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HIV & Value Based Healthcare? .....Incorporating Geriatric Consultation Into HIV Care / Employers Plans for Value Based healthcare'
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From Jules: is this really 'patient friendly value based healthcare?' In HIV we are not getting patient friendly value based healthcare !


from Jules: At least year's Aging Wk in Wash DC, which this year is in NYC in October, a study reported that 50% of HIV+ were not getting care for their comorbidities. This is one of many important problems regarding Aging with HIV. Among older HIV+ it is average to be taking 6-12 medications a day, it is common to have 4-8 comorbidities, called polypharmacy & multi-comorbidity. And a new health concern not receiving attention is the risk for liver disease for those without viral hepatitis, as fatty liver & fibrosis in aging HIV+ is getting attention now. The HIV population is aging quickly and this is not a trend but WHAT IS HAPPENING. 75-80% of HIV+ in the USA are over 40-45 years old, with 50% over 50 and 18-25% over 60-65. We are unprepared to address these developments. First, care needs to meet the needs of aging patients and all too often it does not. With cognitive impairment, reduced mobility, not high health literacy, frailty and multi-comorbidity it is becoming increasingly complicated for aging patients to navigate the healthcare system and to understand and receive the best healthcare & to make the best healthcare decisions. The time spent now with a patient by a doctor is now reduced in all healthcare, not just in HIV, to an amount of time often limited to 10-16 minutes, it is impossible to have a holistic understanding of the patient situation & needs. HIV is unique - The Ryan White Care Act provides $1 billion annually to provide healthcare with funding directly to large-scale hospitals & clinics. You would think HIV+ could get better care. We need a carve-out in the RWCA for aging HIV+ healthcare to provide ALL the services they need to achieve the best care. Patients need full scale care coordinators to insure they receive this. Second, HIV research is not meeting the needs in HIV. We need research to focus on aging patient needs. NIH research funding picks low hanging fruit, and researchers go for this. We need research to understand the science leading to HIV brain disorders, bone loss, heart disease, inflammation, and we need medical interventions. Is this possible? Fractures are much more frequent in HIV+, this goes along with weak bones & bone loss and with weak muscles - and this only gets worse doubly so as HIV+ age. An example of a 'patient-friendly study' is one to tell us after a fracture what is the recovery of an HIV+ person compared to an HIV-negative person Am I dreaming that this is possible? There is no doubt to me that due to immune depletion & abnormality & muscle & bone affects from HIV that recovery after a fracture in an older HIV+ is worse, but this would be a very important study to help understand what is going on for older aging HIV+. Or are these problems too tough to tackle? Does NIH & NIAID leadership think we do not owe this to patients? They are all paid by taxpayer money & the patient is supposed to be the center of attention, this is NOT the case now? Have they decided they cannot help us, so let us die. In the 1980s AIDS activists who were dying forced the federal government to pay attention to HIV & this changed everything. The 1st generation with HIV who survived that time are now aging with HIV & over 60, do we not owe them better, YES we do. It is shameful that OAR, HHS, CDC, NIH, NIAID is not providing exactly what is needed. Funding for PrEP & cure is important but not at the expense of under funding aging/HIV. PrEP is great, cure research is important, although we may not find a cure or a functional cure. But these efforts do not help aging HIV+. Some think that a cure or functional cure is exactly what aging patients need, but this is only partially the case. 30 years with HIV causes damages that just are likely to be irreparable but id inflammation & activation could be reduced this would not hurt. Still, with a functional cure I do not think inflammation & activation would be very reduced or reduced at all. The ultimate point is the needs for aging HIV+ is as important if not more important but does not receive any where near the attention compared to PrEP & cure. We need a NATIONAL DISCUSSION on AGING to discuss and strategize how to handle this problem. Two more key points. Healthcare costs will increase 5 fold for HIV+ over 60 vs younger HIV+; two, how will we house disabled HIV+ who need long term institutional care because they are unable to care for themselves at home. We need to address all these issues but federal & local health & policy authorities ignore the problem. The OAR has said we are planning how to coordinate all the NIH institutes over the next 3-5 years to then begin to address the problem of research & aging/HIV. Unacceptable !!! We need to begin NOW. Industry owes us support on this problem. All industry must step up to do more. Some companies invest in aging research & support and some do not. We need more from all of them. Most advocates do not pay attention & do not recognize this problem. A few do. But there is no real advocacy from the community on a federal level and only in a couple of regions or cities is there some attention, still nothing is getting done. If you think stigma is an issue in HIV, wait to people see how stigma & particularly self-stigma self-esteem will get much worse for older aging HIV+. Globally aging will be a big concern particularly in developing & undeveloped areas including the East, Africa, India since the health infrastructure is much less capable of addressing this aging crisis as it evolves further in these areas. In Western Europe as well services for patients are much needed and they too need a National Discussion on HIV & Aging, in fact the IAS & WHO need to have global discussions about this coming crisis. IAS Conferences must take this on where they can have global roundtable meetings to discuss the many issues.
