Southwest Florida Regional HIV/AIDS Council (RHAC)

Date: September 25, 2013

Time: 9:30AM – 12:00 PM

Place: Charlotte County Health Department

Attendees: Attached list

  1. Dr. Hartner started with introductions around the room, and called the meeting to order.
  2. The Consent Agenda motion for approval P. Dobbins, and seconded by S. Craig. The Clinical Committee Meeting Minutes motion for approval C. Griffith and seconded by E. Stockley.
  3. Financials Report- M. Waite reported that the budget for RW was $759,000 for April 1st- March 31st; we have spent $752,000 which is right on track. M. Waite stated that we are right on track for the Case Management budget.

M. Waite reported that HOPWA has a budget of $161,000 and we have spent about half, which is $80,000. P. Dobbins stated that it is driving her nuts that we send so much money back. P. Brown stated that C. Reynolds will have to come and discuss HOPWA. A. Gallagher stated that the restrictions have tightened. P. Dobbins asked why has the restrictions tighten? Are we getting too much money? V. Clarke stated that we have always received more money than we can spend. R. Bobo stated that he can’t phantom that Hendry County doesn’t have a need for housing. Dr. Beal suggested looking at the needs assessments to see where patients need the most help. Then take that information to Craig Reynolds when you request a meeting with him. S. Stevens also suggested that STRMU should be changed to TBRA to allow for more homeless clients or others who aren’t necessarily ready for self-sufficiency. R. Bobo feels the January meeting would be the best for a visit from Craig Reynolds. We need to review past surveys results and see f there is need for a new survey to gather data. S. Craig mentioned that there are obvious reasons why someone is not allowed HOPWA, but there are gray areas that need addressed as well. S. Stevens that case managers should go through the process even if they don’t believed the clients won’t be accepted. P. Brown stated that HOPWA is not a quick yes or no, there is a process. We track leverage funding. We have worked towards getting clients stabilized; using leverage funding so they have a less need for HOPWA. P. Brown suggested that case managers could keep track for clients who are denied for HOPWA and what was the reason for each instance. R. Bobo stated that would be do-able. P. Dobbins made a motion to have a web meeting with Craig Reynolds in October and seconded by S. McIntosh.

M. Waite reported that from July 1st-August 31st AICP spent $101,000 for 79 clients from July 1, 2012 thru August 31st. R. Bobo is unclear why employers are supposedly not taking third-party checks. Hendry/Glades have no one in AICP at this time.

  1. AICP/ADAP Transition-

L. Wells started off by requesting three pressing questions.

Question #1- K. Medina started by explaining that a letter was sent to Tallahassee that was never answered. And also added why patients can’t have a choice when it comes to which pharmacy they can get their medications from? P. Dobbins added that she agrees with K. Medina, because from clients in a rural perspective have a difficult time getting to a CVS. Then the clients would have to go to another pharmacy for other medications that is not covered. R. Bobo stated that there is only one CVS in a sixty mile radius in Hendry County. Mail order has been suggested; however some clients live 2 miles away from their mail box. We also have issues where the client knows their prescriptions are ready but the pharmacists do not. So when they go to pick up their medications it’s not there. Then we have other instances where clients will use the CVS far away from their house because of stigma and confidentiality. K. Vega stated that it seems that we are the ones getting the training but when the clients present to CVS they don’t know what they are doing. We can’t have a client walk in with a package with all their information; they are already shy of what they have. They feel intimidated and they come back to us. Are CVS staffs being trained for the transition as well? Hendry County has only 1 CVS, Collier County has about 20 but none of them know what they are doing.

Answer #1 L. Wells stated that we are aware of all this issues. The letter that was sent to us was answered but with a call that lasted 45 minutes, we talked about the possibility of expanding our network. P. Dobbins stated that what we are looking for is feedback which will be very helpful to us. S. McIntosh suggested that there be follow up correspondence to show that any issues were resolved. J. Hartner stated that letters that are private that apply to specific clients should not be discussed.

