The impact of state policy on the costs of HIV infection

Economic benefits of the United States’ AIDS drug assistance Program: A systematic review of cost analyses to guide research and policy priorities

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The AIDS Drug Assistance Program (ADAP) is a $2.4 billion a year program.

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Little formal economic analysis of the ADAP in the literature.

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The few economic analyses of ADAP use 2008 or older data.

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ADAP programs’ healthcare delivery have changed substantially since 2008.

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Updated person-centered cost effectiveness models assessing ADAP are needed.

As part of the Ryan White HIV/AIDs Program, the federally-funded, state-administered AIDS Drug Assistance Program (ADAP) provides prescription drug medications, including antiretroviral therapy, for people with HIV (PWH) who are uninsured/underinsured and have a low income. ADAP expenditures are ∼$2.4 billion annually, but there is a dearth of formal economic analysis supporting the societal perspective. We conducted a systematic review of economic analyses of the United States’ AIDS Drug Assistance Program to establish future research priorities based on gaps in knowledge. We searched six electronic databases for articles published before January 2022 that met inclusion criteria. We used the 2022 Consolidated Health Economic Evaluation Reporting Standards to assess the quality of reporting of the economic evaluations. We extracted data into categories to assess gaps and needs for future economic evaluation. Seven studies met inclusion criteria. Two used the same modeling approaches but were published with slightly different outcomes. The few economic analyses that focused solely on ADAP were conducted using 2008 or older data. The most recent study modeled the net cost per quality-adjusted life-year (QALY) secondary to reducing new HIV cases among those virally suppressed, but did not include the economic or health benefits for PWH. ADAP programs’ delivery of antiretroviral therapy has shifted from primarily direct provision to subsidizing insurance plans. None of the models take these shifts into account. Updated person-centered cost effectiveness models assessing ADAP are needed on a national and state-by-state level to guide policy decisions and coverage determinations.

HIV Patients in the HCUP Database: A Study of Hospital Utilization and Costs

This study examines the utilization of hospital care by HIV patients in all hospitals in eight states (California, Colorado, Florida, Kansas, New Jersey, New York, Pennsylvania, and South Carolina), and examines the cost of hospital care for HIV patients in six of these states (California, Colorado, Kansas, New Jersey, New York, and South Carolina). The eight states in the sample account for more than 52% of all persons living with AIDS in the United States; the six states account for 39%. The unit of observation in both studies is a hospital admission by a patient with HIV. Hospital data were obtained from the Healthcare Cost and Utilization Project (HCUP), State Inpatient Database (SID), which is maintained by the Agency for Healthcare Research and Quality (AHRQ). The HCUP contains hospital discharge data and is a federal/state/industry partnership to build a multistate health care data system. Using multivariate analytic techniques and data from 2000, results indicate that cost and length of a hospital stay vary significantly across states after accounting for a patient's gender, insurance type, race, age, and number of diagnoses, as well as the teaching status and ownership category of the hospital.

Five myths about cancer care in America

In this commentary we debunk a number of the most common misconceptions about cancer treatment, such as claims that the war on cancer has been a failure and that treatment costs are unsustainable. In addition, there is good evidence that patients value these treatments more highly than traditional cost-effectiveness analysis would indicate. We argue that coverage policies placing undue burden on patients are socially wasteful and will likely discourage further innovation.

Are community-based pharmacists underused in the care of persons living with HIV? A need for structural and policy changes

OBJECTIVE

To describe community pharmacists' perceptions on their current role in direct patient care services, an expanded role for pharmacists in providing patient care services, and changes needed to optimally use pharmacists' expertise to provide high-quality direct patient care services to people living with human immunodeficiency virus (HIV) infections.

DESIGN

Cross-sectional study.

SETTING

Four Midwestern cities in the United States in August through October 2009.

PARTICIPANTS

28 community-based pharmacists practicing in 17 pharmacies.

INTERVENTIONS

Interviews.

MAIN OUTCOME MEASURES

Opinions of participants about roles of specialty and nonspecialty pharmacists in caring for patients living with HIV infections.

RESULTS

Pharmacists noted that although challenges in our health care system characterized by inaccessible health professionals presented opportunities for a greater pharmacist role, there were missed opportunities for greater level of patient care services in many community-based nonspecialty settings. Many pharmacists in semispecialty and nonspecialty pharmacies expressed a desire for an expanded role in patient care congruent with their pharmacy education and training.

