Public Financing and Delivery of HIV/AIDS Care Securing the Legacy of Ryan White (2005) / Chapter Skim
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Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs
Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs
Pages 213-245
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From page 213... ...
to create an eligibility category based on HIV infection. To guide its deliberations, the Committee developed estimates of the likely impact (financial and on the health of the HIV-infected population)
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Both options are described in detail in Chapter 5. For brevity, "the Committee" is replaced by "we." METHODS The approach to the analysis was to pose and then answer three broad questions for each option: · What are the likely health benefits of implementing an alternative approach to public financing of HIV care in terms of mortality and life expectancy?
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We then estimated the number of people who would receive HAART assuming implementation of a proposed change in public financing of HIV care. This estimate was based on program eligibility and enrollment, as well as the association of insurance status and ancillary services covered with HAART use.
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The services included HAART, viral resistance testing, HIV monitoring labs, outpatient visits (adjusted for specifically listed outpatient services) , other medications, inpatient care, emergency care, substance abuse treatment, mental health care, case management, dental care, obstetrics/gynecology, home health/visiting nurse care, and prevention counseling.
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. The benefits package is richer than current average Medicaid benefits because unrestricted coverage of three key ancillary services (case management, mental health, and substance abuse treatment)
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to estimate participation in HIV care (Kahn, 2002)
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0.40 Kahn, 2002; Kahn et al., 2002; Moorman et al., 1998; Palella et al., 1998 By income odds ratio (OR) getting ARV if < $25,000 0.60 Andersen et al., 2002 By insurance status OR getting ARV if uninsured 0.74 Andersen et al., 2002 OR getting ARV if Medicaid alone 0.83 OR getting ARV if Medicare -- other 0.82 OR getting ARV if HMO insurance 0.90 continued
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From page 220... ...
$9,222 Schackman et al., 2002; Expert Judgment Other medicines 1.00 $3,980 Aldridge et al., 2002; Bozzette et al., 2001 Prevention counseling 1.00 $272 Holtgrave et al., 2002 Monitoring labs 1.00 $682 Schackman et al., 2002 Outpatient medical 1.00 $1,629 Bozzette et al., 1998; Bozzette et al., 2001; Shapiro et al., 1999 Sexually transmitted disease, 1.00 $14 IOM, 1997; Gable et tuberculosis, and al., 1996; HepNet hepatitis screening Hepatitis C InfoCenter, 2003 Inpatient medical 1.00 $4,246 Bozzette et al., 1998; ` Bozzette et al., 2001 Emergency department 0.33 $846 Bozzette et al., 1998 Dental 1.00 $513 Bozzette et al., 1998; Capilouto et al., 1991 Obstetrics/gynecology 0.20 $446 Bozzette et al., 1998 Home health/visiting nurses 0.20 $5,000 London et al., 2001; MetLife, 2002 Gain in Use Due to Baseline Improved OR for Cost Use Coverage ARV Use ppy Substance 0.075 0.075 1.700 $6,193 Ashman et al., 2002; abuse Burnam et al., 2001; treatment Conover and Whetten-Goldstein, 2002; Finkelstein and Tiger, 2002; Lo et al., 2002; Marx, 2002; Messeri et al., 2002; Sherer et al., 2002; Strathdee et al., 1998; Zaric et al., 2000 Mental 0.220 0.09 1.400 $1,380 Ashman et al., 2002; health Burnam et al., 2001; Lo et al., 2002; Messeri et al., 2002; Sambamoorthi et al., 2000; Sherer et al., 2002; Turner et al., 2001
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APPENDIX A 221 TABLE A-1 Continued Gain in Use Due to Baseline Improved OR for Cost Use Coverage ARV Use ppy Case 0.600 0.15 1.500 $826 Katz et al., 2001; Lo management et al., 2002; Magnus et al., 2001; Marx, 2002; Messeri, 2002; Sherer, 2002 Federal Matching Rates for Medicaid Sources Florida 58.83 DHHS, 2003 Georgia 59.60 Illinois 50.00 New York 50.00 Texas 59.99 Baseline Effects of Financing Estimate Sources Proportion eligible Publicly insured/in care 0.92 Expert Judgment Publicly insured/not in care 0.975 Expert Judgment Uninsured/in care 0.53 Expert Judgment Uninsured/not in care 0.50 Expert Judgment Enrollment rates Publicly insured/in care 0.90 Expert Judgment Publicly insured/not in care 0.40 Expert Judgment Uninsured/in care 0.90 Expert Judgment Uninsured/not in care 0.30 Expert Judgment If enrolled, in care Publicly insured/in care 1 Expert Judgment Publicly insured/not in care 0.75 Expert Judgment Uninsured/in care 1 Expert Judgment Uninsured/not in care 0.75 Expert Judgment Enrollment rate adjustment, Enhanced Medicaid program 0.667 Expert Judgment Baseline Health Effects Estimate Sources Utility deficit due to advanced disease 0.120.24 Tengs and Wallace, 2000 Utility change (drop) for being on HAART .03 Expert Judgment continued
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. We defined HAART need based on HIV disease stage.
