Overview

Article excerpt

This issue of the Health Care Financing Review features four articles on payment and service delivery for care of individuals with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). These articles focus on the following topics: the cost and financing of care for persons with HIV disease, Medicare utilization of beneficiaries with AIDS, HIV/AIDS drug assistance programs funded under Title H of the Ryan White Care Act, and health-based payment systems for HIV/AIDS.

This issue contains four papers relating to payment and service delivery for care of individuals with HIV or AIDS. The extent of the HIV/AIDS problem is well known, and the financing and service delivery problems have become more pronounced over time. New therapies and methods of organizing care can have significant effects. For instance, the rapid increase in use of new combination drug therapies has had a dramatic effect on the survival of persons with HIV (Centers for Disease Control and Prevention, 1997).

The financing burden for HIV/AIDS care is large. Medicaid(1) and Medicare(2) account for the largest proportion of Federal spending for care and assistance for persons with HIV/AIDS (Henry J. Kaiser Family Foundation. 1998). In Fiscal Year (FY) 1998, the Federal share of Medicaid spending for HIV/AIDS is expected to be $1.9 billion, and Medicare will spend $1.4 billion (22 and 16 percent, respectively, of total Federal HIV/AIDS spending). In addition the State portion of Medicaid spending for HIV/AIDS care is $1.6 billion, or 46 percent of the $3.5 billion combined Medicaid spending.

Medicaid payments for HIV/AIDS care are projected to rise to $2.6 billion (Federal) and $2.2 billion (state), or a total of $ 4.8 billion, by FY 2002. HCFA estimates that, nationally, Medicaid serves more than 50 percent of all persons living with AIDS and up to 90 percent of all children with AIDS (HCFA, Office of the Actuary, 1998).

Medicare's share of treatment costs for HIV/AIDS disease continues to rise as new medical technologies and drugs enable more persons to survive the 29-month waiting period for Medicare coverage under the Social Security Disability Insurance program. Medicare payments for HIV/AIDS care are projected to be $2.1 billion by FY 2002 (HCFA, Office of the Actuary, 1998).

The four papers on HIV/AIDS highlight important aspects of the changing care environment for persons with HIV/AIDS disease. In the first article on this theme, Hellinger provides an overview of the available health services research on costs and financing of care for persons with HIV/AIDS. This study focuses on the impact of the diffusion of new combination drug therapies on the cost and financing of HIV/AIDS. The proportion of treatment costs attributable to drugs has increased significantly since the diffusion of new combination drug therapies, and the proportion of costs attributable to hospital inpatient care has decreased. The number of persons living with HIV has increased, and persons with HIV have been starting antiretroviral therapies earlier in their illness. Changes in treatment regimens as well as in the demographic characteristics of persons living with HIV affect the cost and financing of HIV/AIDS care. Increasingly, persons with HIV in Medicaid are being enrolled in managed care plans, which affects payments. At this time, the major difficulty in analyzing the impact of these changes on cost and financing of care for persons with HIV is the lack of timely data.

The second article, by Fasciano, Cherlow, Turner, and Thornton, presents an analysis of Medicare utilization using administrative claims data for the period 1991-93. The article describes an AIDS case-finding process for use with claims files and discusses its potential accuracy. Using this method, the authors estimate that at the end of 1993, 12 percent of AIDS cases in the United States were covered by Medicare. The more than 37,000 Medicare beneficiaries with AIDS were older than the general population of people with AIDS and were more likely to be female. …