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Re: North Carolina Medicaid and NC Health Choice Draft Section 1115 WaiverApplicationThe Duke Health Justice Clinic and North Carolina AIDS Action Network (NCAAN)appreciate the opportunity to comment on North Carolinas Medicaid and NC Health ChoiceDraft Section 1115 Waiver Application (Draft Waiver).The Duke Health Justice Clinic is a project of Duke School of Law and has been providingfree legal assistance to low-income people living with HIV/AIDS since 1996, as well aspolicy research and advocacy on issues related to HIV, including access to healthcare.NCAAN is a state-wide advocacy organization that aims to improve the lives of people livingwith HIV/AIDS and affected communities through outreach, public education, policyadvocacy, and community-building to increase visibility and mutual support of peopleliving with HIV/AIDS throughout the state.I.
There are over 7,000 people living with HIV in North Carolina who depend on Medicaid forhealthcare.1 If Medicaid is expanded, another 4000 5000 people living with HIV will beeligible for benefits.2B.
The vision of the National HIV/AIDS Strategy is that the United States will become a placewhere new HIV infections are rare, and when they do occur, every person, regardless ofage, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic
circumstance, will have unfettered access to high quality, life-extending care, free fromstigma and discrimination.Medicaid has a major role to play in the achievement of these goals, by providing care andprevention services to people living with HIV as well as those who are at risk. A study ledby researchers at the University of North Carolina found that when HIV patients are treatedwith antiretroviral medications and their HIV virus is suppressed to an undetectable level,they are 96 percent less likely to transmit HIV.3 Thus the highest goal of HIV treatment isviral suppression. To achieve that goal, efforts must be focused on the steps along the HIVcare continuum: diagnosis, linkage to care, retention in care, prescription of antiretroviraltherapy, and viral suppression.4 Medicaid policies can have a profound impact on each ofthese steps.Even though suppression of HIV virus greatly reduces the chances of transmission, only45% of people living with HIV in North Carolina were virally suppressed in 2014.5 Withoutproper healthcare, people living with HIV may not learn of their HIV status, fail to receivecare, lack consistent access to antiretroviral medications, develop resistance tomedications, and experience a rise in viral load that makes it easier to transmit HIV.Providing adequate healthcare to people living with HIV, including easy access to HIVspecialists and antiretroviral medications, is critical to controlling the HIV epidemic, topublic health, and to managing public finances.C.
To achieve viral suppression and optimal outcomes, people living with HIV must receivecare from a provider with HIV expertise. Many HIV specialists are physicians trained inInfectious Diseases, but not all Infectious Diseases specialists have the experience tomanage patients with HIV. Many providers with HIV expertise are physicians assistants ornurse practitioners. There is no board certification for HIV medicine, but severalprofessional organizations have identified the necessary qualifications, including the HIVMedicine Association (HIVMA), American Academy of HIV Medicine (AAHIV), andAssociations of Nurses in AIDS Care (ANAC). The AAHIV has a credentialing process for HIVphysicians, nurse practitioners, physicians assistants and pharmacists. ANAC created theHIV/AIDS Nursing Certification Board for certification of registered nurses and nursepractitioners in HIV nursing.6 Some state Medicaid programs, including Florida, haveestablished additional criteria for designation as an HIV specialist.7Myron Cohen, Ying Q Chen, Marybeth McCauley, et al. "Prevention of HIV-1 Infection With Early Antiretroviral Therapy,"New England Journal of Medicine, 365 (6): 493505. (August 2011), accessed athttp://www.nejm.org/doi/full/10.1056/NEJMoa1105243, April 16, 2016.4 https://www.aids.gov/federal-resources/policies/care-continuum/5 NC Department of Health & Human Services, HIV Continuum of Care in North Carolina Reported HIV Case Data, 2014,accessed at http://epi.publichealth.nc.gov/cd/stds/figures/factsheet_HIV_continuum_of_care_2014.pdf ,April 15, 20166 Joel E Gallant, Adaora A. Adimora, J Kevin Carmichael, et al., Essential Components of Effective HIV Care: A Policy Paperof the HIV Medicine Association of the Infectious Diseases Society of America and the Ryan White Medical Providers3
Having access to HIV specialists and antiretroviral medications does not alone lead to viralsuppression. Support services must be provided to low income and vulnerable peopleliving with HIV to keep them in the HIV continuum of care: diagnosisenrollment in carestaying in careprescription of antiretroviralsadherence to treatmentachieving the long-term goal of viral suppression.These supports include enhanced care management, prevention services, transportation,housing, and linkage to social services. Many of these services are offered through RyanWhite-funded clinics and AIDS Services Organizations. The goal is to provide wrap aroundservices that address the needs of the whole person and help keep the person in care andadherent to treatment. Medicaid can have a role in providing these support services. NorthCarolina Medicaid currently offers targeted case management. It will be important for DHBto carefully assess how this program will be handled in the managed care setting.
We support a strong prescription drug standard that ensures that people living with HIVand other chronic conditions have access to the medications they need to stay healthy,including new therapeutic agents as they become available. We applaud the legislativerequirement in S.L. 2015-245 that all PHPs shall be required to use the same drugformulary, which shall be established by DHB9 Providing consistency in formulariesacross PHPs will reduce administrative burden on providers and minimize confusionamong Medicaid beneficiaries. The current Medicaid formulary provides excellent access toHIV medications, and this robust formulary should be maintained. As long as the statemaintains a strong fee-for-service Medicaid formulary, and applies it to managed care, theneeds of people living with HIV will be served.However, we are concerned that the requirement for a uniform formulary is not clearlystated and detailed in the Waiver draft. The draft contains only a brief mention in section126.96.36.199 that all PHPs will be required to use the States preferred drug list (PDL). Weencourage DHB to make clear in the final Waiver application that 1) all PHPs will berequired to use a uniform formulary; 2) the uniform formulary will be the FFS formulary;and 3) the current FFS formulary will be maintained and strengthened.Additionally, we urge DHB to include standardized requirements for drug utilizationmanagement. In other states, MCOs have increasingly chosen to limit access to HIVmedications not only through narrowing their formularies, but also through employing9
People living with HIV Need Easy Access to Qualified HIV Specialists andContinuity of Existing Provider Relationshipsi. Essential Providers (S.L. 2015-245 5(13))
Florida requires the following: In no instance may the limitations or exclusions imposed by the Managed Care Plan bemore stringent than those specified in the Handbooks, the applicable federal waivers, and Medicaid fee schedules exceptthat, pursuant to s. 409.973(2), F.S., the Managed Care Plan may customize benefit packages for non-pregnant adults, varycost-sharing provisions, and provide coverage for additional MMA services as specified in the MMA Exhibit. FloridaAgency for Health Care Administration, Medicaid Managed Care Contract, Attachment II, Core Contract Provisions,November 1, 2015, 87, accessed at http://www.fdhc.state.fl.us/medicaid/statewide_mc/pdf/Contracts/2015-1101/Exhibit_II-A-Managed_Medical_Assistance_MMA_Program_2015-11-01.pdf, April 18, 2016.11 We encourage DHB to maintain its current FFS utilization management requirements and preferred drug list. Asdiscussed above, HIV drugs should be exempt from prior authorization and other restrictive utilization managementrequirements. Prescribing of HIV medications is highly individualized and physicians follow detailed guidelinesdeveloped by the NIH, Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents,http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf12 Legislative Report, 28-2910
in force in some states, including Minnesota and Colorado.13 The final Waiver applicationshould be further fleshed out to include this requirement.14We note that the list of Essential Providers in the Waiver draft is currently limited toFederal Qualified Health Centers (FQHCs), Rural health centers, free clinics, and local healthdepartments. The Legislative Report accompanying the Waiver draft indicates that DHBmay identify additional Essential Providers. We ask that the list of Essential Providers beexpanded to include Ryan White-funded clinics. Including Ryan White-funded clinics isconsistent with the goal to maintain and enhance the current safety net infrastructureexpressed in the Waiver draft.15 A vast majority of Medicaid beneficiaries with HIV receivecare from Ryan White-funded clinics. Ryan White providers offer expert HIV caremanagement as well as comprehensive care and services such as case management, whichfacilitate and support successful treatment of HIV. Ryan White providers created theoriginal Medical Home model, so they are experienced in providing holistic care in a costeffective structure.Many organizations already designated Essential Providers receive Ryan White fundingand offer HIV specialty services. However, some Ryan White-funded clinics operate inorganizations that do not fall under the proposed Essential Providers designation,including non-FQHC clinics and academic medical centers. We urge DHB to expand the listand add Ryan White-funded clinics to the list of Essential Providers.Designating Ryan White-funded clinics as Essential Providers would align Medicaid planswith Qualified Health Plans in the Federally Facilitated Marketplace, which include RyanWhite-funded clinics as Essential Community Providers.16ii. Network AdequacyThe Waiver draft provides little concrete detail about network adequacy standards. Weunderstand that DHB is awaiting the release of the federal managed care regulations, whichwill provide direction on the development of network adequacy standards. We hope thatDHB will quickly review those rules when they are released and provide more detail aboutnetwork adequacy standards in the final Waiver application. We encourage DHB to includerobust time, distance, and patient to provider ratios that promote access to providers. Wealso support a requirement that people living with HIV be permitted to go out of network ifthe PHP has not contracted with a provider with HIV expertise.
