Monday, July 31, 2006

Human rights and HIV prevention/care

I've been reading with interest the news coverage (and sometimes lack of it) of Human Rights Watch's statement about the effects of human rights abuses in Zimbabwe on HIV prevention and care. Appropriately enough, the coverage focuses, as it was intended to, on the specific issues of discrimination against and persecution of persons with HIV and AIDS in that African nation, noting that these abuses hinder the fight against HIV, even spreading it further.

I'm not seeing much coverage of the report in the U.S., however. This doesn't particularly surprise me. And, if there were such coverage, it would also not surprise me if the reporters failed to make a connection between Zimbabwe and the U.S. or, for that matter, Texas.

I'll just help them out a little. While we don't seem to be bulldozing houses where people with HIV/AIDS live in Texas nor do we show overt patterns of exclusion from health care (on the basis of health status), we still have our little human rights quirks.

Nearly every one of the providers with whom we spoke reported serious violations of medical privacy. In New Mexico, a patient first learned that he was HIV-positive from a receptionist in front of a waiting room full of people. Police in St. Louis found a young man's HIV medication when they searched his car and disclosed his HIV status to his father, saying he had a right to know. The New York City Department of Health disclosed a person's HIV status to his employer. A teacher in Florida informed an entire class that a particular student was HIV positive. A receptionist at a nursing home in Texas told a woman that the man holding her baby might give it AIDS. These incidents are likely the tip of the iceberg, for even people who reported egregious breaches of confidentiality were typically too afraid to confront the problem if it meant disclosing their HIV status to more people. Nevertheless, such breaches of confidentiality can and do unravel HIV-positive people's lives. After their HIV status was disclosed, several people were literally driven out of Paris, Texas with hate mail and vandalism of their homes.

Actually, that passage is from an ACLU study, completed in 2003. Notice how often "Texas" occurs as a keyword in that passage. Somehow I doubt things have changed all that much in the past 36 months.

And what this means is: fear of loss of confidentiality, reluctance to get tested, continued spread of HIV, continuing disparaties in accessing health services even when services are available.

Confusion about the doughnut hole

The New York Times looks at consumers' pain with the doughnut hole, the gap in coverage for the Medicare prescription drug plan. It turns out that consumers are not the only ones confused about this gap. Count me as confused, and, I'd say, count a fair number of the people who are trying to help consumers enroll as misinformed.
Other beneficiaries have underestimated the size of the coverage gap. They incorrectly believed that it would run from $2,250 to $3,600, the figures emphasized in brochures published by the government and insurance companies.

In fact, the coverage gap is twice as large as those numbers would suggest. The $2,250 is a measure of total drug spending. The $3,600 is a measure of out-of-pocket costs; it corresponds to about $5,100 in total drug spending. Under the standard benefit, a consumer is personally responsible for $2,850 of drug spending in the coverage gap — the amount from $2,250 to $5,100.

If I understand this, the initial coverage is calculated on the cost of the medications that a consumer receives. What the consumer pays does not matter. While the initial amount of $2,250 was set there because that was the average cost paid by Medicare consumers for medications prior to the introduction of this benefit, the program is not counting consumer cost but cost to the program for medications. That means, of course, that those with only average or below average medication needs might save some money on the program--if premiums and co-pays do not exceed what they paid for medications in the past. With a 25 percent co-pay, this first segment of coverage involves consumers paying $562.50 for $2,250 in medications, plus the monthly cost of premiums.

For those with "above average" medication needs, say someone with HIV, the program counts the cost of medications up to $2,250--not counting premiums and co-pays--and then counts out-of-pocket expenses--premiums, co-pays, medication costs--in the gap before beginning catastrophic coverage. The co-pay is 100 percent of $2850 in medications, plus the cost of monthly premiums.

The total that the consumer would pay in drug costs prior to catatrophic coverage is apparently $3,412.50. Is the remainder the estimated cost of premiums? What a cockamammy program!

