MN HIV Services Planning Council
Meeting Minutes for February 8, 2005
Redeemer Missionary Baptist Church

 

 

I.                  Welcome and introductions; lighting of the candle

Aaron Keith called the meeting to order at 9:05 a.m.  Introductions were made.  Dan and Bob lit the candle to commemorate the beginning of the process of developing our next Comprehensive Plan.  Dan said he wants to be mindful of why we’re doing this – those who have already passed away, those who are living with HIV, and those who don’t know their status.  Bob added that one of our many tasks is to ensure access to appropriate care for all of those living with HIV/AIDS and that’s what we accomplish through the Comprehensive Plan.

 

II.             Review the minutes and proposed agenda

The minutes from the January meeting were approved by unanimous consent with no changes.  The proposed agenda stands as written.

 

III.   Open Forum

No one wished to use the time.

 

IV.     Co-chair update

Aaron Keith shared that the ADAP situation will be discussed throughout today’s agenda.  Dan Schreiner is here to discuss rebate vs. direct purchase of drugs.  Another area that the Planning council is considering is advocacy regarding ADAP – Aaron Keith asked members who had ideas to talk to him or Paul.  He further reported that there is a state map with each legislator’s picture, phone number, etc. in case Planning Council members would like to identify who represents him or her in the legislature.

 

V.       ADAP discussion rebate vs. direct purchase

Dan Schreiner, TA Consultant presentation regarding benefits of rebate vs. direct purchasing of ADAP drugs

Dan shared that his background includes previous work with HRSA dealing directly with ADAP.  He provided background regarding options that are available to states with respect to accessing medications.  There are two ways that states can purchase medications for their ADAP programs – directly purchasing them from manufacturers at a discount or purchasing drugs and then submitting a rebate request to the drug company.  In general, states that directly purchase drugs spend less money on medication than those who use the rebate system.  He then briefly reviewed a comparison of financial information from eight states that directly purchase medications.  The benefits of a direct purchase system are reduced cost but the drawback is often an inconvenience for clients.

 

Dan then described the current rebate system that Minnesota uses, which is a standard 304B program.  Dan began his analysis by looking at the epi, number of enrolled clients, average utilization, federal ADAP appropriation, state contributions, financial eligibility, number of drugs on the formulary, and the average cost per client.  When using this information to look at Minnesota Dan could see a cost benefit when he compared MN to the other eight states.  Dan added that rebate programs do have some expense associated with them, including a transaction fee that each of the contracted pharmacies charge for each prescription.  That transaction fee covers some expense pharmacies incur for doing work on behalf of the rebate program.

 

Jonathan asked if other states contribute Title I or Title II dollars to support ADAP.  Dan said in Georgia Title I funds are allocated to medication, Florida has pharmacy assistance programs, and Chicago contributes some funding within the EMA for funding drug programs. 

 

With respect to MN – Dan said about six to eight percent of those being served are on the drug program alone.  Dan added that something to keep in mind with respect to rebates is that states can apply for rebate based on the purchase price of medications rather than the amount paid for that particular drug (i.e., 80/20 copay – get rebate on 100% of cost even if insurance covered 80% of the purchase price), which is consistent with rebates for the Medicare policy (if only a portion of the drug is paid for it can be rebated at 100% of the price).

 

Dan then illustrated a comparison of the states analyzed and their upfront costs per antiretroviral by state.   Minnesota pays more for every drug compared to direct purchase states.  When negotiating prices in a rebate situation, there is a reduced cost for purchasing drugs (10 – 12% in MN) with additional rebates after purchase.  When direct purchase prices are set the rates are negotiated and regulated by the Office of Pharmacy Affairs (OPA).  When reviewing drug prices the OPA tries to ensure there is little discrepancy between direct purchase price and the ultimate price after rebate.  Dan then factored in the rebate that Minnesota is able to realize (60%), which illustrates that Minnesota is paying less for most drugs than any of the other states analyzed.  If the state were to move from rebate to direct purchase Minnesota would not get the rebate revenue but would purchase at the reduced price.  Dan feels that the combination of the relatively small discount with the rebate is a much better deal for Minnesota.  For those clients cycling in and out (six to eight percent) of the program there is more of a discount available.  If Minnesota was direct purchase it would also not be able to purchase insurance premiums for any clients.  Dan described Minnesota’s program as a model program – spreading the cost of care between federal funds, state funds, and private entities with some patient responsibility (cost share premiums).

