Building Success

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When it comes to Effective HIV reform, don’t throw the baby out with the bathwater
by Mariel Selbovitz, MPH, and Leslie G Selbovitz, MD

LifeGuide [Treatment Horizons]

Extensive progress in improving and coordinating care for HIV/AIDS patients has been made due to the combined efforts of patients, activists, and researchers. Despite the well intended efforts of federal healthcare reform, we are in an era of fiscal restraint with the message to the American public being that we will need to make sacrifices. There is only so much money to go around, and there is even less when we consider how much of it is borrowed from overseas. So, measures to reduce government spending are on the immediate horizon.

Our success in caring for patients with HIV/AIDS—the baby, in this case—is now at risk because the effort to provide care for all may mean there will be less money for existing programs. Healthcare reform will make the bathtub overflow with unmet financial needs for the increasing numbers of patients requiring healthcare. As the tub is necessarily emptied, those programs that have more funding will be asked to contribute to those that have less. So, the question before us is: Will the progress in HIV/AIDS care fall victim to the impending dilution of available dollars?

To understand the progress made in HIV care, we should look at a recently published paper by the HIV Medicine Association (HVMA) and the Ryan White Medical Providers Coalition (RWMPC). The authors have captured the elements of a comprehensive approach to HIV treatment and care.

Released at the 49th Annual Meeting of the Infectious Diseases Society of America (IDSA 2011) on October 21, 2011, and published in the December 1, 2011 issue of Clinical Infectious Diseases, “Essential Components of Effective HIV Care: A Policy Paper of the HIV Medicine Association of the Infectious Diseases Society of America and the Ryan White Medical Providers Coalition” by Joel Gallant et al. is a well written description of the evolution of HIV care and the enormous successes due to a comprehensive and coordinated approach that has been developed to control this disease. These essential components include an appropriate care team that provides comprehensive primary and specialty care along with case management, psychosocial services and alcohol and drug treatment, HIV medical provider expertise, access to an HIV expert, quality improvement, electronic health records, and sustainability through adequate reimbursement, including public health funding. Taken together, the integrated components of medical care for HIV patients defines what is called a “medical home,” which is a model that is felt to be essential to the success of healthcare reform initiatives. At the end of the paper, Gallant et al. make reference to the storm clouds that may be gathering to jeopardize this success as the Patient Protection and Affordable Care Act (ACA) is implemented over the next several years. The large expansion of the number of people receiving health insurance coverage under healthcare reform to achieve universal coverage could have the unintended impact of diluting funding for HIV care.

While Gallant et al. have defined the state of the art in HIV care and the threats that are looming, they also note that the ACA and National HIV/AIDS Strategy (NHAS) together provide an unprecedented opportunity to improve further access to, and management of, HIV care. In addition, healthcare that is driven by measurable outcomes, such as the levels of viral control achieved by providers, has the promise to justify more sustainable and innovative funding streams for achieving these goals. So, hope exists that the comprehensive and coordinated care approach currently provided to many HIV patients can remain viable and even promote improved access to HIV experts and care programs if there are enough of these providers and if funding is not depleted in a Peter-Pays-Paul scheme.

Despite the success of putting together components of effective HIV care, not all is perfect. Funding has been a concern for these programs, even prior to the healthcare reform law. There have been efforts previously initiated by states to improve upon the weaknesses of inadequate fee-for-service payment mechanisms by Medicaid programs using a managed care approach called capitation. Capitation is a window to the future of one frequently discussed method of healthcare reimbursement. Though intended to provide some support for infrastructure costs, capitation is designed to restrict expenditures and is thus a double-edged sword.

Capitation means that a certain dollar amount is allocated for each covered individual per unit of time. So, in rather straightforward terms, each head has its price. Therefore, the entire population receives care under a collective, fixed budget. Under healthcare reform, there are additional models of budgeted reimbursement emerging for providers of HIV/AIDS care that are similar to payments for care of other populations with chronic illness.

For example, the Gallant et al. paper points out that the Maryland Medicaid program pays special capitation rates for HIV patients with geographic and hepatitis C adjustments. These capitated payments are enhanced by fee-for-service reimbursement for antiretroviral drugs, and viral load and drug resistance testing. In New York, the Department of Health’s AIDS Institute established HIV special needs plans (SNPs) for HIV patients on Medicaid in New York City. Unlike the Maryland Medicaid program, SNPs pay all inclusive capitation rates, which now cover services previously paid for on a fee-for-service basis.

The risk that the strictly capitated and other models of fixed reimbursement bring is that the total amount to be spent on care is budgeted in advance, possibly with some adjustments for quality and safety of care. Therefore, unexpected expenses, including major breakthroughs in HIV treatment, may be difficult, if not impossible, to fund. Even public health funding through the Ryan White CARE Act may be inadequate to make up the difference. Innovation based upon translational research from the laboratory to the individual may suffer. For example, the discovery that the presence of HLA-B 5701 is associated with hypersensitivity reactions to abacavir may not be tested in practice if corners need to be cut.

Healthcare reform initiatives emphasize the importance of the medical home model of care. As noted above, the synthesis of the various funding programs and fundamental approach to HIV/AIDS care has already in effect created the medical home model in many areas of the country. Nevertheless, the December 2, 2011 Morbidity and Mortality Report from the CDC sounds a surprising alarm. Approximately eighty percent of HIV infections in the U.S. have been diagnosed. In 2010, of the estimated 942,000 persons aware of their infection, seventy-seven percent have been linked to care. Among those HIV-infected adults receiving care, eighty-nine percent were prescribed ART with seventy-seven percent of them having viral suppression. However, only half remain in care (fifty-one percent) and even fewer (forty-five percent) received prevention counseling. Thus, there is the need for even greater coordination at all points in the continuum by public health officials and HIV care providers than has been the case to date.

If there is adequate funding for the infrastructure mentioned above to manage HIV across the continuum by some as of yet unforeseen source of money, with the number of identified infected patients expected to grow with wider testing, then healthcare reform has the potential to do more good than harm. However, if the overpowering goal of reform becomes reduction in the growth of healthcare costs, then the HIV patient population is at risk for poorer outcomes.

There are two fundamental truths our society needs to grapple with:

1. Healthcare is too expensive in total for the U.S. to sustain the current way of doing business, and
2. Primary care providers, infectious diseases experts and hospitals are underpaid for what they are expected to do.

How we reconcile this conundrum for the entire nation while preserving the gains for the HIV patient community will be a critical challenge. However, the integrated model of care now afforded many HIV patients provides a roadmap for other chronic disease patient populations, which if applied tenaciously, will reinforce and strengthen the current approaches to caring for the HIV patient population.

Ms. Selbovitz is the AIDS Treatment Education and Policy Advocacy Program Director at Health People in the Bronx, New York, and chair of the Cornell ACTG CAB. She is a member of the AIDS Treatment Activists Coalition (ATAC) and the Campaign to End AIDS (C2EA). Ms. Selbovitz holds a Master’s in Public Health from Johns Hopkins University.

Dr. Selbovitz is the Chief Medical Officer and Senior Vice President for Medical Affairs at Newton-Wellesley Hospital in Newton, Massachusetts, a teaching hospital of Partners HealthCare System in Boston. He is also Clinical Professor of Medicine at Tufts University School of Medicine.

December 2011