Friday, July 28, 2006

Web site collects HIV/AIDS prevention videos

Eric Krock, Executive Director of AIDSvideos.org, has sent us a notice that this organization has been

busy creating a free basic HIV/AIDS video curriculum in English. On the web site, you can already see:
- Introduction to HIV and AIDS: What You Need to Know (17 min.)
- Top Ten Myths About HIV/AIDS (9 min.)
- Crystal Methamphetamine and HIV: The Connection (7 min.)

Krock says that the curriculum will be rounded out with a video on prevention for positives and one on sterilizing drug works in the near future. The next phase of the organization's work includes getting this basic "doctor-approved" curriculum translated and filmed in "every language in the world."

In the meantime, the site provides links to videos already available in other languages and English from several other organizations, including PBS, faith-based organizations, and others.

The videos are free for viewing online or for downloading. The site takes a neutral point of view, but acknowledges that some of the video sources to which it links may not. This looks like a good resource for prevention workers and for individuals seeking prevention information.

Thursday, July 27, 2006

Community forum in Brazos Valley

Another dink-around, and I found an interesting new resource from the Brazos Valley area. It's called "Consumer Connection," and it is an online discussion board for "those who are infected or affected by HIV/AIDS." The forum is managed by Christopher Hamilton, MPH, a planner with the Brazos Valley Council of Governments. BVCOG is the administrative agency for Ryan White planning and services in the central Texas area.

Topic areas include planning, events, stigma, medications, local meetings, and so on. While some of the discussion has a local flair, there is focus on state and national concerns. It's worth a visit.

Tuesday, July 25, 2006

XVI International AIDS Conference online

The International AIDS Conference will be held in Toronto (Canada, not Texas*) next month. The Kasiser Family Foundation will be the official web casters. Some parts of the conference will be available on the web in real time for free. Others will be available later, along with transscripts. Texas AIDS Network will (attempt to) carry headlines provided by KFF on our website for easy updates.

*Yep, there really is a Toronto, Texas. It's out there off Hwy 67 between Alpine and Marfa, which is why neither of us have ever heard of it before. Now I'm curious to know more about it, but that's for another day.

Tuesday, July 18, 2006

"Sweeping" changes to Medicare

I am puzzled by this and trying to track down more information. Apparently the feds are changing their payment system for Medicare, getting ready to adopt a new software system (from [what a shock] a no-bid contract with 3M). There's a lot of squealing going on. I was around during the transition to DRG's (diagnosis related groups) and their threat to the Free World, and this is all sounding somewhat similar.

From the squealing, it's clear that some things will be reimbursed at lower rates, e.g., hip transplants. There's not information that I can see about where increased reimbursement is going to happen--and that is the part of the story that is missing so far. The feds are apparently going to shift things around, pay more for some things, less for others, not save any money, just make things a little more in line with current thinking about health care priorities.

Now I don't know what those priorities are and where the money is going. I'd save the squealing until we see the whole picture here.

Monday, July 17, 2006

Local funding cuts in Denton County

It's almost a sign of the times, some would say. The temperatures are soaring. Hurricane season is upon up. And Texas is cutting funds to social services. Why should we be surprised?

This time the cuts are in Denton County, according to Ava Thomas Benson, reporting for the Denton Record-Chronicle and republished in the Dallas Morning News. Among the agencies facing cuts is AIDS Services of North Texas. The rationale for the cuts is that the county is only going to fund those agencies that provide the services that the county would have to provide anyway--that is, they don't want to raise taxes to pay for health and social services. It's a Texas thing.

Friday, July 14, 2006

Facing the future with HPV vaccine

Medscape (reg. req.) has a new CME module posted about the new vaccine for human papilloma virus: "Facing the Future: The Impact of HPV Vaccination on Adolescent Health." The module includes slides and talk transcripts of discussions of clinical data and social/economic implementation issues. So far, I've only reviewed the third one: "Acceptance and Implementation of HPV Vaccines," by Amy Rosenthal. Rosenthal spends quite a bit of time looking at parental concerns and how to deal with them. Her target audience is, of course, physicians, maybe nurses, but her insights will be useful for advocates as well.