 

If Minnesota is still interested in converting to a direct purchase program some considerations that Dan pointed out are:  the possible impacts of the change on clients (including how many clients can be served) and the possible cost/savings to the program.  Currently clients meet with their pharmacist who can also provide patient education, clients can pick up prescriptions at 1,000 pharmacies throughout the state as needed, and pharmacists are able to help compare medications for possible drug interaction.  If Minnesota were a direct purchase state, medications would be sent to the client’s home or other designated location so they’re not as accessible.  And, access to pharmacists and the information they have would not be similar to the current system.  There are additional elements with respect to the responsibilities of the program, including HRSA reporting and ensuring that funds are used as the payer of last resort to name a few.  These are responsibilities that currently fall on the pharmacies.  Dan further described the programmatic changes that would be impacted by this decision – the example he used would create additional program costs of $222,912 per year.

 

In conclusion Dan said he generally assumes that direct purchase is more cost effective than rebate.  He looks at the overall impact on the client as well as the program cost/savings.  In Minnesota the upfront costs are in-line with other states analyzed and by using rebate the overall costs are greatly reduced.  Clients have access to pharmacies throughout the state and the costs to the program would likely increase if it were changed to a direct purchase system. 

 

Amy added that in terms of lobbying and advocacy MCHA is something to keep in mind because the high-risk insurance pool typically doesn’t like to serve the ADAP pool of clients.  Members then asked questions.  Dan did not factor in increases to insurance premiums in his analysis and added that there are other ways to handle those increases (i.e., supplementing premiums with Title I funds and/or increasing cost share premiums).  Megan is curious to see a comparison of rebate savings vs. increases in premium costs.  Dan further added that using increasing drug costs as a rationale for increased health insurance premiums is a bit of a red herring.  Megan asked if Dan had ideas for other sources of funding.  Dan said Title II or Title III – Title I was not intended to pay for medications.  For certain populations of people Title III funded programs may be able to be contracted with Title I funds to provide medications. 

 

Dan offered his email address and phone number so people could contact him directly with questions.

 

VI.     Title II and ADAP update, Amy Moser

Amy thanked Dan for all of the work he’s done in preparing his analysis.  The NIH grant is still pending.  The integrated health care grant guidance that was supposed to come out is still not here – DHS is waiting for the guidance with the intention of reapplying for those funds.  The guidance for the SAMSHA grant has been received and because of the change in scope DHS has forwarded it on to the Department of Health (MDH). 

 

The Title II application is in and they are hoping to hear about the award right around April 1^st.  The training calendar is at the printer and should be out in the next couple of weeks, including case management training and forum dates.  Around October DHS should be moving into their new building in St. Paul so some locations still haven’t been determined.  Training for the mental health program that recently transitioned to DHS will be coming soon.

 

Legislative update.  The Governor has proposed eliminating single people from eligibility for MN Care and reducing the eligibility for those with families.   He further proposes reinstating an income spend-down to qualify for GAMC.  Amy will email staff information about the four bills that have been introduced in the legislature relating to health care and the proposed changes.  DHS is forecasting that about 45 people on MN Care who may lose their coverage but he doesn’t anticipate that all of them will apply to HIV specific programs (Program HH).  By using formulary plus funding about 23 people were moved from Minnesota Limited Benefit (MNLB) to Program HH.  Aaron Keith asked about planning for waiting lists.  Amy explained that the formulary committee is working to develop criteria in anticipation of waiting lists starting.  The technical request (TA) for an ethicist was approved and that person will be working with the formulary committee to finalize waiting list criteria (medical based vs. first come, first served).  The Planning Council will also be working with the ethicist to decide how to plan for action in an environment of scarce resources.

 

Discussion moved to the current forecast.  Currently there are multiple variables in place that make forecasting very difficult.  These include the impact of Medicare Part D and rebates that haven’t been billed or received yet.  DHS is trying to forecast every two months so they can be proactive if/when waiting lists need to be in place.  It is not clear if there will be wait lists for drugs, insurance or both.  Dave asked the Planning Council members feel free to contact him with any questions.