L. Wells continued with Patient Choice. Patient Choice is really a big one and we know it is and it is challenging for all of us because we have to balance that with funding as well as access. Back in the time when we contracted with CVS we had that in mind and had to make every decision possible on getting the best price while making sure we have the most access as possible and lowest price as possible. One of the things from our audit is that we were criticized on our rebate structure. At the time that they visited, we did apply to become a rebate state, however the components were not in place and the criticisms was fair, because had we be rebating as much as we could and should we probably would have dollars to help in the crisis. We had a large number, and the numbers continue to grow and that’s part of the discussion we had before, which is the increase of about 4000 clients each year that is new to ADAP. So when we contracted with CVS one of the things that CVS has provided was annual costs to us, which means we are not paying an administrative costs and dispensing fees, also the only ones that provided us with retail and mail order, meaning that we were able to give clients an option. I am not suggesting that it’s perfect, I am saying that was part of the RFP and through a selection process and criteria they scored the best. Others were strictly mail order. If you have a sole source you are managing a lot of the administrative fees and dispense fees; which you can be used elsewhere. At that time cost was very important because we had limited dollars. We had to spend every penny we had to eliminate the wait list but at the same time recoup dollars in order to help with the short falls. CVS was the one that won. We are currently under the process of new solicitation that is being handled right now and the hope is that we will be able to have an open network. The challenge to that is we have to think about HRSA stating that it has to be structured to get the best price but more over when you are paying for insurance policy you want to make sure that what you are paying for your premiums, copays and costs does not exceed what you would pay for a person in you program. When we open a network now we have to think about what will the dispense fee be, that is what we will learn in the process because most pharmacies and pharmacists are going to charge you an administrative fee and a dispense fee. Imagine we are not paying for any of that right now, however when we open it if the average dispense fee is $8.50 which can go up to $25, multiply that by 3 bottles, multiply that by 12 times for a year. Now these dollars that can be going to medications are now going to dispense and administrative fees.

Question #2 R. Bobo stated my understanding is that we are a 340B entity in Hendry County and that you pay the 340B negotiated rate that the federal government has negotiated with the pharmacies to be paid. The rebate is contingent on what the insurance companies pays and what the 340B pricing is. What is this about coming in at low costs? I understand dispensing fees but I don’t understand where you negotiate the price of the drug.

Answer #2 L. Wells answered that when we have patient choice in order for the client to have a variety of choices; their access has to be in the network. That means that network allows any pharmacy to dispense on their behalf. Part of the reason we went with CVS at the time is because we didn’t have a dispense fee, which has nothing to do with the price of the drug. It has to do with the pharmacists charge to dispense a drug. So evaluating what potential fees might be, we assessed other states and what they are paying and how many have moved to sole source. Which you will find if you do the assessment that many are doing that and you will also find that Publix themselves are requiring their employees to use a sole source. So once we open the network that question is will there be fees? At this time we do not know. What I am saying to consider, as an agency, where do you want your money to go? And if you think about the average cost of a dispense fee and multiply that by the 16,500 clients we served last year and that number has nothing to do with the price of the drug. When we’re talking about sole source those are the things we are thinking about, the cost vs. the access. We are trying to pick up the heaviest costs which are the drugs and the premiums. Everyone knows that some of the drugs range from $1500-$2000 on the market, so these drugs are very costly. We are to ensure just about every client that says “I need”, they’re able to get those drugs. So do we put that money out for administrative fees or do we maybe create, what may not be the most convenient, but access to your life saving drugs. Yes, you may have to go 3 blocks, but I don’t have to tell you “No, I cannot serve you”, yes, you may not prefer mail order because you have to go to 2 miles to your mailbox but you are going to get your drugs. That is the position that we are in, trying to make sure that it applies to everyone. If you remember when that wait list was there it was painful to say no.

