Gates' speech in Vienna and the ADAP funding crisis

[Ann]

Gates has delivered a keynote speech at the hiv/aids conference currently going on in Vienna. His speech is now circulating the internet and here is one thing that's brought up some questions for me...

Gates said it's vital the delivery costs of HIV drugs be reduced. In many cases, the cost of getting drugs to those who need them is much higher than the actual medication.

"If we could limit delivery costs to no more than twice the cost of the drugs themselves, we could treat more than twice as many people for the same amount of money," Gates said. link

This got me thinking.... How much ADAP funding is being used/wasted to support the bureaucracy behind the program? How many people are being employed to implement this program and how much paperwork are they pushing around that is over-burdensome, essentially unnecessary, and costly?  Same for Ryan White.

I'm curious to know if any of you in the States who use these programs think that too much of the available funds are being wasted in bureaucracy. Is this possibly an area that could be stream-lined and made more cost effective?

Please know that I'm fully aware that Gates is probably mainly thinking about Africa when he says this, but I want (you) to focus on how his thoughts may apply to ADAP and other programs in the States.



edited to fix punctuation

[wtfimpoz]

Gates has delivered a keynote speech at the hiv/aids conference currently going on in Vienna. His speech is now circulating the internet and here is one thing that's brought up some questions for me...

Gates said it's vital the delivery costs of HIV drugs be reduced. In many cases, the cost of getting drugs to those who need them is much higher than the actual medication.

"If we could limit delivery costs to no more than twice the cost of the drugs themselves, we could treat more than twice as many people for the same amount of money," Gates said. link

This got me thinking.... How much ADAP funding is being used/wasted to support the bureaucracy behind the program? How many people are being employed to implement this program and how much paperwork are they pushing around that is over-burdensome, essentially unnecessary, and costly?  Same for Ryan White.

I'm curious to know if any of you in the States who use these programs think that too much of the available funds are being wasted in bureaucracy. Is this possibly an area that could be stream-lined and made more cost effective?

Please know that I'm fully aware that Gates is probably mainly thinking about Africa when he says this, but I want (you) to focus on how his thoughts may apply to ADAP and other programs in the States.



edited to fix punctuation

I for one want to know why our elected officials are preoccupying themselves with the humanitarian crisis in Africa when it continues to worsen every day in the US.

[Ann]

I for one want to know why our elected officials are preoccupying themselves with the humanitarian crisis in Africa when it continues to worsen every day in the US.

Um, hello, I think this must be a record for going off-topic.

Please know that I'm fully aware that Gates is probably mainly thinking about Africa when he says this, but I want (you) to focus on how his thoughts may apply to ADAP and other programs in the States.

And since when is Bill Gates an "elected official"?

[phildinftlaudy]

Gates has delivered a keynote speech at the hiv/aids conference currently going on in Vienna. His speech is now circulating the internet and here is one thing that's brought up some questions for me...

Gates said it's vital the delivery costs of HIV drugs be reduced. In many cases, the cost of getting drugs to those who need them is much higher than the actual medication.

"If we could limit delivery costs to no more than twice the cost of the drugs themselves, we could treat more than twice as many people for the same amount of money," Gates said. link

This got me thinking.... How much ADAP funding is being used/wasted to support the bureaucracy behind the program? How many people are being employed to implement this program and how much paperwork are they pushing around that is over-burdensome, essentially unnecessary, and costly?  Same for Ryan White.

I'm curious to know if any of you in the States who use these programs think that too much of the available funds are being wasted in bureaucracy. Is this possibly an area that could be stream-lined and made more cost effective?

Please know that I'm fully aware that Gates is probably mainly thinking about Africa when he says this, but I want (you) to focus on how his thoughts may apply to ADAP and other programs in the States.



edited to fix punctuation

Hi Ann:
Good question and points.  I know that Ryan White funding has a very very small allowance for administrative, otherwise known as indirect costs.  I will check with the person who oversees it here where I work and see what the percentage is.  If I remember correctly it is only around 3 or 4%.  This is extremely low considering that most nonprofits have administrative cost factors of between 18%-25%.  Administrative costs (indirect costs) are the standard cost of "doing business" (i.e. management overhead, liability insurance, audits, agency infrastructure, administrative support - for report submission, data collection - which are all required by these funds).  The majority of the funding has to be to support direct costs (case managers, etc).  Where there could be some savings would be to have a more limited pool of providers of these services (in other words, have larger providers, with most of the funding allocated to them, but less number of providers), so that these administrative costs are more consolidated and not being incurred by hundreds or more providers across the nation.  

The problem with this is that it then limits choice.  Also, if this type of system was implemented, based on economy of scale, some large providers might now want to open a satellite office in an area that doesn't have as much demand which could force cllients to have to travel further to receive services.  