We also encourage DHB to detail how it intends to measure compliance to the accessstandards. States have used a combination of evaluation methods, including relying on selfreports from MCOs, external quality reviews, and direct tests conducted by the statesthemselves. A report by the Office of Inspector General concluded that the procedures forevaluation were weak.17 We urge DHB to develop strong measures to measure compliancewith access standards.iii. Access to HIV Specialists:Direct Access to Specialists Without Referral: To ensure adequate access to care, anadequate number of HIV specialists located throughout the state must be available topeople living with HIV who are enrolled in Medicaid. Including Ryan White-funded clinicsas Essential Providers as discussed above, will facilitate the inclusion of HIV specialists. Tofurther ensure access, beneficiaries should have direct access to HIV specialists without theneed for a referral by a primary care physician. This is in keeping with the standardpractice of MCOs in other states such as California.18 Texas requires [t]he MCO [be]responsible for implementing procedures to ensure that Members have prompt access toappropriate services for STDs, including HIV. The MCO must allow Members access to STDservices and HIV diagnosis services without prior authorization or referral by a PCP.19Maintenance of Existing Provider Relationships: Additionally, it is essential that existingprovider relationships be maintained, including where a beneficiary currently receivesservices from a specialist at a distant location. As noted above, many people living with HIVchoose to seek HIV care outside their local communities because of stigma or specializedmedical needs. Such beneficiaries who currently travel a distance to receive HIV specialistcare at facilities such as UNC Healthcare, Wake Forest Baptist, Duke, Carolinas HealthSystem, and ECU/Brody should be able to maintain these relationships, even if plansavailable in their local communities may not include these providers.Identification of HIV Specialists: Finally, it is of no benefit for a provider to be included ina network unless PHPs afford sufficient transparency, including complete, accurate, andaccessible provider directories that identify HIV specialists. This can be difficult becausethere is no board certification in HIV medicine. However, as discussed above, there areresources DHB can use to set standards for HIV specialists that can be used by PHPs,
Office of Inspector General, State Standards for Access to Care in Medicaid Managed Care, September 2014, OEI-02-1100320, accessed at http://oig.hhs.gov/oei/reports/oei-02-11-00320.pdf, April 15, 2016.
including guidelines from the HIV Medicine Association20, the American Academy of HIVMedicine21, and HIV specialist definitions in HIVAIDS Specialty Plans.22Provider Discrimination: Provider discrimination protections are critical to people livingwith HIV and others with high cost conditions that require specialty care and expensivetreatments. Narrow provider networks that exclude HIV specialists are an increasinglypopular strategy employed by some health plans to discourage enrollment by individualswith HIV and other high cost conditions. It is critical to state and enforce providerdiscrimination protections to ensure HIV providers and others serving costly patients arenot excluded because of the patient population that they serve.Federal regulations prohibit discrimination against providers that serve high-riskpopulations or that specialize in conditions that require costly treatment, such asHIV/AIDS.23 In the Legislative Report, DHB states the intention to includenondiscrimination language in PHP contracts, and we urge DHB to specifically addressdiscrimination protections in the final Waiver application.Summary of Recommendations for HIV Providers and Relationships:DHB should align with federal QHP standards and include Ryan White-fundedclinics as Essential Providers.The Waiver application should include the requirement for a good faith efforteffort to contract with Essential Providers.DHB should set clear network adequacy standards, evaluate MCO compliance bydirectly querying the MCO, and build in performance measures for access to care.Network adequacy factors should include reasonable access to HIV specialists.Plans should be required to cover out of network HIV specialists to maintainexisting provider relationships, particularly if the needed expertise is inaccessibleunder the network adequacy standard.DHB should develop uniform criteria for designating HIV specialists, and requirethat such specialists be identified as such in provider directories.DHB should adopt protections to prohibit PHPs from provider exclusion measuresthat discriminate against people living with HIV to control costs.
HIV Medical Association, Identifying Providers Qualified ot Manage the Longitudinal Treatment of Patients with HIVInfection and Resources to Support Quality Care, March 2013, accessed athttp://www.hivma.org/uploadedFiles/HIVMA/Guidelines_Patient_Care/HIVMA_Standards_Practice_Guidelines/HIV_Guidelines/Guidelines_Content/Revised%20Qualified%20HIV%20Provider%20Policy%20Statement%20Approved%203%2016%2013.pdf, April 15, 2016.21 AAHIV Credentialing, accessed at http://www.aahivm.org/about , April 18, 10216.22 Florida Agency for Healthcare Administration, Medicaid Managed Care Contract, Attachment II, Exhibit II-C, HIV/AIDSSpecialty Plan, November 1, 2015, accessed at https://ahca.myflorida.com/medicaid/statewide_mc/pdf/Contracts/201511-01/Exhibit_II-C-HIV-AIDS_2015-11-01.pdf, April 15, 2016.23 42 CFR 438.214(c).20
Quality Measures
We support the proposal to identify performance measures for managed care plans.Monitoring for effective management of HIV is critical to promoting improved individualhealth outcomes, the public health, and cost containment. As North Carolina develops itsapproach to quality measures in a changing health care landscape, we urge DHB to takeinto account existing, nationally-endorsed quality measure sets and other federal healthcare quality improvement initiatives that include HIV-specific quality and outcomemeasures. Recently the Centers for Medicare & Medicaid Services and Americas HealthInsurance Plans (AHIP) as part of their Core Quality Measures Collaborative, released aconsensus set of core quality measures. The guiding principles used by the Collaborative indeveloping the core measure sets are that they be meaningful to patients, consumers, andphysicians, while reducing variability in measure selection, collection burden, and cost.24The Core Measures including measures for HIV.25 DHB should incorporate appropriate HIVquality measures, including NQF #2082 - Viral Load Suppression, which is included in thisconsensus set.In determining specific HIV measures to be used in North Carolinas Medicaid program, theDivision of Health Benefits should consult with experts at the North Carolina Department ofPublic Health HIV/STD Prevention and Care Branch, the North Carolina AIDS Educationand Training Center, and other recognized experts in HIV treatment.ii.
Performance Incentives
We also support DHBs intention to tie performance on quality measures to PHP payments,using payment rewards and sanctions.26 We hope such plans will be addressed more fullyin the final waiver application. We encourage DHB to look at the success of performanceincentives for HIV/AIDS quality measures in Louisianas Medicaid managed care program,Bayou Health. This program includes eight incentive-based performance measures,including the HRSA HIV/AIDS Bureau viral load suppression core measure.27 As a directresult of including these incentive-based performance measures, Louisiana has achieved aviral suppression rate of 50 percent among all people living with HIV 20 percent higherthan the national average.28The consensus set includes measures developed by The U.S. Department of Health and Human Services HealthResources and Services Administration (HRSA) HIV/AIDS Bureau in its Revised Performance Measure Portfolio, includingCore Performance Measures. These core performance measures include viral load suppression, prescribed antiretroviraltherapy, medical visits frequency, gap in medical visits, and PCP prophylaxis.25 Centers for Medicare & Medicaid Services, Core Quality Measures Collaborative, HIV/Hep C Core Measures, accessed athttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/HIVHep-C-Core-Measures.pdf , April 18, 2016.26 Legislative Report, 24.27 IPRO, Quality Companion Guide Managed Care Organizations 58, February 2015, accessed athttp://dhh.louisiana.gov/assets/docs/BayouHealth/CompanionGuides/LA_QCG_MCO.pdf, April 18, 2016.28 Health Management Associates & National Alliance of State & Territorial AIDS Directors, Financing HIV PreventionServices: Collaboration and Innovation between Public Health and Medicaid Agencies, 78, [hereinafter NASTAD, Financing24
Consumer Transparency
People living with HIV have important relationships with their HIV specialists, and it iscritical that the enrollment process does not interrupt these relationships. In other statesthat have implemented managed care in recent years, such as Illinois and California, thetransition has been challenging for people living with HIV, and has resulted in disruption ofprovider relationships, raising the potential for dropping out of care or losing access tomedications.30Medicaid applicants and beneficiaries must have sufficient information and support tomake informed choices prior to enrollment. We support DHB adopting a model consistentwith the Beneficiary Support System outlined in Section 438.71 of the proposed Medicaidmanaged care rule.31 CMSs Beneficiary Support System requires additional personalizedassistance to beneficiaries living with chronic, complex conditions and empower them tomake informed choices about which plan is appropriate. This type of support shouldinclude information about the services not covered or not fully covered by Medicaid thatmay be available through Ryan White providers and AIDS Drug Assistance Program.Active enrollment is essential to ensuring that beneficiaries are enrolling into plans thatcover their provider network and care and treatment needs. Prior to enrolling in a plan,beneficiaries must have access to clear and detailed plan information, including scope ofcoverage (including formulary information), provider networks, and availability of careHIV Prevention], accessed at https://www.nastad.org/sites/default/files/NASTAD-HIV-Prevention-Financing-Final.pdf,April 28, 2016.29 A copy of the Core Measures are attached.30 Michael D. Dalzell, HIV: A Fragile Population Enters Managed Care, Managed Care, December 2013, accessed athttp://www.managedcaremag.com/archives/2013/12/hiv-fragile-population-enters-managed-care, April 18, 2016.31 80 Fed. Reg. 31272.
coordination services. This information must include any utilization management or othercoverage limits imposed on services, as well as PHP performance on quality measures. Asdiscussed above, transparency is key, especially with respect to prescription drugs andidentification of HIV specialists.While active enrollment is optimal, many beneficiaries will fail to enroll in a PHP on theirown. Thus careful attention must be paid to the auto-assignment process. We support theproposed protections regarding auto-assignment into plans, particularly the requirementthat the state seek to preserve existing provider beneficiary relationships. The LegislativeReport indicates that DHB plans to consider as one factor in auto-assignment thebeneficiarys primary care provider. We ask that for people with serious chronic diseasessuch as HIV/AIDS, the auto-assignment factors also include the beneficiarys specialistprovider. Medicaid beneficiaries with HIV in a number of states, including California andIllinois, experienced disruptions in care due to auto-assignments to managed care plansthat did not contract with their current HIV specialist and/or plans that lacked providerswith HIV expertise. In California, there were complaints that people living with HIV wereauto-assigned to a pediatric clinic that had no HIV specialist.We strongly support a warm hand-off model for the transition to managed care, underwhich people with chronic diseases such as HIV/AIDS who must change providers have theoption to stay with their current HIV providers until they are able to form a newrelationship with experienced HIV providers in their new PHP.Summary of Recommendations for HIV Enrollment Procedures:Beneficiaries must have the information they need to make an informed decisionabout enrollment, including information about formularies, providers, and planperformance.DHB should include prior specialist relationships as an auto-assignment factor.We strongly support a warm hand-off model for the transition to managed care.
