Routine HIV Testing Depends on Reimbursement


Sunday, June 27 is National HIV Testing Day.  This year, HIV Law Project and many of our allies are focused on the need to routinize HIV testing, and toward this end to ensure that health care providers are reimbursed by insurers for routine testing.

Risk-Based HIV Testing is Outdated

Too many people — an estimated quarter of a million — are living in the U.S. with undiagnosed HIV.[1]  This is due, in part, to the fact that current HIV screening practices reflect outdated assumptions about risk and the demographics of HIV. Risk assessments typically focus on known risky behavior of the individual or their sexual partner(s). Yet a partner’s infidelity or history of injection drug use, for instance, are often unknown. Risk assessments, therefore, regularly fail to capture true risk, particularly for women with no identified risk factors.

Further, populations once considered at low-risk for infection can no longer be considered so, as infection patterns and the demographics of HIV are changing. Women, young people, Blacks and Latinos, and individuals living outside of metropolitan areas all represent an increasing proportion of infected individuals.[2] As a result, many people who are at risk for HIV infection, or may already be living with HIV, are not being tested and remain unaware of their status. For this reason, over a third of new HIV diagnoses are made late in the course of the illness.[3] 

In 2006 the Centers for Disease Control & Prevention (CDC) recognized this evolution and changed their HIV testing guidelines. The new guidelines recommend routine HIV screening for everyone between the ages of 13 and 64 in all health care settings, including primary care.

Importance of Universal, Routine HIV Testing

As the CDC’s revised screening guidelines recognize, early diagnosis and treatment are central to the fight to slow the HIV epidemic and improve the lives of people living with HIV.

Testing Improves Health Outcomes

Early diagnosis allows for medical interventions which can slow disease progression and increase life expectancy. When a positive diagnosis is made routine monitoring can begin and treatment can be started when medically appropriate. Universal, routine HIV testing would result in increased rates of early diagnosis, allowing people with HIV to live longer, healthier lives. 

Testing Reduces New Infections

With testing should come linkage to care and access to appropriate medication.  Anti-retroviral treatment lowers the viral load of HIV-positive individuals.  A decreased viral load decreases infectiousness, meaning that a person who has been tested and connected to care is less likely to transmit HIV than someone whose HIV is undiagnosed. In addition, individuals often decrease their high-risk behavior upon receipt of an HIV diagnosis. People who are aware of their HIV status are 68% less likely to engage in unprotected intercourse with HIV-negative partners than those who are unaware of their status.[4] Testing, therefore, is an important tool in slowing the spread of HIV.

An Efficient Use of Resources

The benefits of early detection outweigh the costs of routine screening.[5] Firstly, early screening results in longer life expectancy.[6] Second, early screening saves health care costs by preventing further transmission, as discussed above. Third, routine screening saves money as health care costs are far higher among those individuals with more advanced disease: approximately $14,000 for individuals at the earliest stage of disease as compared with $36,500 for those with the most advanced disease.[7]

The Present Challenge: Routine HIV Testing Depends on Reimbursement

Despite the clear advantages of routine testing, the CDC’s recommendations remain an unfulfilled promise. Doctors cite competing priorities and lack of time as reasons for not testing. Of course with no mechanism to reimburse routine testing, it will never be prioritized. Reimbursement is critical to motivating providers who are pressed for time and resources to screen patients whom they perceive to be low risk.[8]

In most parts of the country health care providers are not reimbursed for routine HIV screening. Medicaid currently serves more than 50% of people living with HIV/AIDS. While federal law allows states to cover routine HIV testing of Medicaid-eligible adults, many state Medicaid programs fail to do so, reimbursing screening only for high-risk individuals. Similarly, private insurers typically do not reimburse for routine screening. Ensuring reimbursement across the spectrum of insurers is a necessary precondition to achieving routine testing.

