aids drug assistance programs (adaps) adequate versus ideal models joey wynn, chairman, south...

AIDS Drug Assistance Programs (ADAPs) Adequate versus Ideal models

Joey Wynn, Joey Wynn, Chairman, South Florida AIDS Network (SFAN) Chairman, South Florida AIDS Network (SFAN)

aaa+ conference, Washington D.C.aaa+ conference, Washington D.C.

July 21July 21stst, 2009 , 2009

Ideal versus Adequate ADAPs

Initial Dialogue about the concepts of Initial Dialogue about the concepts of ideal ADAP models versus ideal ADAP models versus

adequate programsadequate programs

(The good, bad & the ugly!)(The good, bad & the ugly!)


Our goals for today’s discussion: Our goals for today’s discussion: Identify and create awareness of the importance of appropriate Identify and create awareness of the importance of appropriate

characteristics for ADAP Programs nationwidecharacteristics for ADAP Programs nationwide Identify & Understand the barriers and challenges associated with Identify & Understand the barriers and challenges associated with

evaluating ADAP Programs throughout the country (widen the evaluating ADAP Programs throughout the country (widen the net to see the real picture!) net to see the real picture!)

Begin to identify primary questions, & needed data to answer Begin to identify primary questions, & needed data to answer them them

Hold an interactive dialogue resulting in a clearer understanding Hold an interactive dialogue resulting in a clearer understanding and expectation of what ADAPs should be doing for their clients and expectation of what ADAPs should be doing for their clients based on their local environmentsbased on their local environments

Evaluate the need for further investigation into this topic and the Evaluate the need for further investigation into this topic and the usefulness of such data for the community usefulness of such data for the community


Key elements (core or medical model) of a local Key elements (core or medical model) of a local HIV primary care systemHIV primary care system

Number of Patients accessing servicesNumber of Patients accessing services Primary care visits (System-wide capacity) Primary care visits (System-wide capacity) Laboratory diagnostics (availability and capacity)Laboratory diagnostics (availability and capacity) Specialty Labs (Genotype, Pheno, Virtual Pheno, etc..)Specialty Labs (Genotype, Pheno, Virtual Pheno, etc..) Medications (Formulary Management, PBM, etc…) Medications (Formulary Management, PBM, etc…) Financial resources to maintain systemFinancial resources to maintain system


Other elements to considerOther elements to considerPayor Sources – Funding stream MatrixPayor Sources – Funding stream MatrixFinancial Limitations (Rationing Care) Financial Limitations (Rationing Care)

• Level of Sufficiency of resources versus Level of Sufficiency of resources versus demand /need demand /need

Patient’s “Quality of Life” indexPatient’s “Quality of Life” indexLoss of productive time for PatientLoss of productive time for PatientLoss of productivity levels – Staff Loss of productivity levels – Staff Patient mortality Patient mortality


Who Pays for these Medications?????Who Pays for these Medications????? ADAPADAP General Revenue (State Tax Dollars)General Revenue (State Tax Dollars) State MedicaidState Medicaid Federal Medicare Programs (A,B,C,D)Federal Medicare Programs (A,B,C,D) Ryan White A – F (formerly I, II, III, IV)Ryan White A – F (formerly I, II, III, IV) Private Insurance Plans Private Insurance Plans Local Indigent Plans – Hospital DSH programsLocal Indigent Plans – Hospital DSH programs Patient Assistance Progams – PAPs….. Patient Assistance Progams – PAPs…..

www.PPARx.org www.PPARx.org

The Cost of Care! Check please! (Pharmaceuticals)

State of FLA Medicaid State of FLA Medicaid Reimbursement BrowardReimbursement Broward

Medipass = 824 Medipass = 824

Broward CountyBroward County

Ryan White Title One Ryan White Title One

(Part A) = 2,340 (Part A) = 2,340

Florida ADAP 7/2006Florida ADAP 7/2006

Broward County Broward County

2,504 active clients2,504 active clients

Reyataz $759.63Reyataz $759.63 Reyataz $1,067.93Reyataz $1,067.93 Avg cost per client:Avg cost per client:

