WASHINGTON — Reimbursement for routine, universal HIV screening will prove challenging in both the private and public sectors, Dr. Michael Horberg and Ms. Christine Lubinski said in separate presentations at a meeting on HIV diagnosis and prevention and access to care.
In September 2006, 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, 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.
“Yes, we have the capacity to do it, and yes, 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 U.S. population, including more than 16,000 active HIV-infected patients.
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. Once diagnosed, however, more than 90% 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 barriers to expanded HIV screening 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. While most managed care organizations support targeted screening for pregnant women and for individuals with high-risk behavior, they have not 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 Kaiser serves. Kaiser differentiates between “screening,” defined as testing without counseling, and “testing,” which includes the HIV antibody test, counseling, and patient education. “Testing in [Kaiser Permanente/Group Health Cooperative] is the desired norm. … We are uncomfortable screening without a proper testing process,” Dr. Horberg said.
But, he added, despite the potential roadblocks, “We are confident 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. Since 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, 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 done in 25 states, 22% of HIV-infected individuals were already Medicaid eligible at the time of diagnosis.
Federal law allows HIV screening to be covered by states either under fee-for-service or Medicaid managed care, but this service is “optional.” A recent study by George Washington University's Center for Health Services Research and Policy found that Medicaid programs in 32 of the 48 states surveyed covered targeted HIV testing and counseling. A few state programs also covered services such as HIV risk assessment and case management.
But as yet, with the exception of New Jersey, most state Medicaid programs have not adopted routine HIV testing. California has employed a special waiver to provide broad family planning services including HIV testing and counseling for men and women of childbearing age up to 200% of the poverty level. However, that type of waiver is unlikely to be granted elsewhere, she noted.