# Presentation: 793312

**Presented by Deborah L. Parham, PhD., RN**
**Associate Administrator**
**HIV/AIDS Bureau**
**Health Resources and Services Administration**

**Overview of the Ryan White Care Act AIDS Drug Assistance Program (ADAP)**
**Presidential Advisory Committee on HIV/AIDS**
**Treatment and Care Subcommittee**
**July 17, 2003**

## What is ADAP?

- The ADAP provides medications for the treatment of HIV disease
- Beginning in FY 1996, Congress earmarks funds that must be used for the ADAP
- A formula based on AIDS prevalence is used to award ADAP funds to States and territories

## What does ADAP pay for?

- Medications
- Health insurance with a prescription drug benefit
- Adherence support (ADAP Flexibility)
- ADAP Supplemental
- 	(3% reserved for areas with “severe need”)

## ADAPs -- National Overview

- 57 ADAPs, including DC, PR, VI, Guam,  Marshall Islands, Northern Mariana Islands, and the American Samoa Islands.
- Wide variation in program characteristics due to individual State administration of each ADAP and AIDS prevalence in each State.
- Differences most pronounced in areas of funding, eligibility criteria, formulary size, and cost-saving strategies.

## HRSA / HAB Goals

- Ensure cost-effective use of funds
- Provide comprehensive services to the maximum number of people
- State ADAPs that fail to aggressively pursue cost-savings may have to provide convincing justification for congressional or government inquiries
- Ensure parity of services among Ryan White, Medicaid, and the privately insured
- Identify unmet need
- Community unmet needs
- Partially unmet needs

## HAB / ADAP Initiatives

- Develop ADAP infrastructure
- Centrally administered:  accountability, parity, consistency, and cost-savings
- Cost-effective procurement of drugs
- 340B Program
- ADAP 340B Rebate Option
- 340B Direct Purchase Option
- Pharmacy Benefits Management
- Prime Vendor
- ADAP monitoring and forecasting
- ADAP Monthly Report (AMR)
- ADAP Budgeting Tool

## ADAP is the most rapidly growing CARE Act Program

## ADAP Funding: 1995-2003

- From 1995-2003 (projected)**:**
- Total ADAP Funding Projected for 2003 is $948,047,280
- Title I contributions to ADAP decreased from a high of 22% in 1995 to a low of 2% in 2002 and Title II base funds decreased from a high of 47% in 1995 to 5% in 2002
- State funds to ADAP decreased from a high of 26% to a projected 16% in 2002
- Title II ADAP earmark increased from 25% in 1996 to a projected 65% of all ADAP resources in 2002
- Supplemental ADAP funding is 3% of the ADAP Earmark for “Severe need” States

**Notes:**
33 States contribute to the ADAP funding stream

## ADAP Outcomes: FY 1994-2002

- Number of clients served increased from approximately 49,000 to more than 144,685
- Total ADAP funds spent on antiretrovirals increased from 43 percent in 1994 to almost 90 percent in 2002
- Increase in number of women and minorities accessing ADAP

## Projected ADAP Outcomes: FY 2003

- In FY 2003, a projected 151,730 clients will receive ADAP services nationwide
- States project that almost 89,537 clients will receive ADAP services each month
- Continued increase in number of women and minorities accessing ADAP services

**Notes:**
As of March 2003 FY02 client enrollment is 144,685 and utilization is 83,757

## Financial Eligibility Criteria: FY 1999-2003

***The 2003 FPL is $8,980 per year per individual**

## Financial Eligibility Criteria: FY 2003 

**(as of April 2003)**

**Territories did not submit ADAP Profiles**

## Medical Eligibility Criteria

**Territories did not submit ADAP Profiles**

## Medical Eligibility Criteria 

**(as of April 2003)**

**Territories did not submit ADAP Profiles**

## ADAP Formulary Size: FY 1999-2003

***MA, NH & NJ Reporting open drug formulary **

## Formulary Coverage:  FY 2003

**(as of April 2003)**

## State ADAPS Cost Containment Strategies

**To Maximize resources, ADAPs have adopted a wide variety of cost-containment strategies, including:**
**Section 340B Drug Discount Program**
- Point of purchase
- Rebate option
- Prime vendor

