The Emerging Crisis in HIV Care Provision

1
The Emerging Crisis in HIV Care Provision

• Michael S. Saag, MD
• Director, UAB Center for AIDS Research
• 30th PACHA Meeting
• June 20, 2006

2
8 Year Survival in HAART Era
Updated from Chen, et al, 8th CROI, 2001
3
CD4 Count at HAART Initiation
4
Key Points

• Mortality is much higher when patients are
  diagnosed late in the course of infection (CD4 lt
  200 /ul)
• The majority (gt 75) of newly diagnosed patients
  are diagnosed late (except preg Women)
• Many (? Most) HIV infected patients in the US
  dont know they are infected
• Universal, opt-out testing is needed

5
Study objectives

• Determine the annual health care expenditures in
  for HIV stratified by CD4 count
• Describe the distribution of cost components of
  health care expenditures (i.e. medications,
  labs, etc)
• To analyze the effect of changes in clinical
  status (CD4) on expenditures

Chen, et al, Clinical Infectious Diseases
200642-1003-1010
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Methods

• The University of Alabama at Birmingham (UAB)
  Studies of HIV/AIDS Longitudinal Outcomes Metrics
  database
• Established for patients receiving care at the
  UAB HIV clinic (1917 clinic) in January 1994
• Information pertaining to health care utilization
  added to database in March 1999
• Includes hospitalizations, laboratories,
  procedures, medications, clinical and other
  outpatient expenditures

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Methods

• Inclusion criteria for expenditures study
  participation
• Patient received primary care at UAB 1917 clinic
• Baseline CD4 count available within /- 90
• days of March 1, 2000
• gt 1 follow-up clinic visit or hospitalization
• between June 1, 2000 March 1, 2001

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Expenditures

• Cost outlay required to pay for any service or
  medication used by a patient
• Assumptions
• All patients had Medicare insurance
• Complete billing for all health care use
• Collection rate 100
• Broken down by cost component

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(No Transcript)
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Overall expenditures
Patients with CD4 counts lt 50 expend 2.6 times
more health care dollars than those with CD4
counts gt 350 (Plt0.001)
11
Overall expenditures
The increased expenditures for patients with more
advanced disease are largely due to non-ARV
medication and hospitalization costs
12
Overall expenditures
Expenditures for physician/clinic costs account
for lt 2 of overall expenditures
13
Change in clinical status
45,000
40,000

35,000
P0.003
30,000

25,000
Mean Annual Cost

20,000
15,000
10,000
5,000
0
CD4 lt50
CD4 50-199
CD4 200-349
CD4 gt350
CD4 Category (cells/ul)
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Change in clinical status
16,000
P0.03
14,000

12,000
10,000
P0.05

Mean Annual Cost
8,000
6,000

4,000

2,000
0
ART Meds
Non-ART Meds
Hospital
Other
Physician/Clinic
Cost Component
15
Study conclusions

• Antiretroviral therapy is cost effective
• Medications are the most expensive cost component
  of expenditures for HIV-infected patients
• Physician/clinic costs account for lt 2 of
  expenditures

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Provision of medications

• Every American who needs HIV treatment and care
  should have access to it
• People who are HIV-positive need essential
  medications
• Without the drugs, providing care is difficult
  to impossible

PACHA. Achieving and HIV-Free Generation
IDSAnews 200616(1)7
17
Policy implications

• Provision of antiretroviral and other essential
  medications
• Funding for ADAPs

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Reality Check

• Operating budget of our clinic 2.1M / yr
• Third party payment 500,000/yr
• RW Title III 508,000/yr
• Flat Funded for 7 years
• 2.5 cut in 2006
• Despite 60 increase in patient volume over last
  5 years
• Annual Deficit 1.1M per year

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Key Points

• Mortality is much higher when patients are
  diagnosed late in the course of infection (CD4 lt
  200 /ul)
• The majority (gt 75) of newly diagnosed patients
  are diagnosed late (except preg Women)
• Many (? Most) HIV infected patients in the US
  dont know they are infected
• Universal, opt-out testing is needed
• With more universal testing, a 25 -50 increase
  in patient volume will occur

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Who will take care of these patients?
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Montgomery Alabama

• Dr. LW, Medical Director, resigned from MAO
  6/7/06. I will be the Acting Medical Director
  while we recruit and hire a new Medical Director.
  We are currently actively looking to fill two
  positions A full time Medical director, and a
  part-time physician to see patients mainly in our
  rural satellite clinics.
• As you know, Montgomery AIDS Outreach (MAO) is a
  Ryan White Funded Agency. We currently have
  myself and two Nurse Practitioners as provider
  staff. We have full time clinics in Montgomery,
  and Dothan, and hold once or twice a month
  clinics in six other satellite clinic sites. We
  follow 1000 patients over a 23 county area of
  south central Alabama. Please contact me for any
  other information.

Dr. Laurie Dill 9 June 2006
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Policy implications

• Provision of antiretroviral and other essential
  medications
• Funding for ADAPs
• Need dramatic increase in funding to increase
  clinic capacity
• Increase Title III funding
• Provide incentives for younger MDs to go into
  HIV Medicine

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Training qualified HIV providers

• Creative solutions must be found to encourage
  more doctors, PAs, and advanced practice nurses
  to choose to develop the skills necessary to
  treat HIV
• Tuition reimbursements
• Ensure adequate reimbursements for HIV care
• As we expand our capacity to treat HIV-positive
  Americans, we must not forget quality
• HIVMA called for authorizing CARE Act funding to
  train clinicians in HIV care

PACHA. Achieving and HIV-Free Generation
IDSAnews 200616(1)7
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Ryan White HIV/AIDS Treatment Modernization Act
of 2006 (S.2823)

• 75 of CARE Act funds to be spent on core medical
  services
• Requires that ADAP programs cover a minimum
  formulary based on the DHHS Public Health Service
  Guidelines

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Ryan White HIV/AIDS Treatment Modernization Act
of 2006 (S.2823)

• No provisions to promote availability of
  qualified HIV care providers
• No significant increase in Title III allocation
• No training incentives

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Provision of medications

• Every American who needs HIV treatment and care
  should have access to it
• People who are HIV-positive need essential
  medications
• Without the drugs, providing care is difficult
  to impossible

PACHA. Achieving and HIV-Free Generation
IDSAnews 200616(1)7
27
Provision of HIV CARE

• Every American who needs HIV treatment and care
  should have access to it
• People who are HIV-positive need essential
  medications
• Without the drugs, providing care is difficult
  to impossible
• Without qualified HIV care providers and
  clinics, HIV drugs mean nothing

PACHA. Achieving and HIV-Free Generation
IDSAnews 200616(1)7