Possible Solutions

Numerous possible approaches to provider reimbursement have been contemplated. States could be encouraged to expand their Medicaid programs to include routine testing, as the Centers for Medicare & Medicaid Services did in June 2009.[9] Alternatively, Congress could change Medicaid law to require coverage of routine testing, as proposed by Senator Kirsten Gillibrand (S.1446), and/or require private insurers to cover routine testing, as proposed by Congresswoman Maxine Waters (HR 2137).  Similarly, the states could pass legislation mandating that all insurers cover routine HIV testing, as California did in 2008.[10] Finally, the United States Preventive Services Task Force, a government panel that makes preventive service recommendations, must change its grade for HIV testing from a “C” to a “B” which would ensure, under the guidelines established by the newly passed Patient Protection and Affordable Care Act, that testing is covered by private insurers. While none of these solutions is, on its own, comprehensive in scope, each would provide a critical step forward toward routinizing HIV testing. Until there is a fix to the issue of reimbursement, routine testing will remain elusive.


[1] The Kaiser Family Foundation. “Fact Sheet: The HIV/AIDS Epidemic in the United States”. February 2009.

[2] Center for Disease Control and Prevention. “Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings”. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/

Rr5514a1.htm (accessed April 6, 2010).

[3] Id. 

[4] Marks, G. et al. “Meta-Analysis of High-Risk Sexual Behavior in Persons Aware and Unaware They Are Infected in the United States”. AIDS 39 (2005): 446-53.

[5] Sanders, G.D., Bayoumi, A.M., Sundaram V., et al. “Cost-effectiveness of Screening for HIV in the Era of Highly Active Antiretroviral Therapy.” New England Journal of Medicine, 2005, Vol. 352: 570-585.

[6] Id.

[7] Guttmacher Institute. “Bulk of Health Care Costs for People with HIV Are For Drugs, Hospitalization.” Perspectives on Sexual and Reproductive Health, June 2006, Volume 38, Number 2.  Available at http://www.guttmacher.org/pubs/journals/3811906.html

[8] Gever, J. “Physicians Reluctant to Follow CDC Call for Routine HIV Testing.” medpageToday, November 20, 2008. Available at http://www.medpagetoday.com/HIVAIDS/HIVAIDS/11874

[9] See Letter from Centers for Medicare & Medicaid Services to State Health Officials, dated June 24, 2009 noting that “(s)tates… have the option of covering routine HIV testing of Medicaid-eligible adults as a preventive or screening benefit under section 1905(a)(13) of the (Social Security) Act.” Available at http://www.cms.gov/SMDL/downloads/SHO062409.pdf   

[10] See AB 1894 (Krekorian, Chapter 631, Statutes of 2008) which added H&S Code Section 1367.46 and Insurance Code Section 101023.91.

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  • nycprochoicemd

    Thanks for this important reminder of why we need to be screening everyone for HIV, not just people we think are at risk.  I’d like to elaborate on the issue of reimbursement.  In many states, a special informed consent document is required prior to HIV testing.  In New York, for instance, I can’t order an HIV test without a signature from the person to be tested.  To properly complete that informed consent document takes about 5 minutes, because we have to explain about HIV, risks and benefits of testing, false positives and negatives, the window period, and also provide details on where the person can get anonymous screening.  So, given that the typical primary care doctor has 15 minutes per patient for *everything*, including taking a history, doing an exam, reviewing medications, discussing and implementing a plan, making follow up appointments, talking about preventive care, and writing a note, it becomes obvious why that (unreimbursed) 5 minutes seems an impossible investment.

     

    Although I certainly think that patients deserve more than the 15 minutes I’m allowed to give them, that’s another battle.  What we need to do is get rid of the special informed consent document.  This special protection was necessary in the days when we didn’t know what caused HIV, when it was stigmatized within the medical community, and when people were terribly discriminated against based on their HIV status.  However, these days it’s a barrier to screening people for HIV.  We routinely order tests for people that could come back positive for worse diagnoses than HIV without having to get a special informed consent document completed.  We discuss the test with the patient and proceed without needing to document it.  In fact, requiring a separate consent for HIV actually stigmatizes it and makes it seem less routine, when in fact that is what it should be; as routine as screening for diabetes or high cholesterol.

  • autumn

    NYS so so needs to ditch that informed consent thing because it is based on the idea that HIV status is a stigma yet at the same time we DO do nonconsent HIV testing when we test newborns and I, as a maternity nirse have to go explain this to patients, complete with mandated OUTDATED information!!

    The way it’s set up seems to purpetuate the stigma, and that bothers me too.