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Provider Perspectives
HIV Case Managers and Medicare Part D
Because they are eligible for Medicare through disability, America's HIV-positive population is significantly affected by Medicare Part D. This population has been widely unrecognized in the Part D transition as a specific group in need of specialized prescription drug attention and coverage. As the Program Manager for HIV and AIDS Case Management at Howard Brown Health Center, David Dempsey directly experiences the effects Part D is having on both consumers and health care providers amidst this transition.
Chicago's Howard Brown Health Center has six full-time case managers working with HIV-positive clients. On the effects of Part D on caseloads, David Dempsey states, "Providers have been as confused as clients ... It was hard for us to reassure clients that the information we were giving them was correct." While case managers are trying to use all the information they have, Part D information is ever-changing and unclear. The Part D program is not only new to clients, but to those employed to assist consumers. Clients will come to Howard Brown with an array of issues, such as cancellation of Medicaid or ineligibility for Extra Help. Dempsey stresses that Part D problems are significantly difficult to maneuver, as case managers receive ambiguous and inadequate answers. The frustration clients experience is shared by case managers, as neither client nor provider seems able to fully obtain real answers.
Individual cases testify to the invisibility of important HIV issues under Part D. After January 1, as Medicare consumers were losing Medicaid coverage, David Dempsey had one dual-eligible client who had not been auto-enrolled in a Part D plan. Dempsey helped the client by corresponding with Medicare himself, and enrolling the client in Extra Help. This required going over the client's individual medications, which was time-consuming and confusing. Case managers at Howard Brown have also spent substantial time checking dual-eligibles' Part D plans to ensure that all necessary HIV medications are covered under their new plans. During the last three months of 2005, Dempsey also spent large amounts of time with clients concerning Part D prescription options. A large allocation of Dempsey's time was spent navigating the Part D program with clients, coordinating with the AIDS Drug Assistance Program, exploring drug options, and calculating premium costs. He believes that even more people will be calling Howard Brown after the May 15 enrollment deadline. This foreseen influx of calls will require further allocation of time.
No extra funding has been provided to Howard Brown in lieu of these rapid changes in Medicare. Case managers have relied on free Part D trainings provided by advocacy and outreach services throughout Chicago. These trainings have helped Dempsey understand the core of Part D fundamentals, and he knows that he, and many other providers, would have no idea what to do had he not participated in these comprehensive informational sessions.
As exhibited in the addition to case manager duties, the effects Medicare Part D is having on the HIV/AIDS community is dramatic. Dual eligibles have lost their Medicaid prescription drug coverage and been facilitated into less beneficial Part D plans. While this group of HIV clients are eligible for Extra Help to assist with premiums and coverage gaps, they are still paying more money for medication copays. This greater financial burden for Medicare beneficiaries then affects social service agencies, asproviders scramble for other means of financial assistance for their financially strained clients. For HIV-positive clients that are not eligible for financial assistance, Part D looms as even more of a mess. Social services like Howard Brown are being forced to find adequate financial assistance to help clients with rent and other finances they cannot afford due to gaps in Part D premiums.
Dempsey has worked with another client who was getting his HIV medications through the AIDS Drug Assistance Program (ADAP). Under ADAP, clients pay no copayment or premium for their HIV drugs. This particular client has been forced into a Medicare Part D plan, will soon fall into the donut hole, and will be paying more out of pocket each month for his prescriptions. This situation applies to many people in the HIV-positive community. Another client at Howard Brown was near being sent to a nursing home, simply because he was in serious need of HIV medication. Part D would cover this medication only if the consumer was institutionalized. Another confusing component to Part D is that many other states in the country have waiting lists for people applying to ADAP. Because state funding has been cut nationwide for this program, despite the high need, people in Illinois are being pushed to get their medications through Part D to lessen the state burden. HIV/AIDS clients have subsequently been pushed out of the comprehensive ADAP program and forced to begin paying more for their drugs under Part D. These glitches have seriously affected clients' ability to afford necessary medications, as well as the caseload and emphases of the Howard Brown Health Center case managers.
Howard Brown's Emergency Client Assistance funds help clients to balance prescription costs under Part D. Part D's effects on social service funding, as well as the time and energy of social service workers, have taken away from other serious priorities HIV case managers have with clients. On Part D's effects on the work of HIV/AIDS case managers, David Dempsey states, "I just think that it's more of a financial burden on clients, caused a lot of confusion, and took away quite a bit of time from the social workers being able to work with clients on other issues."
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