Thursday, July 13, 2006

Medicaid buy-in for Texas

The new issue of In Touch, the Health and Human Services Commission's electronic newsletter, carries a story about Medicaid buy-in for Texas. The program will begin September 1. It will allow disabled persons who are well enough, thanks to treatment, return to work without losing access to the tretment that they need to stay well.

Beginning Sept. 1, certain Texans with disabilities will be able to purchase their health insurance through Medicaid by paying a monthly premium. Those who apply for the Medicaid Buy-In program must meet work and disability requirements as well as resource and income limits.

Work requirement: The person applying must have enough earnings and
FICA contributions in a calendar quarter for the Social Security Administration
to count it as a qualifying quarter. Currently, this amount is $970 a quarter.

Disability requirement: If the person applying already receives disability benefits from the Social Security Adminsitration, that person automatically meets the disability requirement. If there is no such disability determination, HHSC’s Disability Determination Unit will process the person’s information using Supplemental Security Income criteria without consideration of earned income.

Resource limit: The person applying must have $2,000 or less in countable resources. Certain resources will be excluded from the person’s countable resources.

Income limit: The person applying must have monthly income under
250 percent of the federal poverty level. For an individual, that means income
of less than $2,042 a month. Certain income will be excluded when determining
income eligibility.

Those participating in the Medicaid Buy-In program with unearned income
above the Social Security Income federal benefit rate, which is currently $603 a
month, will pay monthly premiums based on that income. In addition, those whose
income after mandatory payroll deductions is more than 150 percent of the
federal poverty level will pay an additional premium based on that earned
income.
HHSC provides a FAQ about Medicaid buy-in on their website, which provides more information.

Wednesday, July 12, 2006

Profile of a hemophiliac

Ack! That sounds like the title of a movie. It's not--just the contents of a feature article from USA Today: "A Legacy of Tainted Blood," by Steve Sternberg. The young man profiled provides through his life story a (partial) history of HIV in among hemophiliacs and a sense of his current struggles to live a normal life. Ironically, HIV is a greater threat to that normal life than hemophilia.

The story's sidebar carries some interesting information about the major hemophilia organizations, their past divisions, and their current--common--goal.

Tuesday, July 11, 2006

To download DSHS Exceptional Item Request

The Department of State Health Services' Exceptional Item Request is available for download by opening the agenda for the DSHS Advisory Council's July 7 meeting and clicking on the appropriate links. (Regrettably, Adobe Acrobat does not allow one to copy a link by right-clicking, so I can't provide the direct link for you here.) Background on HIV/AIDS-related EIRs is here, here, here, and here.

Monday, July 10, 2006

THMP MAC meeting, July 7

We tried, but we couldn't--be two places at once. The Department of State Health Services hearing on its legislative appropriations request overlapped with the Texas HIV Medication Program (THMP) Medication Advisory Commitee (MAC) meeting held last Friday. I decided that our efforts were better directed toward the LAR, so I ended up missing the MAC meeting even though I arrived prior to its scheduled conclusion. I did, however, pick up the trash a bit and snag a copy of the meeting packet (or most of one).

MAC minutes for November 18, 2005, and February 17, 2006, were approved. These should be posted on the web soon (scroll down to the bottom of the page).

The client utilization review shows a sharp drop in th enumber of clients being served by THMP. The drop can be attributed to the number of clients who are eligible for Medicare Part D. So far, more than 1500 clients have been transitioned from THMP to Medicare Part D. This does not, however, include clients who are eligible for less than 100 percent low-income subsidy: "THMP continues to provide medicaitons to clients who receive the partial low income subsidy or are denied the subsidy."

The MAC considered two new medications for the formulary and discussed the legislative appropriations request. We'll have to wait for more news on this later.

