February 17, 2006

In the News
1. Plan Requirements in Medicare’s New Drug Prescription Program Limit Access to Medications
2. President’s Budget Request for Fiscal Year 2007 Includes Increase for HOPWA

CARE Act in Brief
1. Status Update on the Ryan White Comprehensive AIDS Resources Emergency Act

Announcements
1. Condoms4Life Offers “People of Faith Use Condoms” Materials
2. Grants for the Provision of Community-based, HIV Related Mental Health Services for Minority Populations.
3. National Conference on Social Work and HIV/AIDS to Convene in Miami, FL

In the News
1. Plan Requirements in Medicare’s New Drug Prescription Program Limit Access to Medications
On February 13, the New York Times offered doctors’ and pharmacists’ impressions of Medicare’s new drug benefit program (also known as Part D), which applies to 100,000 HIV positive individuals. They tell the Times that although many drugs are “theoretically” covered by the new benefit, they are not readily available. This lack of drug access stems from the complicated restrictions and requirements of the plans offered through the Medicare program, the newspaper revealed. These include restrictions on the use of medications, the need to receive insurers’ “prior authorization” to prescribe medications, and the requirement to provide medical documentation to justify the use of certain drugs.

How the Drug Benefit Works
Scores of companies offer plans under Part D. In most states, the Medicare program has at least 40 drug plans from which to choose, the Times noted. Each plan has developed its own list of covered medications, known as a drug formulary. However, the inclusion of a drug on a given plan’s formulary does not always mean that the drug will be covered automatically. Drug plans can require doctors and patients to obtain prior authorization for certain drugs on their formularies. The process by which this authorization is granted varies by plan. However, the Times reported, a plan could require individuals to choose the correct authorization form from a field of 25 to 30 and submit it before authorization is granted.

Concerns Raised over Plans’ Procedures in New Drug Benefit Program
Although commercial insurers and their pharmacy benefit managers have used similar techniques for years, one doctor in Missouri, Jeffery A. Kerr, told the Times that the techniques being used by some Medicare plans were more onerous and restrictive. In addition, "The use of prior authorization is far more prevalent in Medicare than in commercial insurance programs," commented John Feather, executive director of the American Society of Consultant Pharmacists. Dr. Kerr added that such requirements are more noticeable because Medicare beneficiaries are high users of prescription drugs. "Medicare drug plans have created significant hurdles that patients and physicians must jump over before getting their medications. The prescription drug plans are playing a dangerous game,” he warned.

Dr. Steven A. Levenson, who serves as the president-elect of the American Medical Directors Association, commented on drug plan techniques as well. "We have seen signs that Medicare drug plans are using management controls to deter access to medically appropriate drugs, including drugs on their own formularies," he stated.

These controls can often delay or deny individuals access to the medications they need to remain healthy. Further, they complicate matters not only for doctors and their patients but for pharmacists as well. The chairman of Walgreen’s, Dr. W. Bernauer, commented, "It is impossible for pharmacists to keep track of all these formularies and prior authorizations.”

“We have a world of chaos," a pharmacist in North Carolina said.

In order to ease the confusion, Dr. Bernauer recommends that the government “use its leverage to promote greater standardization of policies and procedures."

Insurers’ Response
However, according to the Times article, insurers contend that their requirements “save money and promote the proper use of the medications.”
Francis S. Soistman, Jr., executive director of one such insurer—Coventry Health Care, explained to the Times that his company’s 39 prior-authorization forms for drug prescriptions were justified because “each drug requiring prior authorization has unique clinical criteria that must be met,” and the forms “serve as a checklist of necessary information needed for our review.”

As part of this rigorous, prior-authorization review, Coventry requires doctors “to provide details of laboratory results, “all office notes,” and other data to show why certain drugs are needed,” the Times elaborated. For some HIV medications, the newspaper continued, the doctor has to specify the patient’s viral load and white blood cell count. Similarly, Blue Cross’ AmeriHealth plan has 17 forms for high-cost, injectable medications “to treat complex conditions like cancer, hemophilia, and HIV infection….”

Administration’s Oversight of Drug Benefit
As reported by the Times, the Administration repeatedly assured beneficiaries that they would have “convenient access to ‘all medically necessary drugs.’" However, it also granted insurers some latitude to define medical necessity. And while officials have developed a model form to request coverage or prior authorization for a drug, the Administration stressed that "use of this model form is optional," adding that a "Medicare drug plan may require additional information or documentation."