CONCLUSION

Structural-level policy changes needed to transform community-based pharmacy settings to patient-centered medical homes include recognizing pharmacists as important players in the multidisciplinary health care team, extending the health information exchange highway to include pharmacist-generated electronic therapeutic records, and realigning financial incentives. Comprehensive policy initiatives are needed to optimize the use of highly trained pharmacists in enhancing the quality of health care to an ever-growing number of Americans with chronic conditions who access care in community-based pharmacy settings.

The Impact of State AIDS Drug Assistance Policies on Clinical and Economic Outcomes of People With HIV

We investigated the effect of changes to state AIDS Drug Assistance Programs (ADAP) policies, which govern access to antiretroviral therapy (ART), on clinical and economic outcomes among low-income people living with HIV/AIDS. Retrospective analyses of ART access were conducted on state ADAP policies, using data from ADAP Monitoring Reports and Kaiser Family Foundation from 2006 to 2010. We found stricter eligibility requirements reduce the number of HIV-positive individuals with ART access through ADAP, and decreased ART use increases mortality by 2.67 quality-adjusted life years (QALYs) per beneficiary. If the ADAP income eligibility cutoff were decreased by 50 percentage points in each state, 4,626 individuals would lose ART access nationwide. Based on a $22,143 cost/QALY, this policy would save $274 million in health care expenditures (2012 dollars), but result in 12,352 QALYs lost, valued at $1.2 billion. Therefore, states should exercise caution in restricting programs that increase ART access for low-income people living with HIV/AIDS.

State-level spending on health care and social services for people living with HIV/AIDS in the USA: a systematic review

Every year for the past decade, approximately 50,000 people have been diagnosed with HIV or AIDS in the USA, and the incidence of HIV/AIDS varies considerably from state to state. Studies have shown that health care services, most notably treatment with combination antiretroviral therapy, can help people living with HIV/AIDS (PLWHA) live healthier, longer lives, and prevent the spread of HIV from person to person. In addition, social services, such as housing support and provision of meals, have also shown to be important for helping PLWHA adhere to antiretroviral treatment and maintain contact with health care providers for improved health outcomes. Although spending on health care and social services for PLWHA varies across the USA, the relationship between state-level spending on these services and HIV/AIDS-related outcomes is not clear. We therefore conducted a systematic review of peer-reviewed literature to identify studies that explore state-level spending on health care services and/or social services for PLWHA and HIV/AIDS-related health outcomes in the USA.

Community-Based Pharmacists’ Needs for HIV-Related Training and Experience

Objective:

To examine pharmacists’ self-reported competence in providing care to persons living with HIV (PLWH) and their HIV-related training and experience needs.

Methods:

We interviewed 28 community-based pharmacists providing care to PLWH in 4 Midwestern cities. Results: Less than half (46%) of the pharmacists considered themselves competent to provide PLWH care, and less than a third (29%) worked with PLWH during their pharmacy residency. Specialty pharmacists need training on opportunistic infections and HIV-related comorbidities, nonspecialty pharmacists need general training in HIV treatment and patient communications skills, and all pharmacists require a mechanism to keep updated in the latest HIV treatment recommendations.

Conclusion:

In the current era of patient-centered care, a pharmacist that is well rounded—not just in dispensing antiretroviral medications but highly knowledgeable in different aspects of ART and HIV-specific patient care—can make a valuable contribution to the health care team. Pharmacy school curricula and continuing professional education need to be aligned to meet the knowledge and competency needs of community pharmacists who are strategically positioned to provide care to PLWH.

State policy influence on the early diffusion of buprenorphine in community treatment programs

BACKGROUND

Buprenorphine was approved for use in the treatment of opioid dependence in 2002, but its diffusion into everyday clinical practice in community-based treatment programs has been slow. This study examines the net impact of efforts by state agencies, including provision of Medicaid coverage, on program-level adoption of buprenorphine as of 2006.

METHODS

Interviews were conducted with key informants in 49 of the 50 state agencies with oversight responsibility for addiction treatment services. Information from these interviews was integrated with organizational data from the 2006 National Survey of Substance Abuse Treatment Services. A multivariate logistic regression model was estimated to identify the effects of state efforts to promote the use of this medication, net of a host of organizational characteristics.

