Academic journal article Health Care Financing Review

Profile of Medicare Beneficiaries with AIDS: Application of an AIDS Casefinding Algorithm

Academic journal article Health Care Financing Review

Profile of Medicare Beneficiaries with AIDS: Application of an AIDS Casefinding Algorithm

Article excerpt


Understanding the role Medicare plays in the service system for people with AIDS has become increasingly important. With the advent of new life-prolonging therapies, more people disabled by AIDS will survive long enough to qualify for Medicare. Thus, the number of people with AIDS who are covered by Medicare is likely to rise over time, with a corresponding increase in Medicare expenditures for AIDS.

Little is known about the number or characteristics of people with AIDS who are covered by Medicare or about the share of AIDS costs borne by the Medicare program. Although several studies have estimated Medicare's share of inpatient hospital costs for treating human immunodeficiency virus (HIV) infection, the only information about the fraction of AIDS care financed by Medicare comes from surveys, such as the AIDS Cost and Services Utilization Survey (ACSUS), which focused on a relatively small (and potentially unrepresentative) sample of AIDS patients (Berk, Maffeo, and Schur, 1993).

This article presents an initial look at the population of people with AIDS who received Medicare-covered care during 1991, 1992, or 1993. The article discusses the AIDS epidemic and Medicare eligibility rules in relation to AIDS, describes the casefinding process and the evidence supporting its potential accuracy, and presents our findings from applying this casefinding process to a 100-percent sample of Medicare beneficiaries from 1991-93. In addition to estimating the number of Medicare beneficiaries with AIDS, we examine cases' eligibility, service use, and expenditure patterns. The results highlight the growing role Medicare is playing in funding AIDS-related care and provide a basis for future AIDS policy.

The AIDS casefinding methodology, which was developed at Mathematica Policy Research, Inc. (Thornton et al., 1997), approximates the 1993 Centers for Disease Control and Prevention (CDC) surveillance case definition for AIDS (Centers for Disease Control and Prevention, 1992). The methodology searches the Medicare claims data bases for diagnosis codes that suggest the presence of various elements of the CDC definition, including those for HIV infection and the occurrence of an AIDS-indicator condition. This methodology builds on an earlier approach reported by Keyes, Andrews, and Mason (1991), which was developed by Barbara Turner and extended in her work with the New York State Medicaid staff (Turner, McKee, Fanning, and Markson, 1993a, b).

Overall, we estimate that, at the end of 1993, 12 percent of AIDS cases in the United States were covered by Medicare. Approximately three-fourths of these beneficiaries qualified for Medicare because of a disability; the others were eligible because they were age 65 or older or had end stage renal disease (ESRD). Mortality rates were high among Medicare beneficiaries with AIDS: over 40 percent of the cases we identified between 1991 and 1993 had died by the end of 1993. While living, Medicare beneficiaries with AIDS required substantial levels of medical care; we estimate that Medicare spent more than $2,400 per enrollment month for these beneficiaries. In contrast, Medicare expenditures for all disabled beneficiaries averaged slightly less than $4,000 annually. These high expenditures reflect a high level of inpatient care: three-fourths of the beneficiaries with AIDS were admitted as inpatients during the 12 months following their identification by the algorithm.

AIDS Epidemic

The current CDC case definition of AIDS, in place since 1993, classifies persons as having AIDS if they show evidence of HIV infection and either one or more of a group of specified AIDS-defining conditions or a CD4+ T-lymphocyte (CD4 T-cell) count below 200 cells/[micro] L (Centers for Disease Control and Prevention, 1992). AIDS-defining conditions include a wide array of disease manifestations resulting from HIV infection; these include the serious opportunistic infection pneumocystis carinii pneumonia (PCP) and such cancers as Kaposi's sarcoma. …

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