THE AIDS INSTITUTE      Opportunities forExpanding HIV Testing through       Health Reform     Carl Schmid, Deputy Executi...
Health Reform•   As Health Reform is implemented to expand access to:     • Medicaid     • Medicare     • Private Insuranc...
US Preventive Services Task Force• Sponsored by Agency for Healthcare Research and Quality(AHRQ) at the U.S. Department of...
USPSTF GradesGrade       Definition                                                      Suggestions for PracticeA        ...
HIV Testing-July 2005 Review• Strongly recommends that clinicians screen forHIV in all adolescents and adults at increased...
HIV Testing-July 2005 Review• No recommendation for or against routinelyscreening for HIV adolescents and adults who areno...
Who is “At Risk?”A person is considered at increased risk for HIVinfection (and thus should be offered HIV testing)if he o...
Persons at higher risk for HIV infection                  •   Those seeking treatment for STDs;                  •   Men w...
Persons at higher risk for HIV infection•   Women and men whose past or present sex partners were HIV-       infected, bis...
High Risk Settings•High-risk settings include STD clinics, correctionalfacilities, homeless shelters, tuberculosis clinics...
Implementation of Health Reform &      Prevention Coverage              •   Medicaid Expansion         •   Medicare Improv...
Medicaid•Enhanced 1% Federal Medical AssistancePercentage (FMAP) for Grade A & B USPSTFServices (beginning in 2013)    • A...
Medicaid•   Probably best opportunity to diagnose people with HIV     • Medicaid will cover all low income people (up to 1...
Medicare Coverage Rule•Authority Granted Under Medicare Improvements forPatients and Providers Act of 2008 (MIPPA)•Provide...
Medicare & Health Reform•   Annual Wellness Visit     • Includes a Health Risk Assessment     • Provides Personalized Prev...
Medicare•A good opportunity to diagnosis people withHIV – for those who are poor and disabled, orover 65    • Annual Welln...
Private Insurance• Requires new plans to cover services that receive aGrade A or B from the USPSTF with no cost sharing(Be...
Private Insurance•A Very Good Opportunity to Diagnose Peoplewith HIV    • Coverage for those who are at risk    • Some pla...
Exchanges•   Exchanges will be composed of private insurance plans      • Coverage for A & B services•   Exchanges must co...
Exchanges•   Good opportunity to diagnosis people with HIV     • Anyone above 133% FPL not covered by private     insuranc...
Concluding Thoughts• Health Reform Provides An Excellent Opportunity toIncrease HIV testing because of prevention coverage...
Concluding Thoughts•   Still have work to do through federal regulation•State decisions key for Medicaid, plus Private Ins...
USPSTF Grade A & B Recommendations             • Alcohol misuse counseling             • Blood pressure screening         ...
Coverage of Other HIV Preventive Services•   Need a determination from the USPSTF•   Need studies on their effectiveness• ...
Resources•USPSTF:www.uspreventiveservicestaskforce.org•USPSTFGrade A & B Recommendations:www.uspreventiveservicestaskforce...
THE AIDS INSTITUTE        THANK YOUCarl Schmid - cschmid@theaidsinstitute.org             202-462-3042         www.theaids...
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Opportunities for Expanding HIV Testing through Health Reform

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Opportunities for Expanding HIV Testing through Health Reform

  1. 1. THE AIDS INSTITUTE Opportunities forExpanding HIV Testing through Health Reform Carl Schmid, Deputy Executive Director 2011 National HIV Prevention Conference Atlanta, GA August 16, 2011 The AIDS Institute
  2. 2. Health Reform• As Health Reform is implemented to expand access to: • Medicaid • Medicare • Private Insurance/Exchanges•Opportunity to Cover Preventive Services that receive a Grade Aor B from the U.S. Preventive Services Task Force (USPSTF) •Opportunity to Expand Coverage of HIV Testing • But not routine testing, yet •Other HIV Prevention Services The AIDS Institute
  3. 3. US Preventive Services Task Force• Sponsored by Agency for Healthcare Research and Quality(AHRQ) at the U.S. Department of Health and Human Services• Leading independent panel of private-sector experts inprevention and primary care• Conducts rigorous, impartial assessments of scientific evidence foreffectiveness of clinical preventive services, including screening,counseling, and preventive medications• Recommendations are considered the "gold standard“ for clinicalpreventive services• Key to coverage determinations The AIDS Institute
  4. 4. USPSTF GradesGrade Definition Suggestions for PracticeA USPSTF recommends the service. There is a high certainty Offer or provide this service. that the net benefit is substantial.B USPSTF recommends the service. There is a high certainty Offer or provide this service. that the net benefit is moderate or there is a moderate certainty that the net benefit is moderate to substantial.C USPSTF recommends against routinely providing the service. Offer or provide this service only There may be considerations that support providing the if other considerations support service in an individual patient. There is at least moderate offering or providing the service to certainty that the net benefit is small. an individual patient.D USPSTF recommends against the service. There is no Discourage the use of this service. moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.I USPSTF concludes that the current evidence is insufficient to Read the clinical considerations ofStatement assess the balance of benefits and harms of the service. the USPSTF Recommendation Evidence is lacking, of poor quality, or conflicting, and the Statement. If the service is offered, balance of benefits and harms cannot be determined. patients should understand the uncertainty about the balance of The AIDS Institute benefits and harms.
