Barriers and Facilitations to HIV Testing in Private Care Settings

1. HIVI HIV Initiative of Kaiser Permanente and Care Management Institute Barriers and Facilitations to HIV Testing in Private Care Settings Michael Horberg, MD MAS FACP Director, HIV/AIDS Kaiser Permanente Clinical Lead, HIV/AIDS, Care Management Institute

2. Conflicting National Guidelines (1) • CDC Guidelines Routine testing of all Americans aged 13-64 However, no consideration of older Americans and risk assessment • USPSTF Guidelines No recommendation for routine testing (C Level) Recommend at-risk testing (A Level) All pregnant women (A Level) Evidence-based but too restrictive Slide 2

3. Conflicting National Guidelines (2) • Private insurers usually defer to USPSTF • Some 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

4. 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

5. 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

6. No HIV diagnosis or access to care measure Other Screening Measures TB, gonorrhea/chlamydia, syphilis Hepatitis B and C High risk sexual behavior Substance use Process Measures Retention in care CD4 cell count Appropriate PCP prophylaxis and ART Influenza, Pneumococcus, and Hepatitis B immunization Outcome Measures HIV RNA control AMA/HIVMA/HRSA/NCQA Measures Slide 6

7. 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

8. 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 Medicaid • Preventive services included in healthcare reform • Again, California and DC mandate coverage Slide 8

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 Slide 9

10. KP HIV Testing (1) • Performs >340,000 HIV tests annually • <25% of our total patient population • 55.8% tested for HIV if diagnosed with STI • However, 43.4% if include Hepatitis B/C • 27.1% new HIV+ met AIDS criteria (CD4 <200/µL) • 87-96% prenatal testing rates • All of these numbers are improving Slide 10

11. KP HIV Testing (2) Slide 11

12. 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

13. Access to Care and Outcomes (KP) 2007 data: • 88.6% newly recognized HIV+ in care within 90 days • 76.8% retention in care • 86.8% appropriately given ART • Median adherence 93.8% HIV+ on ART • 92.9% HIV+ on ART with maximal viral control Slide 13