I suppose this will be a direction that might eventually occur as the government seeks out cost savings for these programs.  I don't believe they would be able to lower the administrative cost allowance much more, as most providers would not be able or willing to do the service if it was much lower.

[wtfimpoz]

Um, hello, I think this must be a record for going off-topic.

And since when is Bill Gates an "elected official"?

duh, you're right.  sorry

[Ann]

I know that Ryan White funding has a very very small allowance for administrative, otherwise known as indirect costs.... If I remember correctly it is only around 3 or 4%.  This is extremely low considering that most nonprofits have administrative cost factors of between 18%-25%.

If you do remember correctly, that's not too bad. Is it the same for ADAP?

Also, am I remembering correctly that many ASOs - non-profits - are partially funded by Ryan White? What about how these funds are being used?

[phildinftlaudy]

If you do remember correctly, that's not too bad. Is it the same for ADAP?

Also, am I remembering correctly that many ASOs - non-profits - are partially funded by Ryan White? What about how these funds are being used?

Ryan White funds are strictly monitored here.  We just had a grueling audit of ours.  They go through everything.  Every expenditure from salaries to office supplies, etc.  The documentation must be extremely well maintained.  From start times to end times for case management, full client file - with all relevant documentation (i.e. case plans, follow ups, signatures, recertifications, etc). 

The biggest complaint I have ever had working in the nonprofit arena is that there are Executive Directors of these nonprofit agencies pulling in high six figure salaries.  While they may be managing a multi-million dollar agency and the agency wants to have and retain qualified people, I do believe there is a point where the salary of some of the Execs puts them out of touch with the clients that it is their mission to serve and they start providing services more to ensure that their salary stays at a certain level or goes higher than to actually provide services with the primary purpose of benefitting people.

If you want to see what some of these Exec salaries are check out their IRS 990 forms which are public domain and available on www.guidestar.org (you can search by the name of the nonprofit -and if you register - which is free - you can pull up the 990s). For example: the Gay Men's Health Crisis agency in NYC received $14.2 million in government funding in 2008, with a total budget of $24 million.  Their Executive Director salary = $$206,816; Chief Operating Officer = $198,585.  Some EDs of nonprofits (please note I said some) seem to want to be "baby Fortune 500 Execs."

[Ann]

The biggest complaint I have ever had working in the nonprofit arena is that there are Executive Directors of these nonprofit agencies pulling in high six figure salaries. 

Some EDs of nonprofits (please note I said some) seem to want to be "baby Fortune 500 Execs."

Yes, we've had that with ASOs in the UK too. I suppose that's what was in the back of my mind when I started this thread.

I've long thought there should be some sort of realistic cap on the salaries of non-profit execs.

[Miss Philicia]

And what pray tell is a realistic cap for someone living/working in Manhattan, and in the capacity of being responsible for an organization with a budget on the order of something as large as GMHC?  Lower the pay too far and it will only make this organization more disorganized than it already is.  

I would think a more realistic way to lower costs is more along the lines of something more simple, like why ADAP enrollees get their drugs on a monthly basis instead of a 3-month basis.  Keep in mind that unlike in the UK most get their drugs from a private pharmacy, so that's where there's more overhead costs per enrollee, or at least that's how I see it.

Above that, dealing just with the ADAP side, ours (meaning bureaucracy portion) is administered by the state Department of Health, it's not outsourced anywhere. I'm not sure if that just comes out of the general state budget or from Ryan White, but I don't think it's bloated from what I see.  IIRC the friend of mine who, until recently, was the co-chair of the Ryan White planning council told me it's a very small office in Harrisburg dealing with it all.  My interaction with this entity is fairly restricted to my once yearly re-certification, and they handle it directly without a tier of case workers -- a simple form to fill out and mail back.  It was the same in New York.  I fully admit to being ignorant of what process is used in all fifty states, but right there are two states with larger than normal amounts of ADAP enrollees.

[Ann]

I would think a more realistic way to lower costs is more along the lines of something more simple, like why ADAP enrollees get their drugs on a monthly basis instead of a 3-month basis.

Yes, see, this is the kind of thing I'm getting at. It would seem to me to be far more cost effective and have a smaller paperwork and going-across-desks profile to dole out the meds in larger quantities. Provided of course that the patient was stable on their combo and not looking at a possible change which would leave them with an unwanted surplus.

And what pray tell is a realistic cap for someone living/working in Manhattan, and in the capacity of being responsible for an organization with a budget on the order of something as large as GMHC?  Lower the pay too far and it will only make this organization more disorganized than it already is. 