RESULTS

The availability of Medicaid coverage for buprenorphine was a significant predictor of its adoption by treatment organizations.

CONCLUSION

Inclusion of buprenorphine on state Medicaid formularies appears to be a key element in ensuring that patients have access to this state-of-the-art treatment option. Other potential barriers to the diffusion of buprenorphine require identification, and the value of additional state-level policies to promote its use should be evaluated.

The Changing Pattern of Hospital Care for Persons Living With HIV

OBJECTIVE

To compare inpatient utilization and costs by persons living with HIV in 2000 with inpatient utilization and costs in 2004.

DATA SOURCES

Data on 91,343 hospital discharge abstracts representing all HIV-related admissions in 6 states (California, Florida, New Jersey, New York, South Carolina, and Washington state) in 2000 and data from 72,829 hospital discharge abstracts representing all HIV-related admissions in the same states in 2004 are used. These data were obtained from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project, and they were combined with data on the number of persons living with HIV that were obtained from the Centers for Disease Control and Prevention and 2 state departments of health.

STUDY DESIGN

This study compares the hospital care received by persons living with HIV in 6 states in calendar year 2000 with the hospital care received by persons living with HIV in calendar year 2004 in the same 6 states. This study also compares population-based measures of hospital utilization (ie, to measure the average utilization of hospital care per person living with HIV in each state) across the 6 states.

RESULTS

This study found that the average age of a hospitalized patient with HIV rose from 41 to 44 years and that the average number of diagnoses rose from 6.0 to 7.4. Moreover, it was found that the average number of admissions per person living with HIV fell 39% and that the percentages of female and black patients with HIV remained the same.

CONCLUSIONS

Hospitalized patients living with HIV are getting older and sicker, although the average number of admissions per person living with HIV continues to fall.

The impact of managed care on access to highly active antiretroviral therapy and on outcomes among Medicaid beneficiaries with AIDS

Medicaid has promoted managed care plans (MCPs) to control health care costs for HIV-infected enrollees. This article examines the impact of MCP enrollment on use of highly active antiretroviral therapy (HAART), antiretroviral therapy (ARV), hospitalization, and death among Medicaid beneficiaries with AIDS. A retrospective longitudinal cohort study of 7,028 Medicaid beneficiaries with AIDS in California was conducted from 1999 to 2001. The impact of MCP enrollment was estimated using single-equation and bivariate probit models. Baseline HAART use was found to be significantly lower for beneficiaries in MCPs versus fee-for-service (FFS). The effect was attenuated and not significant after correcting for selection bias. MCP enrollment was not associated with overall ARV use, mortality, or hospitalization. MCP enrollment does not substantially affect medication use or clinical outcomes. Before making changes to care delivery, policy makers should address the potential costs and benefits of MCP over FFS Medicaid for chronically ill beneficiaries.

The cost of care for patients with HIV from the provider economic perspective

Health care costs for HIV infection are often reported from the economic perspective of third party payors and little data exist to show how total costs are distributed across specific health service categories. We used a retrospective cohort design to measure total medical costs for 1 year in a randomly selected sample of 280 patients treated for HIV infection at an urban health care facility. Inpatient and outpatient costs were measured from the economic perspective of the health care provider. Hospital costs included ward, ancillary, and procedure costs. Ambulatory included medications, primary and specialty care, case management, ancillary, and behavioral comorbidity treatment costs. The mean total was $20,114 per patient, of which $6,322 was for inpatient and $13,842 was for ambulatory services. Specific ambulatory costs were: medications, $9,257; primary, specialty and ancillary services, $3,470; and behavioral comorbidity treatment, $1,111. The mean annual outpatient ancillary cost was $841. Over 30% of the total service cost was for building and administrative overhead and approximately 25% of both hospital and clinic costs were for ancillary services. Independent predictors of high cost were CD4 counts, Medicaid eligibility, and behavorial comorbidities. Our outpatient costs were higher, with less variation than previously reported. Increasingly, there has been a shift of HIV care from hospital to ambulatory settings. We postulate that reimbursement rates have not captured the recent flourishing of ambulatory care. If reimbursement is not commensurate with outpatient advances, providers may be paradoxically underreimbursed for improving care.

