SPNS/Fax: An Electronic Report from HRSA/HAB's SPNS Cooperative Agreements:
Volume 3, Issue 10 (May 15, 1998)

Information dissemination from 27 Innovative Models of HIV Care projects funded as Special Projects of National Significance by the HIV/AIDS Bureau (HAB) of the Health Resources and Services Administration (HRSA).

Introduction

Welcome to SPNS/Fax: An Electronic Report from HRSA/HAB's SPNS Cooperative Agreements. In each issue of SPNS/Fax, we will highlight findings from the HRSA Special Projects of National Significance Program Cooperative Agreements. The projects have been funded to develop innovative models of HIV/AIDS care. SPNS/Fax reports are distributed every two weeks by fax machine to all subscribers. All issues of SPNS/Fax are also available at this Web site. Due to slight differences in the media, issues distributed by fax machine may appear slightly different from those posted on this Web site, but the content is identical.

Maryland Medicaid initiated an 1115 waiver in June 1997 that required enrollment of all Medicaid recipients in a Medicaid-approved Managed Care Organization. Special provisions of the 1115 waiver in Maryland included a risk-adjusted rate for patients with AIDS. The Johns Hopkins Medicaid AIDS Capitated Care Program, funded by the HRSA/HAB's SPNS, is nested within the Infectious Diseases Division of the Department of Medicine. There are 14 physicians from the Infectious Disease Division, 8 mid-level practitioners who provide primary care, and approximately 12 designated AIDS specialists from other divisions and departments. Services provided include: the Moore Clinic, which provides 20,000 patient visits per year; a 21-bed inpatient unit; the Bayview Special Care Unit, a chronic care facility; a home care program; clinical research; specialty services; and the Moore Clinic Database to collect data on resource utilization, payments, events, and demographics. Approximately 60 percent of all patients in the program are Medicaid recipients.

Patients with AIDS receive care under a capitated rate based on historic claims data minus 10 percent (excluding mental health). Claims data used for the capitated rate setting were for Medicaid payments during the first two quarters of 1995. Patients were identified through the AIDS Registry operated by the Maryland State AIDS Administration.

The chart to the right shows how Johns Hopkins established the capitated rate. These data revealed that payments for AIDS patients averaged $1,890 per month with an anticipated capitation rate of $2,161 for most of those enrolled in the managed care program.

The data collected also illustrate other critical issues in cost assessment. As expected, hospital care was the most expensive category; however, the 52 percent was substantially less than the 63 percent as a statewide experience. Payment data across CD4 strata are quite stable at $1,000-$1,200 per month until the CD4 50 threshold is reached. There was no significant difference in payment for injection drug users (data not shown). In addition, payments for care after selected AIDS-defining complications were especially high for CMV retinitis, toxoplasmosis, MAC bacteremia, AIDS dementia, and PCP (PCP and MAC are preventable). Although the Infectious Disease Division administered this program, provided all primary care, developed the network, and controlled flow through the system, the reimbursement for this service was only 1.1 percent of the total payments.

The transition period at Johns Hopkins for moving from fee-for-service to managed care took place during the development period of new therapies for HIV. This transition has a marked impact on the allocation of resources within the Hopkins program and will impact the capitation rate beginning in 1999.

For more information about this project, contact John Bartlett, M.D., Chief, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Ross 1159, 720 Rutland Avenue, Baltimore, MD 21205, 410.955.7634.

SPNS/Fax is produced by The Measurement Group–PROTOTYPES Evaluation and Dissemination Center (EDC). Editorial comments should be made to The Measurement Group at 5811A Uplander Way, Culver City, California 90230, 310.216.1051, 310.670.7735 (fax).
 

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