Appropriation victories

When we testified at the Department of State Health Services Stakeholder hearing in April, we had a lot of points to make in a very short period of time.
  • One of the points was that the Department should make a request for increased funds for HIV. The reason for making so simple a point is that, without a request, the legislature will pay less attention to HIV. The community can request additional funding, but it is harder to justify that funding when the state's agency responsible for HIV acts as if there is no need by failing to include a request in its Legislative Appropriation Request (LAR). This has happened in the past with the Department, leading to some fairly tough battles to secure funding. While the simple fact of inclusion in an LAR does not guarantee funding, it does improve the chances of getting funding. Texas AIDS Network is pleased that the Department has acted on our request (while acknowledging that staff in the HIV Program itself had a critical role to play in making this happen).
  • Another point that we made is that the Department's request should be assigned a high priority. Items in the list of Exception Item Requests may be assigned a rank or relative priority by the requesting agency. The priority assigned has some effect on appropriations. Legislators consider the relative priority as an indicator of importance and need. When funds are in short supply, only the highest priority items may be funded. Others may receive funds as they become "available," i.e., when the Comptroller certifies that there is enough money in the state's treasury to supply the request. Texas AIDS Network is gratified that all of the EIRs related to HIV/AIDS received the highest priorities. Only the gap in mental health hospital funding received such a high priority (#2).
  • A third point that we made was that funding for the Texas HIV Medication Program should be increased sufficiently to allow for expansion and improvement of the program. Typically, the Department has only made appropriation requests based on current services. That is, the Department requests funds that will allow a program to provide only the same services as are currently available to clients who meet current eligibility requirements. Such a "current services budget" does not allow for effective planning to meet actual need. The LAR for HIV Medications, regrettably, only covers current services and does not meet the need that has been identified for expansion and improvement of THMP to include medications for co-infections or to treat the side-effects of HAART. Texas AIDS Network will continue to advocate for increased funding to go beyond current services and meet the need.
  • Another point in our testimony was that the Department needed to request funds for services and prevention. The Network is pleased that the Department has risen to the challenge posed by federal funding cuts and made a modest attempt to make up for the shortfall. Again, the request made by the Department only achieves "current services," but, in the face of cuts, that represents progress.

On the whole, the DSHS LAR for 2008-2009 has responded to many of our requests. While there is work to be done to see that the Texas Legislature funds these requests and to convince them to go beyond current services to meet the need, we should all pause and savor the victory. All too often, we simply move from one stage to another in a lengthy process without appreciating what we have accomplished so far. Community members who participated in this process should take a moment to pat themselves on the back, enjoy a moment of achievement. And then get back to work, of course!

DSHS LAR hearing, 2008-2009 appropriations (EIR 4)

Continued from previous two posts . . .

The Department's fourth ranked Exceptional Item Request is for HIV/STD Prevention, Surveillance, and Screening Activities. The amount requested is $4,300,000 for each year of the biennium ($8.6 million total).

From the Department's budget justification:

At the end of 2004, there were an estimated 52,600 persons living with HIV/AIDS in the State of Texas. More than 4,000 Texans were diagnosed with HIV in 2004. Of these, 34 percent of men and 63 percent of women were African American. Federal funding for HIV services, prevention and surveillance in Texas has continued to decline for the past three years. This funding request will allow DSHS to track and document changes in the epidemic which will allow local community planning groups to identify risk groups and choose prevention methods that have proven effective with the population. In addition, HIV service planning would allow local providers to identify how to prioritize and effectively use funds to address the medical needs of persons with HIV/AIDS living in their community. Improved STD screening will allow the laboratory to upgrade technology that would improve the sensitivity of the equipment from the current 70% to 90% for diagnosing Chlamydia and Gonnorhea. Moving to the amplified testing will improve Chlamydia detection by identifying an additional 1,500 cases per year.

No unusual discussion by DSHS Advisory Council members occurred in relation to this item, the matter of priorities and relative worth having already been addressed in relation to the previous EIR for HIV medications. Texas AIDS Network offered public comment on all three EIRs and made a point of noting that the Department had not requested funds for services or prevention since at least 1991. We also emphasized the cuts in federal funds over the past three or four years and the effect that these have had on HIV services in Texas.