The relationship between HAART use and employment for HIV-positive individuals: an empirical analysis and policy outlook

OBJECTIVE

This study jointly analyzes the determinants of the use of highly active antiretroviral therapy (HAART) along with the determinants of employment status for human immunodeficiency virus (HIV)-positive individuals.

METHODS

Data from the HIV Cost and Services Utilization Study (HCSUS) were analyzed using a bivariate probit model. HSCUS collected data on 2864 individuals in 180 clinics, hospitals and private practices in 28 urban areas and 24 clusters of rural counties in the United States. We used data from the baseline interview to categorize individuals as employed or unemployed and for the determination of HAART use.

RESULTS

The empirical results suggest that individuals taking HAART have an increased likelihood of working and that individuals with private health insurance are more likely to use HAART compared to individuals with public health insurance coverage or no coverage.

CONCLUSIONS

Due to the fact that employment of HIV-positive is directly related to HAART use, policymakers need to look to the private health insurance industry and public program to increase access to HAART. Suggested models for consideration are mandating insurance benefits and ADAP expansion.

Effective HIV treatment and the employment of HIV(+) adults

OBJECTIVE

To examine whether highly active antiretroviral therapy (HAART) helps HIV-infected patients return to work, remain employed, and maintain hours of work.

DATA SOURCE

Longitudinal data from a national probability sample of HIV+ patients older than 18 years old who made at least one visit in the contiguous United States in early 1996.

STUDY DESIGN

We consider the effect of HAART on three employment outcomes: (1) returning to work within six months of treatment, conditional on not working pretreatment; (2) remaining employed within six months of treatment, conditional on working pretreatment; (3) hours of work conditional on working at the second follow-up survey. We use a bivariate probit model to jointly model employment and treatment with HAART for the first two outcomes and the two-stage least squares method for hours of work. State policies regarding prescription drug coverage are used as instrumental variables for HAART to account for a key source of potential bias-the more severely ill tend to have the most difficulty working, but are also the most likely to be on HAART.

PRINCIPAL FINDINGS

Our results indicate that HAART increases the probability of remaining employed by HIV patients and hours of work for those working within six months of treatment. In the case of remaining employed, the employment effect (an increase from 58 percent to 94 percent in the probability of remaining employed) is statistically significant and the related incremental income is sizable compared to the incremental costs of HAART. Sensitivity analyses demonstrate that the results are robust to different specifications for insurance coverage.

CONCLUSIONS

Patients who are working are more likely to remain employed because of treatment with HAART. HAART prescribed to patients in less advanced stages of the infection may lead to the greatest gain in employment.

Effect of medical, drug abuse, and mental health care on receipt of dental care by drug users

We examined the association of patterns of health care in 1996 with subsequent dental care in 1997 or 1998 for 47,260 drug users enrolled in New York State Medicaid. From Medicaid files, we identified psychiatric care, prescribed antidepressants, a regular source of medical care, regular drug treatment (6+ contiguous months), and clinical conditions. Of this cohort, 58% received dental care. The adjusted odds ratios (AOR) of dental care were increased for drug users receiving psychiatric care and antidepressants (1.66 [1.55, 1.77]), psychiatric care alone (1.48 [1.41, 1.56]), or only antidepressants (1.18 [1.10, 1.27]), vs. neither. AORs of dental care were also higher for those with a regular source of medical care alone (1.27 [1.23, 1.35]) or with regular drug treatment (1.33 [CI 1.25, 1.41]) vs. neither. Mental health care and, to a lesser extent, a regular source of medical care and regular drug treatment may promote dental care in this vulnerable population.

HIV and the law: integrating law, policy, and social epidemiology

In the foundational piece in this issue of the journal, “Integrating Law and Social Epidemiology,” Burris, Kawachi, and Sarat present a model for understanding the relationship between law and health. This article uses the case of a specific health condition, the human immunodeficiency virus (HIV) infection, as an opportunity to flesh out this schema and to test how the model “fits” the world of the HIV pandemic. In applying the model to this communicable disease, we hope to illustrate the multitude of ways that laws affect the course of the pandemic as well as the course of an individual’s vulnerability or resilience to the disease, and how the complexities of an individual’s life dealing with the virus interface with the world of laws and legal institutions.