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Has Magellan, PACE, and the Federal Government Damaged the Pennsylvania ADAP Program?

| 6 Comments
                    It's that time of year again when anyone living in Pennsylvania must reapply for pharmaceutical coverage under Pennsylvania's ADAP program, also known as SPBP (Special Pharmaceutical Benefit Program). This program was once a high quality, beneficial, comprehensive, and supportive program to people living with HIV. Unfortunately, the quality of this program has begun to suffer because Pennsylvania has outsourced administration of this program to Magellan and PACE. Furthermore, the grant that pays for this program places additional requirements on patients who need this life saving medication (HIV can still kill you without medication remember?).

                    As a result of these changes, and others over the years, a combination of the Federal Government requirements and the administration by Magellan and PACE have made the application process burdensome. This has resulted in cause for anxiety for many patients who need this medication. So, I thought I would review this application in my blog for everyone living in Pennsylvania (Please consult your case manager for additional assistance if you need it! That is what they are there for!). You will see how this application in itself is a barrier to care. It is confusing and any mistake will result in a denial of service for medication. As we all know a denial can mean a delay in obtaining medication, which in turn increases the likelihood of medication resistance and increases in viral load resulting in what? Higher transmission rates!

PAGE 1 - A.K.A - Let's confuse the hell out of our patients.

     The first page looks innocent enough right? WRONG. See that box titled "SPBP Eligibility Mandatory Criteria"? The third criteria states "Your prescribing physician must sign and date page 5." (SPBP Application). First, why the hell would anyone be applying to a program to pay for HIV medications that does not have HIV? Second, if a person is REAPPLYING for the program the box to the right states that the physician's signature is "Not Required". Seems simple enough right? Think again. Your physician or nurse practitioner is still required to provide a signature on page 4 of the application. Every patient is also required to disclose CD4 and Viral Load information (we'll get to that in a minute). This page represents the first barrier to care.

Page1.jpgPage 2 - This page is relatively straight forward.
Nothing to worry about here, just need to provide simple name, address, phone number, and demographic information.
Except for that little part about requiring you to disclose whether or not you have a case manager. Forgetting to check this box may result in a denial letter. Better cross those t's and dot those i's.

Page2.jpgPage 3 - DANGER WILL ROBINSON! DANGER!

You better make sure that you provide a copy of current insurance or be ready to explain WHY you do not have insurance. Hmmmm....what could be a reason why someone with HIV is applying for SPBP and does not have insurance? Could it be insurance affordability or perhaps that fact a person will die without the medication? This section represents yet another barrier to HIV care.

Page3.jpg

Page 4 - Remember that comment about page 4 from above?

Here is the page I mentioned above in page 1. Make sure you still get your prescribing clinician's signature along with your CD4 or Viral Load count from your last test. Failing to provide this information will result in denial of service. Also, be sure to check off that little box below regarding income. Apparently, forgetting to check this box causes problems also.
Page4.jpg

Page 5 - Proof that you have HIV.

If you have just received an HIV + Diagnosis, I am sorry...please do not let this application discourage you from obtaining access to treatment. Take care of your health! Even if the Pennsylvania ADAP program prevents you from doing so. Finally, this section is just really stupid. Why would anyone be applying for a program that does not have HIV? The drugs have no psychoactive effect and there are better ways of determining if SPBP is being used for other purposes without alienating and stressing out patients...trust me, the HIV stigma causes more than enough stress. Still....if you do not get this page signed what happens?  DENIED.
Page5.jpg

Pages 6 and 7 - What would obtaining medical treatment be in a country that values profit over care than requiring you to release private information! YAY! Seriously, this needs to be signed or you will be denied care.

Page6.jpg

Page 7 (Page 6 Continued)

Page7.jpg

Page 8 - Last, but not least, page 8.

This page is also one of the few pages that are fairly straight forward.....if unnecessary and burdensome to people living with HIV.
Page8.jpg

                To put things into perspective, the application for SPBP used to comprise a single page and one could easily obtain the medications needed to keep living a healthy life. However, the program requirement changes and the involvement of for-profit organizations in the administration of a health care program have degraded service, put up barriers to care, and potentially delay access to medications that can lead to increased transmission rates. According to the person I spoke with at SPBP when completing my own application to ensure that I would not be denied for not dotting an "i" on page 53 of paragraph 4 section 32b....the grant that pays for the SPBP program requires this information. When I asked why, they could not, or would not, answer that question. I think this is a question that we all deserve an answer to. This information is private and is something that is not required for other illnesses. I can see how it might be used as a tool to reduce transmission, but at what expense? By denying a person access to life saving care? That defeats the purpose of the program.

