Published in 2003, find my contribution and early thoughts about HIV Special Needs Plans.  By July 2003, all HIV SNPs had become operational.  By September 2006, they are:  MetroPlus, NewYork-Presbyterian System SelectHealth, and Amida Care.

http://www.routledge.com/books/details/9780789015877/

Chapter 20: Social Work, New York State AIDS Centers and Special Needs Plans

Eli Camhi

©2003 The Haworth Press, Inc. Binghamton, NY, Camhi, E.,  Chapter 20: Social Work, New York State AIDS Centers, and Special Needs Plans in A history of AIDS social work in hospitals: a daring response to an epidemic, pages 199-201, Willinger, B., Rice, A. Editors.

Social workers have been on the front line serving the HIV-infected and -affected community since the very beginning of the epidemic. In New York City, from the mid-1980s through the mid-1990s, most AIDS cases were first encountered in hospitals. Hospital social workers, traditionally employed as discharge planners, were among the first to serve these individuals, partnering with nurses, physicians, and other health care providers struggling to  overcome the often lethal consequences of untreated opportunistic infections while attempting to restore the patient’s social, economic, and psychological support system.

Hospital administrators, medical directors, and social work departments soon learned that to address the complex and multiple needs of newly diagnosed AIDS patients, dedicated multidisciplinary teams were necessary. The AIDS Institute of the New York State Department of Health developed specialized contracts for hospitals willing to create and support such teams. These hospitals were called designated AIDS centers (DACs) and were required to  establish a continuum of care that included dedicated inpatient AIDS units linked with outpatient HIV primary care clinics often within departments of infectious diseases. Experienced multidisciplinary teams were created to include physicians, nurses, social workers, counselors, psychiatrists, dieticians, and assorted hospital clerical and administrative staff.

To recruit hospitals to become DACs, the state compensated them with an enhanced outpatient HIV primary care Medicaid rate to offset care team costs. In addition, the state provided the DACs with the ability to select either per diem or DRG (diagnosis-related group) rate of payment. Most DACs chose the per diem rate over the DRG rate because of the unadjusted DRG rate; for example, the standard of care for treatment of Pneumocystis carinii pneumonia (PCP) was twenty-one days of IV therapy in contrast to the DRG rate of only sixteen days. The state’s fiscal strategies catalyzed rapid change in the care delivery system. Prominent hospitals added specialized staff members quickly, including AIDS center social workers in inpatient and outpatient settings. A fundamental component of the model was aggressive and specialized case management by specialized social workers at various points of care.

In the mid-1990s, breakthroughs in AIDS drug development resulted in the availability of antiretroviral therapies that dramatically reduced the virus’s ability to compromise patient immune systems and permit opportunistic infections. This, in turn, resulted in dramatic and significant declines in deaths, hospitalizations, and lengths of stay. In AIDS centers and other hospitals throughout New York State, the total average daily inpatient AIDS census dropped from 2,646 in 1992 to 1,276 in 1998, approximately 52 percent (Chiasson et al., 1998).

These trends required another significant shift in the service delivery model. Prior to 1995, staff resources for AIDS care were concentrated heavily on hospital inpatient units. Some AIDS centers provided one inpatient social worker for every twelve to eighteen hospitalized AIDS patients. In the early days of the epidemic some New York City hospitals averaged a daily inpatient AIDS census of well over sixty patients (Chiasson et al., 1997). With the success of new treatments, outpatient care was now center stage. Clinics began to experience rapid growth as patients sought access to these new therapies. Some hospitals wisely reallocated the now surplus inpatient team of social workers and others to the outpatient setting to meet the increasing demand for service, but many others did not. Pressure on hospitals to  decrease costs resulted in a significant reduction of social work staff and, in some cases, the downsizing of hospital social work departments.

When length of stay (LOS) declined, per diem rates in most cases paid less per patient than DRGs; it was then that most DACs abandoned the per diem rate. When LOS declined, clinic cost increased because more patients entered and remained in care. Unfortunately, outpatient AIDS care is not entirely self-sufficient. For many years, AIDS center clinics were subsidized with inpatient dollars as well as by various federal grants. This trend of shifting from a predominately inpatient model to one of predominately outpatient care did not go unnoticed. The AIDS Institute, again, began to plan for a change in reimbursement for the HIV care delivery system.

As early as 1995, the state began to develop a unique and innovative model of reimbursement that would essentially permit the rapid and specific allocation of funds to where the care was needed. HIV special needs plans (SNPs) were proposed to operate as Medicaid-managed care plans exclusively for HIV-infected adults and their dependent children. Through a remarkable collaboration, the state, persons with AIDS, community-based organizations, and health care providers together crafted a model that would preserve the  best of the payment structure of the Medicaid fee-for-service plan while supporting opportunities for new and more effective reimbursement strategies. In addition, SNPs would provide a viable alternative to mainstream Medicaid-managed plans as the state moved toward mandatory enrollment of the uninfected Medicaid community.

HIV special needs plans operate using a monthly capitated rate based upon either an HIV or AIDS diagnosis. All standard Medicaid benefits are included and medication is carved out. Patients continue to fill their prescriptions at local pharmacies. Universal case management is required, provided by the SNP or through linkage agreements with grant-supported   community-based organizations and designated AIDS center hospitals. Social workers in the community and in the AIDS centers will continue to have the opportunity to fill significant roles in the SNP case management model.

As of January 2003, HIV special needs plans have yet to be licensed. However, in New York City, seven entities are aggressively preparing for the state’s licensure. It is expected that at least three SNPs will be operational by the first quarter of 2003 and the remainder by July 2003. If successful, SNPs will become self-sustaining vehicles that finance the continually evolving HIV care delivery system, insuring and protecting our most precious resource: our community.

REFERENCES

Chiasson, M.A., Berenson, L., Li, W., Schwartz, S., Singh, T., Forlenza, S., and Mojica, B. (1997). Accelerating decline in New York City AIDS  Mortality. Presented at the Fourth conference on Retroviruses and Opportunistic Infections, Washington, DC, January.

Chiasson, M.A., Berenson, L., Li, W., Schwartz, S., Singh, T., Forlenza, S.,  and Mojica, B. (1998). Accelerating decline in New York City AIDS  Mortality. Presented at the Fifth conference on Retroviruses and Opportunistic Infections, Chicago, IL, February.