Geriatric-HIV Medicine Is Born: From One Syndrome to Many: Incorporating Geriatric Consultation Into HIV Care
pdfs attached above
Antiretroviral therapy has enabled people to live long lives with human immunodeficiency virus (HIV). As a result, most HIV-infected adults in the United States are >50 years of age. In light of this changing epidemiology, HIV providers must recognize and manage multiple comorbidities and aging-related syndromes. Geriatric principles can help meet this new challenge, as preservation of function and optimization of social and psychological health are relevant to the care of aging HIV-infected adults, even those who are not yet old. Nonetheless, the field is still in its infancy. Although other subspecialties have started to explore the role of geriatricians, little is known about their role in HIV care, and few clinics have incorporated geriatricians. This article introduces basic geriatric nomenclature and principles, examines several geriatric consultation models from other subspecialties, and describes our HIV and Aging clinical program to encourage investigation of best practices for the care of this population.
Aging With HIV Program at the Center for Special Studies, New York City
The HIV and Aging Program at New York-Presbyterian Hospital/Weill Cornell Medical Center was founded in 2014 to meet the needs of patients aged ≥50 years. The program is supported in part by foundation funding and has 2 goals. The first goal is to provide integrated geriatric care within the existing Center for Special Studies human immunodeficiency virus (HIV) clinic sites. Two geriatricians offer weekly geriatric consultation alternating at our 2 clinical sites. They document in the outpatient electronic health record and attend outpatient interdisciplinary rounds at the end of the day where all patients seen that day are discussed. They communicate actively with the physicians, social workers, psychiatrists, and nutritionists to identify problems and problem-solve interventions. Inpatient consultation is also provided to clinic patients admitted to the hospital.
The second goal is to provide patient-driven education and program opportunities both within and outside of the clinic, as determined by a focus group-based needs assessment. The program offers Gold Stars, an internal social worker-driven support group that focuses on providing the space for socialization and general support while educating group participants on a variety of topics relevant to aging with HIV. In addition, the program has sponsored an arts program and links with other community-based groups to organize opportunities for patients to attend group dances and long-term survivor support groups.
CMS -What are the value-based programs?
"With fee-for-service, doctors and hospitals are paid based on the number of health care services they deliver, such as tests and procedures. Payment generally has little to do with whether their patients' health improves. A value-based approach is designed around patients." AETNA
Employers Accelerate Move To Value-Based Care In 2018
Aug 17, 2017 Forbes
The nation's largest employers are moving quickly toward value-based approaches to contain health costs and improve quality, employers and health benefits firms say. With the National Business Group on Health (NBGH) reporting that almost two in five - nearly 40% - of employers are incorporating some "type of value-based benefit design"[see below] into their workers' health plans next year, it's clear the shift from fee-for-service medicine is no passing fad.
"Many employers are increasingly focused on how health care is delivered and paid for in addition to how it is structured," says Ellen Kelsay, chief strategy officer for NBGH. "Past efforts focused on plan design and health care management haven't proven sufficient in driving down costs and improving quality."
In a value-based model, doctors and hospitals are paid to care for populations of patients making sure they get the right care, in the right place and at the right time. They are also measured on the quality of care they provide rather than the fee-for-service approach, which is based on the volume of care delivered no matter how it turns out for the patients.
For employers, the value-based approach also means employees can pay a lower co-pay or premium if they "take steps to manage chronic conditions or obtain higher-quality or more efficient care," NBGH said in its newly released 2018 health care strategy and plan design survey.
Employers are also working with insurers who manage their benefits to contract with value-based entities like accountable care organizations (ACOs), which are proliferating across the country. NBGH said 21% of employers "plan to promote ACOs in 2018 but that number could double by 2020 as another 26% are considering offering them."
"Employers are ramping up efforts to positively affect the supply side of the health care system by pursuing health care payment and delivery reform initiatives," Kelsay says. "These activities are evident in the rising interest in accountable care organizations, centers of excellence, bundled payments and value based benefit design."
ACOs put doctors, hospitals and a team of providers including social workers under the same umbrella to care for populations of patients. The ACO has a contract with Medicare, Medicaid, private insurers or employer-based plans to improve quality, lower costs and then keep any money saved from year to year based on the arrangement with the insurer.
NBGH Press Release
Large U.S. Employers Project Health Care Benefit Costs to Surpass $14,000 per Employee in 2018, National Business Group on Health Survey Finds
August 8, 2017
With costs continuing to rise, employers shifting control efforts to how health care is delivered and paid for

WASHINGTON, August 8, 2017 - Faced with another 5% increase in health care benefit costs, a growing number of large U.S. employers plan to focus more on how health care is delivered and paid for while still pursuing traditional methods of controlling costs such as cost sharing and plan design changes, according to an annual survey by the National Business Group on Health. As a result, more employees will have access to broader health care services including telemedicine, Centers of Excellence and onsite health centers during open enrollment while not experiencing major increases in their costs.
