Insurance issues as a barrier to HIV care: using a newsletter to raise awareness

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By Kathleen Xu, MPH & Ranjani Paradise, PhD

“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.

In order to support our case managers, providers, and patients, the CQI team focused the April 2013 issue of our newsletter, Facts for Action, on insurance and HIV. This newsletter was disseminated to all staff and patients in order to raise awareness about the effects of insurance issues on HIV care.

The first page displays a timeline and comprehensive list of insurance issues that case managers have been working hard to overcome, while the second page includes a list of recommendations for providers and patients about how they can work together with their case managers to avoid insurance issues. Especially in the multidisciplinary setting of CHA’s HIV clinics, the newsletter served as an important reminder for all staff to collaborate as a team and communicate with each other and their patients to provide the best care for their patients.

National HIV Testing Day is an important annual event promoting HIV testing and encouraging all people to learn their HIV status. Getting tested is only the first step to managing HIV. As we reflect on our work with the CQI team, we are reminded that in addition to encouraging testing, we must ensure that those tested positive have access to the medical care that they need.

Special thanks to the HIV Continuous Quality Improvement (CQI) team and the CHA HIV clinics’ case management staff for their help in compiling the Facts For Action newsletter!


The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.