$865 $865

Truvada $738.55Truvada $738.55 Truvada $998.16Truvada $998.16 Avg $ per prescription:Avg $ per prescription:

$301.66 $301.66

Norvir 100mg $276.19Norvir 100mg $276.19 Norvir 100 mg Norvir 100 mg $372.85$372.85

Avg daily = $82,532Avg daily = $82,532

Monthly = $1,403,044Monthly = $1,403,044

BREAKDOWN OF COUNTY HEALTH BREAKDOWN OF COUNTY HEALTH DEPARTMENTS BY PHARMACY CATEGORYDEPARTMENTS BY PHARMACY CATEGORY

UNION

MADISON

TAYLOR

HAMILTON

SUWANNEE

LAFAYETTE

DIXIE

COLUMBIA

GILCHRIST

LEVY

BRADFORD

ALACHUA

PUTNAM

MARION

LAKECITRUS

SUMTER

HERNANDO

BAKER

NASSAU

DUVAL

CLAY

ST JOHNS

FLAGLER

VOLUSIA

SEMINOLE

ORANGE BREVARD

OSCEOLAPASCO

HILLSBOROUGH

POLK

MANATEE

HARDEE

INDIAN RIVER

OKEECHOBEEST LUCIE

MARTIN

PALM BEACH

BROWARD

DADEMONROE

HIGHLANDS

COLLIER

HENDRYLEE

CHARLOTTE GLADES

DESOTO

SARASOTA

JEFFERSON

PINELLAS

SANTA ROSA OKALOOSA

WALTON

HOLMESJACKSON

WASHINGTON

CALHOUNBAY

GULF

GADSDEN

LIBERTY

FRANKLIN

LEON

WAKULLA

ESCAMBIA

JUNE 2006

13

CATEGORY I – County Allocation W/Staff Pharmacist

CATEGORY II – County Allocation W/O Staff Pharmacist

CATEGORY III – All Other Counties Share Communal Funding Allocation

FLORIDA AIDS DRUG ASSISTANCE PROGRAM

DRUG EXPENDITURE BY COST

NUCLEOSIDEs / TIDEsNUCLEOSIDEs / TIDEs $3,348,699.44$3,348,699.44 FUSION INHIBITORFUSION INHIBITOR $ 75,529.24$ 75,529.24

