The State of ADAPsReview of the 2011 National ADAP Monitoring Project Annual Report and Update on the ADAP CrisisBritten PundNational Alliance of State & Territorial AIDS DirectorsJuly 5, 2011

Presentation Agenda

Highlights from the 2011 National ADAP Monitoring Project Annual Report

Update on the ADAP Crisis

Questions and Answers

National Alliance of State & Territorial AIDS Directors (NASTAD)

Represents the nation’s chief health agency HIV/AIDS and viral hepatitis staff in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands and the U.S. Pacific Islands– Provides technical assistance and other support to

health department HIV/AIDS and viral hepatitis programs

– Provides national leadership on HIV/AIDS and viral hepatitis policy and programs

– Educates about and advocates for necessary federal funding

Highlights from the

2011 National ADAP Monitoring Project

Annual Report

Methodology

Respondents

All ADAPs receiving federal ADAP earmark funding through the Ryan White Program were surveyed.– 57 jurisdictions were surveyed in September 2010; 52

responded.– 57 jurisdictions were surveyed in February 2011; 49

responded.

Non-responders represent <1% of estimated living HIV and AIDS cases in the United States.

Requested Data

Survey requests data and other program information for:– A one-month period (June 2010 or December 2010)– The current fiscal year (FY2010)– Other periods as specified

Data offers a monthly “snapshot” comparison from previous survey periods.

The Report

Module One

Detailed information related to :– ADAP budgets– Client enrollment and utilization– Client demographics– Program eligibility– Program management and administration

Module Two and Module Two Supplement

Detailed information related to:– Prescription distribution and payment methods– Expenditures and prescriptions filled– Insurance coordination– ADAP coordination with Medicare Part D– ADAP coordination with Pre-existing Condition

Insurance Plans (PCIPs)– Updated client enrollment and utilization– Hepatitis treatments

Highlights from Module One

The National ADAP Budget

In FY2010, the national ADAP budget grew to $1.79 billion, a 13% increase from FY2009.

All funding streams increased incrementally over the last year.

Part B ADAP Earmark$800,033,562

(45%)

Part B ADAP Supplemental$41,750,000

(2%)

Part B Base Contribution Directed to ADAP

$20,573,517(1%)

Part B Supplemental Contribution Directed to ADAP

$12,500,358(1%)

ADAP Emergency Funding $24,999,313

(1%)

State Contribution$346,239,277

(19%)

Part A Contribution Directed to ADAP

$15,288,430(1%)

Other State or Federal$5,018,513

(<1%)

Drug Rebates$522,589,581

(29%)

The National ADAP Budget, by Source, FY2010

Total = $1.79 billion

The National ADAP Budget

FY1996 $200 m

FY1997 $413 m

FY1998 $544 m

FY1999 $712 m

FY2000 $779 m

FY2001 $870 m

FY2002 $962 m

FY2003 $1,071 m

FY2004 $1,187 m

FY2005 $1,299 m

FY2006 $1,386 m

FY2007 $1,428 m

FY2008 $1,522

m

FY2009 $1,582 m

FY2010 $1,789 m

26%

40%

53%

65% 68% 66% 64% 65%61% 59% 56% 54% 51% 49%

45%

25%

28%

22%

18%17%

17% 17% 16%19%

19%22%

21%21%

14% 19%6%

5%

6%

7%7% 7% 9% 10% 12% 15% 17%

18% 21%

31% 29%43%

26%19%

11% 9% 10% 10% 9% 7% 7% 5% 7% 7% 7% 6%

National ADAP Budget, by Source, FY1996-FY2010

ADAP Earmark State Rebates Other

The National ADAP Earmark

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

$0

$100

$200

$300

$400

$500

$600

$700

$800

$900

$51.9

$167.0

$285.5

$460.6

$527.6

$571.3

$619.8

$692.9$728.0

$764.7 $779.8 $775.3 $774.1 $778.6$800.0222%

71%61%

15%8% 8% 12%

5% 5% 2% -1% 0% 1% 3%

Part B ADAP Earmark, FY1996-FY2010

Mil

lio

ns o

f D

oll

ars

ADAP Emergency Funding

In August 2010, the Obama Administration reprogrammed $25 million to address ADAP waiting lists and other unmet ADAP needs.

Funding awards were made to 30 states.

Funding amounts ranged from $38,111 in Alaska to $6.9 million in Florida.