I have no idea as I do not live in NYC and don't know the what the current cost of living is there. And I'm not saying "pay them peanuts", but they should be in it as much, if not more, for the service than for the money. Otherwise, they should just go find some for-profit outfit to work for. I don't know what it's like at GMHC, but I do know of some ASOs where the execs make a disproportionately high salary compared to what they actually achieve - both personally within the organisation and in the wider community.

And please understand that I'm NOT accusing any of these services of anything. I'm just curious to know what others, with first-hand experience of these services, think about what role admin and bureaucracy are playing in the current crisis as to funding expenditures.

[Miss Philicia]

Yes, see, this is the kind of thing I'm getting at. It would seem to me to be far more cost effective and have a smaller paperwork and going-across-desks profile to dole out the meds in larger quantities. Provided of course that the patient was stable on their combo and not looking at a possible change which would leave them with an unwanted surplus.

I have no proof of this, but it's one of those things that seems so obvious to me (the once a month supply thing) that I suspect there must be something in the original legislation that prevents changing it, which is why I've insisted going back and re-analyzing the original structure of the entire thing, especially if it's (ADAP) still going to be used at all with the recently passed healthcare legislation, though I'm still not actually clear on how that all fits in.

Though, of course, anything that involves a massive rewriting of legislation has much risk too.  The bottom line is that the current system is exposed massively to the whims of bubble recessions and state budget slashing to the state contribution portion of ADAP.  Always has been.  Anything less is just a band aid.

[pozniceguy]

I am familiar with several not- for- profit   groups  the overhead ( indirect cost vary all over the chart from a few %age point to as high as 70%      ....one agency  ( Red Cross)  use a major portion of the overhead money to "stock" supplies for emergencies and for "advertising"  , another is the local  "helping Hands"  group  they are more in the 6% range  a few permanent employees  (  nurse, Doctor, two interviewers, a food pantry clerk ) and an army of volunteers..( more than 30 at a time)    they also provide resources to help get all the Medical aid (  HIV  or any other need) people  require including Transport.
so trying to judge what is Low or High is not cut and dry.....  I get all my meds from a central mail in Pharmacy  ( Expresssscripts)   3 months at a time  with automatic shipments.They have litterally millions of people they provide this service to ,  I cant think of a more efficient way to distribute  meds... they buy in Huge quantity, ship under special deals with Postal and other delivery services  and are very reliable....  Once a year my ID Dr writes a new script  and faxxes to them   meds come in the mail.

why are individual offices dispensing anything???   except emergency supplies...

Nick

[Miss Philicia]

I get all my meds from a central mail in Pharmacy  ( Expresssscripts)   3 months at a time  with automatic shipments.

Is this ADAP?  I thought you got things under the VA.  Maybe I'm recalling things incorrectly.

[WillyWump]

Interesting point you raise Ann.

I found a chart from NASTAD here... http://www.nastad.org/Docs/highlight/201053_2010%20National%20ADAP%20Monitoring%20Report.pdf

on page 15 it goes over ADAP Program Expenditures for each state. One of the columns is "Program Administration" which I assumed was the cost to administer the program. However some states, such as Texas, have $0 in Program Admin fees. Some states show a sizable amount in this column, such as Florida almost $4millin.

Now im perplexed how some states such as Texas have zero admin costs. Jsut doesnt seem right when some states have millions in Admin costs.

Perhaps someone knowledgable can review the chart and provide some insight. Also the chart is from FY2008, so it is somehwat dated but could not find an updated one.

-Will

[phildinftlaudy]

Interesting point you raise Ann.

I found a chart from NASTAD here... http://www.nastad.org/Docs/highlight/201053_2010%20National%20ADAP%20Monitoring%20Report.pdf

on page 15 it goes over ADAP Program Expenditures for each state. One of the columns is "Program Administration" which I assumed was the cost to administer the program. However some states, such as Texas, have $0 in Program Admin fees. Some states show a sizable amount in this column, such as Florida almost $4million.

Now im perplexed how some states such as Texas have zero admin costs. Just doesnt seem right when some states have millions in Admin costs.

Perhaps someone knowledgeable can review the chart and provide some insight. Also the chart is from FY2008, so it is somewhat dated but could not find an updated one.

-Will

Hi Will -
I would suppose that some of the data reflecting "zeros" is not being reported and/or being reported correctly.  One of the biggest issues the feds have when distributing funding out to states is that each state has its own way of collecting data (some have better data collection and reporting methods then others).  If you notice PA has a bunch of zero's - I would suspect that something was in error in regards to their data reporting system when the information was gathered for this report.  Also, some states will include "administration" costs within the costs of the purchase of the drugs. --- The standards for data reporting still leave a lot to be desired.