Texas AIDS Network will support this Exceptional Item Request. We recommend that concerned members of the Texas HIV/AIDS community address this request with their state representatives and senators. If possible, community members should consider making this item the subject of a third visit with legislators. Usable talking points can be found in the budget justification. The Network will be preparing additional materials for these district visits in the coming weeks.

Saturday, July 08, 2006

Who's visiting?

I've had a wee break and am now in catch-up mode. There will be some "back posting," so you may want to scroll through earlier "dates" in July. (This is to avoid piling all the posts into one date's heading.)

In catching up, I'm looking at usage statistics for the month of June. It is, among other things, gratifying to see that the Zoom Cloud actually turns out to be useful. Five percent of June's readers used the cloud to find more articles.

I never much pay attention to the list of ISP's that readers use, but June's list is interesting because it shows some of the diversity of visitors to this blog:
  • Unknown
  • roche.com
  • rr.com
  • swbell.net
  • aol.com
  • mskcc.org
  • comcast.net
  • washington.edu
  • osd.mil
  • verizon.net
  • asaustin.org
  • bellsouth.net
  • aoc.org
  • airtelbroadband.in
  • statefarm.com
  • hearstsc.com
  • clearwire-dns.net
  • qwest.net
  • shawcable.net
  • andrews.edu
  • optonline.net
  • sbcglobal.net
  • aclutx.org
  • globalsat.net
  • harriscountyhealth.com
  • ca.gov
  • bol.net.in
  • swrxservices.org
  • cdc.gov
  • abbott.com
If you're worried about being "seen," at least 25 percent of the ISP resolve as "unknown." On the other hand, I thought it was interesting to see the .edu's, .org.s, and .gov's that showed up on the list.

One other interesting tidbit was in the search terms used. While the overwhelming majority of search visitors (as opposed to link visitors or subscribers) come to the site from Google, only a few of the search terms that they use seem to show up in the reports that I have available to me. Last month, someone searched for "carolyn parker swahili." That's one way to find me. Jambo, jamani!

Friday, July 07, 2006

DSHS LAR hearing, 2008-2009 appropriations, EIR 3

Continued from previous post . . .

The Department's third ranked Exceptional Item Request is for HIV Medications. The request is for $3,986,216 in FY08 and $8,852,458 in FY09 ($12,838,872 total for the biennium). The requested amount would serve an additional 962 persons in FY08 and 1982 in FY09.

From the LAR draft:
At the end of 2004, there were an estimated 51,600 persons living with HIV/AIDS in the State of Texas. Federal funding for HIV services, prevention, and surveillance in TExas has continued to decline for the past three years. The funding request will allow the Texas HIV Medication Program (THMP) to continue providing life-saving medications to a growing number of clients with HIV disease whose incomes are at or below 200% of the federal poverty level. Resource needs are increasing because: (1) clients live longer because of effective treatment and stay on the program longer; (2) the number of people living with HIV disease increases each year; (3) the current medical standard results in clients taking a greater number of drugs; (4) newer, more effective drugs have come on the market at higher costs; and (5) older drugs continue to rise in cost at almost double the rate of inflation.

Once again, the DSHS Advisory Council's discussion took an ominous turn when this Exceptional Item Request was introduced. The word "ominous," in this case, does not imply anything sinister so much as "here we go again." Dr. Jaime Davidson, an endocrinologist from Dallas, raised the question of relative importance and relative funding. His question was based on the comparatively high request for HIV/AIDS versus the comparatively low request for obesity prevention. Tobacco use and obesity as causal factors for a number of expensive illnesses will cost the state a comparatively higher amount of money and affect a comparatively larger number of individuals--so the question came from an entirely reasonable point of view. However, as the Commissioner responded, there are increasing federal funds available to support these efforts while there is a decline in federal support for HIV/AIDS. The state, he said, was being called on for greater funding for HIV/AIDS because there were no other sources to fund this program while there are other "partners" that can be called upon for tobacco use and obesity prevention programs.

