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Introduction of protease inhibitors and other potent HIV drugs led to a dramatic decrease in AIDS mortality, hospitalization, and complication rates. The US Healthcare Finance Administration (HCFA) spent $4.9 billion in fiscal year (FY) 1998 on AIDS-specific patients in the Medicaid and Medicare programs. A Johns Hopkins Hospital study found the 26% decrease in Medicaid inpatient support was accompanied by a 14% increase in outpatient costs for treating AIDS patients (<50 CD4+) during FY 1997. There is concern about sources of outpatient funding as AIDS moves into the chronic disease category.

Johns Hopkins Cost Analysis

J.G. Bartlett, MD, J. Keruly, MD and R. Moore, MD, Johns Hopkins Hospital, Baltimore, Md, analyzed Medicaid payment data on patients in the hospital's HIV Care Program. By 1996, hospitalizations for AIDS decreased 76%, mortality fell 45%, and HIV complications dropped at least 65% compared with 1993; however, 19% of HIV patient hospital admissions in FY 1998 were for unrelated complications.

The 1995 introduction of antiprotease drugs prompted detailed analysis of 1995, 1996, and 1997 data. Bartlett grouped the data by CD4+ T cell counts (<50, 50-200, and 200-500/cubic mm) and by average monthly Medicaid payment/patient categorized as total, inpatient, outpatient, and pharmacy. Key findings were:

  • the average total monthly payment for a <50 CD4+ patient in 1995 was $2629 and $2585 in 1997 vs $1172 and $1615, respectively, for a 50-200 CD4+ patient.
  • average outpatient payments increased 26% while inpatient costs decreased 14% for a <50 CD4+ patient during the same period.
  • use of protease inhibitors by the three CD4+ groups led to an average decrease in total monthly Medicaid payments ranging from $256 to $392 per patient.

HIV-related complications in patients having <200 CD4+ fell during the last 4 years. The decrease occurred in all patients including injection drug users (IDUs), gay men, and heterosexuals according to death, PCP, Mycobacterium avium(MAC) bacteremia, and cytomegalovirus (CMV). During FY 1998, unrelated complications accounted for about 19% of HIV hospital admissions at Johns Hopkins notably 13% liver failures due to hepatitis C, 11% renal failures, and IDU soft tissue infections.

The RAND cost study

S. A. Bozzette, MD, PhD, University of California, San Diego, summarized the RAND cost study conducted on over 231,000 adult HIV patients treated in January-February 1996. The published report appears in the December 24, 1998, issue of the New England Journal of Medicine and on the Internet at: www.nejm.org. In addition, this issue of NEJM carries a related editorial authored by R Steinbrook, MD.

Federal Funding for AIDS Patients

T.R. Graydon, MS, US Health Care Financing Administration (HCFA), Baltimore, Md, reported that in FY 1998 combined Federal and State Medicaid spending for persons with AIDS was $3.5 billion. Medicare spent an additional $1.4 billion. Both programs supported 105,000 persons with AIDS. Graydon estimates that total Medicaid and Medicare funding will reach $7 billion within 4 years.

HCFA has two additional programs to help AIDS patients. This agency provides health insurance for low income uninsured children. Another effort assures adult patients portability in carrying health insurance from one job to another without facing a period of ineligibility because of a preexisting condition such as AIDS.

All FDA-approved drugs, including protease inhibitors and other potent antiretrovirals, qualify under Medicaid for reimbursement. In FY 1997, Medicaid spent $374 million or $4,000/patient for this class of drugs. There was an appreciable decrease in expenditures needed for treating opportunistic infections, such as Pneumocystis carinii pneumonia (PCP), during the same period.

HCFA keeps all state Medicaid directors up-to-date on advances in HIV treatment. Recently, the agency distributed the April 1998 report of the NIH panel on the principles of therapy and guidelines for the use of antiretrovirals (MMWR 47: No. RR-5). This report and update (No. RR-12) can be obtained from the Centers for Disease Control and Prevention (CDC)National AIDS Clearing House at: www.cdc.gov/epo/mmwr_rr.html

For professional correspondence, please contact Mr. Graydon by Fax at: (410) 786-9004 or by E-mail at: rgraydon@hcfa.gov.

Remarks from the Chair

E. M. Daniels, MD, PhD, OXO Chemie, San Francisco, Calif, chair for the panel presentations on HIV/AIDS costs of treatment and patient adherence expressed several concerns. In the presence of significant advances in behavioral interventions to prevent HIV, prophylaxis and treatment of related opportunistic infections, and new therapies:

  • many HIV-infected individuals remain untested,
  • diagnosed persons often lack access to care, and
  • patients must desire and adhere to treatment with highly active antiretroviral therapy (HAART)

HAART can be expected to further decrease the mortality and morbidity of HIV/AIDS but depends on continued efforts to develop more effective and less complicated regimens. Development of drugs that positively effect the immune system are also essential.

Drugs such as HAART and other interventions are moving HIV/AIDS into the chronic disease category. This is shifting care from in-hospital to the outpatient clinic. Daniels expressed concern that funding may not follow the shift. Lower inpatient revenues often result in less support for clinics and needs to be brought to the attention of fiscal planners.

For professional correspondence, please contact Dr. Daniels by Fax at: (650) 246-2222 or by E-mail at: edaniels@oxochemie.com.

Eugene A. Conrad

Presented at the American Public Health Association (APHA) Meeting held on November 17, 1998

Copyright © 1998, 1999 Conrad Group Inc. All Rights Reserved
Eugene A. Conrad, PhD, MPH / ISSN 1078-2230 /December 1998
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