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We estimated an increase from 15 to 30 percent in use of substance abuse services among injection drug users (IDUs) , who constitute half of individuals with HIV/AIDS, based on published data (Sherer et al., 2002)
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. These estimates were formed based on a number of sources, including HCSUS data, data collected from HRSA's Client Demonstration Project sites (specifically, data on people living with HIV/AIDS collected from service providers in a delimited geographic area)
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. We used expert judgment to assign a utility gain of 0.1 for receiving substance abuse treatment and an increase in service utilization of 0.075 (Zaric et al., 2000)
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will receive HAART as a result of gaining access to insurance coverage or higher provider reimbursement (leading to a greater willingness to accept publicly insured patients)
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In care 235,000 Not in care 100,000 Uninsured (22%) In care 117,500 Not in care 50,000 670,000 Those aware who need HAART by insurance and care status Private In care 88,821 Not in care 26,285 Public In care 191,187 Not in care 56,579 Uninsured In care 77,317 Not in care 22,881 463,070 Those aware and in care who receive HAART by insurance status Private 62,350 Public 123,024 Uninsured 44,626 230,000 Those aware who need but do not receive HAART by insurance and care status (HAART use deficit)
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228 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE TABLE A-3 Increase in HAART Use Anticipated Given Implementation of HIV-CCP Estimate Estimate Population by Subpopulation Total Eligible Public Currently in care 216,200 Currently not in care 97,500 Uninsured Currently in care 62,275 Currently not in care 25,000 400,975 Enroll, if eligible Public Currently in care 194,580 Currently not in care 39,000 Uninsured Currently in care 56,048 Currently not in care 7,500 297,128 In care, once enrolled in the program Public Currently in care 194,580 Currently not in care 29,250 Uninsured Currently in care 56,048 Currently not in care 5,625 285,503 Need HAART in the program Public Currently in care 158,303 Currently not in care 23,797 Uninsured Currently in care 36,880 Currently not in care 3,701 222,681 Receiving HAART in the program Public Currently in care 129,275 Currently not in care 19,433 Uninsured Currently in care 30,118 Currently not in care 3,023 181,848 Receiving HAART outside of the program (private and other public programs) Private (in care)
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APPENDIX A 229 TABLE A-4 Increase in HAART Use Anticipated Given Implementation of Enhanced Medicaid Estimate Estimate Population by Subpopulation Total Eligible Public Currently in care 216,200 Currently not in care 97,500 Uninsured Currently in care 62,275 Currently not in care 25,000 400,975 Enroll, if eligible Public Currently in care 129,721 Currently not in care 26,000 Uninsured Currently in care 37,365 Currently not in care 5,000 198,086 In care, once enrolled in Enhanced Medicaid program Public Currently in care 129,721 Currently not in care 19,500 Uninsured Currently in care 37,365 Currently not in care 3,750 190,336 Need HAART in Enhanced Medicaid program Public Currently in care 105,536 Currently not in care 15,864 Uninsured Currently in care 24,587 Currently not in care 2,468 148,455 Receiving HAART in Enhanced Medicaid program Public Currently in care 67,910 Currently not in care 10,208 Uninsured Currently in care 15,821 Currently not in care 1,588 95,527 Receiving HAART outside of the Enhanced Medicaid program (private and other public programs) Private (in care)
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, and 15 percent have symptomatic disease but not AIDS. This heavy contribution of individuals with more severe disease reflects several factors characterizing these individuals: higher awareness of infection, high levels of uninsurance and public insurance, low observed HAART use among individuals who are uninsured or publicly insured, greater likelihood of enrolling in HIV-CCP than less sick individuals, and clearer need for HAART.
