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The American Journal of Managed Care June 2019
Reports of the Demise of Chemotherapy Have Been Greatly Exaggerated
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Patrick H. Conway, MD, MSc
Association of Decision Support for Hospital Discharge Disposition With Outcomes
Winthrop F. Whitcomb, MD; Joseph E. Lucas, PhD; Rachel Tornheim, MBA; Jennifer L. Chiu, MPH; and Peter Hayward, PhD
US Care Pathways: Continued Focus on Oncology and Outstanding Challenges
Anita Chawla, PhD; Kimberly Westrich, MA; Angela Dai, BS, BA; Sarah Mantels, MA; and Robert W. Dubois, MD, PhD
Understanding Price Growth in the Market for Targeted Oncology Therapies
Jesse Sussell, PhD; Jacqueline Vanderpuye-Orgle, PhD; Diana Vania, MSc; Hans-Peter Goertz, MPH; and Darius Lakdawalla, PhD
Cancer Care Spending and Use by Site of Provider-Administered Chemotherapy in Medicare
Andrew Shooshtari, BS; Yamini Kalidindi, MHA; and Jeah Jung, PhD
Will 2019 Kick Off a New Era in Person-Centered Care?
Ann Hwang, MD; and Marc A. Cohen, PhD
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Enhanced Care Coordination Improves HIV Viral Load Suppression Rates
Ross G. Hewitt, MD; Debra Williams, EdD; Richard Adule; Ira Feldman, MPS; and Moe Alsumidaie, MBA, MSF
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Thomas B. Valuck, MD, JD; Sarah Sampsel, MPH; David M. Sloan, PhD; and Jennifer Van Meter, PharmD

Enhanced Care Coordination Improves HIV Viral Load Suppression Rates

Ross G. Hewitt, MD; Debra Williams, EdD; Richard Adule; Ira Feldman, MPS; and Moe Alsumidaie, MBA, MSF
Enhanced care coordination in New York City that leveraged surveillance data with a health plan’s Medicaid managed care roster improved its HIV viral load suppression rate.

Optimizing HIV treatment benefits the health of the individual and the community at large. Health department HIV surveillance data matched with Medicaid managed care rosters can be used to target people with HIV infection who have an unsuppressed viral load or are unengaged in care. MetroPlus Health Plan, a Medicaid managed care organization, implemented a 2-pronged approach: street outreach and peer care connection interventions.

Study Design: A cohort study that included demographics, program contact type and frequency, antiretroviral therapy refill pattern, and CD4 count and HIV viral load values/ranges and dates.

Methods: Members without a viral load test result during the prior 9 months (not engaged) received outreach, and those with unsuppressed viral loads received intensified care coordination and peer support. A retrospective statistical analysis was conducted on cohort members with sufficient viral load data. A subanalysis excluded members who had suppressed viral loads at baseline.

Results: A total of 1429 (82%) members in the state cross-referenced list were still enrolled in the plan at study initiation. Successful contact with targeted members by outreach was 60% compared with 40% by care coordination and peer support combined. Members who were successfully contacted by the program had a 44% suppression rate (<200 copies/mL) and a greater likelihood of achieving viral load suppression (odds ratio, 1.55; 95% CI, 1.23-1.95; P <.01) than those who were not.

Conclusions: Surveillance data were successfully used to target HIV-positive Medicaid members who had an unsuppressed viral load or were unengaged in care. Individuals with an unsuppressed viral load can achieve suppression through intensified outreach, care coordination, and peer support by a Medicaid managed care plan.

Am J Manag Care. 2019;25(6):e167-e172
Takeaway Points
  • Enhanced care coordination and support for HIV-positive members by a Medicaid managed care plan that leveraged surveillance data helped those who had an unsuppressed viral load or were unengaged in care achieve viral load suppression.
  • Within 2 years, 44% of those successfully contacted achieved a viral load of less than 200 copies/mL.
  • More effort will be needed to reach and support HIV-positive people who continue to have a chronically unsuppressed viral load.
Untreated HIV infection results in loss of immune function, which ultimately leads to opportunistic infection or neoplasms and death.1 Antiretroviral therapy (ART) is highly efficacious in both research studies and real-world populations in restoring or preserving immune function, extending life span, and improving the quality of life for HIV-positive individuals.2,3 For individuals to fully benefit from ART, they need to know they are infected, engage in regular HIV care, and receive and adhere to ART. These are the elements of the HIV care continuum.4-6

At the end of 2015, the latest year for which data are reported, approximately 1.1 million individuals were living with HIV in the United States.7 New York City has been an epicenter of the AIDS epidemic in the United States.8-10 In 2016, approximately 110,000 individuals were living with HIV in New York City and almost 50% of those with a diagnosis were not engaged in HIV care programs.11

Upon initiation of ART, plasma virus concentration (viral load) declines rapidly to undetectable levels with high medication adherence.12 With poor or no medication adherence, viral load becomes detectable again, and over time, HIV infection progresses to AIDS with poor health outcomes such as AIDS-related morbidity and hospitalizations.13,14 Suboptimal medication adherence can lead to loss of immunologic benefit and viral resistance, limiting future treatment options.15 Moreover, despite good adherence to medication, some patients with HIV will have detectable viral loads even when being treated with ART.

Low medication adherence is detrimental not only to the individual but also to the community, as the increase in viral load poses an increase in the risk of transmission,16 which is associated with the level of viremia.17 Thus, the goal of HIV care is to achieve and maintain viral load suppression through a high level of medication adherence. However, a portion of the treated population continues to have difficulty achieving or maintaining viral load suppression. Social determinants of health play an important role in viral suppression.18,19 Factors that affect medication adherence include depression, adverse effect severity, self-efficacy, and social support.20 Low levels of engagement in care, especially in the early stages of treatment (eg, missed visits), are correlated with poor medication adherence.13

New York State (NYS) created a task force to develop specific recommendations to improve the diagnosis, treatment, and prevention of HIV in its citizens. One recommendation in the resulting blueprint to end the epidemic was to “use client-level data to identify and assist patients either lost to care or not virally suppressed.”21 This was an example of the CDC’s Data to Care initiative, a novel public health strategy that aimed to use HIV surveillance data to identify HIV-diagnosed individuals not in care, link them to care, and support the HIV care continuum.22

The NYS Department of Health (NYSDOH) maintains 2 large databases that are operationally separate: the HIV Surveillance Registry, which contains individual identifiers, viral load, and other HIV-related laboratory results; and an active roster of all Medicaid managed care recipients, which contains individual identifiers, contact information, and Medicaid plan assignments. The surveillance registry had been previously used only for epidemiologic monitoring on a population health and not an individual health basis. In April 2014, the NYS Public Health Law was amended to allow for the information within the registry, which was created with strict confidentiality protections, to be cross-referenced with its Medicaid roster in an individually identified manner. This identified some people who were not engaged in HIV care or who were known to have an unsuppressed viral load at last observation. The comparison showed that a few Medicaid managed care plans insured a large number of the HIV-positive individuals in New York City. In August 2015, the NYSDOH AIDS Institute shared the resultant comparison with 5 plans and funded a pilot program to allow the plans to target the identified population with specific enhanced care coordination, which began in January 2016.

The goal of this cohort study was to assess the effectiveness of the first 2 years of a Medicaid managed care plan’s program. Using surveillance program viral load data, care coordinators and peer counselors reached out to viremic members to address barriers to medication adherence and to engagement in care.

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