PROTEASE INHIBITORPROTEASE INHIBITOR $1,979,395.14$1,979,395.14 WASTINGWASTING $ 13,790.31$ 13,790.31

NON-NUCLEOSIDENON-NUCLEOSIDE $ 618,676.69$ 618,676.69 NEUROPATHYNEUROPATHY $ 3,916.59$ 3,916.59

OPPORT. INFECTIONOPPORT. INFECTION $ 87,000.05$ 87,000.05 OTHERSOTHERS $ 9,555.64$ 9,555.64

ANEMIA/NEUTROPENIAANEMIA/NEUTROPENIA $ 89,117.35$ 89,117.35 HEPATITIS (PILOT)HEPATITIS (PILOT) $ 4,542.34$ 4,542.34

HYPERLIPIDEMIAHYPERLIPIDEMIA $ 45,561.45$ 45,561.45 HYPERGLYCEMIAHYPERGLYCEMIA $ 333.14$ 333.14

JUNE TOTALJUNE TOTAL $ 6,276,117.38$ 6,276,117.38 APRIL EXPENDITURE MAY EXPENDITURE

5,614,365.67 5,943,824.77

JUNE 2006

9

FLORIDA AIDS DRUG ASSISTANCE PROGRAMTOP TEN DRUG EXPENDITURES

$1

,34

6,7

67

.44

30041

$7

23

,25

0.1

3

1621$

69

2,3

63

.54

1408

$6

24

,13

7.3

2

1482

$4

68

,00

0.5

9

1770

$4

12

,90

5.4

5

545

$3

12

,97

1.6

3

1162

$2

84

,87

7.5

9

609

$1

99

,42

9.4

7 471

$1

49

,52

5.7

2

799

$-

$200,000.00

$400,000.00

$600,000.00

$800,000.00

$1,000,000.00

$1,200,000.00

$1,400,000.00

**

TR

UV

AD

A

KA

LE

TR

A

RE

YA

TA

Z

**

CO

MB

IVIR

SU

ST

IVA

**

*T

RIZ

IVIR

VIR

EA

D

**

EP

ZIC

OM

LE

XIV

A

VIR

AM

UN

E

CLIENT USAGE

JUNE 2006

11

Total Amount $5,214,228.88

FLORIDA AIDS DRUG ASSISTANCE PROGRAMADAP FORMULARY- TOTAL 69 MEDICATIONS

*By prior authorization only #Seasonal availability only Pediatric formulations may be available by special arrangement with Central Pharmacy

ABACAVIR (ZIAGEN)ABACAVIR (ZIAGEN) EFAVIRENZEFAVIRENZ (SUSTIVA)(SUSTIVA) MEGESTROL (MEGACE ES MEGESTROL (MEGACE ES & MEG. SUSPENSION)& MEG. SUSPENSION) SULFADIAZINE SULFADIAZINE

ABACAVIR/LAMIVUDINE ABACAVIR/LAMIVUDINE (EPZICOM)(EPZICOM) EMTRICITABINEEMTRICITABINE (EMTRIVA)(EMTRIVA) METFORMIN METFORMIN

(GLUCOPHAGE)(GLUCOPHAGE) TENOFOVIRTENOFOVIR (VIREAD) (VIREAD)

ABACAVIR/LAMIVUDINE/ABACAVIR/LAMIVUDINE/ZIDOVUDINE (TRIVIZIR)ZIDOVUDINE (TRIVIZIR) ENFUVIRTIDEENFUVIRTIDE (FUZEON) *(FUZEON) * MICONAZOLE MICONAZOLE

(MONISTAT)(MONISTAT)TENOFOVIRTENOFOVIR/EMTRICITABINE /EMTRICITABINE (TRUVADA) (TRUVADA)

ACYCLOVIR (ZOVIRAX)ACYCLOVIR (ZOVIRAX) ERYTHROPOIETIN (EPOGEN, ERYTHROPOIETIN (EPOGEN, PROCRIT)PROCRIT)

NANDROLONE (DECA-NANDROLONE (DECA-DURABOLIN)DURABOLIN) TERCONAZOLE TERCONAZOLE (TERAZOL)(TERAZOL)

AMANTADINE (SYMMETREL) #AMANTADINE (SYMMETREL) # ETHAMBUTOL (MYAMBUTOL)ETHAMBUTOL (MYAMBUTOL) NELFINAVIR (VIRACEPT)NELFINAVIR (VIRACEPT) TESTOSTERONE (GEL, PATCH, TESTOSTERONE (GEL, PATCH, INJECTABLE)INJECTABLE)

AMITRIPTYLINE (ELAVIL)AMITRIPTYLINE (ELAVIL) FILGRASTIM (NEUPOGEN)FILGRASTIM (NEUPOGEN) NEVIRAPINE (VIRAMUNE)NEVIRAPINE (VIRAMUNE) TIPRANIVIR (APTIVUS)*TIPRANIVIR (APTIVUS)*

AMPRENAVIR (AGENERASE)AMPRENAVIR (AGENERASE) FLUCONAZOLE (DIFLUCAN)FLUCONAZOLE (DIFLUCAN) NORTRIPTYLINE NORTRIPTYLINE (PAMELOR)(PAMELOR) TMP/SMZTMP/SMZ (BACTRIM, SEPTRA)(BACTRIM, SEPTRA)