I used to work for the state and reporting information up to the feds for various block grants was a challenge as our systems didn't always capture it the way they wanted it captured.

Florida's data seems to be accurate for that time period.  If you notice, even though Administration" is $3.8 million this is on a total budget of $100 million - so it would be around 3.8%.  With a state administered program this would be about right (since the predominance of the service is contracted out - i.e. purchase of the drugs).  Some states contract out the actual handling of enrollment, etc.  Some states include it as part of their Department of Health, others may put it as part of Medicare/Medicaid office functions - this would also reflect in how they (the state) chooses to categorize or assign the administrative costs associated with the program.

Unfortunately, the report does not list all these various nuances that are part of a system that leaves ultimate eligibility determination up to each of the states.  The pro side is that this type of system allows states flexibility in tailoring the program in some ways to the specific needs of their population; the negative is that it makes data analysis and actual equities/inequities difficult to identify.

[Joe K]

It's hard to know how much is spent on ADAP administration, depending upon how the state implements the program. When I was in Florida, the state administered ADAP through a network of public pharmacies. The pharmacies dispensed medications and additional staff was responsible for determining eligibility for either ADAP or Ryan White services. These operations were under the direct control of the state government and they were the most poorly run organizations that I have ever had the misery of having to use. The paperwork requirements were beyond foolish, with staff giving different answers to the same question.

The average wait time for picking up drugs, even with the mandatory 10 day advance phone order requirement, could take from 2-8 hours. If they didn't fill a refill, that you ordered, you had to wait until they got to your refill. The entire process is designed to be the most inhumane, humiliating experience you could ever experience and they expect you to kiss their feet for service. I worked with that system for 10 years and the waste is beyond comprehension. No counseling on the meds, forget asking questions and be grateful that the state is supplying your medications.

Fortunately there were some employees, who actually cared and they were always put down by management, as if being nice to us, was somehow a stretch. I am grateful for the drugs they provided, but when I contrast their program, with that of Michigan (central administration/local drug stores/mail order) and I can guarantee that Florida wastes millions on a poorly designed/run program.

 

[Miss Philicia]

That sounds really, really dreadful.  I'll stick with the private pharmacy system we use.  I can even just walk in, request refills, and return in 20-30 minutes and it's all ready, and I'm talking a dozen different prescriptions.  I rarely wait in a line either, and this isn't an obscure place either it's on the ground floor of the building where my HIV clinic is, and I go to the largest clinic in the city in terms of case load.

Also, when debated the relative merits of different delivery systems we all must step out of our comfort zone and think of what is the easiest for the most poverty-sticken patient group, since HIV disproportionately effects such groups.  I'm organized enough to go to a web site and order a 3-month supply on my own, but perhaps that's not the best solution for those people who can't do that.  I really can't say, but it's the first thing I think to consider.  Someone in a homeless shelter must be provided with what is the most simple.

[Joe K]

That's why I said that Michigan's program was superior. Anyone can apply, personally or through an advocate and one office in Lansing handles all the paperwork. Very quick and efficient. Once approved, you get a number that almost any pharmacy will accept, because the state pays the bill. This system was particularly useful, in Detroit proper, as pharmacies were often some of the only stores still operating in vast areas of abandoned housing. The only requirement to get your drugs, was to get to the nearest drug store, or make arrangements through local agencies. Very nice, respectful system.

[leatherman]

If you want to see what some of these Exec salaries are check out their IRS 990 forms which are public domain and available on www.guidestar.org (you can search by the name of the nonprofit -and if you register - which is free - you can pull up the 990s).

excellent! thanks for that link.

[phildinftlaudy]

excellent! thanks for that link.

no problem Mikie -
I use it often -- gives a good idea of where agencies are spending their money. 
In addition to the Exec salaries, you can see that in a case of GMHC, they spent over $1,000,000 on consulting fees in 2008 for public relations/marketing.
The even question the foundation where I work, as the Exec Director here makes almost $300,000 per year, plus gets car paid for and expense account and we are a $20 million agency that supports a $1.5 billion dollar healthcare system.

[tednlou2]

Kentucky ADAP, atleast here in Louisville, is run through Volunteers Of America.  I think that is part of a religious group, no?  I'll ask my counselor how much administrative costs are.  Their office is in a health department building with the HIV/STD testing clinic next door.  The office is so dirty looking and the carpet looks about 40 years old with stains, so I know they aren't spending money on that.

I've noticed many saying they can fill scripts at their pharmacy under ADAP.  I think here everything comes from the University of Kentucky Pharmacy.  I think (think) that is the only place you can get meds on ADAP. 

[BlueMoon]

Ohio recently dropped 320 people from the ADAP rolls.  I wonder if there was a corresponding drop in the payroll of the administering agency.