Payor Considerations for Treatment of HIV


Payor considerations in the treatment of HIV are explored.

Adam C. Welch, PharmD, MBA:From a payer’s perspective, what are some of the pressures and priorities that payers are seeing with this epidemic?

Alina Orozco, RN: I’m representing Florida, which has a unique situation with Clear Health Alliance. That’s an HIV specialty plan, established 11 or 12 years ago, looking at community-based organizations and the models that existed to help individuals living with HIV achieve better health outcomes. For everyone who’s involved in HIV treatment, adherence to treatment, education, and support for PrEP [pre-exposure prophylaxis] are very important. How do we support the providers treating patients on the front lines of the epidemic? How do we reach and engage individuals who’ve been lost to care? Our population is aging with HIV. As a Medicaid health plan, we have a large burden of individuals who are affected by social determinants of health. A large portion of our membership may be affected by insecurity around food and housing because it’s an older population.

Because of the dynamics of Medicaid, as a payer, our membership is half men and half women. The majority of our members are Black or Hispanic. Behavioral health is also critical. Payers obviously were very much attuned to—at least in Florida—looking at those needs, working with community-based organizations, and working with providers. A lot of our providers sought to bring in [patients] from the Ryan White [HIV/AIDS Program]. They’re very experienced in community-based responses and knowledgeable of the resources at the community level. Opioid use disorder is something we’re also very much aware of, not just in HIV but as a larger part of the country.

We’ve started a program where we definitely work to help minimize some of the barriers to medication-assisted treatment [MAT]. We do work with SAMHSA [Substance Abuse and Mental Health Services Administration] to encourage our providers to complete an 8-hour course on MAT and hopefully increase the availability of buprenorphine for our members. There are a lot of areas. We’re looking at health care settings, providers, social determinants of health, and the needs of our members. The key is working as a community collaboratively, internally within the health care system and payers and externally with our regulators, providers, and community-based organizations.

Adam C. Welch, PharmD, MBA: Payers are an invested team member in this battle against HIV. They’re an essential part of the team to ensure quality care in this country.

Alina Orozco, RN: They are, and they should be. We probably need to do a better job overall nationally in that arena, because they are key players in the decision-making process for a lot of patients in education, support, and access to treatment.

Christian B. Ramers, MD, MPH, FIDSA, AAHIVS: As providers, we don’t like seeing more patients with HIV. It’s been frustrating that the curve has been dropping, but we’re stuck at 30,000 a year. The payers should care about those 30,000. Every one of those patients, because HIV is a lifelong infection that’s incurable, is going to be on therapy for the rest of their lives. The life span of an individual with HIV is pretty close to what it is for the general population. A 20-year-old who comes in with a new HIV diagnosis is going to have to be on very expensive medicines for the next 50 years, which cost the whole system about $1 million [for each patient]. We have tools that can prevent those infections. If we were to find everybody with HIV, get them linked into care, get them supported, and get their viral load undetectable, they can’t transmit anymore. For those at risk, we have very good prevention tools, like PrEP, that can prevent new infections. If we work together and get that 30,000 down to 0, we have a chance of ending the epidemic.

Ann Khalsa, MD, MSEd, FAAFP, AAHIVS: We need to be partners in this. Florida has a great system, but not all states have an integrated system where the health care plan is a payer that’s vested and doing supportive things. Phoenix is a fast-track city working to end the HIV epidemic, so we receive extra federal funding because we’re a hot spot. We’re still getting 20-plus new patients every week in our clinic, with over 4500 patients already there. Nothing is changing even though we have the techniques to do it. Part of it is the social determinants of health and health care disparities. It’s a disease driven by communities of color. We still have a lot of MSM [men who have sex with men] and transgender patients, but they’re relatively disenfranchised. The education isn’t there. Arizona will cover their treatment and prevention with Medicaid and Ryan White if we can get them in, but we have a hard time reaching them. So there are disparities.

Yes, the epidemic is prevalent in terms of incidence in communities of color, but it depends on what region of the country. Nationwide it’s largely African American in terms of the proportion of individuals getting newly infected. In the Southwest, we’re mostly Hispanic. Also, 50% are under age 35. That means the other 50% are over age 35. We’ve got patients newly infected in their 60s and 70s, and they don’t think they’re at risk. As a society and a health care team, we need to address the risk behaviors of individuals who don’t think they’re at risk.

Transcript edited for clarity.

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