## State ADAPS Cost Containment Strategies (...continued)

** ****Other Financial Mechanisms**
- Negotiated pharmacy discounts
- Wholesaler discounts
- Voluntary manufacturers’ rebates
- Purchasing health insurance premiums
- Federal Supply Schedule
- Alternative Methods Demonstration Program

## Current Status of ADAPs 

**340B Direct Purchase States (22 States and 3 Territories):** AL, AR, AZ, CO, DE, FL, GA, GU, HI, IA, IL, KY, LA, MS, MT, NE, NM, NV, OH, PR, SC, TN, TX, VA, and VI
**340B Rebate States (26 States)**: AK, CA, CT, ID, IN, KS, MA, MD, ME, MN, MO, NC, NH, NJ, NY, ND, OK, OR, RI, SD, UT, VT, WA, WV, WI, and WY
**Mandated Rebate States (1 State):** PA
**Voluntary Rebate States (1 State): **MI
**Other (District of Columbia)**: Wash., DC (FSS)

**(as of April 2003)**

## State ADAPS Cost Containment Strategies (...continued)

** ****Program restrictions to control expenditures    (as a last resort)**
- Capped enrollment
- Waiting lists
- Capped expenditures
- Limited formularies

## Status of State ADAPs with Waiting Lists (as of 7/14/03)

## Current ADAP Initiatives

-  Supplemental
-  Flexibility
-  Insurance

## Supplemental Treatment Drug Grants

- 3 percent ($21.43 million) of ADAP Earmark funds for FY 2003 will be used for supplemental grants to ADAPs in States exhibiting severe need to remove restrictions
- Financial eligibility requirement  200% of FPL
- Medical eligibility restrictions
- Limited formulary compositions for antiretrovirals and medications to treat opportunistic infections
- State match required of $1 for each $4 of grant funds received

## Eligibility Criteria for severe need

- States with income eligibility standard
-  _<_ 200% FPL as of 1/1/00
- States requiring that applicants meet additional medical criteria
- States that implement restrictions regarding access to PIs or other antiretroviral drugs
- States with < 10 meds on their formulary to treat opportunistic infections

## ADAP Flexibility Policy

- In July 2000, HAB published the ADAP Flexibility Policy
- Purpose: To fund support services directly tied to
- Gaining “Access” to Medications,
- Increasing “Adherence” to medication regimens, and
- “Monitoring” client’s progress in taking HIV-related medication

## ADAP Flexibility PolicyConditions/Limitations

- No client waiting list or limits on client enrollment
- No restrictions or limitations on HIV medications
- Administrative support is maintained
- Current comprehensive coverage of Anti-retroviral and OI treatment/prevention therapies consistent with PHS Guidelines

## ADAP Flexibility PolicyNotables

- HAB MUST APPROVE A STATE’S REQUEST TO USE ADAP FUNDS UNDER THE FLEXIBILITY POLICY.

## In January 1999, HAB published the ADAP Insurance Policy which allows the use of ADAP funds to purchase health insurance services that includes the full range of HIV treatments as well as access to comprehensive primary care services.

**ADAP Insurance**

**Notes:**
22 States have ADAP Insurance

## ADAP Insurance  (...continued)

- Several State ADAPs have been able to demonstrate considerable savings by purchasing health insurance services as opposed to purchasing prescription medications for their clients.
- These State ADAPs have found that this approach has greatly increased the number of individuals who can access needed medications while broadening the range of services available to these individuals.

## Contact Information

- U.S. Department of Health & Human Services
- Health Resources and Services Administration
- HIV/AIDS Bureau
- Division of Service Systems
- AIDS Drug Assistance Program
**Address:**  5600 Fishers Lane
-                   Parklawn Building, Rm. 7A-55
- 	   Rockville, Maryland  20857
**Phone:** 	301-443-6745
**Fax:**     	301-443-8143
**Website:**  _[http://www.hab.hrsa.gov](http://www.hab.hrsa.gov/)_