activities that are permissible through Medicaid.32 Innovations related to support servicesfor HIV could contribute greatly to the achievement of viral suppression, by helping to keeppeople living with HIV in care and on their medications. Other states, such as Wisconsin,have developed HIV Medical Homes, building on the Ryan White medical home model, andthe Medicaid Health Home initiative.33Many other states have used 1115 Waivers to test innovative programs and models toprovide suitable care to people living with HIV. For example, by leveraging financingthrough a statewide Delivery System Reform Incentive Payment Program (DSRIP)Medicaid 1115 Waiver, the City of Houston developed a program to link newly HIVdiagnosed and out-of-care HIV patients to care and treatment.34 In Rhode Island, the stateprovides targeted case management services as covered services as part of its Medicaidmanaged care contracts. Individuals at risk of HIV infection, including men who have sexwith men and active substantive users, receive targeted case management services.35 Theseindividuals receive assessment and referrals to relevant services like behavioral healthservices, HIV testing, and housing.36 New York and Florida have created Special NeedsPlans (SNPs) to provide HIV-specific care to people living with HIV who rely on Medicaid.37In North Carolina, a Special Needs Plan or an HIV focus within a standard PHP couldsupport HIV care and the goal of viral suppression.Summary of Recommendations for Innovative Strategies:DHB can make use of the flexibility built into the Waiver process to offer supportservices to enhance treatment success for people living with HIV.We urge the Division of Health Benefits to engage with the HIV community,including major HIV providers as well as the Department of Public Health HIV/STDPrevention and Care Program to explore ways in which Medicaid innovation cancontribute to the fight against HIV/AIDS in North Carolina.
We are disappointed that HIV/AIDS providers, advocacy groups, and beneficiaries were notinvolved in development of the draft Waiver. While we applaud DHB for engaging withvarious stakeholders, we strongly support a participatory model in which all stakeholdersare brought together at the table to have a voice in the entire process of Medicaid reform.We also urge DHB to create a mechanism that enables stakeholders, including consumers,Vikki Wachino, CMCS Informational Bulletin, Coverage of Housing-Related Activities and Services for Individuals withDisabilities, June 26, 2015, accessed at https://www.medicaid.gov/federal-policy-guidance/downloads/CIB-06-262015.pdf, April 18, 2016.33 http://www.arcw.org/whats-new/about_the_arcw_medical_home/index.php34 NASTAD, Financing HIV Prevention, at 2023.35 Ibid at 12.36 Ibid at 13.37 New York State HIV Special Needs Plan Model Member Handbook 22 (2014), accessed at http://www.health.ny.gov/diseases/aids/general/resources/snps/docs/hiv_snp_model_member_handbook.pdf, April 18, 201632
to be part of Medicaid oversight on an ongoing basis. Such stakeholder groups have beencreated in other states implementing managed care, such as Texas.38 DHB should create anadvisory committee that has broad representation and real voice.Summary of Recommendations for Stakeholder Engagement:We urge DHB to engage in an open, public process for stakeholder involvement bothduring the process of planning for managed care and afterward.
The Waiver draft and Legislative Report both recommend that managed care organizationsbe exempt from the insurance provisions in Chapter 58 of the North Carolina GeneralStatutes. However, Chapter 58 includes many excellent consumer protections that DHBshould adopt for Medicaid managed care. Relevant consumer protections contained inSection 58 include:No penalty for using out-of-network providers when in-network providers cannot meethealth needs of the insured.39Extended or standing referrals to specialists for beneficiaries with chronicdegenerative, disabling, or life-threatening disease or conditions.40Clearly stated rights of appeal for: utilization review,41 insurer grievance procedures,42notice of right to external review,43 and exhaustion of the internal grievance process.44Clear definition of the term medical necessity.45Clearly defined information that must be provided to beneficiaries by the PHPs about:o The details of their health coverage plano Procedures used for reviewing claimso Reasons for denial of coverageo Specifics about the drug formularyo Criteria for determining whether treatments are considered experimental46Provider protections against retaliation for appealing denials.47Access to information about the utilization review procedures. 48
See, for example, Texas State Medicaid Managed Care Advisory Committee,https://www.hhsc.state.tx.us/about_hhsc/AdvisoryCommittees/smmcac.shtml;39 N.C.G.S. 58-3-200(d).40 N.C.G.S. 58-3-223.41 N.C.G.S 58-50-6142 N.C.G.S 58-50-6243 N.C.G.S 58-50-77.44 N.C.G.S 58-50-79.45 N.C.G.S 58-50-61(12), and 58-3-200(b).46 N.C.G.S. 58-3-191.47 N.C.G.S. 58-50-62.48 N.C.G.S. 58-50-61(e)(3), and 58-50-61(m).38
Currently, North Carolina Medicaid and the Department of Public Health, including theHIV/STD Prevention and Care Branch, operate in silos that result in lost opportunities forimproving HIV prevention and care. The Medicaid reform process presents an opportunityfor new collaborations between these departments to address issues such as best practices,data sharing, quality measures, and prevention. As an example of the potential in thiscollaboration we point to Louisianas partnership between public health and Bayou Care.As part of this partnership, Louisianas public health and Medicaid divisions signed a datasharing agreement that allows them to share Medicaid claims and eligibility data andpublic health data and statistics for the administration and evaluation of the Medicaidprogram and public health services.49 The divisions also hold monthly meetings. Thanks inpart to this collaborative relationship, Louisiana included viral load suppression rates in itsquality measures, which has also encouraged managed care organizations to work directlywith Louisianas public health division and include its STD/HIV program resources intotheir case and disease management programs.50 As a result of this collaboration, Louisianahas achieved a viral load suppression rate of 50%, which is higher than the nationalaverage. Also, Louisiana MCOs are developing a direct working relationship with thestates public health department and STD/HIV Program and are incorporating public healthresources into their case and disease management programs and referring members tothem.Medicaid can also support public health by ensuring that preventive care is widelyavailable, and by monitoring PHP performance in delivering preventive care. In 2013, theU.S. Preventive Services Task Force (USPSTF) assigned an A grade to HIV testing for alladults age 15-65 regardless of risk, as well as for others at risk and all pregnant women.We urge the DHB to require PHPs to provide for coverage of preventive services with aUSPSTF grade of A or B and monitor performance this area. Ensuring that Medicaidbeneficiaries receive appropriate preventive care will contribute to the fight againstHIV/AIDS.51Summary of Recommendations for Medicaid/Public Health Collaboration:DHB should engage with the Department of Public Health to explore potentialcollaborations between DHB, PHPs and DPH in the areas of data sharing, quality measures,support services, and prevention.DHB should require PHPs to cover preventive services with an A or B grade, andmeasure performance in this area.
Medicaid expansion is crucial to North Carolinas transition to managed care. There are5,000 or more people living with HIV in North Carolina who presently have no healthcoverage, as well as thousands more who are at risk of HIV. We join the many voices urgingthat expansion of Medicaid be incorporated into North Carolinas 1115 Waiver.
On behalf of the organizations listed below, we thank you for the opportunity to offercomments to this draft waiver and for your commitment to implementing Medicaid in waysthat ensure access to prevention, care, and treatment for people living with HIV and otherchronic conditions. Please contact Allison Rice (email@example.com) or Lee Storrow(firstname.lastname@example.com) if we can be of assistance.Respectfully Submitted,
Supporting OrganizationsAIDS United, Washington, D.C.Ballantyne Family Medicine, CharlotteCarolinas CARE Partnership, CharlotteEast Carolina University Infectious Diseases, GreenvilleNational Alliance of State and Territorial AIDS Directors, Washington, DCPositive Wellness Alliance, LexingtonRegional AIDS Interfaith Network (RAIN), CharlotteSouthern AIDS Coalition, Birmingham, ALSouthern HIV/AIDS Strategy Initiative, DurhamTriangle Empowerment Center, Inc., DurhamWarren-Vance Community Health Center, Inc., HendersonWellness & Education Community Action Health NetworkWestern North Carolina AIDS Project, AshevilleWomen's Empowerment Team of the East, Greenville
This document was developed to help health systems and third-party payers identify physicians who arebest qualified to manage the care of HIV-infected patients and to compile clinical tools, standards andresources to promote high quality HIV care. The suggested standards are intended for medical providersmanaging the care of HIV-infected patients in an out-patient or clinic setting.The criteria recommended below are based on a large body of evidence that indicates that, regardless ofa physicians specialty training, the two best predictors of high quality, cost effective HIV care arepatient management experience and ongoing professional development through HIV-related continuingmedical education.Qualified HIV Physician CriteriaCategory
CriteriaCriteria should be met for all three of the categories asidentified below.
Patient Management
Board Certification
OrSignificant Clinical Experience
Completion of HIV-related Maintenance of Certification modules and the HIV Practice Improvement Module isencouraged as part of professional development for physicians who focus on HIV medicine.
