Slide 1

Barriers and Facilitations to HIV Testing in Private Care Settings

Michael Horberg, MD MAS FACPMichael Horberg, MD MAS FACPDirector, HIV/AIDS Kaiser PermanenteDirector, HIV/AIDS Kaiser Permanente

Clinical Lead, HIV/AIDS, Care Management InstituteClinical Lead, HIV/AIDS, Care Management Institute

HIVI HIV Initiative of Kaiser Permanente and Care Management Institute

Conflicting National Guidelines (1)

CDC GuidelinesCDC GuidelinesRoutine testing of all Americans aged 13-64

However, no consideration of older Americans and risk assessment

USPSTF GuidelinesUSPSTF GuidelinesNo recommendation for routine testing (C Level)Recommend at-risk testing (A Level)All pregnant women (A Level)

Evidence-based but too restrictive

Slide 2

Conflicting National Guidelines (2)

Private insurers usually defer to USPSTFSome insurers are developing own

guidelines KP is bridge of USPSTF and CDC

Professional societies are not uniform in opinion ACP, IDSA, AMA, ACOG, AAP support CDC AAFP does not recommend routine testing of all

Slide 3

Statutes as Barriers

Written informed consent considered hardship by providers Time consuming, burdensome Not for other sexually transmitted infections or routine

blood tests

Laws changing 40+ states and DC no longer require written consent

Only California and DC mandate coverage of testing costs

Slide 4

Lack of Quality Metrics

No nationally accepted metric on HIV testing None in HEDIS, AMA PQRI VA and KP measure stage of disease at time of

diagnosis

There are HIV care metrics (see next slide)

Many have called for HIV testing measurements

Slide 5

AMA/HIVMA/HRSA/NCQA Measures

No HIV diagnosis or No HIV diagnosis or access to care measureaccess to care measure

Other Screening Measures

1. TB, gonorrhea/chlamydia, syphilis

2. Hepatitis B and C

3. High risk sexual behavior

4. Substance use

Process Measures

1. Retention in care

2. CD4 cell count

3. Appropriate PCP prophylaxis and ART

4. Influenza, Pneumococcus, and Hepatitis B immunization

Outcome Measures

1. HIV RNA control

Slide 6

Reimbursement Issues (1)

Targeted testing has not been an issue Cost of test vs. cost of testing

Some issues with routine testing reimbursement

Many insurance companies have relaxed reimbursement policy Don’t usually look at HIV risk when handling claim

AMA and AAHIVM published guidelines for coding for testing and services

Slide 7

Reimbursement Issues (2)

CMS now covering targeted HIV testing Thought will cover most patients at risk Recognizes increased sexual activity among

older adults Anticipated that private insurers will follow suit

Unclear how CMS changes affect MedicaidPreventive services included in healthcare

reformAgain, California and DC mandate coverage

Slide 8

Slide 9

KP HIV Demographics--Overview

Largest private provider of HIV care in US >19,000 in 2009 regional variation (~200 to >6500)

Demographics reflect states we serve

Aging, but not dying Mortality 1.6%--less than national average (3.4%)

Employ a multi-disciplinary specialty model

KP HIV Testing (1)

Performs Performs >340,000>340,000 HIV tests annually HIV tests annually <25% of our total patient population

55.8% 55.8% tested for HIV if diagnosed with STItested for HIV if diagnosed with STIHowever, However, 43.4%43.4% if include Hepatitis B/C if include Hepatitis B/C27.1%27.1% new HIV+ met AIDS criteria (CD4 new HIV+ met AIDS criteria (CD4

<200/<200/µL)µL)87-96%87-96% prenatal testing rates prenatal testing ratesAll of these numbers are improvingAll of these numbers are improving

Slide 10

KP HIV Testing (2)

Figure 33. Number of KPNC members tested for HIV and rate of testing: 1995 - 2009

75018 77125

104080112483 118985

131639135203

814138160182740 84556

947989018888671

65602

27.429.6 29.3 28.7 29.0

41.743.5

37.836.1

33.829.829.6 31.530.3 30.3

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Fig 37a. Rate of testing for HIV among KPNC prenatal women by 6-month period for 2000 - 2009*

85.4 85.5 85.9 85.8 85.1 85.3 84.5 86.5 87.2 87.584.1 83.1 83.4 82.9 83.5 83.1 83.8 84.0 84.9 84.4

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* Data for 2009 complete after 03/31/2010 Slide 11

KP HIV Testing Quality Improvement

Expanded HIV testing guidelines More universal but targets at-risk populations

• Especially patients diagnosed with STI

No upper age limits All pregnant women (and consideration of

continued risk during pregnancy) Looking to expand

• Include Adolescents• Include evidence-based counseling and prevention

Slide 12

Access to Care and Outcomes (KP)

2007 data:88.6%88.6% newly recognized HIV+ in care newly recognized HIV+ in care

within 90 dayswithin 90 days76.8%76.8% retention in care retention in care86.8%86.8% appropriately appropriately given ART given ART Median adherence 93.8%Median adherence 93.8% HIV+ on ART HIV+ on ART92.9%92.9% HIV+ on ART with maximal viral HIV+ on ART with maximal viral

controlcontrolSlide 13