  5. 5. HIV Testing-July 2005 Review• Strongly recommends that clinicians screen forHIV in all adolescents and adults at increased riskfor HIV infection• Recommends that clinicians screen all pregnantwomen for HIV• Grade A Recommendation The AIDS Institute
  6. 6. HIV Testing-July 2005 Review• No recommendation for or against routinelyscreening for HIV adolescents and adults who arenot at increased risk for HIV infection• Grade C Recommendation• Reconfirmed in 2007 The AIDS Institute
  7. 7. Who is “At Risk?”A person is considered at increased risk for HIVinfection (and thus should be offered HIV testing)if he or she reports 1 or more individual riskfactors or receives health care in a high-prevalence or high-risk clinical setting The AIDS Institute
  8. 8. Persons at higher risk for HIV infection • Those seeking treatment for STDs; • Men who have had sex with men; • Past or present injection drug users;• Persons who exchange sex for money or drugs, and their sex partners; • Persons who request a test; The AIDS Institute
  9. 9. Persons at higher risk for HIV infection• Women and men whose past or present sex partners were HIV- infected, bisexual individuals, or injection drug users;• Persons with a history of transfusion between 1978 and 1985; • Persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test. The AIDS Institute
  10. 10. High Risk Settings•High-risk settings include STD clinics, correctionalfacilities, homeless shelters, tuberculosis clinics, clinicsserving men who have sex with men, and adolescenthealth clinics with a high prevalence of STDs• High-prevalence settings are defined by the CDC asfacilities known to have a 1% or greater prevalence ofinfection The AIDS Institute
  11. 11. Implementation of Health Reform & Prevention Coverage • Medicaid Expansion • Medicare Improvements • Private Insurance Reform • Exchanges The AIDS Institute
  12. 12. Medicaid•Enhanced 1% Federal Medical AssistancePercentage (FMAP) for Grade A & B USPSTFServices (beginning in 2013) • At risk individuals, including those in high prevalence areas/risk settings • Not a federal required benefit • State decision to implement The AIDS Institute
  13. 13. Medicaid• Probably best opportunity to diagnose people with HIV • Medicaid will cover all low income people (up to 133% FPL) • +16 million people • Coverage Incentive not that great • US Congressional Bill to Require State Medicaid Coverage of Routine HIV Testing (HR 1774) • Sponsor: Rep. Alcee Hastings, plus 28 co-sponsors The AIDS Institute
  14. 14. Medicare Coverage Rule•Authority Granted Under Medicare Improvements forPatients and Providers Act of 2008 (MIPPA)•Provides Option for Medicare (CMS) to Cover Grade A or BPreventive Services , but with co-pays• Through a National Coverage Determination CMS decidedto cover HIV Testing for High Risk Individuals (Dec. 2009) The AIDS Institute
  15. 15. Medicare & Health Reform• Annual Wellness Visit • Includes a Health Risk Assessment • Provides Personalized Prevention Plan Services• No co-pays for Preventive Services Approvedthrough Coverage Determination• Began January 1, 2011 The AIDS Institute
  16. 16. Medicare•A good opportunity to diagnosis people withHIV – for those who are poor and disabled, orover 65 • Annual Wellness Visit should help particularly if discuss sexual and IDU history • Proposed rule: “Behavioral risks, including but not limited to…sexual practices” • Coverage for People who are At Risk • But not for Routine Testing The AIDS Institute
  17. 17. Private Insurance• Requires new plans to cover services that receive aGrade A or B from the USPSTF with no cost sharing(Began September 23, 2010) • All plans starting in 2014•Additional Preventive Care and screenings for womendeveloped by HRSA • IOM Study to help HHS Develop Rule • Recommended Coverage for Annual HIV Counseling and Testing for Sexually Active Women • HHS Decision August 2011 The AIDS Institute
  18. 18. Private Insurance•A Very Good Opportunity to Diagnose Peoplewith HIV • Coverage for those who are at risk • Some plans currently cover routine testing • Some states (e.g. CA) require coverage for Routine HIV testing The AIDS Institute
  19. 19. Exchanges• Exchanges will be composed of private insurance plans • Coverage for A & B services• Exchanges must cover Essential Benefits • Opportunity to add additional preventive services • Developed through regulation•States can require coverage of additional services • But at its own cost The AIDS Institute
  20. 20. Exchanges• Good opportunity to diagnosis people with HIV • Anyone above 133% FPL not covered by private insurance will be in an exchange (or pay penalty) • + 32 million people• State Advocacy critical since Exchanges will beimplemented at State level The AIDS Institute
  21. 21. Concluding Thoughts• Health Reform Provides An Excellent Opportunity toIncrease HIV testing because of prevention coverage• Mostly determined by USPSTF Grade•While Routine Testing would not be covered, manyopportunities to increase testing for those people whoare at risk, including those in high risk settings and highprevalence areas The AIDS Institute
  22. 22. Concluding Thoughts• Still have work to do through federal regulation•State decisions key for Medicaid, plus Private Insuranceand Exchanges• USPSTF is currently reviewing Grade for Routine Testing • Could be a Significant Game Changer The AIDS Institute
  23. 23. USPSTF Grade A & B Recommendations • Alcohol misuse counseling • Blood pressure screening • Cervical cancer screening • Chlamydial infection screening • Cholesterol abnormalities • Depression screening • Gonorrhea screening • Healthy diet counseling • Hepatitis B screening, pregnant women • STI counseling • Syphilis screening The AIDS Institute
  24. 24. Coverage of Other HIV Preventive Services• Need a determination from the USPSTF• Need studies on their effectiveness• Possible candidates: • Condom distribution • Syringe Exchange • Counseling, Sexuality Education • PEP & PrEP• Slow process, but a CDC priority The AIDS Institute
  25. 25. Resources•USPSTF:www.uspreventiveservicestaskforce.org•USPSTFGrade A & B Recommendations:www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm•USPSTFHIV Screening Recommendations:www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm The AIDS Institute
  26. 26. THE AIDS INSTITUTE THANK YOUCarl Schmid - cschmid@theaidsinstitute.org 202-462-3042 www.theaidsinstitute.org The AIDS Institute
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