The Large Employers' 2018 Health Care Strategy and Plan Design Survey found employers project the total cost of providing medical and pharmacy benefits to rise 5% for the fifth consecutive year in 2018. Including premiums and out-of-pocket costs for employees and dependents, the total cost of health care is estimated to be $13,482 per employee this year, and projected to rise to an average of $14,156 in 2018. Employers will cover nearly 70% of those costs while employees will bear about 30%, or nearly $4,400 in 2018. For the second consecutive year, employers ranked specialty pharmacy (26%) as the top driver. Eight in ten employers ranked it among the top three cost drivers. Specialty pharmacy costs are likely to remain a top concern as new high-priced drugs come on the market. "Employers are recognizing that traditional cost control techniques alone aren't able to reduce costs to the point where they are no longer a drain on the bottom line," said Brian Marcotte, president and CEO of the National Business Group on Health. "While employers continue to address costs through health care management and plan design efforts, they are also ramping up efforts to positively affect the supply side of the health care system by pursuing health care payment and delivery reform initiatives."
According to the survey, an increasing number of employers plan to adopt the following strategies:
⋅Telehealth utilization surging: Virtually all employers (96%) will make telehealth services available in states where it is allowed next year. More than half (56%) plan to offer telehealth for behavioral health services, more than double the percentage this year. Telehealth utilization is on the rise, with nearly 20% of employers experiencing employee utilization rates of 8% or higher.
⋅Accountable Care Organizations (ACOs) could double by 2020: Twenty-one percent of employers plan to promote ACOs in 2018 but that number could double by 2020 as another 26% are considering offering them. Employers are slightly more confident about the ability of ACOs to improve health care quality beyond what the system does today, compared to reducing costs.
⋅More employers opening health centers: More than half of employers (54%) will offer onsite or near site health centers in 2018 and that number could increase to nearly two-thirds by 2020. These centers have a positive impact on business performance metrics, because they often result in decreased absenteeism and improved presenteeism.
⋅Centers of Excellence (COEs) embracing bundled payment arrangements: Almost nine in ten employers (88%) expect to use COEs in 2018 for certain procedures such as transplants or orthopedic surgery. Bundled payments or other types of alternative payment arrangements will be used by 21-48% of COEs contracts, depending on the medical procedure or condition.
⋅Growing interest in value-based benefit design. Nearly 40% of employers have incorporated some type of value-based benefit design in which employees receive reduced cost sharing or premium reductions when they take steps to manage chronic conditions or obtain higher-quality or more efficient care. There has been some increase in the use of value-based benefit design to steer employees toward telehealth (18% in 2018 vs. 16% in 2017).
"One of the most interesting findings from the survey is thatemployers arefocused on enhancing theemployee experience. For example, there is a big increase in the number of employers offeringdecision support, conciergeservices and tools to help employees navigate the health care system. The complexity of the system and proliferation of new entrants has made it difficult for employees to fully understand their benefit programs, treatment options and where to go for care," said Marcotte.
According to the survey, 66% of companies will offer medical decision support and second opinion services in 2018, an increase of 47% from this year. Additionally, the number of companies offering high-touch concierge services will jump from 28% this year to 36% in 2018.
Among other survey findings:
⋅Nine in ten employers (90%) will offer at least one Consumer Directed Health Plan (CDHP) in 2018. In addition, nearly 40% of employers will offer a CDHP as the only plan option in 2018, compared with 35% this year.
⋅The most common CDHP design is a high-deductible health plan (HDHP) paired with a Health Savings Account, offered by 80% of employers with any type of CDHP. About a quarter of employers (28%) pair a HDHP with a Health Reimbursement Arrangement.
⋅To help control surging specialty pharmacy costs, 44% of employers will have site of care management tactics in place in 2018, a 47% increase over this year. Seven in ten employers will use more aggressive utilization management protocols.
"As employers look ahead,we expect them toincreasinglyfocus onvalue purchasing opportunities within the delivery system andimproving the experience forhealth care consumers.Findingsolutions to the growing challenge of skyrocketing specialty pharmacy costswill also remain a top priority," saidMarcotte.
About the Survey
The Large Employers' 2018 Health Care Strategy and Plan Design Survey was conducted between May and June 2017. A total of 148 large employers participated in the survey. Collectively, respondents represent a wide range of industry sectors and offer coverage to more than 15 million employees and their dependents. Two-thirds of respondents belong to the Fortune 500 and/or the Global Fortune 500, and 42 belong to the Fortune 100.
About the National Business Group on Health®
The National Business Group on Health is the nation's only non-profit organization devoted exclusively to representing large employers' perspective on national health policy issues and helping companies optimize business performance through health improvement, innovation and health care management. The Business Group's mission is to keep its membership on the leading edge of innovation, thinking and action to address health care cost and the delivery, financing, affordability and consumer experience with the health care system. Business Group members, which include 73Fortune 100 companies, provide health coverage for more than 50 million U.S. workers, retirees and their families. For more information, visit www.businessgrouphealth.org.

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