State Funding

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

$0

$50

$100

$150

$200

$250

$300

$350

$400

$50.4

$117.4 $119.4 $125.5 $128.8$149.6

$160.4$171.9

$226.6

$252.8

$304.9$294.1

$328.5

$215.3

$346.2

133%

2% 5% 3%

16%7% 7%

32%

12%21%

-4%

12%

-34%

61%

State Funding, FY1996-FY2010

Mil

lio

ns o

f D

oll

ars

Drug Rebates

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

$0

$100

$200

$300

$400

$500

$600

$11.9 $22.6 $33.7 $46.4 $54.5 $60.0$83.1

$109.9

$146.2

$196.5

$230.3$262.6

$327.1

$497.6$522.6

90%

49%

38%

17% 10%

39%

32% 33%

34%

17%14%

25%

52%

5%

Drug Rebates, FY1996-FY2010

Mil

lio

ns o

f D

oll

ars

Cost-recovery

“Cost-recovery” for medications purchased through ADAP (other than drug rebates) represented $50.5 million in FY2010.

Private insurance recovery represented 58% of all cost-recovery.

Private Insurance$29,176,302

(58%)

Medicaid$15,764,359

(31%)

Other $5,570,345 (11%)

Cost Recovery and Other Cost-Saving Mechanisms (Excluding Drug Rebates), FY2010

Total = $50.5 million

ADAP Expenditures, FY2009

In FY2009, ADAPs expended $1.4 billion on prescription drugs, representing 85% of all ADAP expenditures.

ADAPs expended $176.1 million on insurance payments, representing 10% of all ADAP expenditures.

Two percent of ADAP funds were expended for program administration costs.

Prescription Drugs $1,430,230,842 (85%)Prescription Dispensing

Costs $17,090,460 (1%)

Insurance Premiums $101,623,665 (6%)

Insurance Co-payments and Deductibles $74,457,786

(4%)

Client Outreach $1,363,314 (<1%)

Adherence and Monitoring $10,791,413 (1%)

Quality Management $3,373,897 (<1%)

Program Administration $27,146,476 (2%)

Client Enrollment Costs $4,537,753 (<1%)

Other $6,923,355 (<1%)

ADAP Expenditures, FY2009

Total = $1.7 billion

ADAP Client Enrollment and Utilization

On average, 2,806 new clients were enrolled in ADAP each month in FY2009.

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

31,317

43,494

53,76561,822

69,40776,743 80,035

85,82594,577 96,404 96,121

101,987110,047

125,479

135,59639%

24%

15%12%

11%

4%

7%

10%

2%0%

6%8%

14%

8%

ADAP Client Utilization, June 1996-2010

Cli

en

ts S

erv

ed

ADAP Client Gender, Race/Ethnicity, and Age

Seventy-seven percent (77%) of ADAP clients are male.

Blacks and Hispanics comprise 55% (33% and 22% respectively) of ADAP clients served.

Almost half (48%) of ADAP clients are between the ages of 45 and 64.

Seventy-five percent (75%) of ADAP clients had income levels at or below 200% of the Federal Poverty Level (FPL).

Non-Hispanic Black/African

American33%

Non-Hispanic White35%

Hispanic22%

Asian1%

Native Hawaiian/Pacific Islander

<1%

American Indian/Alaskan

Native<1%

Multi-Racial5%

Other1%

Unknown2%

ADAP Clients Served, by Race/Ethnicity, June 2010

≤100% FPL

101-133% FPL

134-200% FPL

201-300% FPL

301-400% FPL

>400% FPL

Unknown

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

45%

11%

19%

14%

5%

1%

3%

ADAP Clients Served, by Income Level, June 2010

Percent of Clients

Fed

era

l P

overt

y L

evel

ADAP Client Demographics

ADAP Client Insurance Status

Twenty-two percent (22%) of ADAP clients had private insurance.

Seven percent (7%) of ADAP clients were dual beneficiaries of both Medicaid and Medicare.

Uninsured

Private Insurance

Dually Eligible (Medicaid & Medicare)

Medicare

Medicaid

0% 10% 20% 30% 40% 50% 60% 70%

61%

22%

7%

13%

9%

ADAP Clients Served, by Insurance Status, June 2010

Percent of Clients

ADAP Eligibility Criteria

ADAP income eligibility in June 2010 ranged from 200% FPL in eight states to 500% FPL in six.

Fourteen ADAPs reported having asset limits in place in June 2010.

ADAP Management Policies

Thirty-three ADAPs have specific ADAP management policies in place, including:– Three ADAPs (6%) require client cost-sharing– Three ADAPs (6%) limit clients to a maximum number

of prescriptions per client per month– Twelve ADAPs (24%) maintain a clinical criteria for

client access to some medications on the ADAP formulary

– Twenty-six ADAPs (51%) require prior authorization for clients access to some medications on the ADAP formulary

Highlights from Module Two

ADAP Client Utilization

ADAPs provided medications to 127,998 clients in December 2010.

Client utilization increased by 2% between June 2009 and December 2010; client utilization decreased by 2% between June 2010 and December 2010.

