WASHINGTON — Reimbursement for routine, universal HIV screening will prove challenging in both the private and public sectors, Dr. Michael Horberg and Christine Lubinski said in separate presentations at a meeting on HIV diagnosis and prevention and access to care.
Last year, the Centers for Disease Control and Prevention recommended that diagnostic HIV testing and “opt-out” HIV screening be made a part of routine clinical care in all health care settings for patients aged 13–64 years (MMWR 2006;55[RR-14]). Kaiser Permanente, which is the country's largest staff-model HMO, is “grappling with this now. We have to look at the implications,” said Dr. Horberg, director of HIV/AIDS Policy, Quality Improvement, and Research at Kaiser.
“We have the capacity to do it, and we have the will to do it. But it is a lot of money,” said Dr. Horberg.
As for the public sector, “There are significant roadblocks. … The Centers for Medicare and Medicaid Services and the [Bush] administration have little commitment to expand the federal contribution to the Medicaid program in any way, shape, or form,” said Ms. Lubinski, executive director of the HIV Medicine Association. This association is a multidisciplinary arm of the Infectious Diseases Society of America that represents medical professionals involved in HIV care.
However, a few states—most notably New Jersey—have committed their Medicaid funds to cover broad-based HIV testing for low-income beneficiaries, Ms. Lubinski noted.
The Kaiser Permanente/Group Health Cooperative system covers approximately 3% of the entire U.S. population, including more than 16,000 active HIV-infected patients. The numbers vary widely by region, from about 180 patients in Ohio to nearly 5,500 in California.
Currently, nearly two-thirds of HIV-infected patients within Kaiser are not diagnosed until they meet AIDS criteria, “which means our case-finding is not very good,” Dr. Horberg remarked. However, more than 90% of patients who are diagnosed enter into care within 120 days of diagnosis. Last year, more than 70% of those patients were on highly active antiretroviral therapy, he said.
Kaiser has been performing about 340,000 HIV antibody tests a year, which account for 15% of its target population aged 13–65 years. The majority are pregnant women, of whom more than 90% are currently tested. If Kaiser were to adopt the CDC guidelines, it would mean about 5 million more tests—and 1,773 newly identified cases—at a cost of at least $26,599,450 annually.
Aside from cost, other potential barriers to expanded HIV screening in managed care include the fact that many managed care organizations follow recommendations from the U.S. Preventive Services Task Force, not the CDC, in determining what type of tests to cover. The USPSTF has not yet issued guidelines on universal HIV screening.
Although most managed care organizations do support targeted screening for pregnant women and for individuals with high-risk behavior, they have not yet generated broader screening policies. “Most are probably waiting for the USPSTF,” Dr. Horberg said.
The CDC's provision that prevention counseling should not be required as part of HIV screening is already posing problems in states that require informed consent for HIV testing, including many of the states that Kaiser now serves. Kaiser differentiates between “screening,” defined as testing without counseling, and “testing,” which includes the HIV antibody test, pre- and posttest counseling, and patient education.
“Testing in [Kaiser] is the desired norm. … We are uncomfortable screening without a proper testing process,” explained Dr. Horberg.
However, he added, despite the potential roadblocks, “We are confident that we can handle all new HIV-infected patients identified.”
The public sector is another story. It would take an act of Congress before Medicare, which has only recently begun to cover any preventive health services, would cover HIV screening. Because the upper target age of the CDC recommendation is 64 years, the only people for whom Medicare would cover screening are the 6.8 million current beneficiaries under age 65 who qualify by disability. And that number includes about 100,000 who have already been diagnosed with HIV/AIDS, Ms. Lubinski said.
Thus, the bulk of the reimbursement for HIV screening would fall to Medicaid, which currently provides health coverage to about half of all people with AIDS in the United States and a significant number of those newly diagnosed with HIV. In an analysis that was done in 25 states, 22% of HIV-infected individuals were already Medicaid eligible at the time of their diagnosis.
Federal law allows HIV screening to be covered by states either under fee-for-service or Medicaid managed care. This service is “optional” and thus depends on the individual state's policy.