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. The quality of life adjustment assumes that in addition to extending life, there are benefits to antiretroviral therapy (e.g., reduced morbidity due to fewer opportunistic infections and slower progression of HIV disease)
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Gained HAART 105,403 2.648 billion Substance abuse treatment, mental 23,982 1.750 billion health treatment, case management Other services (additional costs Assumed zero 775 million associated with bringing people into care) Outpatient reimbursement = Undetermined 387 million Medicare or Medicare + 5% Total 129,385 5.560 billion $42,972 *
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cThis excludes the cost of care provided by the Ryan White CARE Act, which is included under care for the uninsured. See text for discussion of potential CARE Act savings.
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is included in federal share of Medicaid/Medicare. Medicare & Medicaid Services (CMS)
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235 continued billion billion billion High Value 155,262 $6.67 -- 129,114 $5.51 $42,669 127,514 $5.59 $43,808 billion Gained; Cost; 129,385 $5.56 $42,972 billion billion billion a c Outcomes: QALYs Societal Cost/QALY Low Value 103,508 $4.45 -- 129,582 $5.60 $43,207 131,256 $5.53 $42,122 b 804,000) Case high)
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Use risk and income case private private insurance TABLE Variable By Base Low High HAART Individuals Individuals public Relative family
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237 continued billion billion billion billion billion billion NA 142,675 $5.78 $40,490 134,662 $5.65 $41,944 158,114 $6.00 $37,967 -- $5.61 $43,361 -- $5.97 $46,113 -- $6.03 $46,603 billion billion billion billion billion billion billion 100,965 $5.05 $49,973 116,291 $5.33 $45,837 124,108 $5.47 $44,607 120,590 $5.41 $44,840 -- $5.51 $42,582 -- $5.15 $39,830 -- $5.09 $39,340 )
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238 billion billion billion billion billion High Value -- $5.62 $43,401 -- $5.62 $43,402 -- $5.66 $43,777 132,383 $5.77 $43,572 131,384 $5.62 $42,789 Gained; Cost; billion billion billion billion billion a Outcomes: QALYs Societal Cost/QALY Low Value -- $5.50 $42,452 -- $5.50 $42,541 -- $5.46 $42,167 126,387 $5.35 $42,343 127,387 $5.50 $43,160 f $1,656)
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0.6) (0.45; (0.45; (0.20; (0.15; 0.15 (0.12; 0.92 (0.87; 0.53 (0.42; 0.975 (0.93; 0.50 (0.4; 0.90 0.90 0.40 0.30 i Enrollment status Eligible Rates insured insured and care care management in in insurance care Public Uninsured Public Uninsured care Publicly Uninsured Publicly Uninsured Case Eligibility Proportion By In Not Enrollment In Not
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240 billion High Value 137,315 $5.96 $43,386 131,642 -- $42,235 117,430 $47,347 133,105 -- $41,771 Gained; Cost; billion a Outcomes: QALYs Societal Cost/QALY Low Value 121,454 $5.16 $42,503 127,128 -- $43,735 141,340 -- -- $39,337 125,665 -- $44,244 0.9)
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a subseq with 132,383 -- $41,999 131,184 -- $42,383 considered is comparison case) (base facilitate 126,387 -- $43,991 127,587 -- $43,578 to insurance program, private the section.
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Different insurance status distributions affected cost and QALYs gained a little, and cost per QALY gained almost not at all. Varying current HAART use among those publicly insured or uninsured by ±20 percent produced relatively substantial changes in terms of both total cost and QALYs gained, and moderate variation in cost effectiveness ($34,000 to $54,000 per QALY gained)
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National Association of State and Territorial AIDS Directors, AIDS Treatment DATA Network and Kaiser Family Foundation: Washington, DC. Andersen R, Bozzette S, Shapiro M, St Clair P, Morton S, Crystal S, Goldman D, Wenger N, Gifford A, Leibowitz A, Asch S, Berry S, Nakazono T, Heslin K, Cunningham W
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2002, June 6. Data from Reggie (Ryan White CARE Act services data)
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2002. Adequacy of treatment for serious mental illness in the United States.
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