Abstract
In 1990, New York State instituted Comprehensive Medicaid Case Management, also known as Target Case Management (TCM), for people dealing with multiple comorbid conditions, including HIV. The goal of TCM is to assist clients in navigating the health care system to increase care engagement and treatment adherence for individuals with complex needs. HIV-positive individuals engaged in care are more likely to be virally suppressed, improving clinical outcomes and decreasing chances of HIV transmission. The purpose of this study was to understand the impact of TCM management on outcomes for people with HIV. Data were obtained from Amida Care, which operates not-for-profit managed care Medicaid and Medicare Special Needs Plans (SNPs) for HIV clients. Changes in clinical, cost, as well as medical and pharmacy utilization data among TCM clients were examined between January 2011 through September 2012 from the start of case management enrollment through the end of the study period (i.e., up to 6 months after disenrollment). Additionally, CD4 counts were compared between Amida Care TCM clients and non-TCM clients. Notable findings include increased CD4 counts for TCM clients over the one-year study period, achieving parity with non-TCM clients (i.e., Mean CD4 count > 500). When looking exclusively at TCM clients, there were increases in medication costs over time, which were concomitant with increased care engagement. Current findings demonstrate that TCM is able to achieve its goals of improving care engagement and treatment adherence. Subsequent policy changes resulting from the Affordable Care Act and the New York State Medicaid Redesign have made the Health Home the administrator of TCM services. Government entities charged with securing and managing TCM and care coordination for people with HIV should provide thoughtful and reasonable guidance and oversight in order to maintain optimal clinical outcomes for TCM clients and reduce the transmission of HIV.
Highlights
With Affordable Care Act (ACA) implementation and many of those with HIV accessing care through the expansion of Medicaid and access to other programs resulting from these reforms, there is concern about the fate of case management programs for those with HIV [1]
Among the 1.2 million people in the U.S infected with HIV, only 40% are engaged in care, 37% prescribed anti-retroviral therapy (ARV), with 30% achieving the targeted clinical outcome of viral suppression [5]
To assess care engagement and treatment adherence, we examined utilization and prescription fills for ARVs and psychotropic medication
Summary
With Affordable Care Act (ACA) implementation and many of those with HIV accessing care through the expansion of Medicaid and access to other programs resulting from these reforms, there is concern about the fate of case management programs for those with HIV [1]. Due to ACA, there may be restrictions in case management and other supportive services for people with HIV which have been historically provided through the Ryan White Program [2]. For those concerned with HIV care delivery, losing support for “wrap around” non-medical services such as case management is contraindicated by the available evidence that these services are effective in keeping people with HIV engaged in care and adherent to treatments [3, 4]. Approximately 840,000 people in the U.S are not receiving effective HIV care as evidenced by a lack of viral suppression This finding is critical since those who are virally suppressed have better health outcomes and lower risk of HIV transmission [3]. The failure to achieve better rates of viral suppression can be attributed to a synergy of complex factors including behavioral health problems, unstable housing, incarceration, poor health literacy, and the economic, food, and housing insecurities endemic to poor communities of color which have the highest rates of HIV incidence [6,7,8,9,10]
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