Questions #3 P. Dobbins stated that how the agreement came about CVS and explaining everything has been helpful, nobody here would want it to go to administrative or dispensing fees; we want it to go to the drugs for the people that we serve. Now what we are trying to say is that there are some challenges that we face and one of them is if we are going to sole sourcing can we do it with all their medications, instead of having to use 2 different pharmacies.

Answer #3 L. Wells replied that although we are only paying for the medications on our formulary it doesn’t mean that CVS cannot provide the other medications. It does not preclude CVS to cover all their medications, however I understand there all challenges if a person wants to use this pharmacy and is required to use the CVS. P. Dobbins stated that what I am saying is, the client right now goes to CVS and gets their most expensive drugs but the ones that are perceived as not HIV related drugs have to go elsewhere. L. Wells states that they can get all their drugs at CVS, HIV related or not. M. Cuffage states that they can but ten times the price. They would pay $36 for a drug that costs $4 at Publix. L. Wells states that she understands. When Dr. Beal and his team had to reduce the formulary we had to look at the drugs that the plan could get for free or for low cost and/or there was PAP that would sustain it. Granted it is not a great situation, if we can have an open formulary, that’s where we would go. If our insurance clients put a little transition in so we could rebate on them consistently we can begin to expand out formulary. But it is going to take all of us when we are making that decision, it’s not just black and white, it’s always something that’s dependent and that has a cause and effect. So, to answer your question expanding the network, which is what we want to do desperately but we have to balance that with the cost. Now I certainly don’t want to see 15-20 million going out the door for dispense and administrative fees.

M. Kehoe voiced his concerns pertaining to clients having the right to choose any pharmacy that they want. L. Wells stated that they can however, if they want ADAP to cover their drugs they would have to go to the contracted pharmacy.

S. Craig stated that she believes that whoever ADAP is contracted with needs to include language in the contract how to deal with the clients and there has to be a mechanism that when someone leaves there without any medications because CVS didn’t know what the client was talking about. There has to be some kind of connection between your level and the contracting pharmacy to get it handled relatively quickly. L. Wells stated in those situations please send me in writing what has happened so when we go back and evaluate them, I have those issues so I am able to see if there is a reoccurring issue in a particular area. In cases where there is an issue if you call our office and there is a problem often times we find that the client states that they have this but when they get to CVS that is not the case. The contract is up for bidding once again so all of those things will be taken into consideration.

Dr. Beal stated that he hears the issue about the other drugs and patients having to pay a higher price, yet if we know that information couldn’t we take that up with CVS. Can’t we make this easier for the patients? We could advocate for them. I am feeling a real disconnect knowing in really knowing what the problems are in the field. Would you share what have been the trends in the complaints you track? Are they going up or down, or are they stable or static?

L. Wells replied that they actually peak about a year ago. I sent out a crosswalk that I personally developed based on different complaints. Once that went out the complaints began to diminish, they didn’t stop but it reduced a lot of the issues. What we are still seeing, are individuals that go to CVS and they do not have there medications. We have addressed this with the Vice President of retail and they have gone out and done some personal training. I have asked all County Health Departments that if there are issues please put them in writing. D. Beal asked if it was appropriate that the area get written feedback in return to know that the issue has been resolved. L. Wells stated yes they should. S. Craig added is the pharmacy aware why a client wouldn’t be able to receive their drugs so they can let the client know and they can tell their Case Manager. Then the Case Manager could explain it to the client. L. Wells stated the one instance that happens frequently is that the client would provide them with the ADAP card first before they give them their pharmacy insurance card. If pharmacies run the ADAP card as a primary it will not go through because it’s payer of last resort. We are trying to educate our clients and staff about providing their insurance card first. K. Medina stated, setting aside the issues with CVS, clients want to stay at their pharmacies. They are attached to them because they have seen them at their lowest because that is the relationship they have. So they may be able to give them that lower price on medications, switching to another pharmacy that may not be that personal to people.