 

Aaron Keith asked how DHS will continue to inform community members about forums.  Amy reported that DHS has had forums quarterly and will probably continue that schedule.  She added that the Formulary Committee is looking for more members and will be meeting again on March 9^th at 5:30 at the Aliveness Project (date subject to change depending on availability of the ethicist).  Eric suggested that a letter go out to providers explaining the current situation and offering information on advocacy and/or identifying other funding sources because programs could be cut.  Staff suggested drafting an update letter regarding some of the recent developments.  Gwen suggested holding a meeting instead so that folks would have an opportunity to ask questions.  Jonathan asked if that could be a provider focused forum.  Amy will check with Dave.

 

VII.   Title I update, Jonathan Hanft

Jonathan handed out the update outline and a table of the agencies funded through the recent RFP process.  He reminded members that there are three minority AIDS initiative (MAI) programs being funded providing care advocacy and outreach.  There is nothing new to report about the award – he is anticipating notification around the same time as Title II (April 1).  Depending on the outcome of the awards for Title I and II, the Planning Council may have to revisit allocations at the April meeting.

 

An update on TA – Dan (here today) is part one.  Part two is the ethicist – working with the Formulary Committee and Planning Council (there may actually be two separate consultants).  The ethicist working with the Planning Council will advise on making decisions during times of cuts.  The third TA request is going in today and is to look at health care financing, looking at strategies other states have used and are there ways to better coordinate programs currently funded by Titles I and II.  A conference call is scheduled for Monday to discuss all of the logistics for the second and third ADAP related technical assistance requests. 

 

VIII.CSAD update, Joan Othieno

Joan handed out information about the status of the project.  CSAD is the Special Project of National Significance (SPINS) demonstration project that Minnesota received to look at the service needs of the African born community.  The project considers those both in and out of care.  Currently the project staff is faced with challenges reaching folks who are not in care.  They have begun to transcribe the tapes and hope to present preliminary findings in two months. 

 

IX.          Committee written reports;time for questions, discussion    

Planning and Priorities Committee

Comprehensive Plan update and tour

Dan shared that the Planning & Priorities Committee is currently working on developing the Comprehensive Plan for 2006 to 2009.  Materials that the committee is working with, including the agenda and work plan, were passed out to all members.  During the allocations process Aaron Keith referred to goals and objectives in the Comprehensive Plan that were included on the service area review (SAR) summaries members used in decision-making.  Dan shared that the committee will be asking Planning Council members for more input on the comp Plan at the March meeting.  The group is also looking for more participants in the process.  The first Planning and Priorities Committee meeting of each month will be dedicated to developing the new Plan.  The hope is to have a draft to Planning Council members by June.  Dan then reviewed the questions that the Committee will be addressing in the Plan and shared the status of where the group is in the process.  Copies of the current Comprehensive Plan are available for all interested.  Dan then shared the logo that’s being developed for use in identifying Comprehensive Plan documents and how the Comprehensive Plan fits into the overall Planning Council process.

 

HIV Positive Committee

Update on Technical Assistance

Randy reported that the committee is preparing to meet with Lennie, the consultant providing technical assistance to the committee.  Dates for the retreat/meeting currently being discussed are March 18^th and 19^th or 25^th and 26^th.

Needs Assessment and Evaluation Committee

Community Participation Committee

Bob shared that there is a Community Participation meeting on Friday and encouraged any/all to attend if they are available.

 

Operations Committee

          ADAP Ad Hoc Committee

Francis said that the committee is in the process of editing and rewriting the position paper and are hoping to bring it back to the March Planning Council meeting.

 

X.          Announcements, evaluation, next agenda

Debra announced that the Community Advisory Board is sponsoring another forum on March 3^rd that will talk about HIV status disclosure.  They are flying in a national speaker to do two forums - Celebrating Your Spirit on March 3^rd (childcare is available – call the MAP AIDSLine to register) and on March 4^th for professionals and providers in the field.

 

Mary Doyle announced that Elizabeth Dickenson sent her a notice about the Health and Human Services Committee of the legislature.  They are meeting today and tomorrow and will be discussing the DH’ budget.

 

Documents distributed at or before the meeting:

·        Agenda and minutes from January 11^th meeting

·        Written committee reports

·        The ADAP Report – An Information Resource for ADAP Administrators

·        Title I update outline

·        Table of services/vendors funded through the RFP process

·        Comprehensive Plan Table of Contents

·        Comprehensive Plan Outline

·        Comprehensive Plan Agenda/Work Plan

·         

 

MOTION: Debra moved Eric seconded adjournment of the meeting.

 

Adjourned at 11:30 a.m.