Medicare Must Address High ART Costs, Investigators Argue

A new study that investigated the relationships between HIV status and Medicare drug spend has found that although use of antiretroviral therapy (ART) was associated with savings among individuals with Medicare Part A and Part B coverage, the cost of ART and its impact on adherence continue to be major issues for persons under Medicare Part D.

Findings were published today in Health Affairs, and they also show HIV may influence utilization of mental health services in addition to medical care. Up to this point, there has been a lack of empirical data in this area, the study authors noted.

“An increasingly older population of people with HIV raises concerns about how HIV may influence care for Medicare patients,” they wrote. “Using 2016 Medicare claims, we compared risk-adjusted spending and utilization for Medicare beneficiaries with and without HIV, as well as subgroups of people receiving antiretroviral therapy.”

Medicare spend varied widely, when comparing totals for persons living with HIV (PLWH) who regularly received ART and those who did not with beneficiaries who did not have HIV.

The greatest difference was that 220.6% more was spent by PLWH, which was seen when investigating health care spend—including for ART—compared with persons who did not have HIV. PLWH who were not receiving ART still had a higher spend vs a general population, but this dropped sharply to 95.4% more.

Dose response was also shown to be an influential factor in Medicare spend, in that a longer time on ART equated to less spent on treatment for comorbid chronic conditions. Further, no matter the length of time on ART, not being on the treatment was linked to the highest overall spending for infections (65.6% more), mental health care (44.1% more), and other medical conditions (16.5% more), the study investigators noted.

“Chronic conditions associated with aging may lower the willingness of some physicians to prescribe ART, which can subsequently lead to deleterious effects among older adults living with HIV,” they wrote. “As a result, the full costs of care for older patients with HIV who have a high chronic condition burden may be higher than for older people without HIV.”

The patient population included in their analysis contained 4,479,775 Medicare beneficiaries without HIV and 21,564 PLWH; among the latter group, 9% were shown to have no 2016 spending on ART.

Individuals living with HIV tended to be younger, male, and of a non-White race vs those without an HIV diagnosis. They also tended to have higher rates of certain comorbidities. For example, chronic kidney disease and depression were more common whereas congestive heart failure (CHF) and chronic obstructive pulmonary disease were less common.

Study data also show the following:

• Between PLWH on ART and those with no ART spend, higher rates of dementia, CHF, and diabetes were seen in the latter group
• ART prescriptions were less often filled for an entire year among Black PLWH vs White patients
• PLWH had a higher adjusted yearly spend vs the non-HIV study population: $50,140 vs $16,219 (a 209.1% difference); of this, $2024 pertained to Medicare Parts A and B claims
• According to number of months on ART for 2016, the mean total health care spend was lowest for those taking ART for all 12 months:
  • 12 months: $12,492
  • 9 to 11 months: $15,230
  • 5 to 8 months: $19,667
  • 1 to 4 months: $23,521
  • 0 months: $24,467
• The lowest overall total spend was $11,282 for those not living with HIV

Higher rates of emergency department use with no hospital admission, acute care hospitalizations, and psychiatric hospitalizations also were seen when comparing these outcomes between patients without HIV and PLWH. However, when looking at the similar outcomes within the PLWH cohort for those on regular ART vs those with no ART spend, rates for all 3 were higher among the latter group.

The study investigators attribute most of the higher spend they saw between PLWH and those without a diagnosis of HIV to the cost of ART.

Because they also saw similar age- and risk-adjusted Parts A and B spending among PLWH who had consistent ART prescriptions for 12 months and persons without HIV, they suggested there may be a link between ART and savings with Parts A and B. This is especially important because Medicare cannot negotiate drug prices, and the price of ART is continually rising, the study authors wrote.

Moving forward, the authors suggested several solutions aimed at improving outcomes in this area. Future analyses need to examine connections between the cost-effectiveness of ART and how that may have an impact on other chronic conditions and how social and structural barriers may prevent access to ART, since all Part D plans are federally required to cover the treatment. In addition, there needs to be more support for both PLWH and their care teams when mental health wellness is a concern, because this can influence ART initiation and adherence.

“It is essential for Medicare to implement strategies that will reduce ART prices without affecting timely access to treatment among people with HIV,” they concluded, “especially as more people continue to age into Medicare.”

Reference

Figueroa JF, Katz IT, Hyle EP, et al. The association of HIV with health care spending and use among medicare beneficiaries. Health Aff (Millwood). 2022;41(4):581-588. doi:10.1377/hlthaff.2021.01793