From: Billi Goldberg <bigoldberg@igc.apc.org>
Subject: VA Summary 8/28/92
Note: Copyright 1992, Dan R. Greening. Non-commercial reproduction allowed.
Archive-Number: 6094
Organization: unspecified
Date: Sat, 5 Sep 92 22:48:23 PDT

                   AIDS INFORMATION NEWSLETTER
                   Michael Howe, MSLS, Editor
                     AIDS Information Center
                VA Medical Center, San Francisco
                     (415) 221-4810 ext 3305
                         August 28, 1992 
              FINANCING CARE FOR PATIENTS WITH AIDS
             By Gail R. Wilensky, PhD, Administrator 
     The spread of the acquired immunodeficiency syndrome (AIDS) epidemic is 
posing new challenges for health care providers and payers.  The Health Care 
Financing Administration (HCFA) is working to meet these challenges in a 
number of ways. 
     As the incidence of AIDS increases among poor women and their children, 
Medicaid will bear a growing proportion of the costs of AIDS treatment. 
Medicaid already is the largest payer of medical services for people with 
AIDS. Jointly financed by the federal government and the states, Medicaid 
provides some or all of the health care coverage for more than 40% of patients 
with AIDS.  In 1992, state and federal Medicaid programs will spend a total of 
about $2.1 billion on AIDS-related health care or about 25% of the total cost 
of such care. 
     To date, the human immunodeficiency virus (HIV) has infected about 1 
million Americans.  In the United States, annual mortality from AIDS increased 
from 131 people in 1981 to 31,196 people in 1990, according to the Centers for 
Disease Control, Atlanta, GA.  Projections for total AIDS deaths during 1991 
through 1993 range from 165,000 to 215,000 people. 
     Individuals with HIV need a broad range of treatments and support 
services to combat its relentless clinical course, which begins with a few 
minor symptoms and progresses with opportunistic diseases that lead, 
eventually, to death.  As treatment advances have prolonged many patients' 
lives, HIV disease has become more of a chronic condition than an acute one. 
     Because of the many-faceted nature of the health care financing system, 
public and private payers must work together to finance a continuum of care 
for people with HIV and AIDS.  The task of providing inpatient care for 
patients with AIDS falls disproportionately on public hospitals, whose 
capacity in many  cities already is strained.  The continued participation of 
private insurers and philanthropic organizations, as well as the dedication of 
the medical community, is critical to providing care for HIV- infected 
patients. 
     While Medicaid bears the largest burden of AIDS financing, the Medicare 
program is playing an increasingly important role.  Although primarily an 
insurance for people aged 65 years and older, Medicare also provides benefits 
to certain disabled people 2 years after they qualify for Social Security 
disability insurance benefits.  New medications are allowing more AIDS 
patients to survive the waiting period.  In 1992, Medicare will spend about 
$280 million on AIDS treatment; by 1996, the program's share is projected to 
rise to about $690 million. 
     Despite widespread misconceptions, poverty or high medical expenses alone 
do not qualify a person for Medicaid.  To be eligible, a person not only must 
lack financial resources, but also must meet certain categorical requirements. 
Congress designed the Medicaid program to serve impoverished children, 
parents, and pregnant women, and impoverished aged, blind and disabled people.

Single people who are not pregnant or disabled, and childless couples between 
the ages of 22 and 64, cannot qualify for Medicaid.  Most adults with AIDS 
qualify for Medicaid because they are disabled and have low income and limited 
assets. States have a great deal of flexibility in deciding which Medicaid 
services to  cover, how much to pay, and what utilization controls to impose.  
Therefore, the scope of Medicaid benefits available to patients with AIDS may 
vary widely. HCFA encourages states to use the maximum number of Medicaid 
options available to provide care for patients with AIDS. 
     Two optional Medicaid plan services that may be particularly helpful to 
people with AIDS are case management and hospice care.  States can use case 
management programs to help AIDS patients gain access to medical, social, and 
educational services.  Alabama, Maryland, Pennsylvania, and Washington state 
offer people infected with HIV this benefit.  In addition, 24 states cover 
hospice programs, which help AIDS patients receive comprehensive home care and 
medical services when the illness reaches its final stages.  All state 
Medicaid programs now cover the cost of the drug zidovudine; some states cover 
other drug therapies, as well. 
