# Presentation: 686615

## The Emerging Crisis in HIV Care Provision 

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

## 8 Year Survival in HAART Era

- Updated from Chen, et al, 8th CROI, 2001

**8 Year Survival in HAART Era**

## CD4 Count at HAART Initiation

|  | Median CD4 | 0-50 | 51-200 | 201-350 | >350 |
| --- | --- | --- | --- | --- | --- |
| 1996 | 115 | 32.6% | 30.2% | 24.4% | 12.8% |
| 1997 | 180 | 21.4% | 31.8% | 16.9% | 29.9% |
| 1998 | 221 | 16.1% | 31.3% | 26.3% | 26.3% |
| 1999 | 212 | 23.9% | 25.4% | 21.1% | 29.6% |
| 2000 | 144 | 34.7% | 23.5% | 20.4% | 21.4% |
| 2001 | 202 | 25.0% | 23.9% | 23.9% | 27.3% |
| 2002 | 166 | 30.3% | 23.3% | 24.4% | 22.1% |
| 2003 | 98 | 36.5% | 23.5% | 24.7% | 15.3% |
| 2004 | 170 | 31.3% | 23.4% | 28.1% | 17.2% |

## Key Points:

- Mortality is much higher when patients are diagnosed late in the course of infection (CD4 < 200 /ul)
- The majority (> 75%) of newly diagnosed patients are diagnosed late (except preg Women)
- Many (? Most) HIV infected patients in the US don’t know they are infected
- Universal, opt-out testing is needed

## 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

- 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

- Study objectives

- Chen, et al, Clinical Infectious Diseases 2006;42-1003-1010

## 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

## 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
-  _>_ 1 follow-up clinic visit or hospitalization
-     between June 1, 2000 – March 1, 2001

## 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

## Slide 9

| Characteristic                 (n = 635) | Number (%) or Median (range) |
| --- | --- |
| Demographic characteristics
  Age
  Male sex
  White race | 
35 (18-66)
491 (77%)
376 (59%) |
| Behavioral characteristics
  Men who have sex with men
  Injection drug use | 
394 (62%)
65 (10%) |
| Insurance status
  Public
  Private
  None | 
197 (31%)
344 (54%)
94 (15%) |

## Overall expenditures 

| CD4 strata (cells/L)  | Total | ARV | Non-ARV | Hospital | Other Outpt. | Physician/clinic |
| --- | --- | --- | --- | --- | --- | --- |
| < 50 | $36,532 | $10,885 | $14,882 | $8,353 | $1,909 | $533 |
| 50-199 | $23,864 | $11,862 | $6,685 | $3,369 | $1,416 | $532 |
| 200-349 | $18,274 | $11,935 | $3,452 | $1,186 | $1,365 | $336 |
| > 350 | $13,885 | $9,407 | $1,855 | $1,408 | $930 | $285 |
| All | $18,640 | $10,500 | $4,240 | $2,342 | $1,199 | $359 |

- Patients with CD4 counts < 50 expend 2.6 times more health care dollars than those with CD4 counts _>_ 350 (P<0.001)

- Overall expenditures

## Overall expenditures 

| CD4 strata (cells/L)  | Total | ARV | Non-ARV | Hospital | Other Outpt. | Physician/clinic |
| --- | --- | --- | --- | --- | --- | --- |
| < 50 | $36,532 | $10,885 | $14,882 | $8,353 | $1,909 | $533 |
| 50-199 | $23,864 | $11,862 | $6,685 | $3,369 | $1,416 | $532 |
| 200-349 | $18,274 | $11,935 | $3,452 | $1,186 | $1,365 | $336 |
| > 350 | $13,885 | $9,407 | $1,855 | $1,408 | $930 | $285 |
| All | $18,640 | $10,500 | $4,240 | $2,342 | $1,199 | $359 |

- Overall expenditures

- The increased expenditures for patients with more advanced disease are largely due to non-ARV medication and hospitalization costs

## Overall expenditures 

| CD4 strata (cells/L)  | Total | ARV | Non-ARV | Hospital | Other Outpt. | Physician/clinic |
| --- | --- | --- | --- | --- | --- | --- |
| < 50 | $36,532 | $10,885 | $14,882 | $8,353 | $1,909 | $533 |
| 50-199 | $23,864 | $11,862 | $6,685 | $3,369 | $1,416 | $532 |
| 200-349 | $18,274 | $11,935 | $3,452 | $1,186 | $1,365 | $336 |
| > 350 | $13,885 | $9,407 | $1,855 | $1,408 | $930 | $285 |
| All | $18,640 | $10,500 | $4,240 | $2,342 | $1,199 | $359 |

- Overall expenditures

- Expenditures for physician/clinic costs account for _<_ 2% of overall expenditures

## Change in clinical status

- $0

- $5,000

- $10,000

- $15,000

- $20,000

- $25,000

- $30,000

- $35,000

- $40,000

- $45,000

- CD4 <50

- CD4 50-199

- CD4 200-349

- CD4 >=350

**CD4 Category (cells/ul)**

**Mean Annual Cost**

- *

- *

- *

- * *P*=0.003

## Change in clinical status

- $0

- $2,000

- $4,000

- $6,000

- $8,000

- $10,000

- $12,000

- $14,000

- $16,000

- ART Meds

- Non-ART Meds

- Hospital

- Other

- Physician/Clinic

**Cost Component**

**Mean Annual Cost**

- *

- *

- *

- *

*P*=0.03

*P*=0.05

## 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  _<_ 2% of expenditures

## 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 2006;16(1):7

## Policy implications

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

## 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

## Key Points:

- Mortality is much higher when patients are diagnosed late in the course of infection (CD4 < 200 /ul)
- The majority (> 75%) of newly diagnosed patients are diagnosed late (except preg Women)
- Many (? Most) HIV infected patients in the US don’t know they are infected
- Universal, opt-out testing is needed
- With more universal testing, a 25 -50% increase in patient volume will occur

## Who will take care of these patients?

## 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

## 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

## 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 2006;16(1):7

## 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

## 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

## 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 2006;16(1):7

## 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 2006;16(1):7