A highly effective model for delivering HIV care has been developed by the Ryan White Program,the Department of Veterans Affairs and others. The model is detailed in Essential Components ofEffective HIV Care: A Policy Paper of the HIV Medicine Association of the Infectious DiseasesSociety of America and the Ryan White Medical Providers Coalition (available online atwww.hivma.org or by emailing email@example.com).HIV Provider Experience and Patient Outcomes: Selected ReferencesAIDS mortality rates lower at sites with HIV experience. AIDS Alert 1999;14(11):129-30.Bach PB, Calhoun EA, Bennett CL. The relation between physician experience and patterns of care forpatients with AIDS-related Pneumocystis carinii pneumonia: results from a survey of 1,500 physicians inthe United States. Chest 1999;115(6):1563-9.Brosgart C, et al. Community patterns of care for HIV disease: experience makes a difference.Proceedings of Int Conf AIDS 1998;12:1143-44.Brosgart CL, et al. Clinical experience and choice of drug therapy for human immunodeficiency virusdisease. Clin Infect Dis 1999;28(1):14-22.Hecht FM, et al. Optimizing care for persons with HIV infection. Society of General Internal MedicineAIDS Task Force. Ann Intern Med 1999;131(2):136-43.Horberg, et al. Influence of provider experience on antiretroviral adherence and viral suppression. HIVAIDS (Auckl) 2012;4:125-133.Kitahata MM, Van Rompaey SE, Shields AW. Physician experience in the care of HIV-infected persons isassociated with earlier adoption of new antiretroviral therapy. J Acquir Immune Defic Syndr 2000;24(2):106-14.Kitahata MM, et al. Physicians experience with the acquired immunodeficiency syndrome as a factor inpatients survival. N Engl J Med 1996;334(11):701-706.Laine C, et al. The relationship of clinic experience with advanced HIV and survival of women. AIDS1998;12(4):417-424.Landon, BE, et al. Physician specialization and the quality of care for human immunodeficiency virusinfection. Arch Intern Med 2005;165:1133-1139.Landon, BE, et al. Physician specialization and antiretroviral therapy for HIV: adoption and use in anational probability sample of persons infected with HIV. J Gen Intern Med 2003;18:233-241.Markson LE, et al. Repeated emergency department use by HIV-infected persons: effect of clinicaccessibility and expertise in HIV care. J Acquir Immune Defic Syndr 1998;17(1):35-41.Moore RD, et al. Improvement in the health of HIV-infected persons in care: reducing disparities. Clin InfDis 2012;55(9):1242-51.Shapiro M, et al. Variations in the care of HIV-infected adults in the United States. JAMA 1999;281:2305-2315.Rackal, JM, et al. Provider training and experience for people living with HIV/AIDS. Cochrane DatabaseSyst Rev. 2 2011;15(6):CD003938.Stone VE, et al. Relation of physician specialty and HIV/AIDS experience to choice of guidelinerecommended antiretroviral therapy. J Gen Intern Med 2001;16: 360-368.HIVMA 703-299-1215 email@example.com www.hivma.org3
Willard CL, Liljestrand P, Goldschmidt RH, Grumbach K. Is experience with human immunodeficiencyvirus disease related to clinical practice? A survey of rural primary care physicians. Arch Fam Med 1999;8(6):502-8.Wilson IB, Landon BE, Hirschhorn LR, et al. Quality of HIV Care Provided by Nurse Practitioners, PhysicianAssistants, and Physicians. Ann Intern Med 2005; 143(10): 729-36.
Human immunodeficiency virus (HIV) antiretroviral agents and effective HIV care management transformedHIV disease from a death sentence to a chronic condition for many in the United States. A comprehensive HIVcare model was developed to meet the complex needs of HIV patients, with support from the Ryan Whiteprogram, the Veterans Administration, and others. This paper identifies the essential components of aneffective HIV care model. As access to health care expands under the National HIV/AIDS Strategy and thePatient Protection and Affordable Care Act, it will be critical to build upon the HIV care model to realizepositive health outcomes for people with HIV infection.
Gallant et al
California, have adopted the HIVMA and AAHIVM recommendations for identifying HIV experts, while other states,including Arizona, have developed their own definition usingsimilar criteria [40, 41].Caseloads and appointment times vary greatly according toprovider expertise, disease severity, and comorbidities. Clinicstaffing levels and available resources also affect the number ofpatients that providers can effectively manage. Evolving productivity standards that support quality care by HIV cliniciansshould reflect the complexity and intensity of HIV care andallow adequate time to monitor and manage the patients HIVtreatment and primary care needs and provide oversight ofcomorbidity management.Access to an HIV Expert
Available at http://www.aidsinfo.nih.gov/Guidelines/Default.aspx.
Available at http://www.hivma.org.
Available at http://www.iasusa.org/guidelines/.
HHS-proposed initialRecommendedcore set of healthnational measure2011 MedicareNQFquality measures for(HIVMA/HRSA/NCQA)a PQRS numberb numberc Medicaid-eligible adults
HRSA/HAB HIVcore clinicalperformancemeasuresd
Retention in care
Gonorrhea/chlamydia screening
Syphilis screening
Tuberculosis screeningHepatitis B screening
Hepatitis C screening
Influenza immunization
Pneumococcal immunization
PCP prophylaxis
Abbreviations: ART, antiretroviral therapy; HAB, HIV/AIDS Bureau; HHS, US Department of Health and Human Services; HIV, human immunodeficiency virus;HIVMA, HIV Medicine Association; HRSA, Health Resources and Services Administration; NCQA, National Committee for Quality Assurance; NQF, National QualityForum; PCP, Pneumocystis pneumonia; PQRS, Physician Quality Reporting System.a
Horberg et al, Development of National and Multiagency HIV Care Quality Measures, CID 2010; 51:73238.
Measure included and assigned a number in CMS 2011 Physician Quality Reporting System Individual Quality Measures, http://www.cms.gov/PQRI/15_MeasuresCodes.asp.c
Health Resources and Services Administration. HIV/AIDS Bureau. HIV Performance Measures, http://hab.hrsa.gov/deliverhivaidscare/habperformmeasures.html.
The PQRS, developed by the Centers for Medicare and Medicaid Services (CMS), provides incentive payments to providersfor reporting on certain HIV-related quality measures. Reportingof HIV measures is currently limited to registries; this createsadministrative barriers to participation for some programs,limiting the potential for the PQRS to improve HIV care [52].Electronic Health Records
City of Baltimore
Rest of state
SSI adult
SSI childb
Source: New York State Department of Health AIDS Institute, August 2011.Abbreviations: HIV, human immunodeficiency virus; SSI, supplementalsecurity income; TANF, temporary assistance for needy families.a
These rates will be adjusted in October 2011 to reflect costs for services suchas pharmaceuticals that were previously paid on a fee-for-service basis becausethese services will be incorporated into the managed care benefit package.
References1. Losina E, Schackman Bruce R, Sadownik Sara N, et al. Racial and sexdisparities in life expectancy losses among HIV-infected persons in theUnited States: impact of risk behavior, late initiation, and early discontinuation of antiretroviral therapy. Clin Infect Dis 2009; 49:15708.2. Saag MS. Ryan White: an unintentional home builder. AIDS Read2009; 19:1668.3. Walensky RP, Paltiel AD, Losina E, et al. The survival benefits of AIDStreatment in the United States. J Infect Dis 2006; 194:119.
44. Slatore CG, Cecere LM, Reinke LF, et al. Patient-clinician communication: associations with important health outcomes among veteranswith COPD. Chest 2010; 138:62834.45. Bennett HD, Coleman EA, Parry C, Bodenheimer T, Chen EH. Healthcoaching for patients with chronic illness. Fam Pract Manag 2010;17:249.46. Saha S, Jacobs EA, Moore RD, Beach MC. Trust in physicians and racialdisparities in HIV care. AIDS Patient Care STDs 2010; 24:41520.47. Campo RE, Narayanan S, Clay PG, et al. Factors influencing the acceptance of changes in antiretroviral therapy among HIV-1-infectedpatients. AIDS Patient Care STDs 2007; 21:32938.48. Volkmann ER, Claiborne D, Currier JS. Determinants of participationin HIV clinical trials: the importance of patients trust in their provider.HIV Clin Trials 2009; 10:1049.49. Backus LI, Boothroyd DB, Phillips BR, et al. National quality forumperformance measures for HIV/AIDS care: the Department of VeteransAffairs experience. Arch Intern Med 2010; 170:123946.50. Horberg Michael A, Aberg Judith A, Cheever Laura W, Renner P,OBrien Kaleba E, Asch Steven M. Development of national andmultiagency HIV care quality measures. Clin Infect Dis 2010; 51:7328.51. HIVQUAL-US. How HIVQUAL Works Available at: http://hivqualus.org/. Accessed 15 June 2011.52. Centers for Medicare & Medicaid Services. Physician quality reportingsystem. Available at: https://www.cms.gov/PQRS/. Accessed 15 June 2011.53. Centers for Medicare & Medicaid Services. EHR incentive programs.Available at: https://www.cms.gov/ehrincentiveprograms/. Accessed 15June 2011.54. Centers for Medicare & Medicaid Services. Health homes for enrolleeswith chronic conditions: Department of Health & Human Services, 2010.55. Zuckerman S, Williams AF, Stockley KE. Trends in Medicaid physicianfees, 20032008. Health Aff (Millwood) 2009; 28:w510w19.56. Shapiro MF, Morton SC, McCaffrey DF, et al. Variations in the care ofHIV-infected adults in the United States. JAMA 1999; 281:230515.57. Agency for Healthcare Research and Quality. Health care coverageanalyses of the 2006 national healthcare quality and disparities reports.Baltimore: Centers for Medicare & Medicaid Services, 2008.58. Chen RY, Accortt NA, Westfall AO, et al. Distribution of health careexpenditures for HIV-infected patients. Clin Infect Dis 2006; 42:100310.59. Kitahata MM, Holmes KK, Wagner EH, Gooding TD. Caring forpersons with HIV infection in a managed care environment. Am J Med1998; 104:5116.60. Feldman I. Changing Medicaid Reimbursement Models for HIV/AIDSin New York State. In: National summit on HIV diagnosis, preventionand Access to Care: The Forum for Collaborative HIV Research, 2010.61. Yehia BR, Fleishman JA, Hicks PL, Ridore M, Moore RD, Gebo KA.Inpatient health services utilization among HIV-infected adult patientsin care 20022007. J Acquir Immune Defic Syndr 2010; 53:397404.
