Background for the studies on ancillary services and primary care use.

Timely and optimal HIV primary care is a key tenet of the Ryan White CARE Act, a safety net programme for vulnerable and marginalized people living with HIV in the USA. Health services researchers, local providers and policy makers suspect that ancillary services are necessary to improve entry into and retention in HIV primary care for vulnerable populations experiencing barriers to HIV services, including access to antiretroviral therapies. This paper provides background to the eight studies featured in this special supplement to AIDS Care. The eight studies examine retrospectively ancillary (support) services data collected after 1996 in six HIV epicenters (New York and Chicago, plus four sites included in the Client Demonstration project-Los Angeles, San Francisco, Orange County [California] and Washington, DC), three smaller hard-hit cities (Boston, New Orleans and St Louis) and several states (California, plus Michigan and Virginia from the Client Demonstration Projects). These varied delivery settings serve racial and ethnic minority populations, men who have sex with men, injection drug users, women and mothers. The studies use a range of analytic approaches to understand whether receipt of certain enabling services correlated with early entry into and retention in care. Ancillary services (support services such as case management, housing, food, transportation, mental health and substance abuse treatment) are used by local HIV medical and community-based organizations in facilitative strategies directed to populations that have difficulty entering or staying in HIV primary care. Understanding the contribution of ancillary services to timely entry into and consistent use of primary care, including the expanding range of HIV therapeutics, is important to service delivery system planners and resource allocation decision-makers.

The role of ancillary services in client-centred systems of care.

The studies in this issue reflect the operation of the Ryan White CARE Act's holistic model of health and support services for people living with HIV in the USA. Ancillary services available through the CARE Act are responsive to predisposing factors, enabling factors, and system characteristics that pose barriers to clients' receipt of primary medical care. That nearly all of the studies use cross-sectional rather than longitudinal data makes it difficult to draw causal inferences. Taken as a whole, however, the studies suggest that receipt of ancillary services such as case management, mental health and substance abuse treatment, transportation, and housing assistance is associated with primary care entry and retention among CARE Act clients. The studies and the literature out of which they arise suggest that there is a need to refine further our understanding of care systems so that we can refine the care systems themselves. Among the concepts proposed for the study of care systems are comprehensiveness, capacity, coordination, integration, cultural competence, and client-centredness.

Associations between HIV-positive individuals' receipt of ancillary services and medical care receipt and retention.

This study examines associations between HIV-positive individuals' receipt of ancillary services and their receipt of and retention in primary medical care. Ancillary care services examined include case management, mental health and substance abuse treatment/counseling, advocacy, respite and buddy/companion services, as well as food, housing, emergency financial assistance, and transportation. The selection criterion used was the receipt of care from January-June 1997 at selected facilities receiving funding under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, a federally funded safety net programme in the USA. The receipt of each ancillary service was associated with the receipt of any primary medical care from a safety net provider. All ancillary services were more strongly associated with primary care receipt than with retention in care or the mean number of primary care visits per year. Mental health and substance abuse treatment/counselling, client advocacy, respite care and buddy/companion services all had significant associations with all primary medical care measures. This is the first time in one study that the primary medical and ancillary services received by all clients at safety net-funded providers from multiple cities and states have been examined. All types of safety net providers, from the largest medical centre to the smallest community-based organization, are represented in this study. The patterns seen here are similar to the findings from the other, geographically more restricted, studies reported on in this volume.

Factors associated with delays in accessing HIV primary care in rural Arkansas.

While debate continues at what stage of human immunodeficiency virus (HIV) disease to begin combination antiretroviral therapy, a number of clinical and public health benefits are linked to early entry into primary care soon after first testing HIV positive. However, HIV-infected patients continue to test late and delay entry into care. We used routinely collected demographic and clinical information to examine which factors are associated with delays in seeking care in a predominantly rural, economically poor area of Arkansas. The study population is 75% African American and male and 70% lack health insurance; nearly one fourth were referred from prison. At diagnosis, two thirds of the population had CD4 counts below 500 cells per microliter. Days from initial HIV diagnosis to entry into care declined from a median of 178 in 1994 to 24 in 1998. In 1998, 75% of the population entered into primary care within 2 months of diagnosis. However, CD4 counts at HIV diagnosis also declined in this period, from a median of 427 in 1995 to 208 cells per microliter in 1998. More recent year of diagnosis was associated with a shorter delay in seeking care; males, and individuals lacking health insurance took significantly longer to enter into care than females and those with insurance, respectively. Our univariate finding of extensive delays in seeking care in the prison population did not hold in the multivariate analysis. We found significant delays in time to initial HIV diagnosis, and further considerable delays in males and those lacking health insurance in the time taken to enter into primary care.

Comorbidity-based payment methodology for Medicaid enrollees with HIV/AIDS.