June 2009 June 2010 December 2010

125,479

135,5967127,998

ADAP Clients Served, June 2009, June 2010 and De-cember 2010

Nu

mb

er

of

Cli

en

ts

ADAP Drug Expenditures

ADAP drug expenditures were $146,457,975 in June 2010.

Ten states accounted for 76% of all drug spending; five states accounted for 57% of all drug spending.

$0

$40,000,000

$80,000,000

$120,000,000

$160,000,000

$110,957,891

ADAP Drug Expenditures and Top 10 States, by Drug Expenditures, June 2010

June 2010 Expenditures

Total = $146,457,975

Average Monthly Cost Per Client

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

$0

$200

$400

$600

$800

$1,000

$1,200

$471

$611

$758 $757

$842 $831

$883 $902

$1,024$1,064

$991 $982$1,005 $995

$949

ADAP Average Monthly Cost Per Client, June 1996-2010

Per

Cap

ita E

xp

en

dit

ure

s

ADAP Prescriptions Filled

In June 2010, the average expenditure per prescription was $325, compared to $302 in June 2009, representing an 8% increase.

Average expenditures per prescription was significantly higher for antiretrovirals ($491) than non-antiretrovirals ($67 for “A1” OIs and $64 for all other drugs).

ADAPs filled a total of 451,148 prescriptions in June 2010, representing an increase of 8% compared to June 2009.

ADAP Drug Expenditures and Prescriptions Filled (Including Drug Purchases and Co-Payments), by Drug Category, June 2010

ARVs$133,379,390

(92%)

"A1" OIs$2,581,031

(2%)

All Other $9,211,929 (6%)

Total = $147.2 million

ARVs271,503(60%)

"A1" OIs38,418(9%)

All Other 141,327, (31%)

Total = 451,148 prescriptions filled

ADAP Drug Expenditures and Prescriptions Filled (Including Drug Purchases and Co-

Payments), June 2010

Drug Purchases$139,168,395

(95%)

Co-Payment Expenditures$7,289,580

(5%)

Total = $147.2 million

Drug Purchases Rx354,650(79%)

Co-Payment Rx96,498(21%)

Total = 451,148 prescriptions (Rx) filled

ADAP Insurance Coordination

2002 2003 2004 2005 2006 2007 2008 2009 2010 -

20,000

40,000

60,000

80,000

100,000

120,000

$-

$40

$80

$120

$160

$200

5,272 7,167 7,277 12,311 13,744

20,960 15,843

30,621

110,369

$19

$30 $38

$75 $84

$75

$107

$159

$194

Clients Served and Estimated Expenditures in Insurance Purchasing and Continuation, 2010

Nu

mb

er

of

Cli

en

ts (

Jun

e)

Fis

cal

Year

Exp

en

dit

ure

s (

in m

illi

on

s)

ADAP Insurance Coordination

In June 2010, 110,338 ADAP clients were served through insurance coordination.

Clients served through insurance coordination more than tripled since June 2009.

Spending on insurance purchasing/continuation represented an estimated $139 per capita in June 2010, about 15% of the average monthly cost per client, based on drug expenditures, in that month ($949).

ADAP Coordination with Pre-existing Condition Insurance

Plans

As of December 2010, 12 ADAPs reported having the ability to enroll clients in PCIPs.

Eleven states had 151 clients enrolled with plans to continue enrolling additional clients.

The average monthly cost per client served in a PCIP was $529 in December 2010, approximately 56% of the annual average cost per client, based on drug expenditures ($949) in that month.

ADAP Coordination with Medicare Part D

To meet the federal requirements and maintain appropriate medication coverage for their clients, 53 ADAPs have developed policies to coordinate with the Part D benefit.

ADAP Pays Part D Pre-miums

ADAP Pays Part D Deductible

ADAP Pays Part D Co-Pays Standard Beneficiary Clients Eligible for ADAP

ADAP Provides Medications During Donut Hole

23

44

3639

36

ADAP Policies Related to Medicare Part D, February 2011

Nu

mb

er

of

AD

AP

s

Twenty-six ADAPs reported signing a data sharing agreement with CMS in December 2010 (see Table 13).

Twenty-three ADAPs, including 9 who do not have a data sharing agreement with CMS, have a data sharing agreement with at least one other entity, including Medicaid, Medicare, private insurance providers, and other entities (e.g. Pharmacy Benefits Managers).

ADAP Coordination with Medicare Part D

Highlights from Module Two Supplement

ADAP Coverage of Hepatitis B Treatment, December 2010

ADAP Coverage of Hepatitis C Treatment, December 2010

ADAP Coverage of Hepatitis A and B Vaccines, December 2010

Year in Review

The “Perfect Storm”

ADAP

Minimal increases in federal appropriations

Fluctuations in state funding

Increased demand due to unemployment and

other economic challenges

Heightened national efforts on HIV testing and linkages into care

High drug costs

Revised HIV treatment guidelines

Patient Protection and Affordable Care Act

Patient Protection and Affordable Care Act (PPACA) signed into law in March 2010.