HRSA HIV/AIDSBureau
Level ofAnalysis
Updated: 11/23/2015
ResolutionHealth, Inc.
HIVHIV RNA Level (revise NQF #0404 CD4 Cell Count or Percentage Performed to assess HIV RNA Level which is now recognized as the keymetric)#0413 HIV/AIDS: Screening for High Risk Sexual Behaviors (NCQA) had endorsement removed in 2013#0573 HIV Screening: Members at High Risk of HIV (Health Benchmarks - IMS Health) had endorsement removed in 2014P23 - HIV: Ever Screened for HIV: Percentage of persons 15-65 ever screened for HIV. Reconsider upon release of additional testing data likelyin summer or fall of 2016. Less than 100% performance expected.Updated medical visit frequency measurement with virtual visits (#2079)Follow up for patients diagnosed with HIV and with low viral loadHepatitis C#0393 Hepatitis C: Testing for Chronic Hepatitis C - Confirmation of Hepatitis C ViremiaTesting of viral load 12 weeks post-end of treatment (AGA currently revising this measure)
Financing HiVPREVEnTiOn SERVicESCollaboration and Innovation betweenPublic Health and Medicaid Agencies
Funding for prevention, care and treatment services directed towards individuals living with or at riskof acquiring HIV comes from an array of public and private insurance and public health programs. Thisarray of services and programs is undergoing a decidedly complex evolution, as the Affordable CareAct (ACA) expands Medicaid and other insurance coverage options; health care financing and deliverysystems are re-designed to emphasize quality and population health; and public health prevention andsafety net roles adapt to these developments.The purpose of this report is to identify emerging opportunities to strengthen and enhance effortsto prevent HIV infection and improve HIV care by forging collaborations between public insuranceand public health programs. State health departments are uniquely positioned to develop and leadpartnerships with their state Medicaid counterparts.
*Centers for Disease Control and Prevention (CDC), HIV in the United States, available at http://www.cdc.gov/hiv/statistics/overview/ataglance.html
HIV testingBehavioral HIV risk reduction interventions(primarily for people living HIV and theirpartners)STD screening and treatmentBiomedical interventions, particularly preexposure prophylaxis (or, PrEP)Linkage, reengagement and retention in HIVmedical care and treatmentPartner servicesCondom distribution
THiS REPORTThe National Alliance of State & Territorial AIDSDirectors (NASTAD) represents the nations chiefstate health agency staff administering HIV/AIDS and viral hepatitis health care, prevention,education and support service programs. Giventhe growing importance of collaboration betweenMedicaid and public health programs, NASTADcontracted with Health Management Associates
case StudieslOuiSianaUsing Medicaid Quality Incentive Payments to Improve Servicesand Outcomes Across the HIV Care Continuum
OVERViEwIn recent years, the Louisiana Department of Health and Hospitals (DHH)Office of Public Health (OPH) STD/HIV Program has successfully implementedinnovative programs to improve access to and the utilization of HIV preventionand treatment services. These programs include the Louisiana Public HealthInformation Exchange (LaPHIE), a bi-directional, electronic information exchangebetween OPHs HIV surveillance systems and participating health care providersthat allows providers to support retention in care for patients with HIV. Anotherprogram of the OPH is LA Links, a Care and Prevention in the U.S. (CAPUS) fundedinitiative which uses regionally located care coordinators to help connect peoplewith HIV care and treatment. Through these and other programs, Louisiana hasachieved a viral suppression rate of 50 percent among all people living withHIV 20 percent higher than the national average of 30 percent.
Bayou Healthmanaged careplans will be heldaccountable forhelping theirmembers livingwith HIV to achieveand maintain viral
Most recently, the OPHs STD/HIV Program has demonstrated its commitmentto improving the health and well-being of people living with HIV by partneringwith the Bureau of Health Services Financing (the states Medicaid program) toleverage the flexibility of its Medicaid managed care program Bayou Health to increase access to and use of HIV care and treatment. Through this combinedeffort, beginning in 2016, the states Medicaid managed care plans will be heldaccountable for helping their members living with HIV to achieve and maintainviral suppression. The new Bayou Health contracts include eight incentive-basedperformance measures, including one HIV-related measure, HRSAs HIV viral loadsuppression measure.5Inclusion of this performance measure should lead not only to improved accessand use of HIV treatment, including anti-retroviral therapy, but also increaseduse of other HIV prevention services. While the Managed Care Organizations
suppression.The new BayouHealth contractsinclude HRSAsHIV viral loadsuppressionmeasure.
Figure 2: HIV Continuum of Care and Viral Suppression Rate, Louisiana 2014100%
40%30%70% of PLWH in care were virally suppressed
20%10%0%Persons living with HIV
In HIV care
Viral suppression(200)
Adapted from Public Health in the Era of Health Reform: Developing an HIV Performance Measure with Managed Care Organizations in Louisiana,presented July 20, 2015
QualiTy mEaSuREThe Bayou Health HIV viral suppressionmeasure is based on the HRSA HIV/AIDS BureauPerformance Measure, National Quality Forummeasure #2082 and is also included in the 2015Core Set of Adult Health Care Quality Measuresfor Medicaid. It measures the percentage ofpatients, regardless of age, with a diagnosis of HIVwith a HIV viral load of less than 200 copies/mLat last HIV viral load test during the measurementyear. The Louisiana Medicaid program selectedthis measure because it is endorsed by the
daTa SHaRingOne of the most valuable lessons learned todate is that timely, reliable, and complete dataare critical but ensuring their availabilitymay require some ingenuity. As a result of thehighly collaborative process to implement theviral suppression measure, OPH and LouisianasMedicaid program have gained a betterunderstanding for the limitations of the data thatMCOs have available through claims submittedby providers. For example, while MCOs mayreceive a claim for a viral load test, the MCO doesnot necessarily have the results of the test. Thismeans that the MCO cannot determine whethera member meets the measure standard for viralsuppression (i.e., viral load less than 200 copies/mL). Additionally, the MCO may not be able todetermine which of its members are living withHIV since the MCO may not have received a claimfor HIV care.
Figure 3: Results of Medicaid and OPH HIV Data Match, July 2015Results of Medicaidand HIV Data MatchJuly 2015
PLWHEnrolled inMedicaid in2014
Patients with noHIV Claim, butMatched in OPH DBN = 2,674
Patients withHIV ClaimN = 5,425
Patientswith ViralSuppressionN = 3,455(64%)
Patientswithout ViralSuppressionN =1,564
Patients withno Viral LoadN = 406
Patientswith ViralSuppressionN = 1,157(43%)
Patientswithout ViralSuppressionN =409
Patients withno Viral LoadN = 1,108
Unpublished data provided by the Department of Health and Hospitals (DHH) Oce of Public Health (OPH) STD/HIV Program, September 28, 2015.
FinancingAll of the MCOs are risk-bearing and are paid amonthly capitation rate, from which the statewithholds two percent. In order to receive thewithheld amount, MCOs must meet or exceed theperformance targets set for the eight value-basedperformance measures, including the HIV viralload suppression measure. MCOs that achieve thetarget for the HIV viral suppression measure willreceive $250,000 of the withheld amount. MCOsthat do not meet the target will not receive thatportion of the withheld amount.
mcO REimBuRSEmEnT OFHiV PREVEnTiOn SERVicESBoth the state Medicaid program and OPHhope that the HIV quality measure will resultin greater focus on Medicaid members living
lessons learned Quality measurement is technical work and implementing new quality measuresrequires careful thought to capture necessary data, validate information, andcalculate measures.
RHOdE iSlandReimagining Medicaid Case Management to Include High-RiskHIV Negative Individuals
nETwORk PROVidERS,claimS, and REPORTingUnder the fee-for-service TCM program, thetarget group was defined, in part, as individualsreceiving case management services fromproviders who are licensed by the Departmentof Health and provide service under contract tothe Department of Health. In effect, approvedRyan White providers were able to bill theMedicaid program forfee for service (FFS)The new MCOenrollees. The new MCOcontract requirescontract requires MCOsto develop a network ofMCOs to developHIV-related TCM providers.a network ofIn order to streamline thedevelopment process, theHIV-related TCMstate provided the MCOswith a list of existing Ryanproviders.White providers and alsocommunicated its expectation that all of thoseRyan White providers should become MCOnetwork providers. About half of the existingproviders also offered other medical services andwere already enrolled providers in each MCOsnetwork. The MCOs also developed contractsdirectly with all Ryan White TCM providers thatwere not already included in their networks.Under the MCO contracts, MCOs negotiate ratesindependently with the provider agencies. Thosenegotiations were initially informed by theestablished state TCM rate and by informationfrom local providers about their costs. In bothhealth plans, the services are billed on a unitbasis, in 15-minute increments. Both plansconveyed that billing processes were new butdid not result in significant disruption or issuesfor Ryan White providers. In advance of the
cOmBining mEdicaidcaSE managEmEnT andPREVEnTiOn SERVicESAs prevention services are prioritized for bothindividuals with HIV or at risk individuals, theoperation of case management can supportprevention but must be structured carefully tocomply with federal and state rules. Indeed,the regulatory structure of the TCM programreflects the challenges of distinguishing betweentraditional case management services andprevention services. Because of the importanceof demonstrating compliance with Medicaid rules,covered services in Rhode Island are documentedas traditional case management services, includingintake screening, assessment and re-assessment,and care plan development. The states providermanual explicitly states that Case managementprovides access to services but does not includethe actual provision of the needed services.Nevertheless, the case management program isdesigned to support the provision of high-impactprevention services. For example, the statescollection of performance measures requiresthat case management providers report viralsuppression trends for HIV positive individuals,and case managers need to be aware throughthe assessment and care planning process ofany risk factors and ongoing need for medical orbehavioral services. Moreover, once the programis expanded to high-risk HIV negative individuals,case management providers will be required torefer such individuals for HIV testing and STDtesting and help link consumers to those services.
plans should be
lessons learned Coordination between plan-based care managers and community-based caremanagement and prevention providers can provide mutual benefits and improve integration of care.