2. President’s Budget Request for Fiscal Year 2007 Includes Increase for HOPWA
A radio report airing today, Friday, February 17, on National Public Radio’s Morning Edition began with the following statement: “The poor generally lose out under President Bush's [fiscal year 2007] budget plan, which calls for a scale back in programs that help the poor with education, housing, and food.”

However, it continued, if the requests in the President’s budget proposal are met by Congress, not all programs serving people with low income would “lose out.” For example, Housing Opportunities for Persons with AIDS (HOPWA) would receive a modest increase of $14 million, raising its budget to more than $300 million—enough, Morning Edition reports, to allow the program to house 3,500 more people. The program currently serves 72,000 individuals nationwide.

One beneficiary of the federal program is profiled in the report. Michele Southerland resides in a house with ten apartments for HIV positive women. Ms Southerland “contracted HIV long ago,” and when she was granted a space in the house several years ago, “she was so thin and sick that she wore sweaters in August.”

The house is located downtown in Wilmington, DE, a city where heroin is easy to find in a state that typically ranks among the top five for per capita AIDS rates, Morning Edition indicated.

Although the Wilmington housing program is small, it provides numerous services, including health care and drug counseling, to the women residing in the house, Morning Edition noted. In addition, residents are allowed to stay as long as they want.

“It's not charity,” the radio report states. “AIDS housing advocates point to research that shows a link between homelessness, drug use, and the spread of HIV.” What’s more, after looking at such factors as how the housing program is designed and managed, the Office of Management and Budget (OMB) has rated it as effective—one of the reasons President Bush wants to increase its funding, Morning Edition added.

Ms. Southerland is preparing to move out of the house to be on her own, the report revealed. “She's earned a degree, and she's looking for a job as a nursing assistant. For now, she works as a receptionist a few blocks away from the house.”

To read a transcript of the Morning Edition report on which this news brief is based, link to http://www.npr.org/templates/story/story.php?storyId=5220354&ft=1&f=1001

CARE Act in Brief
1. Status Update on the Ryan White Comprehensive AIDS Resources Emergency Act
This issue of the CARE Act in Brief seeks to summarize activities related to reauthorization of the Ryan White CARE Act since the beginning of the year. In doing so, this section is designed to help readers gain a better sense of the reauthorization’s current status.

Activities in Congress
Activities related to reauthorization of the CARE Act got off to a quick start in Congress on January 19 and 20, with a series of consecutive meetings called a “listening session” between legislative staff members from the two committees that are leading the reauthorization process (the Senate Health, Education, Labor and Pensions [HELP] Committee and the House Energy and Commerce Committee) and HIV stakeholders. (To learn more about this session, link to the AIDS Action Web site at http://www.aidsaction.org/communications/articles/rwca_testimony/index.htm)

On January 31, the Congressional staff from the two committees began to hold meetings together; which are scheduled twice a week on Tuesdays and Thursdays. During these meetings, participants are negotiating revisions to the CARE Act’s legislative language. The ultimate goal of the meetings is to formally introduce legislation (a bill) that can be passed by both chambers of Congress.

The meetings have been referred to as “bipartisan, bicameral negotiation sessions” because they include legislative staffers from both the Republican and Democratic parties (bipartisan), and the negotiations are taking place with staffers from both the House of Representatives and the Senate (bi-cameral).* Staffers participating in these meetings have told AIDS Action and other organizations that they hope to complete their negotiations by the end of March.

Prior to the initiation of these negotiating sessions, the HELP and Energy and Commerce committees had recommendations for changing the CARE Act. These recommendations came from a variety of sources, including outside organizations and individuals, the Administration, as well as Members of Congress—both those who sit on the reauthorizing committees and those who do not.

The negotiating sessions are confidential, and participating staffers have been asked not to discuss the content of these sessions with advocates. (Approximately 20 – 30 staffers have been participating in the sessions.) A small amount of information has, however, been shared with AIDS Action in accordance with the rules. AIDS Action has been told that staffers in the negotiating sessions are still in an “exploratory phase.” Many of the proposed recommendations that they have received are still under consideration, and they continue to welcome new submissions.