     To enable states to expand Medicaid services to a specific population, 
such as AIDS patients, HCFA also is authorized to grant special waivers of 
regular programs requirements.  Since 1987, HCFA has approved waivers allowing 
15 states to provide additional in- home or community services to AIDS 
patients who otherwise would have to be institutionalized.  Two other states 
have included people with AIDS under waivers granted to serve more broadly 
defined groups of disabled people. Services provided under the waivers include 
case management, specialized foster care, private duty nursing, and personal 
care. 
     In two demonstration sites, HCFA soon will test the feasibility of 
providing Medicaid coverage to people during early stages of HIV infection. 
Mandated by the federal budget of 1990, the demonstration will attempt to 
determine the cost of Medicaid- covered services provided to individuals in 
the early asymptomatic stages of HIV infection.  The project also will assess 
the impact of these early intervention services on the cost of care provided 
in the later stages of the disease (when Medicaid eligibility usually becomes 
effective).  The 3-year, $30 million demonstration also will evaluate the 
impact of early treatment on longevity and quality of life. 
     The nation's strategy to combat AIDS includes continuing research to 
develop a vaccine to prevent infection, as well as aggressively searching for 
a cure.  We must continue educating people about how to prevent infection, as 
well as aggressively searching for a cure.  We must continue educating people 
about how to prevent acquiring the virus and transmitting it to others.  At  
HCFA, we will do our best to ensure that resources are available to care for 
the people affected. 
     Meeting the challenges of the AIDS epidemic requires enhanced cooperation 
and renewed commitment by everyone involved, including government officials, 
the insurance industry, hospitals, individual physicians, and other health 
care workers.  Using creative opportunities available under existing law, HCFA 
stands ready to help the states develop Medicaid services to meet the needs of

patients infected with HIV.  
Inquiries may be directed to Christine Nye, Director, Medicaid Bureau, HCFA, 
6325 Security Blvd., Suite 200, East High Rise, Baltimore, MD 21207. 
Telephone: (301) 966-3870. (JAMA. 1991 Dec 25;266(24):3404). 
             STUDY REVEALS DIFFERENCES IN AIDS CARE 
     A new study by the Agency for Health Care Policy and Research (AHCPR) 
shows significant differences across the United States in the length of time 
patients with acquired immunodeficiency syndrome (AIDS) spend in hospitals and 
how their care is paid.  The study is important because it gives health 
policymakers their first view of AIDS inpatient care based on individual 
discharges from a large, nationally representative sample of hospitals. 
     Findings show that New York and California together accounted for more 
than half of all AIDS hospital stays in the United States in 1986 and 1987, 
the period covered by the study.  However, the two States differed widely in 
how long patients were hospitalized and the cost of their care.  New York led 
the nation with an average hospital stay of almost 19 days while California 
had the lowest average stay--roughly 10 days.  Total hospital inpatient 
charges for AIDS patients in New York averaged nearly $14,000, compared with 
roughly $10,500 in California.  Interestingly, statistics for AIDS patient in 
other northeastern states were closer to those for California than to their 
New York neighbor.  Hospital stays in these other northeastern states were 
shorter than  in New york and their average mortality rates were more similar 
to California's mortality rate than to New York's.  The cost of AIDS care did 
not follow the same pattern.  The average daily charge for AIDS inpatients in 
other northeastern states was higher than in New York, while charges in the 
West, average daily charges lower than in California. 
     The South also showed striking contrasts.  Hospitals there had some of 
the highest overall mortality rates for AIDS patients for all causes and for 
Pneumocystis carinii pneumonia, the most common AIDS-related infection.  The 
South also had the highest rate of uninsured AIDS patients--roughly 21 
percent--and the lowest rate of Medicaid patients--also about 21 percent. 
Private insurance was the expected primary payor for approximately 42 percent 
of AIDS hospitalizations in the South.  In contrast, private insurance was the 
expected primary payor for more than half of all AIDS hospitalizations in New 
York and California while Medicaid covered one-third of New York's AIDS 
hospitalizations and 26 percent of those in California. 
     The study was conducted by Judy K. Ball, Ph.D., of AHCPR's Center for 
General Health Services Intramural Research, and Barbara J. Turner, M.D. of 
Jefferson Medical College.  The researchers used 1986 and 1987 data from 
nearly 6 million discharge abstracts from 438 hospitals in AHCPR's Hospital 
Cost and Utilization Project data base and linked the data to geographic and 
hospital information from the American Hospital Association's Annual Surveys 
of  Hospitals.  Further details are in "AIDS in U.S. Hospitals, 1986- 87:  A 
National Perspective," Hospital Studies Program Research Note 15, AHCPR 
Publication No. 91-0015.  Copies are available from AHCPR, Information and 
Publications Division, 18-12 Parklawn Bldg., Rockville, MD 20857.  Telephone: 
(4301) 443-4100 (Agency for Health Care Policy and Research. Research 
Activities Newsletter, September 1991;145:1-2). 
