Medicaid Managed Care - U.S. Senate Special Committee on Aging

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enough history of this treatment to give us absolute evidence that it will eradicate the virus.
Many cannot take these medications. Many of these medications have severe side-effects.
Many cannot afford these medications or are denied them for various reasons. These
medications can average close to $15,000 per year plus. I average taking $3,700 per month,
not counting my hemophilia medication.
I am not speaking to you as a committed managed care foe. I believe managed care
can work. But, everybody needs to be on the same page when it comes to disease state
management. For every obstacle to quality care with optimum outcomes, there is a solution.
From our perspective, I would like to recommend three elements as part of the solution.
First, there must be an assurance that gatekeepers, case managers, utilization review
officials, and others who approve or disapprove claims must become knowledgeable HIV.
<strong>Managed</strong> care needs to protect consumers by making sure that payers demonstrate expertise
in disease management and are held accountable for providing high quality care.
Those of us who have been fortunate to be treated in a comprehensive hemophilia
center can testify to the improved outcomes generated by those trained the management of
hemophilia.
Second, there must be a federal role in setting certain standards and creating
expectations for specific outcomes. At present, every HMO is different, every state is different,
and managed care plans set their own rules on a daily basis.
I also believe that the federal government must support efforts to risk adjust capitated
payments that managed care organizations use to control their costs. There must be incentives
for quality care instead of incentives to just do it the cheapest way-or where the best profit is.
Most of the time, managed care sees the cost today, but not the cost tomorrow.
Third, a great amount of interest exists in the HIV community for exploring ways to
expand <strong>Medicaid</strong> coverage to people living with HIV, but who are not yet disabled by AIDS.
Incomplete data suggest that this could be done in a cost neutral manner because individuals
could be given protease inhibitors and other treatments that could prevent them from
progressing to AIDS. Finding ways for the federal government, state governments and
managed care organizations to expand coverage and improve outcomes for persons living with
HIV and other disorders is the right thing to do.
I wish that I had more time to discuss with you all that I have dealt with, witnessed,
discovered, and have been educated about as a catastrophic disease advocate. By your
invitation, I will be happy to communicate with you on this issue in our nation's health care
system.
I very much appreciate the opportunity to address this respected body. I would be
pleased to answer any questions that you may have.
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