Starting with a smaller managed care initiative provides a way for MCOs andproviders to develop relationships and mutual respect, paving the way for broaderand more comprehensive initiatives.
Medicaid coverage for HIV care-related services, such as TCM, can provide afoundation for MCO engagement with public health programs and providers andopen the door to opportunities for coverage of other HIV prevention services.
cHicagOMaking the Case for Inclusion of Community-Based Organizationsin Medicaid Managed Care Payment and Delivery Systems
AFC is workingto establish newpartnerships in careand prevention,built on their 30years of servingthe communitywith prevention,care, housing andadvocacy.
caTalOguE OF SERVicESand cROSSwalkBefore engaging MCOs, AFC conducted aninternal assessment of the actual cost ofproviding each unit of service. This analysisproved essential in the initial determinationof whether the agency should pursue this lineof work, and subsequently provided importantbenchmarks throughout the initial negotiatingprocess. AFC then assessed its existing servicemix and developed service packages to highlightkey functions aimed at addressing emerging MCOand population health needs. The result of thiseffort, branded CommunityLinks, is a suite ofservice packagesincluding those that addressprevention, linkage and treatment that can bemarketed and sold to health plans. The cataloguebecame a marketing tool around which AFCconstructed a business case demonstrating itcould perform at the level that the MCO expectedof a business partner.8While AFC thus markets services across the HIVprevention and care continuum, this case studyfocuses on the Reach and Engage service package,which is described in greater detail below.
ESTaBliSHing cOnTacTS,Building RElaTiOnSHiPSand nEgOTiaTingWith their services catalogued and business casefor pitching partnerships honed, AFC establisheda logo, web page and phone line specifically forCommunityLinks. AFC thenbegan reaching out to healthOur Mobileplan contacts as broadlyas possible. Outreach toEngagementhealth plans was prioritizedTeam is designedbased on corporatereputation, relationshipsto find andand responsiveness. Theapproach was undertakenengage healthas a long-term relationshipinsurancebuilding effort and AFC wasmindful not to overwhelm themembers.health plans with informationand proposals. Initial targetsfor engagement included the health plan CEO,the executive responsible for Medicaid plans, orthe companys government affairs representative.Beyond these systematic, strategic steps, AFCreported casting as wide a net as possible forbusiness development contacts, including a coldcall approach: at a certain point we just pickedup the phone and started dialing, when a healthplan was not responsive and other approacheshad failed.
REimBuRSEmEnT andcOnTRacTing STRucTuRESAFC proposed to operate on a monthly flat ratepayment basis, which provides set revenue andallows for simplicity in administration of billingand payments. However, AFC has had to adapt tothe unique preferences of its partner health plans.Currently, one contract is reimbursed at a flatmonthly rate for services provided and the other
lessons learned CBOs interested in establishing new relationships with health plans must beprepared to articulate a value proposition; this may include evaluating the cost tothe CBO of providing each service unit; establishing the CBOs capacity to deliverservices as contracted; and demonstrating to the MCO that the service will result incost savings and better health outcomes.
Contracts should be as specific as possible about all terms; however, they should also offer sufficient flexibility to allow fine-tuning as the relationship and the specific service categories evolve.
By partnering with state HIV programs and other state agencies in these contractingprocesses, providers and state health programs can maximize opportunities to ensure the long-term sustainability of pilot projects like this and foster state-wideapproaches.
HOuSTOnLeveraging Medicaid Delivery System Reform Incentive Payment(DSRIP) Projects to Improve HIV Linkage and Reengagement
OVERViEwThe City of Houstons Department of Health and Human Services Bureau ofHIV/STD & Viral Hepatitis Prevention leadership has leveraged new financingopportunities through a statewide Delivery System Reform IncentivePayment Program (DSRIP) Medicaid 1115 waiver. Specifically, the DSRIPprocess in Texas has opened up a substantial new source of funds to supportexpansion of the Departments use of patient navigators to link newly HIVdiagnosed and HIV diagnosed out-of-care patients to care and treatmentwith DSRIP funds.
Section 1115 waivers are approved by CMS and are vehicles that statescan use to test new ways to deliver and pay for health care services inMedicaid. For example, Section 1115 waivers may be used by states toevaluate policy approaches such as expanding eligibility or services orusing innovative service delivery systems that improve care, increaseefficiency, and reduce costs.Across the country, DSRIP waivers have been designed to support statedelivery system reform goals to improve integration and coordinationof Medicaid services. Typically a Section 1115 DSRIP waiver articulatesstate-specific goals and sets specific milestones that are measureableimprovements in quality and overall population health.9Eligible providers and the process for applying for funding may differsubstantially across DSRIP states. While some states have been fairlyprescriptive about eligibility for funding, the process for designing programs,and the metrics providers are permitted to select, Texas set up a regionalsystem in which providers had flexibility to choose specific projects andselect the metrics for delivery system reform. Specifically, Texas divided itselfinto geographic regions, known as Regional Healthcare Partnerships (RHPs),under which all applicants for DSRIP-funded services are organized. Each RHPis led by an anchor organization, generally the organization with the strongestleadership capacity and experience with safety net services in the area, andall public and private hospitals and non-hospital providers in a given regionare eligible to participate. RHP #3 covers the entire Houston metropolitanarea and is led by Harris Health Systems (HHS), which takes responsibilityfor coordinating the 25 other providers, overseeing the several hundred
a BROadER FRamEwORk OFgOalS, and SPEciFic dSRiPmilESTOnES and PaymEnTSThe Houston health department has effectivelybraided multiple funding sources (includingthose available through the Ryan White andDSRIP programs) to better support its linkage tocare activities. This has allowed the Departmentto create a framework of short, intermediate andlong-term goals, combined with quantifiableobjectives, which would not have been possiblewith any single funding stream. In that largerframework, outcomes include:Short-term: Improved capacity for servicedelivery, caseload optimization, andincreased number of referrals.Intermediate-term: Enhanced capacityto prevent spread of HIV/AIDS; increasedongoing access to medical care amongpeople living with HIV; increased ongoingaccess to non-medical services among
lessons learned Designing appropriate metrics for a milestone-based reimbursement programrequires great attention and flexibility to adjust according to external state and federal frameworks and priorities. Even with two years of planning preparation itwas extremely challenging to get this program fully up and running.
For a program that is bound by a period of time for linkage services, ongoingtraining and workforce development efforts are needed to ensure consumer retention in care after the required time allotted to service linkage workershas expired.
notable Trends inFinancing HiV Preventionn addition to the approaches featured in the case studies, there are other innovative paymentand delivery system reforms that present opportunities for public health departments andproviders to partner with Medicaid to increase access to HIV prevention services. The tablebelow describes some of these emerging opportunities in detail.
States Implementingthe ReformAs of May 2015,19 states haveapproved SPAs with atotal of 26 approvedunique Health Homemodels. Of these, fourstates (AL, WA, WI,NY) expressly includepeople living with HIVor AIDS in the targetpopulation.
Approval ProcessMedicaid agency inthe state must obtaina Medicaid StatePlan Amendment(SPA). As part of theSPA process, statesmust consult with theSubstance Abuse andMental Health ServicesAgency (SAMHSA) toassure that HealthHomes meet theneeds of people withbehavioral healthneeds a prioritypopulation for HealthHome services.
Provider ReimbursementMechanismStates have flexibilityin determining theway in which providersare reimbursed forproviding Health Homeservices. Examplesinclude: Wisconsin:Monthly Case Rate,Rhode Island: Weekly,bundled rate perenrollee, Iowa: PerMember Per Monthpatient management fee
Federal Guidance/ResourcesCMS Medicaid HealthHome Resource Page
DeliverySystem ReformIncentivePlan (DSRIP)
StateInnovationModel (SIM)
States Implementingthe Reform
Approval Process
Provider ReimbursementMechanism
Federal Guidance/Resources
Reimbursement forCHW services variesby program. In somecases, MCOs are hiringCHWs directly andpaying them a salary.In others, MCOs orstate agencies arecontracting withcommunity-basedorganizations, in whichcase reimbursementis often a per-memberper-month payment.
As of June 2015,six states haveimplemented orare implementingDSRIP as part of acomprehensive 1115wavier program.Other states, suchas Alabama, Illinois,and New Hampshireare developing DSRIPwaivers.
Included as part of abroader Section 1115Medicaid waiver. Statesmust apply for andobtain approval for the1115 waiver program.
Performance-basedincentive programs;not grant programs.
Using MedicaidSupplementalPayments to Drive Delivery SystemReform
As of November2015, over half ofstates representing61 percent of theU.S. population (38total SIM awardees,including 34 states,three territoriesand the District ofColumbia) are workingtoward comprehensivestate-based innovationin health systemtransformation.
DSIRP fundingallocation methodologyvaries by state, butin all cases providersmust meet certainprocess and/oroutcome measuresbefore receiving anyDSRIP funding.