         COMPARISONS OF HOSPITAL CARE FOR PATIENTS WITH
              AIDS AND OTHER HIV-RELATED CONDITIONS 
     Significant costs incurred by HIV-positive individuals and institutions 
require that any future policies must increase coverage to include the total 
population of HIV-positive individuals, write Dennis P. Andrulis et al. of the 
National Public Health and Hospital Institute in Washington, D.C.  A total of 
1158 members in five national hospital organizations took part in a survey of 
HIV-related issues.  A total of 325 hospitals reported treating at least one 
other HIV patient.  These 325 hospitals cared for 30 percent (16,213) of all 
AIDS patients believed to have been alive during 1988, and treated more than 
11,000 other HIV patients. Service utilization by other HIV patients was found 
to account for a significant portion of the total HIV burden and related 
costs, representing 35 percent of all HIV-related admissions, 29 percent of 
all inpatient costs, and 35 percent of all inpatient losses. These findings 
suggest the Centers for Disease Control's current definition of AIDS 
understates the total burden of HIV epidemic on hospitals, the researchers 
conclude. (Journal of the American Medical Association. 1992 May 
13;267(18):2482).  
        AIDS COSTS ESTIMATED FOR INNER-CITY DRUG ADDICTS 
      A study of a group of male intravenous drug users (ICDUs) in Brooklyn, 
New York, who were treated for acquired immunodeficiency syndrome (AIDS) 
estimates that their total average annual medical care charge was roughly 
$33,000.  This figure includes $24,171 for hospital inpatient care and $8,831 
for outpatient services. Over 80 percent of the latter charge was for 
pharmaceuticals--mainly zidovudine (ZDV), aerosolized pentamidine, 
ketoconazole, and antituberculosis medications.  Charges for homeless addicts 
and those who changed residences frequently were nearly double the average for 
the group as a whole.  The group consisted of 38 black and Hispanic men, most 
of whom were unemployed.  All were Medicaid recipients.  Each man spent an 
average of nearly 39 days in the hospital during the 1-year study period.  The 
data for the study were collected in 1989.  
      According to the researchers, estimating the use of medical care by 
IVDUs with AIDS patients and the costs of their care is important because they 
now constitute the largest AIDS risk group. Most AIDS studies have focused on 
white, middle-class homosexual or bisexual men.  In contrast, IVDU patients 
with AIDS are disproportionately low-income, inner-city black or Hispanic  
residents.  In New York City, where the current study was conducted, more than 
half of the city's 32,00 diagnosed AIDS patients are IVDUs.  
      The study, which was funded under grant HSO6130 from AHCPR's Center for 
General Health Services Extramural Research, was led by Charles L. Bennett, 
M.D., Ph.D., who is currently with Duke University.  Details are in "Medical 
Care Costs of Intravenous Drug Users with AIDS in Brooklyn," by Dr. Bennett, 
Anthony Pascal, Ph.D., Marilyn Cvitanic, Ph.D., and others.  The article was  
published in the Journal of Acquired Immune Deficiency Syndrome 5(1), 1992, 
pp.1-6. (Agency for Health Care Policy and Research. Research Activities 
Newsletter, April 1992;152:3). 
    HOSPITAL COSTS OF AIDS CHILDREN MUCH HIGHER THAN AVERAGE 
      A new Agency for Health Care Policy and Research study estimates that 
children hospitalized for acquired immunodeficiency syndrome (AIDS) are twice 
as likely to be covered by Medicaid as other hospitalized children (all 
causes), and their hospital stays are longer and more expensive.  The average 
hospital charge for treating a child with AIDS is $18,271-- more than 3 times 
the average $5,562 for other children in the same sample of hospitals (those 
treating pediatric AIDS cases).  The average hospital stay for a child with 
AIDS lasts 18.5 days, compared with 5.5 days for other children's stays in the 
same group of hospitals   
      The study by AHCPR's Judy K. Ball, Ph.D., and former AHCPR researcher 
Susan Thaul, Ph.D., also compares pediatric AIDS discharges with adults AIDS 
discharges.  The estimates are based on data on 196 pediatric AIDS discharges 
from a national sample of U.S. hospitals in 1986 and 1987.  Details are in 
Pediatric AIDS-Related Discharges in a Sample of U.S. Hospitals: Demographics, 
Diagnoses, and Resource Use, Provider Studies Research Note 16 (AHCPR 
Publication No. 91-0032).  The study is available from the AHCPR Publications 
Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907, (800) 358-9295. (Agency 
for Health Care Policy and Research. Research Activities Newsletter, April 
1992; 152:4). 