AIDS Action has also been told that the committees are seeking to deal with the most “contentious issues” first, including issues raised by the Administration’s principles including, but not limited to, "double counting" (also referred to as the 80/20 rule), the creation of a severity of need index and a set of the core medical services, and hold harmless.** (For more information on the Administration’s principles, see August 5, 2005 issue of The Weekly Update at http://www.aidsaction.org/communications/weekly_updates/2005/080505.htm)

In addition, on February 15, House Energy and Commerce Chair Joe Barton (R-TX) held a hearing on the Administration’s proposed budget for FY 2007 with the Secretary of the Department of Health and Human Services Mike Leavitt as the principle witness. In his opening statement, Chairman Barton noted that the authorization for the Ryan White CARE Act had lapsed on September 30, 2005 and stated that he did not believe it made sense to appropriate funding for unauthorized programs (a statement that he has consistently made about all unauthorized programs). For that reason, he said that he anticipated the Energy and Commerce Committee would work to reauthorize the CARE Act. During the hearing, Representatives Vito Fossella (R-NY) and Eliot Engel (D-NY) asked Secretary Leavitt questions about the impact of the Administration’s CARE Act Principles on local jurisdictions, highlighting the bipartisan interest of members of the Energy and Commerce Committee in addressing the CARE Act reauthorization.

On a related note, a senior staff member for the HELP Committee who spoke at a health care event on February 9 told attendees that the Chairman of the HELP Committee, Senator Michael Enzi (R-WY) had made the Ryan White CARE Act reauthorization one of the top three priorities for the HELP committee. (Note: the other two priorities were bioterror legislation and health care costs incurred by uninsured individuals).

Finally, the Senate HELP Committee attempted to schedule a hearing on Tuesday, February 14. The hearing, titled Fighting the AIDS Epidemic of Today: Reauthorizing the Ryan White CARE Act, was to take place in a roundtable format (a format in which the attending Senators are able to engage in discussion with the witnesses). The hearing was to feature only one witness, Elizabeth Duke the administrator of the Health Resources and Services Administration (HRSA). However, the hearing was cancelled because of the Senate leadership’s unanticipated decision to schedule multiple, back-to-back votes referred to as stacked votes. All scheduled hearings for the day were cancelled in the Senate. The hearing has been rescheduled for March 1 at 3:00 p.m.

Activities by the Administration
Since the beginning of the year, the Administration has been involved in events that are likely to affect both the schedule and ability of legislators to reach an agreement on the Ryan White CARE Act. On January 31, the President presented the annual State of the Union address. In the address, he called on Congress to reauthorize the CARE Act. (For more information on the President’s remarks, see the February 3 issue of The Weekly Update).

In addition, the Administration accepted the resignations of two key presidential advisors on domestic HIV policy, including reauthorization of the CARE Act. On February 6, Carol Thompson, director of the White House Office of National AIDS Policy (also known as the “AIDS czar”), announced that she would be leaving her position on Friday, February 10 in order to take a position with the State Department. Then on February 8, Claude Allen, the White House Domestic Policy Advisor submitted a letter of resignation effective on February 28. As the head of the Domestic Policy Office, Mr. Allen played a key role in formulating the Administration’s principles on reauthorization. He had previously served as Deputy Secretary of the Department of Health and Human Services.
The reason for Mr. Allen’s resignation has not been made public. It is not clear how active the Administration will continue to be during the CARE Act reauthorization process or how heavily it will promote their principles in the absence of these two key advisors.

No one has been named as a permanent replacement for either official. However, the Administration has announced that Yuval Levin, associate director for the Domestic Policy Council at the White House, has been assigned to Ms. Thompson’s domestic duties, and another person will temporarily assume her global duties. Currently, AIDS Action is not aware of anyone having been assigned to take Mr. Allen’s duties.

Conclusion
According to Mr. McColl, there is considerably more energy around reauthorization in early 2006 than there had been in the fall of 2005. AIDS Action staff has been told that, since Congress is involved in the upcoming mid-term elections, which will take place in November of 2006 and therefore is likely to compress much of its fall schedule into the summer, the House and Senate will be reluctant to act on any bill which requires a reauthorization (including the Ryan White CARE Act) after June 30. Thus, there is incentive to introduce and pass legislation in the spring. In addition, the President’s call for the CARE Act’s reauthorization in both this and last year’s State of the Union address also created incentive for passage of the bill.

If an uncontroversial bill is drafted, the House and Senate may pass a bill quickly, Mr. McColl said. “If the bi-partisan, bi-cameral negotiations produce a bill that is acceptable to Republicans and Democrats in both the House and the Senate and to the White House, it is possible that a bill can be introduced and passed within a week,” he said, adding, “The CARE Act has a history of bipartisanship, and Members of the Senate and House may be more willing to work together in light of that history.”