MedicaidReimbursement forCommunity-BasedPrevention
An Overview ofDelivery SystemReform IncentivePayment Waivers
State InnovationModels Initiative:General InformationState InnovationModels Initiative:Round TwoThe State InnovationModels (SIM) Program: An Overview
considerations forState Health departments
conclusionhis paper offers a snapshot of how states are working to bridge public health and Medicaid inways that improve HIV services and to finance HIV prevention efforts. Much of this promisingwork is in its infancy, however the programs and trends described here help to provide a set ofpotential options to engender more collaboration across state agencies and with providers.This report describes strategies to reform the delivery of health care that, in different ways and usingdifferent mechanisms, all emphasize the importance of care coordination, prevention and the needto address barriers to healthy lifestyles. Taken together, these new innovations represent a critique ofthe current health care delivery system, which is generally not adequately designed to emphasize orfinance preventive services. Whether creating new incentives for managed care companies, designingspecific initiatives through a state DSRIP program, experimenting with Medicaid health homes, orexploring new uses for community health workers, Medicaid programs and state public health agenciesrepresent opportunities to collaborate on efforts to reform health care delivery so that it prioritizesproven HIV prevention strategies.
notesAssessing the Impact of the Affordable Care Act on Health Insurance Coverage for People with HIV, Kaiser FamilyFoundation, Publication #8535, January 2014, available at http://kff.org/hivaids/issue-brief/assessing-theimpact-of-the-affordable-care-act-on-health-insurance-coverage-of-people-with-hiv/1
Medicaid and HIV: A National Analysis, Kaiser Family Foundation, Publication #8218, October 2011, available athttps://kaiserfamilyfoundation.files.wordpress.com/2013/01/8218.pdf2
In April 2013, the USPTF gave routine HIV screening of all adolescents and adults, ages 15 to 65, an A rating.Asa result, individuals eligible for Medicaid expansion coverage (and most individuals covered through privateinsurance) now receive HIV screening without any cost sharing. Coupled with USPSTF grades for STD screening andcounseling and viral hepatitis screening, these coverage requirements present new opportunities for Medicaid todeliver and pay for prevention services.3
See generally The Critical Role of Public Health Departments in Health Care Delivery System Reform, HealthManagement Associates Accountable Care Institute, April 2014, available at https://www.healthmanagement.com/assets/Publications/The-Critical-Role-of-Public-Health-Departments-in-Health-Care-Delivery-SystemReform.pdf4
U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV Viral LoadSuppression, November 2013, available at http://hab.hrsa.gov/deliverhivaidscare/coremeasures.pdf.5
Centers for Medicare and Medicaid Services, Adult Health Care Quality Measures, available at http://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/adult-health-care-qualitymeasures.html6
A Medicaid State Plan is a continually evolving agreement between a state and the Federal governmentdescribing how that state administers its Medicaid program. The state plan sets out groups of individuals to becovered, services to be provided, methodologies for providers to be reimbursed and the administrative activitiesthat are underway in the state, to assure the state that its program activities will be federally reimbursable andto assure the federal government that federal rules will be complied with. When a state is planning to make achange to its program policies or operational approach, it proposes a state plan amendment to CMS for reviewand approval.7
An Overview of Delivery System Reform Incentive Payment (DSRIP) Waivers, Kaiser Commission on Medicaid andthe Uninsured, Oct. 2014 Issue Brief, available at http://kff.org/medicaid/issue-brief/an-overview-of-deliverysystem-reform-incentive-payment-waivers/9
acknowledgementshis document was developed by the National Alliance of State & Territorial AIDS Directors(NASTAD). NASTAD represents the chief state health agency staff who have programmaticresponsibility for administering HIV/AIDS and hepatitis health care, prevention, educationand support service programs funded by state and federal governments. NASTAD collaboratedwith Health Management Associates (HMA), a national consulting firm specializing in state Medicaidprograms, health care system financing, program evaluation and delivery system reform, on researchand development of this document.NASTAD would also like to thank the individuals at the state and city health departments, communitybased organizations, and Medicaid programs and plans who generously gave their time and contentexpertise for the development of this paper.This publication was supported, in part, by cooperative agreement number U65PS00487, funded bythe Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authorsand do not necessarily represent the official views of the Centers for Disease Control and Preventionand the Department of Health and Human Services.Murray C. Penner, Executive DirectorAndrew Gans, New Mexico, ChairFebruary 2016


text:
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subset: commoncrawl


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The restlessness, the clash and conflict, the violence and warfare we see in our lives and upon Mother Earth is the outcome of our unreliability.
Turn around your mood and enjoy the journey of the reunion as it leaves you refreshed and energised. Calmly advice your staff and know that the results will be beneficial to all.
Changing the pattern of healing and spreading unified healing to all souls in our world, we are truly making a united difference to the collective consciousness. Just continue.
There will be much progress and appreciation of your intervention. Stay calm and grow your inner strength.
The one who has no quarrel or enmity with anyone, so, such a being is ever full of joy and happiness. Always healing, and spreading joy.
Getting to know yourself better is the order of the day. You are surrounded by a blue loving light which is slowly moving you to actualising your highest potential.
Communication with the people in your heart is always appreciated by the world whengratitude and compassion flows out from every pore and cell of your body, heart andsoul.
Time, understanding, matter and effort - to employ these in healing for the good ofothers is their worthy and beneficial use.
Connecting the dots and moving ahead will be fine but you will need to pay attention to the next time you are willing executioners of work planned.


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SPUD is our end-to-end Agri-food Supply Chain Optimization Program designed to connect rural farmers to urban consumers and food processors
Lead Applicant Organization NameJGE FOODCREST SUPPORT SERVICES LIMITED
Lead Applicant Organization Type
- Small company (under 50 employees)
If part of a multi-stakeholder entity (i.e. team), provide the names of other organizations and types of stakeholders collaborating with you.HACHI FARMS: www.hachifarms.com
How long have you / your team been working on this Vision?
- 1-3 years
Lead Applicant: In what city or town are you located?Port Harcourt
Lead Applicant: In what country are you located?Nigeria
Your Selected Place: what's the name of the Place you're developing a Vision for?Port Harcourt
What country is your selected Place located in?Nigeria
Describe your relationship to the place you've selected.I have lived in this city all my life. The large population of middle-class workers reside here in Port Harcourt. Over 50 banks and more than 350 hotels, food processing companies and offices in Port Harcourt. Averagely 60,000 working class persons spending an average of N10,000 monthly A total spend of N600,000 for meals and groceries monthly. 73% of the 60,000 live and work around Woji, Odili road/Abuloma/Trans-Amadi axes; are tech-savvy, brand and health-conscious, and prefers specialized services. Our primary target for the next 3 years is within these axes. This category of customers is actively seeking easier and trendier ways to access quality, safe, and healthy groceries & nutrition
Describe the People and Place: Provide information that would be helpful for an outsider who has never been there and may have no context about this Place to better understand the area.Our primary area of focus will be the workforce and homes in Port Harcourt; then, after the first 2 years, we will expand our operations within the South-South region of Nigeria. Trans-Amadi industrial Layout is the Hub of business, corporate and commercial activities in Port Harcourt and which is where we will be citing our central production and distribution channels: • There are over 100 banks and more than 300 oil and gas servicing and related companies and offices within Trans-Amadi industrial layout, Odili road and other parts of Port Harcourt. • This gives an average staff base of 6000 working class persons spending an average of N1,000 daily amounting to a total spend of N6,000,000 for meals and groceries daily. • Our most important customer base are the millennials; the rising middle-class and the affluent buyers who are tech-savvy, nutritionally enlightened, conscious of brand image, health-conscious, and conscious of where and how they do their shopping or dining. • They make up 73% of the above 6000 client base, each of whom owns a smart phone; can access the internet and are among the average to high salary earners. • This category of customers is actively seeking cheaper ways to access top-notch quality, safe, healthy and nutritious food service, fresh, wholesome and organic groceries.
What is the estimated population (current 2020) in your Place?2053200
Challenges: Describe the current (2020) and the future (2050) challenges that your food system faces.Accessing top quality, safe, healthy and nutritious meals has been very expensive and unaffordable for the average working class, school-runs parents and party planners. 1.4Billion tons of perishable food are lost annually in Nigeria due to the lack of post-harvest storage and processing solutions. According to FIIRO, over 85% Small Holder Farmers in Nigeria don't have access to proper post-harvest storage solutions; a farmer losses between 40% – 50% of farm produce post-harvest and this loss leads to price hikes and continuous price fluctuations. The existing and rather largely expensive form of storage - cooling and refrigeration - rely on access to a reliable and not affordable source of either electricity or diesel fuel which are often lacking or virtually non-existent in rural parts. Therefore, the need for an alternative form of post-harvest storage and packaging for both consumers and producers becomes very pertinent. Accessing top-quality, safe, healthy and nutritious meals have been very expensive and unaffordable for the average working class, school-runs parents and party planners. The existing 'fast foods' and grocery vending outfits are expensive, unhealthy and unsafe.
Address the Challenges: Describe how your Vision will address the challenges described in the previous question.SPUD Project will focus on value-added post-harvest preservation, processing and storage of Fruits &Vegetables as its primary product. This includes tomatoes, carrots, romaine lettuce, leeks, red onions, grains, spinach, pumpkins, sweet potatoes, cucumbers, plantains, yams, water leaves, peppers, apples, sour sops, guavas, pineapples, water melons, oranges and bananas. We secured and operated, during start-up, a facility which housed our office, storage and production at the capacity of 500 units per day. We therefore seek funding to secure a state-of-the-art facility and equipment to scale our production to 3000 units per day due to increased demand. This new state-of-the-art Transportation-Storage-and-Processing facility - which will form the basic framework for the SPUD Project - will receive process, store and distribute the produce supplied directly from rural farms to our bulk-purchase clients (Hotels, supermarkets and food processors) and to our new Whole Foods & Fresh Groceries Hyper-Market/Convenience store which will also house a corner African-style restaurant deploying a innovative-retail-service model – for easy shopping and taking off the stress and hassle.