GRANT AWARDED TO STUDY OUTCOMES AND COSTS OF INPATIENT AIDS CARE 
     The Agency for Health Care Policy and Research has funded a new, 3-year 
$550,000 study to determine if grouping AIDS patients in special hospital 
wards, or dedicated units, improves their outcomes and cuts costs.  As of 
1988, about 40 hospitals in the United States had special units for AIDS 
patients; most hospitals do not separate such patients from other hospitalized 
persons. The study, lead by Linda Aiken, Ph.D., R.N., of the University of 
Pennsylvania, involves 20 hospitals across the country, half of which have 
dedicated units for AIDS patients. 
     The researchers will examine how the organization of care, 
characteristics of attending nurses and their patients, and other factors 
influence clinical outcomes and hospital costs.  In addition, the 
investigators will determine whether AIDS patients hospitalized in dedicated 
units differ from those admitted to general medical units in severity of 
illness and other factors  (Agency for Health Care Policy and Research. 
Research Activities Newsletter, February 1991;150:8). 
                 BOOST FOR INPATIENT AIDS UNITS 
     Despite the proliferation of hospital inpatient AIDS units, some 
administrators remain skeptical of the concept, believing that people with 
AIDS are treated best when admitted throughout the hospital.  A new report 
indicates otherwise. 
     "The data do not support many of the arguments made against AIDS units, 
such as higher costs, patient stigmatization or excessive staff burnout,: 
concludes a report in the American Journal of Public Health (The Inpatient 
AIDS Unit: A Preliminary Empirical Investigation of Access, Economic, and 
Outcome Issues. 1992 Apr;82(4):576-8).  "The AIDS unit [was] not inefficient 
(and)  nursing staff turnover was not excessively high." 
     The report, which evaluates differences in access, costs and outcomes 
between the dedicated AIDS unit model and the "scatter- bed" approach, was led 
by Marianne Fahs, director of health economics at New York's Mount Sinai 
Medical Center (Modern Healthcare. 1992 April 27, p. 52). 
       TREATING HIV PATIENTS MAY COST $10 BILLION BY 1994 
     The Agency for Health Care Policy and Research estimates that the cost of 
treating Americans with HIV could reach $10.4 billion by 1994.  The estimate 
covers patients with AIDS (who account for about two-thirds of the total cost) 
as well as those infected with HIV.  Moreover, the agency figures that the 
average annual treatment for those who test positive for HIV costs $5,150 vs.  
$32,000 each year for those with AIDS.  The AHCPR is part of the Department of 
Health and Human Services' Public Health Service. (Journal of the American 
Dental Association. 1992 May;123(5):18). 
        HIV STRAINING RESOURCES OF HOSPITALS, STUDY SHOWS 
     Hospitals are devoting significant resources to providing care for HIV-
infected patients who have not been diagnosed as having AIDS, according to a 
study of 325 hospitals that, in 1988, cared for patients with HIV infection. 
One-third of the money these hospitals lost treating illnesses linked to the 
virus was spent on services for patients who had not been diagnosed with AIDS. 
On average, each institution lost $109,360 treating the HIV-related illnesses 
of those patients and $204,122 treating patients with AIDS.  For every two 
patients treated for AIDS at the hospitals, another patient was treated for 
other HIV-related illnesses, according to study author Dennis P. Andrulus, 
president of the National Public Health and Hospital Institute, Washington, 
DC. He called on the Centers for Disease Control to expand the clinical 
definition of AIDS so that HIV patients would qualify sooner for Medicaid 
assistance.  But Lawrence M. Barat, MD, a Boston-based AIDS policy adviser, 
said that CDC's contemplated revised definition of AIDS could dilute the funds 
for cities already targeted for federal assistance under the Ryan White AIDS 
funding act. (American Hospital Association News. 1992 May 18;28(20). 
 See: Andrulis DP. Weslowski VB et al. Comparisons of Hospital Care for 
Patients with AIDS and Other HIV-Related Conditions. Journal of the American 
Medical Association. 1992 May 13;267(18): 2482-6. 

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