Examining Treatment Costs Related to HIV-Positive Dually Enrolled Medicare Beneficiaries
In the United States, Medicare and Medicaid account for more than three-quarters of domestic federal spending on HIV/AIDS treatment. In turn, policymakers are interested in monitoring the cost and quality of treatments for HIV/AIDS.
In a recent study, researchers examined the impact of HIV/AIDS care and treatment on Medicare and Medicaid programs specifically in California [Am J Public Health. 2015;105(3):567-574].
In California, more than half of individuals with HIV/AIDS are enrolled in Medicare or Medicaid programs. Due to provisions under the Patient Protection and Affordable Care Act and the recent Medicaid expansion in many US states, coverage has been extended to nondisabled, low-income individuals living with HIV/AIDS. The researchers utilized an algorithm to identify patients with the disease in insurance claims data to estimate costs for treatment. Medicare and Medicaid claims data from 2007 were examined, and the researchers examined antiretroviral (ARV) drugs, HIV-specific monitoring tests, and medical costs. The researchers noted that claims data offer information on a range of healthcare services, including outpatient and inpatient care, long-term care, medication, laboratory, and support services. Therefore, claims data is an advantageous way to examine spending in this patient population, according to the study.
Patients ≥16 years of age living in California were included in the analysis if any Medicare or Medi-Cal claims during 2007 contained a diagnosis for HIV according to the International Classification of Diseases, 9th Revision, and any records indicating a prescription for ARVs. The researchers found that 46% of the full-benefit Medi-Cal enrollees were dually enrolled in Medicare and Medi-Cal. Frequency of treatments and the annual per capita expenditures of medical and pharmaceutical claims were calculated for each study participant.
A total of 18,290 participants satisfied at least 1 of the study criteria. Costs for patients with Medi-Cal only health coverage averaged $33,720 in 2007 US dollars ($43,500 in 2013 US dollars), while costs for patients dually enrolled averaged $7003 expenditures through Medi-Cal and $39,046 expenditures through Medicare (in 2007 US dollars).
These findings indicate that although dually covered patients had greater total medical expenditures reaching approximately $46,050, the costs to Med-Cal were much lower in this patient demographic because most of the funding was through Medicare. The researchers noted, “without annualizing, the spending estimates for Medi-Cal only beneficiaries would appear 11% lower.”
The study’s authors noted limitations, including that the algorithm used could have data errors that do not properly indicate patients with and without an HIV/ AIDS diagnosis.
The researchers concluded, “Our method should help policymakers avoid underestimating the cost of treatment of HIV/AIDS and also avoid overestimation. By setting managed care capitation rates for people living with HIV/AIDS appropriately, policymakers can enhance the sustainability of managed care providers of HIV/AIDS treatment.”—Kerri Fitzgerald