Some portions of reform that will impact ADAPs specifically are:– Medicaid eligibility expansion (2014); – Increase in the number of individuals covered by insurance plans

(2014);– ADAPs’ Medicare Part D expenditures counting toward True Out

Of Pocket (TrOOP) expenditures (2011); – Narrowing and closing of the Medicare Part D “doughnut hole

(ongoing);”– An increase in the Medicaid rebate amount for purchased drugs;

and (2010)– 340B pricing transparency.

Pharmaceutical Partners Contributions

In May 2010, pharmaceutical partners augmented current agreements with ADAPs including:– Providing deeper discounts;– Increased rebates; and/or– Price freezes to ADAP.

Pharmaceutical partners expanded the reach of Patient Assistance Programs (PAPs) and participated in Welvista for waiting list clients.

ADAP Waiting Lists

Over the course of 2010, 19 ADAPs reported a waiting list.

Several ADAPs decreased income eligibility requirements and disenrolled clients from ADAP in order to address shortfalls.

In FY2010, some ADAPs began transitioning clients off of ADAP and onto PAPs as a means of cost-containment. These clients were directed to seek access to medications through PAPs.

ADAP Waiting Lists and Cost-containment, as of May 2011

ADAP Waiting Lists, as of June 30, 2011

8,615 individuals in 13 states*Alabama: 73 individualsArkansas: 40 individualsFlorida: 3,562 individualsGeorgia: 1,630 individuals

Idaho: 20 individualsLouisiana: 824 individuals**

Montana: 29 individualsNorth Carolina: 292 individuals

Ohio: 485 individualsSouth Carolina: 810 individuals

Utah: 25 individualsVirginia: 817 individualsWyoming: 8 individuals

*As a result of ADAP emergency funding, Hawaii, Idaho, Iowa, Kentucky, South Dakota, and Utah eliminated their waiting lists; Idaho reinstituted a waiting list in February 2011 and Utah reinstituted a waiting list in May 2011.

**Louisiana has a capped enrollment on their program. This number represents their current unmet need.

ADAPs with Cost-containment, as of April 13, 2011

Arizona: reduced formularyArkansas: reduced formulary, lowered financial eligibility to 200% FPL

(disenrolled 99 clients in September 2009) Colorado: reduced formulary

Florida: reduced formulary, transitioned 5,403 clients to Welvista from February 15, 2011 to March 31, 2011

Georgia: reduced formulary, implemented medical criteria,participating in the Alternative Method Demonstration Project (AMDP)

Idaho: capped enrollmentIllinois: reduced formulary, instituted monthly expenditure cap ($2,000 per

client per month)Kentucky: reduced formulary

Louisiana: discontinued reimbursement of laboratory assaysNorth Carolina: reduced formulary

ADAPs with Cost-containment, as of April 13, 2011 (continued)

North Dakota: capped enrollment, instituted annual expenditure cap, lowered financial eligibility to 300% FPL (grandfathered in current clients

above 300%FPL) Ohio: reduced formulary, lowered financial eligibility to 300% FPL

(disenrolled 257 clients in July 2010)Puerto Rico: reduced formulary

South Carolina: lowered financial eligibility to 300% FPL (grandfathered in current clients above 300% FPL)

Utah: reduced formulary, lowered financial eligibility to 250% FPL (disenrolled 89 clients in FY2010)

Virginia: reduced formulary, transitioned 207 clients onto waiting list and PAPs, only distributing 30-day prescription refills

Washington: instituted client cost sharing, reduced formulary (for uninsured clients only), only paying insurance premiums for clients currently on

antiretroviralsWyoming: reduced formulary, instituted client cost sharing

Coordinated Strategy to Save America’s ADAPs

Secure additional resources for ADAP from the federal government:– The HIV/AIDS community is advocating for an

increase of $106 million for ADAPs for a total funding of $991 million in FY2012.

Maintain, restore and increase resources for ADAPs from state governments.

Continue agreements between ADAPs and pharmaceutical manufacturers to provide financial stability and augment existing agreements, when possible.

The Outlook for the Future

A bridge to 2014 is slowly being built and will require much construction before ADAPs can fully take advantage of health reform provisions.

Weathering the current storm to reach 2014 will take collaboration from all stakeholders involved in the administration of the program.

Questions and Answers

Resources

For an electronic copy of the 2011 National ADAP Monitoring Project Annual Report, please visit www.NASTAD.org.

For more information about the National ADAP Monitoring Project or the ADAP Crisis, please contact Britten Pund at bpund@NASTAD.org.

Contact Information

Britten PundManager, Health Care Access

NASTADPhone: (202) 434.8044  bpund@NASTAD.org

www.NASTAD.org