ATAZANAVIR (REYATAZ) ATAZANAVIR (REYATAZ) FOSAMPRENAVIR CALCIUM FOSAMPRENAVIR CALCIUM (LEXIVA)(LEXIVA)

OSELTAMIVIR OSELTAMIVIR (TAMIFLU)#(TAMIFLU)# VACCINESVACCINES

ATORVASTATIN (LIPITOR)ATORVASTATIN (LIPITOR) GABAPENTIN (NEURONTIN)GABAPENTIN (NEURONTIN) OXANDROLONE OXANDROLONE (OXANDRIN)(OXANDRIN) HEPATITIS A & BHEPATITIS A & B

ATOVAQUONE (MEPRON)ATOVAQUONE (MEPRON) GEMFIBROZIL (LOPID)GEMFIBROZIL (LOPID) PRAVASTATIN PRAVASTATIN (PRAVACHOL)(PRAVACHOL) INFLUENZA INFLUENZA ##

AZITHROMYCIN (ZITHROMAX)AZITHROMYCIN (ZITHROMAX) GLIPIZIDE (GLUCOTROL)GLIPIZIDE (GLUCOTROL) PROCHLORPERAZINE PROCHLORPERAZINE (COMPAZINE(COMPAZINE))

PNEUMOCOCCALPNEUMOCOCCAL

CLARITHROMYCIN (BIAXIN)CLARITHROMYCIN (BIAXIN) GLYBURIDE (MICRONASE, GLYBURIDE (MICRONASE, GLYNASE, DIABETA)GLYNASE, DIABETA)

PYRIMETHAMINE PYRIMETHAMINE (DARAPRIM)(DARAPRIM) ZALCITABINE ZALCITABINE (HIVID)(HIVID)

DAPSONE (DDS)DAPSONE (DDS) HYDROXYUREA (HYDREA)HYDROXYUREA (HYDREA) RIMANTADINERIMANTADINE (FLUMADINE)*(FLUMADINE)* ZANAMIVIR (RELENZA)#ZANAMIVIR (RELENZA)#

DARUNAVIR (Prezista) (NEW)DARUNAVIR (Prezista) (NEW) INDINAVIR (CRIXIVAN)INDINAVIR (CRIXIVAN) RIFABUTIN (MYCOBUTIN) RIFABUTIN (MYCOBUTIN) ZIDOVUDINE ZIDOVUDINE (AZT,RETROVIR)(AZT,RETROVIR)

DELAVIRDINE (RESCRIPTOR)DELAVIRDINE (RESCRIPTOR) LAMIVUDINE (EPIVIR)LAMIVUDINE (EPIVIR) RITONAVIR RITONAVIR (NORVIR)(NORVIR) ZIDOVUDINE/LAMIVUDINE ZIDOVUDINE/LAMIVUDINE (COMBIVIR)(COMBIVIR)

DIDANOSINE (VIDEX,VIDEX EC)DIDANOSINE (VIDEX,VIDEX EC) LAMOTRIGINELAMOTRIGINE (LAMICTAL)(LAMICTAL) ROSUVASTATIN CALCIUM ROSUVASTATIN CALCIUM (CRESTOR)(CRESTOR)

DIPHENOXYLATE (LOMOTIL) DIPHENOXYLATE (LOMOTIL) LEUCOVORINLEUCOVORIN (FOLINIC ACID)(FOLINIC ACID) SAQUINAVIR SAQUINAVIR (FORTOVASE, INVIRASE)(FORTOVASE, INVIRASE)

DRONABINOLDRONABINOL (MARINOL(MARINOL LOPINAVIR (KALETRALOPINAVIR (KALETRASTAVUDINE STAVUDINE (ZERIT)(ZERIT)

