidemic funding that goes into jurisdictions. So every state's payment mechanism might look different, but the truth is that plans and HIV specialist providers and the people that they serve are a powerful force. If the three groups get together and advocate for the right policy, adequate funding to end the epidemic.

Anna Person: [00:19:18] The listeners can't see me, but I'm nodding vigorously at everything you are saying. And as an HIV clinician, what you're saying is, is really ringing true to me on so many fronts. Unfortunately, we need to come to the end of our conversation. I've learned so much in such a short period of time and Doug and Jenny, you've both touched on this a little bit, but if you could make a plea, how can we as HIV clinicians best partner with Medicaid MCOs? Tell us a little bit more about how that could happen. And Doug and Jenny, I know you've touched on this a little bit already, but I'd love to hear more.

Jenny Babcock: [00:19:59] Well, start by being on your provider networks of your local Medicaid health plans. Partner with your health plans. Be part of their solution. Help them create a solution. Two, I talked a little bit about the regulations and the requirements in Medicaid. There are lots and lots of rules out there that are increasingly robust, that are designed to protect your patients and ensure that they get access to needed care and services. Know what's in them. Go to a webinar. Talk to your friends in the state government, and then consider the gaps that are in those existing rules. And work hard with your plans and advocates in your community to fix those gaps to close them. And I would say lastly, again, Doug talked about this already, fight efforts to reduce funding to the Medicaid program. And these funding reductions are being threatened at the federal level. There is frequently a battle royale at the congressional level that we're engaged in. Fight that and fight it at your state level. This program is a priority. It's a priority for people living with HIV. It's a priority for 83 million people with lower incomes across the country. It should be important to all of us, so make sure it's adequately funded and prioritized.

Doug Wirth: [00:21:13] Go, Jenny. Mission driven health plans know that clinicians have a critical voice to play. So here's the things to put in your tool belt: HIV clinicians, join managed care organizations, quality management committees. And if you don't get a yes right away, keep submitting an application year after year. Behind every no is a yes. You've got to keep going. Apply to join a managed care organization's pharmacy and therapeutics committee to make sure that they have the HIV clinical knowledge and expertise to develop the right drug. Formulary providers ask to meet with the managed care organizations provider services rep team. Everybody has a field team. They go out to provider sites, tell them that you want them to visit your community health center or your designated HIV clinic. Talk about your successes, like how you've increased viral load suppression, the effectiveness that you have in meeting quality metrics, like making sure that people have routine STI screenings on an annual basis, and connect what you do to not only improved health outcomes, but lowering total medical costs. And then every health plan wants to grow. They've got growth teams. They'll come out as well and sit down and tell them about who you are and what you do, and how you meet the community's needs and how you increase quality scores. And then ask them for what you want, materials. You want them to help co-sponsor events, patient education events. Health plans can be a partner. You just need to get to know them. Tell them what you do and how you can help them, and then know what you want from them and ask for it.

Anna Person: [00:23:11] Wow, that was great, I have goosebumps. Thank you both so much Jenny and Doug for coming to talk to us about this important issues. I'm really fired up about Medicaid, managed care organizations, and the ways that we can work together to have the best outcomes possible for people with HIV. And thank you all for joining us for part three of our Let's Talk HIV mini-series. On our next and final episode, my co-host, Dr. John Fangman, will be joined by Dr. Michelle Ogle and Katie Garfield to discuss how Medicaid is addressing social determinants of health. Thank you so much.