“Take the test. Take control.” – National HIV Testing Day slogan
In honor of National HIV Testing Day, we are sharing our experience working with Cambridge Health Alliance’s (CHA) two HIV clinics, The Zinberg Clinic and Somerville Hospital Primary Care, on a Continuous Quality Improvement (CQI) Team. Our team consists of a nurse manager, a social work manager, a nurse practitioner, a community health worker, a program support director, and three Institute for Community Health (ICH) staff members. We meet regularly to track quality measures and strategize how to help the HIV clinics sustain high quality services. One of the issues we have been tracking is the relationship between health insurance coverage and access to care for HIV patients. Insurance policy changes and gaps in coverage impact patients’ ability to maintain ongoing HIV treatment, which is extremely important for reducing HIV viral load and minimizing HIV drug resistance. With 63% of CHA’s HIV patients on public insurance, and a large proportion of them affected by unstable housing and employment situations, their insurance coverage often fluctuates. Therefore, the CQI team has made an effort to better understand the main insurance issues and ongoing policy changes that most affect these patients, so that CHA providers can better support patients through the process.
Over the past few months, our CQI team gathered information and feedback from the two clinics’ case managers about challenges they have experienced with insurance policy changes when trying to maintain coverage for their patients. We learned that as a result of many policy changes over the last 4 years, including those that resulted from the Massachusetts health care reform, the time it took case managers to ensure each patient received adequate coverage quadrupled. Much of the added time was attributed to extra paperwork and delays in insurers’ response time.
One particular challenge case managers and patients have faced in recent years is stricter proof of residency requirements. Since many of CHA’s HIV patients are of low socioeconomic status and have unstable living situations, they often do not have the documents required to prove MA residency (e.g., mortgage papers, utility bills, leases). As a result of this policy change, patients experience unexpected coverage termination and coverage gaps. Case managers must continuously monitor patients’ social and living statuses on a month-to-month basis, as any income, dependency, address or job status changes could disqualify patients for some insurance policies. In such cases, case managers must help patients identify and apply for a new insurance policy depending on the status change and also help them determine which pharmacies accept the new insurance.
Overall, obtaining insurance has become a time-consuming and complicated process for patients and case managers. CHA is fortunate to have dedicated case managers to help patients navigate the complex insurance system, as well as providers who also work hard to keep patients in care and adhering to their medication regimens, even when faced with these insurance barriers.