JUNE 2006

14

Medicare Part D Standard Drug Plan Benefit in 2006

$250 $2250 $5100

$ +

Beneficiary Liability

DeductibleCoverage

Gap

Total Spending

≈ 95%

80% Reinsurance

15% Plan Pays

Catastrophic

Coverage

5% Coinsurance

Medicare Pays Reinsurance

75% Plan Pays

25% Coinsurance

Out-of-pocket

Threshold

Direct Subsidy/Beneficiary Premium

$750 $3600 TrOOP

Total

Beneficiary

Out-Of-Pocket$250

Distribution of Distribution of ARVs by CostsARVs by Costsin the Florida in the Florida Medipass Medipass systemsystem

TradeName Totals

TRUVADA $1,931,337.54REYATAZ $1,628,575.85KALETRA $1,587,139.06VIREAD $1,513,516.01COMBIVIR $1,258,036.14SUSTIVA $929,065.62TRIZIVIR $848,423.24FUZEON $723,897.08NORVIR SOFT GELATIN $715,887.48LEXIVA $690,589.92EPZICOM $602,971.44VIRAMUNE $558,106.88ZERIT $430,191.84ZIAGEN $386,187.23EPIVIR $295,225.04RETROVIR $107,235.15CRIXIVAN $101,507.05APTIVUS $80,112.42VIDEX EC $77,317.70INVIRASE $74,391.51VIRACEPT $59,336.62FORTOVASE $19,027.19NORVIR $10,653.78RESCRIPTOR $10,297.76HIVID $3,954.38AGENERASE $1,035.16VIDEX BUFFERED $661.54VIDEX $387.94

$14,645,068.57

Q3 2005 Dade & Broward reporting

Ideal versus Adequate ADAPs The Ideal ADAP would have:The Ideal ADAP would have:

Culturally appropriate staff with evening & weekend hoursCulturally appropriate staff with evening & weekend hours Ample staffing resources and counseling options available for adherence Ample staffing resources and counseling options available for adherence

services, drug reaction management, utilization review & Pain services, drug reaction management, utilization review & Pain management servicesmanagement services

A variety of geographic locations A variety of geographic locations Negotiated the lowest prices possibleNegotiated the lowest prices possible Delivery options available for certain casesDelivery options available for certain cases The broadest, robust formulary possibleThe broadest, robust formulary possible Web-based options for eligibility that used existing data from local service Web-based options for eligibility that used existing data from local service

delivery system & ease of use for clients & case managersdelivery system & ease of use for clients & case managers Experienced staff for drug to drug interactionsExperienced staff for drug to drug interactions A widely known process to use in the medical communityA widely known process to use in the medical community Frequent reporting about the program available easily with the communityFrequent reporting about the program available easily with the community Established outcomes & performance indicatorsEstablished outcomes & performance indicators Annual Report on outcomes & expendituresAnnual Report on outcomes & expenditures An evaluation component for Insurance purchasing and Premiums An evaluation component for Insurance purchasing and Premiums

assistance assistance A co Pay assistance programA co Pay assistance program A P.A.P. service model on site A P.A.P. service model on site


Reality Check!!!!! Typical Barriers to care:Reality Check!!!!! Typical Barriers to care: Inadequate fundingInadequate funding Lack of staffing resourcesLack of staffing resources Complex infrastructure – (band-aid effect) Complex infrastructure – (band-aid effect) Indigent Population vulnerabilitiesIndigent Population vulnerabilities Geographic accessibilityGeographic accessibility Hours of operationHours of operation State Gov’t Bureau State Gov’t Bureau


Questions and Answers: Questions and Answers: Where do we go from here?Where do we go from here? Is this topic useful?Is this topic useful? Which stakeholders would benefit from Which stakeholders would benefit from

this type of information? this type of information?


Thank you for your time and your Thank you for your time and your thoughts thoughts

aids drug assistance programs (adaps) adequate versus ideal models joey wynn, chairman, south...

Documents