High Level Vision: With these challenges addressed, now provide a high level description of how the Place and the lives of its People will be different than they are now.We are integrating Technology, Supply Chain & Logistics to provide easy access to affordable, safe, nutritious and healthy fresh farm produce, groceries and meals ensuring top-notch quality service delivery using our Post-harvest storage-processing-&-distribution-strategy model. We designed our new Sustainable Produce Urban Delivery (SPUD) and Tech-enabled Organic & Whole Foods HYPER-MARKET/Convenience Stores solution. We designed Our Tech-enabled Post-Harvest Food Processing, Packaging, Storage & distribution solution - The MAP-TECH, MAS-TECH and CAS-TECH a fusion of TECHNOLOGY and the SCIENCE OF FOOD PRESERVATION A standard modern clean-market for everyday shopping where all local and continental fresh farm produce and food items in the regular open market can be found produced, processed and packaged for easy shopping. It features an Innovative Retail Model that have both the regular walk-around easy shopping section and a self-service e-shopping section which is an Artificial Intelligence (A.I) enabled system that activates swiped shopping cards/vouchers and charges per weight and barcode of items purchased A chain of trendy Retail Farmers' Market & Convenience stores with an e-commerce platform for fresh farm produce, fruits & vegetables, sea foods, fresh meat products, organic and whole foods.
Full Vision: How do you describe your Vision for a regenerative and nourishing food future for your Place and People for 2050?FoodCrest Controlled Atmosphere Storage Technology (CAS-TECH), Modified Atmosphere Storage Technology (MAS-TECH) and Modified Atmosphere Packaging Technology (MAP-TECH) is an Artificial Intelligence (A.I) enabled/controlled device which will be embedded and built-into semi-automated packaging machines, storage and transportation chambers and packaging units for nuts, legumes, fruits and vegetables ensuring freshness and nutritional availability all-year-round of these farm produce for large-scale and small holder farmers, food processors and consumers. The MAP-TECH, MAS-TECH and CAS-TECH are a fusion of TECHNOLOGY and the SCIENCE OF FOOD PRESERVATION, designed to automatically regulate the natural atmospheric gases around the food item, the aim of which is, to slow-down, significantly, the deterioration-rate of the food material and then increase its shelf-life significantly. It is a clean-technology and simulates a natural process and is cost-effective and environmentally compatible because it does not require any extra source of energy to operate
How did you hear about the Food System Vision Prize?
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Waste Management Galesville, WI
Rent a Dumpster in Galesville Now!
Quick 1-minute quote in Galesville
Dumpster rental specialists are standing by to give you a quick, no-hassle quote. Let us know what dumpster size you are looking for, when you need it, and what zip code your roll-off is going to.
We are always available to help
Simply give us a call and we will answer any questions you may have about the Galesville dumpster rental procedure, allowed materials, size you may need, etc.
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Get a Quote! (888) 915-4150
Dumpster rental guidelines
When you want to rent a dumpster in Galesville to use at your home, it is a good idea to keep several guidelines in mind. First, determine the size dumpster that can work best for your job. Temporary dumpsters typically come in 10, 20, 30 and 40 yard sizes. Then consider the placement of the dumpster on your own premises. Recommendations call for you to provide a space that's twice the width and height of the container. This can ensure appropriate height and space clearance.
The price you're quoted for the container will include a one-time delivery and pick-up fee, along with regular fees for disposal, fuel and tax. You should also understand you could simply fill the container to the top; no debris should be sticking out. As the homeowner, it's also wise to check with your local city or municipality to determine if a license is needed to place the container on the road.
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Planning Ahead for Your Dumpster Rental in Galesville
Planning ahead for your dumpster rental in Galesville will make your project easier and safer to finish on time. When renting a dumpster in Galesville, follow these hints to help you plan ahead.
1. Clear an area that's big enough for the dumpster to sit for a number of days or weeks. Additionally, make sure that you and other individuals have access to the dumpster. You should have a clear path that prevents accidents.
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Imagine if I should maintain a dumpster longer than seven days?
Most dumpster rental companies in Galesville generally rent containers for a regular speed for 7 days, although most one time customers end up keeping their container an average of three and a half days. When you call to allow the container, conversation with all the customer service representative about the period of time you believe you will need.
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Garbage removal vs dumpster rental in Galesville - Which is right for you?
If you have a job you are going to undertake at home, you might be wondering if it is better to hire someone to come haul off all your waste and junk for you, or in the event you should only rent a dumpster in Galesville and load it yourself.
Renting a container is a better solution in the event you want the flexibility to load it on your own time and you do not mind doing it yourself to save on labour. Dumpsters also work nicely in the event that you've at least seven cubic yards or more of debris. Rolloffs normally begin at 10 cubic yards, so should you just have 3-4 yards of waste, you are paying for a lot more dumpster than you need.
Trash or junk removal makes more sense in case you want someone else to load your old items. It also works nicely should you want it to be taken away fast so it is outside of your own hair or in the event that you only have a few big items; this is likely cheaper than renting an entire dumpster.
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Dumpster Sizes Explained
When comparing dumpster sizes to find one that meets your project's needs, it's vital that you understand how rental companies measure measurements.
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In the event you're coordinating a big commercial project, then you will probably need a 40-yard dumpster or larger. Substantial house renovations may demand a 30-yard dumpster, but most smaller home repairs just need 20-yard or even 10-yard dumpsters. Speak with an expert if you need more guidance on deciding on a dumpster size that matches your project.
What Size Dumpster Do I Want for a Roofing Job?
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A lot of folks order one size larger than they think their projects will require since they want to prevent the additional expense and hassle of replacing full dumpsters that weren't big enough.
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Common things to put in a roll-off dumpster
When you rent a roll-off dumpster, you will be tempted to throw anything and everything indoors. Common items that folks usually dispose of in a dumpster include solid waste material and most routine household and building waste, together with tree limbs and landscaping debris. They are able to be used for business and commercial cleanouts, house renovations, getting cleared of crap when you're moving to another house, larger landscaping occupations and much more.
A record of stuff you cannot set in a roll-off dumpster includes paints and solvents, automotive fluids, pesticides, chemicals, electronics and batteries. If you try and include these things, you will probably end up with an extra fee. Other items that will definitely incur an additional fee include tires, mattresses and appliances. Extra heavy substances are also not enabled; things that are too heavy may surpass authorities transfer regulations and be unsafe to haul.
Reasons to Use a Flat Rate Service when Renting a Dumpster
Dumpster rental firms that charge flat rates are often the top options for contractors and home owners. When you utilize a business that charges a flat rate, you can anticipate at least two benefits.Prevent Hidden Charges
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Dumpster Rental Companies Near Galesville
|Company Name
|United Liquid Waste Recycling
|(920) 349-1600
|Woodland Rolloff Llc
|(715) 798-3059
|A-1 Services Scott's
|(414) 525-1744
|John's Disposal Service
|(262) 473-4700
|A1 Recycling
|(414) 281-8900
|Tire Town Auto LLC
|(715) 389-2909
|A to Z Cleaning & Moving
|(920) 727-9709
|Gauger's Salvage & Refuse Llc
|(608) 753-2656
|Miller Park
|(414) 383-3787
|Orchard Ridge RDF
|(262) 253-8620
Our Service Area
Zip Codes in Galesville54630
Dumpster Learning Center
Other Cities We ServiceDumpster Rental Conover
Dumpster Rental Tigerton
Dumpster Rental Babcock
Dumpster Sizes Available Galesville
Get started in less than 60 seconds. Pick up the phone and get a quote now!
10 Yard
Great for small projects
- 12 feet long
- 8 feet wide
- 4 feet tall
20 Yard
For moderate sized cleanouts
- 22 feet long
- 8 feet wide
- 4.5 feet tall
30 Yard
All around good dumpster size
- 22 foot long
- 8 feet wide
- 6 feet tall
40 Yard
For the largest projects
- 22 foot long
- 8 feet wide
- 8 feet tall
*Dimensions & availability may vary by location. Call to confirm.
Thousands of satisfied customers
We take pride in providing our community with great prices and excellent customer service on dumpster rentals. Join thousands of others and get the dumpster you need, for the price you deserve!
We accept
All major credit cards accepted for dumpster rentals in Galesville.


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This month The Luxury Greece Collection, a division of Greece & Mediterranean Travel Centre is joining Travel Daily to give agents the chance to win a luxurious Greek trip! The 8-night escape explores the must see destinations of Greece. Start in the ancient city of Athens and then relax and unwind on the scenic Greek Islands of Mykonos and Santorini.
To win all you'll need to do is correctly submit BOTH an image and a short description (100 word max limit) to each of the 4 questions asked weekly over February.
Send your answers to email@example.com
Week 1 commencing 3 February 2020
Q1 – It's always nice to treat-yo-self when you're on holidays. Send us through your favourite holiday splurge!
Week 2 commencing 10 February 2020
Q2 – It's Valentine's day week! It's time to KISS (Keep it Simple Silly) and let us know what luxury hotel in Greece you're in love with.
Week 3 commencing 17 February 2020
Q3 – We all know clients want the best of the best! Let us know which of our destinations they've been after lately.
Terms and conditions & Full prize details here


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Swimming Clubs in London
Here you will find accurate info on various businesses belonging to the Swimming Clubs category in London. From the latest category entries up to a list of similar categories in this area. Feel free to 'dig in' and get the data that you are looking for.
Request for Quotation
Are you looking for Swimming Clubs ?
Use our 'Request for Quotation' service and get customized offers from companies in London.
Most popular searches in London in the "Swimming Clubs" business category
Latest entries in London in the "Swimming Clubs" business category
- David Lloyd FulhamUnit 24 Fulham Broadway Retail Centre, Fulham Road- SW6 1BWOpening Times
- Elite Swimming School110 The Vale- NW11 8SLOpening Times
- Ealing Swimming ClubEaling 91 Ruislip Rd E- W13 0ALDetails


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Our ATO Community is here to help make tax and super easier. Ask questions, share your knowledge and discuss your experiences with us and our Community.
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