Pressed about whether or not Congress would be able to introduce and pass a bill, Mr. McColl said, “Congressional staff members have told us that they’d like to produce a bill by the end of March and they are definitely gathering information and engaging in negotiations.” He further stated, “What is not clear is whether they will be able to resolve the controversial issues to everyone’s satisfaction before the election season really kicks in.”

*Although the meetings are referred to as “bipartisan,” there are actually three parties represented as one member of the HELP Committee, Senator James Jeffords, is an Independent.

**Double counting is a term used by the Administration to characterize the method by which people living with AIDS in an Eligible Metropolitan Area (EMA) are counted. For the purpose of funding allocations, they are counted in two different Titles within the Ryan White CARE Act (Title I – cities, and Title II [base] – states). A number of HIV organizations, including AIDS Action, believe that the term “double counting” is an inaccurate characterization. Although it is true that the allocation formula for Title II (base) counts the number of AIDS cases within EMAs, it allocates a smaller percentage of funding for those cases than for cases outside EMAs. The Title II (base ) allocation formula then assigns funding, based on different weights, for a given state’s estimated living AIDS cases. Without going into the full complexities of the formula, the weight assigned to the full state’s estimated living AIDS cases—including EMAs—is 0.8 (or 80%), and the non-EMA portion of the state’s estimated living AIDS cases is 0.2 (or 20%). Therefore advocates refer to this portion of the Title II formula allocation as “80/20.”

To read about AIDS Action’s position on the “80/20” formula allocation, see AIDS Action’s Recommendations To Create an Effective, Efficient, and Equitable Ryan White CARE Act at http://www.aidsaction.org/legislation/rwca/index2.htm.

Announcements
1. Condoms4Life Offers “People of Faith Use Condoms” Materials
Launched in 2001 on World AIDS Day, Condoms4Life is a worldwide public education campaign by Catholics for a Free Choice. Its mission is two-fold: to raise awareness about the devastating effect of the Vatican’s ban on condoms; and to raise the voice of Catholics and all people of faith who believe that the correct and consistent use of condoms is a crucial component of HIV prevention.

Condoms4Life materials, which include posters, postcards, stickers, and a campaign brochure, are available for viewing at http://www.condoms4life.org/resources/newmaterials.htm and can be ordered by sending a request to info@condoms4life.org. Requests should indicate the name of each item, the desired quantity, and how the material will be useful.

2. Grants for the Provision of Community-based, HIV Related Mental Health Services for Minority Populations.
The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services (CMHS) has announced the availability of up to $8,400,000 in fiscal year 2006 for approximately 16 cooperative agreement grants. Annual awards are expected to be approximately $525,000 per year in total costs (direct and indirect) for up to five years.

Funded programs must enhance and expand the provision of effective, culturally competent, HIV related mental health services for minority populations. According to its Web site, SAMHSA intends these grants to result in the delivery of services as soon as possible and no later than four months after the funding award. Domestic public and private nonprofit entities are eligible to apply.

The projects to be supported in this program are to have experience providing culturally competent mental health services in their respective communities, and will develop and implement HIV related mental health treatment services that meet the needs of people living with HIV in that community. All applicants must target one or more of the following populations: African Americans, Latinos(as), Native Americans (non-reservation), Asian Americans, Native Hawaiians, Pacific Islanders, and/or other racial/ethnic minority communities.

Applications are due by May 1, 2006. For more information, link to the SAMHSA Web site at http://www.samhsa.gov/grants06/RFA/sm06_001_hiv.aspx

3. National Conference on Social Work and HIV/AIDS to Convene in Miami, FL
The 2006 National Conference on Social Work and HIV/AIDS will be held from May 25 to May 28 at the InterContinental on Chopin Plaza in Miami, FL. First convened in1988 by the Boston College Graduate School of Social Work, the meeting is the only national conference organized by, and for, social workers working in HIV care at hospitals, clinics, universities, AIDS service organizations, community-based organizations, and social agencies. The conference draws over 500 attendees from the United States and abroad and features more than 120 presentations. In addition, the conference hosts social events and provides opportunities for networking.

Participants can earn 24 hours of social work continuing education credits. For more information on the conference, link to http://socialwork.bc.edu/outreach/hiv-aids/ or contact Vincent J. Lynch, PhD, director of Continuing Education and conference director at 617-552-4038 or lynchv@bc.edu

The AIDS Action Weekly Update
The Weekly Update is written with a mind toward the interests of our members. If you are interested in membership with AIDS Action, we invite you to contact members@aidsaction.org.

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