More Effective Treatment of HIV Patients Possible Through Pay for Performance Model

Increased spending for treatment of HIV patients does not necessarily lead to a more positive clinical outcome, according to a new study presented at the 2013 United States Conference on AIDS.

Under the Affordable Care Act, the health care system will expand, likely including providers who are not experienced in the care of HIV/AIDS patients, according to Christie Olejemeh, RN, MS, of the Washington DC Department of Health’s HIV/AIDS, Hepatitis, STD, and TB Administration. Olejemeh presented data from a poster titled “To End the HIV Epidemics, Pay Providers for Performance: Lessons from Five Medical Care Programs in the District of Columbia.”

Under Ryan White programs, subsidized treatment for HIV/AIDS patients is provided, following the submission and approval of proposals by providers. Funding is not dependent on the performance of providers or patient outcomes.

One way of ensuring that the standard of HIV care is maintained while containing costs might be to pay providers based on their performance. The goal of the study was to evaluate such a model for the treatment of HIV.

The researchers used a conceptual framework to examine the performance of five HIV treatment programs, three (sites A, B, C) of which provide primary ambulatory care, where patients remain under observation and care; the other two (D, E) are subacute care providers, where patients come occasionally for hospitalization and court-ordered treatment. The study team retroactively collected information about CD4 levels and viral loads from a total of 145 patient files, and also looked at data related to the DC AIDS Drug Assistance Program (ADAP), values from DC HIV surveillance laboratory tests to verify baseline laboratory data. Ryan White Part A grant awards were used to calculate treatment cost per patient.

The data showed that at sites A, B, and C, viral suppression at <400 copies was achieved in 79%, 95%, and 83% of patients, respectively. Viral loads >10,000 copies were present in 9%, 5%, and 8% of patients at sites A, B, and C.

At sites D and E, 55% and 59% of patients achieved suppression. Viral loads >10,000 copies were in 8%, 18%, and 17% of patients at sites A, B, and C, respectively.

CD4 counts >350 were present in 95%, 85%, and 67% of patients at sites A, B, and C, and in 18% and 53% of patients at sites D and E.

CD4 counts <200 at A, B, and C were present in 5%, 5%, and 29% of patients, and in 55% and 13% of patients at D and E. Cost of treatment per patient at A, B, and C was $1,508, $1,339, and $1,308, and $2,486 and $2,663 at D and E.

Since the cost per patient at the subacute care sites was up to double that at the primary care sites, while significantly more patients at the former had viral loads >10,000 copies and lower CD4 counts, the researchers concluded that the clinical outcome from spending more to treat HIV patients is not necessarily positive. Believing that an effective strategy must exist for treating HIV/AIDS as it becomes a chronic condition, the study team also recommends that future funding be linked to improved clinical outcome, as measured by clinical variables such as viral suppression; underperforming health providers should be subject to penalties, unless they have legitimate reasons for poor results.