ART Impacts Spending, Care for Medicare Beneficiaries with HIV

Medicare coverage for antiretroviral therapy (ART) did not improve overall spending for Medicare beneficiaries with HIV, but the therapy did appear to positively impact spending outside of HIV treatment costs and coincided with improved utilization patterns, a Health Affairs article found.

“HIV infection may make it more difficult to manage other chronic conditions that accompany aging, which may subsequently increase total costs of care,” the researchers wrote. 

“As the number of older people with HIV continues to increase and more people continue to enroll in Medicare, it is critically important to understand the extent to which HIV is associated with spending and utilization related to other chronic conditions and mental health disorders. Understanding how treatment with ART affects this relationship is equally important.”

The study relied on a 20 percent sample of 2016 Medicare administrative claims data. Participants had Medicare Parts A, B, and D—Medicare Advantage members were not included in the analysis.

The study had 4.4 million individuals without HIV and 21,564 individuals with an HIV diagnosis, of whom 1,974 did not use ART.

Treatment adherence was clearly a challenge in the portion of the study’s HIV community that took ART. Slightly more than half of the participants (51.6 percent_ continued filling their ART prescriptions for an entire year. This trend was more noticeable among Black beneficiaries than White beneficiaries.

The beneficiaries who had HIV experienced higher Medicare spending than those who did not have HIV, particularly in Medicare Part D spending on ART. The total bill for a beneficiary with HIV was $33,087 and 79.2 percent or $26,207 of that was for ART.

Apart from ART spending, beneficiaries with HIV had higher spending than participants without HIV on mental healthcare (44.1 percent higher), HIV-associated conditions and infections (65.5 percent higher), and additional medical conditions (16.5 percent higher).

Total spending for beneficiaries with HIV who had received ART was higher than spending for beneficiaries with HIV who had not received ART. But among spending categories that did not include HIV treatment, spending was higher for individuals who were not receiving ART.

The longer that beneficiaries received ART treatment, the lower their mean spending levels dropped. Beneficiaries who received ART for one to four months had a mean total healthcare spend of $23,521, which was below the mean total spending for beneficiaries with HIV not receiving ART. Beneficiaries who received ART for the full year saw a mean total spend of $12,492.

The study found that Medicare beneficiaries with HIV who received ART exhibited utilization patterns that were similar to Medicare beneficiaries without HIV.

Compared to their counterparts who received ART, Medicare beneficiaries who did not receive ART were more likely to require acute care treatment and they saw longer lengths-of-stay, more time in skilled nursing facilities, and higher rates of psychiatric hospitalizations.

“Because all Part D plans are federally required to cover approved antiretrovirals, patients with HIV without ART spending may also face other important social or structural barriers that impair their ability to engage in care effectively, which we were unfortunately not able to fully capture using Medicare claims data,” the researchers noted. 

“Policy makers and clinical leaders need a better understanding of what is driving the direction of this interaction. Although untreated HIV may lead to worsening mental illness and other chronic medical conditions that limit the use of ART, it is more likely that undertreated mental illness and structural barriers are limiting ART use.”

Policymakers have tried to leverage Medicaid expansion and legislation to improve access to coverage for the HIV community.

Separate research has indicated that Medicaid expansion can help increase the detection of undiagnosed HIV.

Still, challenges remain. Beneficiaries with HIV have faced discrimination in prior authorization policies in southern states and were at risk of losing their coverage when Medicaid work requirements were in place.