Texas AIDS Network will support this Exceptional Item Request. However, since the request will only provide for services at the current level without expanding or improving the Texas HIV Medication Program, we believe that additional funds should be requested. These funds could be used to expand the formulary to cover co-infection with Hepatitis C, better treatment for AIDS wasting, and begin to help with treatment of the side effects of HAART.

Once again, we recommend that concerned members of the HIV/AIDS community begin to meet with their state representatives and senators to discuss this request. At this time, we would recommend that this discussion be the focus of a second visit with legislators, following on an earlier meeting to discuss the restoration of the proposed 10 percent cut in funds for HIV/AIDS. We expect to have a specific recommendation for the additional funds needed for expansion and improvement within the next few weeks.

DSHS LAR hearing, 2008-2009 appropriations (EIR 1)

The Department of State Health Services Council met today to hear DSHS staff present the Department's Legislative Appropriation Request (LAR) for the 2008-2009 biennium. We should be able to download the draft LAR document itself, but the DSHS site is poorly organized. My notes will have to do for now.

The first thing of importance in this appropriations cycle is that the state's leadership has directed all state agencies to submit budget requests that start with a 10 percent cut in the agency's overall funds. For HIV, such a cut will mean the following (from the LAR's Appendix A):
Funding reductions in HIV/STD and Hepatitis C Prevention would result in increased risk o fdisease transmission (HIV and other sexually transmitted diseases), illness, and premature death. The number of clients served by the Texas HIV Medication Program would have to decrease by 801 persons in FY08 and 790 persons in FY09 (a total decrease of 1,591 persons over the biennium). Decreased access to medications for HIV positive Texans will result in rapid disease progression from HIV to full blown AIDS couple with the higher costs of treating AIDS as compared to treating HIV; increased life-threatening opportunistic infections in persons with HIV/AIDS; increased HIV transmission, due to higher viral loads as a result of delayed or no treatment; increased HIV transmission from HIV infected pregnant women to their unborn children; increased HIV infection in minority communities, particularly in the African-American community which bears a disproportionate share of new cases; increased cases of cervical cancer in women with HIV/AIDS; increased costly emergency room visits due to rising morbidity in persons with HIV/AIDS; increased costly hospitalizations due to rising morbidity in persons with HIV/AIDS; increased unemployment for persons with HIV/AIDS due progressive illness (sic); increased demand for more expenside public/state assistance (hospitalization, emergency room) as a result of progressive illness and unemployment; increased premature death related to delayed or untreated HIV/AIDS. A 10% reduction would also affect our Maintenance of Effort Agreement with HRSA and could put DSHS at risk of non-compliance.

The actual reduction which would affect HIV/STD and Hepatitis C Prevention is $3,097,059 per year of the biennium ($6,194,118 total). Needless to say, the Department's first Exceptional Item Request is for restoration of these funds as well as the proposed cuts in other DSHS programs.

Discussion from the Council took a somewhat strange turn when James Springfield, a hospital administrator from the Valley, essentially argued that the Department was not getting with the spirit of the budget cuts. He was apparently of the opinion that the cuts were philosophically valid and that the Department should have looked more closely to determine which programs were "ineffective" and could therefore be eliminated as an item of expense. He expressed the notion that, even though a program is a good thing, inefficiency should not be supported with state dollars. The Commissioner and Budget Officer argued that the Department had done several things to cut expenses, had indeed evaluated programs, and had pared down the list of additional requests. Mr. Springfield seemed unconvinced.

Texas AIDS Network will support this Exceptional Item Request. We recommend that concerned members of the Texas HIV/AIDS community begin meeting with their state representatives and senators immediately to discuss this request and explain its effects on the state of the HIV epidemic in Texas. Useable talking points can be drawn from the information quoted from Appendix A.

More LAR info in next post . . .

Wednesday, July 05, 2006

Appropriations VC resigns

Vilma Luna, a Democrat from Corpus Christi, has announced her resignation from the Texas House, effective July 31. As Vice-Chair of the House Appropriations Committee she has been attentive to health and human service issues and supportive of HIV/AIDS funding. Her loss as a positive supporter on HIV/AIDS funding and as a key legislator in appropriations will be keenly felt.