               Another thing about this lengthy application is that the Federal Government, Pennsylvania Department of Health, and the Pennsylvania Department of Public Welfare is they are more concerned with protecting their assets than protecting the welfare and the health of their citizens. These barriers have also caused people to drop out of care, which is linked to a cascade effect that results in only 25% of HIV patients receiving the care they need to remain virally suppressed. Keeping the HIV virus suppressed is key to reducing HIV transmission. However, the Pennsylvania ADAP program application does little to help reduce this cascade. If anything, it decreases access to care. To the State of Pennsylvania I say this....please stop outsourcing our government to for-profit organizations. The unnecessary and over burdensome requirements of this application have resulted in reduced quality of care and are causing people to drop out of care.

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Comments on Daniel Angelis's blog entry "Has Magellan, PACE, and the Federal Government Damaged the Pennsylvania ADAP Program?"

Since moving back to Pa. from South Florida in July of 2012 I have found the SPBP a life saver. Yes it requires approval every six months but I have found the application process very easy. This program allow the use of any pharmacy and pays my copay. Needless to say even with medicare that copay is extremely high and without SPBP it would make life difficult.

SPBP administers the ADAP program in PA. Let me compare it with Florida and the way they administer their ADAP. In Pa. I can choose the pharmacy I want to use one that is convenient to me. In South Florida ADAP was administered by the county health center and you only had the option of having prescriptions filled at one not so convient county pharmacy. The application process was also controlled by the county health center and required personal contact with an administrator in completing the application which required many more hurdles.

The hurdle in the application problem which you address can be over come. Lets look for ways to help people. Living in the Harrisburg area I have found Hamilton Health Center and their Hope Project very helpful.

Hi there and thanks for commenting. You are correct in that the Pennsylvania ADAP program, also known as SPBP, is a good program. In fact, it has one of the best formularies among any of the programs currently available. However, you should know that if you have primary insurance, the Pennsylvania ADAP program will not cover a copay (see the back of your card). Furthermore, the SPBP program is not administered by "SPBP", it is administered by two for-profit organizations Magellan and PACE.

It is also true that the application issues identified in this blog can be overcome with simple corrections. However, these issues have been present in the past and complaints were made by both program participants and ASO (AIDS Service Organizations) in Pennsylvania with no response to the complaints. If anything, the application has continued to become more and more complex. You should also know that it was only required to renew one's SPBP card once per year. The six month renewal was added later.

So my question is, and this is what this blog entry is designed to shine a light on, WHERE DOES IT END? When do we finally say enough? When do we finally ask, why is it so difficult to obtain access to life saving medication? Where I disagree with you is simply accepting the hurdles this program now presents to people living with HIV. All of these things are known as barriers to care. I am speaking up and advocating for myself and others living with HIV. These barriers need to be removed so people can obtain equal access to life saving medicine.

Hello Daniel, Some friendly back and forth. You mentioned that SPBP did not cover copay with other insurance. That has not been my experience since I have been using it in the last year and a half. " SPBP is the payer of last resort. All other insurance/health benefits must be utilized first." I am on a medicare PPO plan and the SPBP does and has been picking up my copays. Thank God, because by mid February I am already into Stage 4 Catastrophic Coverage.
It is entirely possible that I am miss reading what is happening, but as I look at the monthly insurance statements I get under "Other Payments" they list paid by Pa. ADAP.

Again, all friendly back and forth here. Nice to be picking someone else's brain.

With Gratitude,
Scott


p

Hey Scott, I am glad that SPBP is picking up some of the costs as a secondary payer. Unfortunately, this has not been my experience. If anything I have received reports from other patients who are receiving bills in the mail because SPBP is claiming they are not responsible for paying the bill even though labs and medications are covered. Also, I intended all of my responses to be friendly. Sometimes I use bold text or caps when trying to make a point and invoke inflection. Unfortunately, it does not always come across that way! I apologize if it seemed like I was not responding in a friendly way. Also, I apologize for the delay in responding, my laptop crashed. :-/

Hey Daniel. I'm a social worker at an HIV clinic in PA. Just wanted to clarify some information that you posted. SPBP does not cover lab costs for patients that have insurance (private, Medicare, etc). They will only cover labs if the patient has no insurance. That is why some people are getting bills for their lab work, it must be billed to their insurance first and what is left over is the patient’s responsibility. SPBP only covers co-pays for medications for these patient that have another insurance, as long as the medication is on the SPBP formulary.
I agree with you and believe the new application is just another barrier to care.

One patient experienced problems with SPBP who had not secondary insurance who denied the patient's lab claim. I experienced something similar a few times with SPBP as well.

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This page contains a single entry by Daniel Angelis published on March 23, 2014 3:33 PM.

A Caring Home was the previous entry in this blog.

Denied is the next entry in this blog.

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