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Navigating Challenges in Providing Preventive HIV Care to Members

February 12, 2021

By Edan Stanley

Charles M Karnack, PharmD, BCNSP, adjunct assistant professor of clinical pharmacy at Duquesne University in Pittsburgh, PA, explains common challenges faced by the payer market regarding preventive HIV care, lists potential fixes to improve processes, and points out specific issues like confirming patient eligibility that make preventive treatment especially difficult.

Dr Karnack’s background includes being a clinical pharmacy specialist in nutrition support & home care at UPMC Mercy in Pittsburgh, PA. He is currently retired full time from UPMC, but continues to serve as an adjunct assistant professor of clinical pharmacy at Duquesne University and Pharmacy Consultant for Pediatric Specialty Care in Pittsburgh, PA. 

He explained that in previous practices, patients with HIV were usually referred to a local urban support group, sometimes associated with LGBTQ community, that counseled and coordinated their care. 

Can you comment on the US Preventive Services Task Force’s recommendation in support of preventive HIV care, which led to increased access via an ACA mandate on health plans?

The Preventive Services Task Force has advocated for preventive care measures since the ACA has been in effect. Minimizing out of pocket expenses (co-payments & deductibles) for preventive care was thought to encourage patients to take better care of themselves thus saving costs associated with acute care in the future.  

Can you identify some of the top barriers to care and access for patients with HIV? What role does cost play?

Barriers to health care for HIV patients can be similar to other patient groups who sometimes are ostracized (indigent, transgender, homeless, injectable drug users) by our society. These barriers may include but are not limited to location (urban vs rural), transportation, general education, knowledge of disease symptoms, employment, insurance, age, to name a few.

Cost can definitely play a challenging role in HIV care since many innovative, cutting-edge medications are not immediately available generically. Additionally, once these treatments become available, their prices are often high and slow to decrease to affordable levels for the average patient.

Unfortunately, the drug price is not the only cost. Clinical appointments and laboratory monitoring are often not covered—such as unclear insurance guidelines, incorrect payment codes—meaning added phone calls, further paperwork and signatures, resulting in additional charges like co-payments and deductibles. Often it is difficult for the patient to determine who to contact. There also tends to be a lot of finger pointing between the provider and payer further exacerbating the issue.   

What challenges do you expect payers to face under these measures? 

I think one of the biggest challenges for payers is eligibility verification—obtaining the appropriate documentation from the patient or medical provider to determine whether the medication is being used for HIV prevention or treatment. The concept of prior authorization can be incredibly labor intensive. With the number of forms and necessary phone contacts to complete and secure, it can border near impossible levels for the best nurse liaisons and coordinators to navigate.

As a clinician, I have seen the company runarounds and resulting coordinator frustrations trying to navigate these authorization and coding issues. An increase in the number of patients requesting benefits will add to the level of confusion, besides the variety of different plans (high deductible, low premium.) Determining whether the guidelines for the applied assistance program is federal, state, county, or private adds to further difficulty. 

What can payers do to better to make their members more aware of resources available to them?

Member newsletters, emails, texts, and telecommunication systems can help to provide some information to those patients who are able to access and use these methods. Unfortunately, some patients do not have a permanent address or limited access to a computer or cell phone, whether it be due to their living situation or other social factors (ie, living in shelters and incarceration). 

Making patient assistance programs more available and easier to find, forms less prescriptive and easier to complete, can help some patients and their caregivers navigate these insurance and/or drug company programs. Payers should also focus on making formularies easier to understand, clearly explaining the different tiers, "step" programs and appeal processes, as well as a timely notification of changes in formulary status could also help.  

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