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HIV treatment costs balloon for clinics as funding remains flat
ART costs are the highest, research shows
If President Barack Obama's FY2010 budget does send millions of dollars to HIV/AIDS treatment and prevention programs, the money will arrive none too soon, HIV clinicians and researchers say.
HIV clinics have had budgets stretched to their outer limits in recent years due to federal flat-funding, state cutbacks, increases in bureaucratic requirements, and increases in patient populations.
Funding has not risen, but clinics are seeing more patients with their already stretched resources, experts say.
"This is not a static environment where we see the same number of patients every year," says James L. Raper, DSN, director of the 1917 HIV Clinic at the University of Alabama - Birmingham. Raper also is an associate professor of medicine and nursing at UAB.
"We've continued to increase the number of patients we're seeing," Raper says. "In 2008, we were up to 1,576 patients."
Although the clinic's patient list has increased by about 400 patients in the past four years, its funding has remained the same, saysJames Henry Willig, MD, a clinic physician and an assistant professor in the department of medicine and infectious diseases at UAB.
"We've hired an additional nurse," Willig adds. "We've made adjustments to become more efficient and to do the best we can, but the funding is an issue."
In addition to hiring the new nurse, the clinic has hired two additional support staff workers, another social worker, and another case manager all to accommodate the extra work generated because of administrative inefficiencies of the Ryan White mechanism, Raper says.
But the clinic has received no increase in its Ryan White part C funding, Raper adds.
Willig and Raper recently studied the impact of prior authorization requirements for Medicare part D drugs on HIV clinics and found that this particular bureaucratic rule has cost HIV clinics and their staff considerable time and effort, and none of it is compensated by payers.1
Their study found that over a two year period, 288 prior authorization requests from 144 patients were processed. The mean number of pages of paperwork per prior authorization was 5.8 pages, and the mean time for handling these requests was 26.8 minutes.
Investigators concluded that unremunerated prior authorization-related costs represents 33% of the reimbursement for an office visit and negatively impacts a clinic's operating margins.
"We don't want to frame this research as woe is us - we're not getting enough money," Willig says. "But those PA requests do represent a delay in patients getting access to medications, and that's not optimal because that's a time period that could be harmful to folks."
Also, the added burden of handling prior authorization requests takes a provider's time away from direct patient care, Willig adds.
"When you look at the funding being flat for a long time, and then you add the PA request to it, you're saving money somewhere, but you're packing it on to the clinic," he explains. "We're resolved to take care of the PA requests, but the clinic is operating at capacity."
Another example of how bureaucratic requirements can force HIV clinics to shift resources from patient care to paper pushing is a new billing system required of the UAB clinic.
Alabama receives money from Ryan White part B funding to help get patients off the AIDS Drug Assistance Program (ADAP) list, Raper notes.
"We had one of the longest ADAP waiting lists in the country," he adds.
The state health department could send money directly to clinics to help with the waiting list, but the state decided to have the Central Alabama United Way Foundation administer the details, Raper explains.
"We have to bill the United Way for every eligible patient and every single thing we do in five-minute increments," Raper says. "So every five minutes that a social worker does anything that's Ryan White eligible we have to generate a monthly invoice."
Borrowing from Peter to pay Paul
The irony is that in order for the clinic to receive extra money to handle one bureaucratic problem — the ADAP waiting list — the clinic had to hire an additional social worker and another administrative employee just to do the billing that is required to receive that extra funding, Raper says.
"It's beyond all expectations," he says. "We went from three staff members to five just to manage all of this — it's very inefficient."
Details about how much extra money will be sent to fund the Ryan White Care Act were not available as of early March, but HIV advocates reported optimism in the late winter that the care and treatment budgets would finally be increased. In the FY 2010 budget summary, the money going to HIV/AIDS was described as follows: "The Budget increases resources to detect, prevent, and treat HIV/AIDS domestically, especially in underserved populations."2
HIV clinicians absolutely hope for increased Ryan White funding from the federal government, says Edward M. Gardner, MD, an infectious diseases physician at Denver Public Health in Denver, CO, and an assistant professor in the department of medicine/division of infectious diseases of the University of Colorado Denver in Aurora, CO.
Increased funding especially is needed for HIV testing and prevention to identify what the Centers of Disease Control and Prevention (CDC) estimate are 56,300 Americans who are infected with HIV each year, the experts say.
Prevention funding also should be increased, Gardner says.
"The CDC recommends HIV testing for all adults in the United States, but who's going to pay for it?" Gardner says. "How do you pay for 200 million HIV tests?"
High costs of treatment
Among chronic diseases, HIV has uniquely high treatment costs, Gardner notes.
The expensive medications for HIV treatment are more similar to the costs of treating people who need transplants or who have cancer than they are to treating chronic conditions like diabetes and cardiovascular disease, he explains.
Gardner's research has found that antiretroviral treatment (ART) takes up a large proportion of the total expenditures for persons with HIV.3
"In our study, ART took up 61% of total expenditures for persons living with HIV," Gardner says.
The chief issue that contributes to the high cost of HIV care is ART pricing and how these are covered, he notes.
"The way these medicines are paid for and the types of medical coverage available for people with low-incomes are so challenging," Gardner says. "Payers do shift from ADAP to Medicaid to Medicare and occasionally to private insurance, and there are many payers."
The cost shifting also translates into more uncompensated labor and expenses at HIV clinics. Some providers are hopeful that changes to Ryan White funding provisions could reduce the hidden bureaucratic costs HIV clinics incur.
A grassroots group called Ryan White Medical Providers is working to influence how Ryan White reauthorization takes place, says Raper, who is on the group's steering committee.
"We're working diligently to get some of providers' day-to-day care issues and concerns considered in the reauthorization of the act," Raper says. "It can't just be drug companies and the really highly influential sectors like that controlling this reauthorization."
There are several solutions to these problems, and one is for Medicare part D intermediaries to use one standard format for prior authorization requests, Raper says.
"And they should make their formularies immediately available on line and searchable," he adds.
Also, Ryan White part C funding that goes to HIV clinics should include money that's allocated to support the infrastructure necessary for taking care of patients and for medication acquisition, Raper says.
"Someone needs to recognize that this is a critical issue," Raper says.