Managed care organizations (MCOs) may be incurring financial losses from persons with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) (PWHA). This study developed a statistical model to examine which specific comorbidities are important contributors to the variations in health care costs of PWHA. Individuals were classified into cost groups to simulate biased selection in MCOs. Capitation payments for various cost groups under different methodologies were compared. The statistical model closely matched payments with the actual costs of care. Capitation payments for HIV/AIDS enrollees based on this model will better protect MCOs than the traditional risk-adjustment methods.

Medicaid managed care reimbursement for HIV and its implications for access to care.

The rapid growth of managed care in state Medicaid programs has raised concerns about access to care for people living with HIV and AIDS (PLWH). Even the highest capitation rates that most programs pay to managed care organizations (MCOs) for disabled enrollees are substantially lower than the costs of care, especially when costly protease inhibitor therapy is taken into account. A national study has shown that Medicaid beneficiaries did not have the same level of access to protease inhibitors as did privately insured HIV patients in 1996 and 1997. Low capitation rates can limit access to care for PLWH by discouraging MCOs from having experienced HIV physicians on their provider panels and from enrolling PLWH. Since 1997, however, Medicaid programs in several states have adopted strategies to reduce the financial risks facing MCOs caring for PLWH and enrollees with other high-cost conditions. These strategies include global health-based (risk-adjusted) payment systems, AIDS-specific reimbursement rates, carve outs from capitation rates for medications and other services, risk pools for high-cost enrollees, risk corridors, and stop-loss insurance policies through which Medicaid programs share financial liability with MCOs for catastrophic losses. In addition, several programs have developed HIV centers of excellence. Most state Medicaid programs have yet to adopt any of these strategies. However, the growing numbers and types of experimental approaches to capitating services for PLWH may provide models for other states whose low reimbursement rates currently limit access to care.

Developing a managed care delivery system for people with HIV/AIDS.

Capitated managed care is now a significant part of the healthcare landscape in the United States. Consequently, states across the country are looking to it as a means of lowering their costs for Medicaid recipients. Implementing Medicaid managed care plans, however, requires considerable planning and research to ensure that providers are fairly reimbursed and that patients continue to receive quality care. Efforts to ensure adequate reimbursement and quality care are particularly important for persons with HIV/AIDS and those with other chronic conditions, populations that require considerable healthcare resources and often are covered by Medicaid. The transition to Medicaid managed care can be smoothed through stakeholder input and consideration of the overall healthcare marketplace and political climate, the structure of managed care organizations, the means of informing consumers of their managed care choices, the potential size of the Medicaid patient base, and the need to integrate clinical and social services for patients with HIV/AIDS.

Health-based payment for HIV/AIDS in Medicaid managed care programs.

In recent years, State Medicaid programs have begun adopting health-based payment systems to help ensure quality care for people living with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), and to ensure equity for the managed care organizations (MCOs) in which these people are enrolled. In this article, the authors discuss reasons why such payment systems are needed and describe AIDS-specific capitation rates that have been adopted in several State Medicaid waiver programs. The authors also examine comprehensive risk-adjustment systems both within Medicaid and outside the program. Several research questions needing further work are discussed.

Predicting the effect of the Oregon Health Plan on Medicaid coverage for outpatients with HIV.

The Oregon Health Plan, which took effect in February 1994, extends Medicaid eligibility but limits coverage to conditions and treatments above a certain threshold on a prioritized list. Retrospective analysis was conducted on records of visits to two Oregon human immunodeficiency virus (HIV) outpatient clinics in 1991 and 1992 to determine Medicaid coverage if the plan had been operational. Of 1129 patients, 21.1% were Medicaid-eligible; an additional 56.5% would have been eligible under the Oregon plan. Only 5.0% to 6.8% of these patients' visits were for conditions listed below the plan's coverage threshold; almost none of these were for HIV-specific conditions.

Pediatric acquired immunodeficiency syndrome hospitalizations in New Jersey.

This study examines all acquired immunodeficiency syndrome (AIDS) hospitalizations during 1987 for children younger than 13 years of age in New Jersey, with the AIDS diagnosis confirmed through a match with the state AIDS Registry. Days of hospitalization and cost for 318 admissions and annual utilization measures for the 74 children in the sample were analyzed by sex, age, race/ethnicity, hospital, discharge status, payer, and a severity-of-illness proxy. These measures were also compared with those for 3152 admissions of 1623 New Jersey adolescents and adults with AIDS hospitalized during 1987. Children with AIDS averaged 14.09 days and $8636 per admission, 4.35 admissions per year, and 60.96 days of hospitalization per year at an average cost of $37,110. The severity-of-illness proxy was the best predictor of hospital utilization and mortality. Hospitals varied widely in their proportions of very short and very long stays that signal possibly inappropriate utilization. Medicaid patients had relatively high utilization measures, and Hispanic children, relatively low measures. Per-admission utilization of children was similar to that of adults, but annual hospital utilization was significantly higher for children. Reimbursable outpatient and home care services appear to reduce inappropriate utilization.