The Relationship Between Public Health Recommendations and Insurance Reimbursement

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The Relationship Between Public Health
Recommendations and Insurance Reimbursement

• Bernard M. Branson, M.D.
• Senior Advisor to the Director
• Division of HIV/AIDS Prevention
• National Center for HIV/AIDS, Viral Hepatitis,
  STD and TB Prevention

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CDCs Public Health Recommendations Related to
HIV Infection

• 1986 Test persons at increased risk to prevent
  transmission (MSM, IDU, symptomatic persons,
  prostitutes, immigrants from high-prevalence
  countries, hemophiliacs, newborns of high-risk or
  infected mothers)
• 1987 Also test persons seeking treatment for
  STDs, admissions to hospitals with high HIV
  prevalence
• 1992 Also test inpatients and outpatients in
  acute care hospitals with seroprevalence of 1 or
  diagnosis rate of 1 per 1,000 discharges

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CDCs Public Health Recommendations Related to
HIV Infection

• 1995 Test all pregnant women
• 2001 Test all clients in settings with
  prevalence gt 1 targeted based on risk screening
  in settings with lower prevalence
• 2006 Test all persons aged 13-64 in health care
  settings where yield gt 1 per 1000 targeted
  based on risk screening in settings with lower
  prevalence

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U.S. Preventive Services Task Force 1995

• Clinicians should assess risk factors for HIV
  infection by obtaining a careful sexual history
  and inquiring about injection drug use.
• Periodic screening for infection with HIV is
  recommended for all persons at increased risk of
  infection.
• Screening infants born to high-risk mothers is
  recommended if the mothers antibody status is
  not known.

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U.S. Preventive Services Task Force 2005

• Strongly recommends that clinicians screen for
  HIV all adolescents and adults at increased risk
  for HIV infection (see Clinical Considerations
  for discussion of risk factors). Grade A
• Makes no recommendation for or against routinely
  screening for HIV adolescents and adults who are
  not at increased risk for HIV infection. Grade
  C (confirmed in 2007)
• Recommends that clinicians screen all pregnant
  women for HIV. Grade A

http//www.ahrq.gov/clinic/uspstf/uspshivi.htm
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U.S. Preventive Services Task Force 2005

• Clinical considerations
• A person is considered at increased risk for HIV
  infection (and thus should be offered HIV
  testing) if he or she reports 1 or more
  individual risk factors or receives health care
  in a high-prevalence or high-risk clinical
  setting.
• High-risk settings include STD clinics,
  correctional facilities, homeless shelters,
  tuberculosis clinics, clinics serving men who
  have sex with men, and adolescent health clinics
  with a high prevalence of STDs. High-prevalence
  settings are defined by the CDC as those known to
  have a 1 or greater prevalence of infection.

http//www.ahrq.gov/clinic/uspstf/uspshivi.htm
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2007 Focused Evidence Update for USPSTF

• We found insufficient evidence to change the main
  conclusions of our 2005 evidence synthesis.
  Specifically, the 2005 evidence synthesis found
  no direct evidence on the effects of HIV
  screening on clinical outcomes.
• There remains no direct evidence on benefits of
  screening for HIV infection in the general
  population.

http//www.ahrq.gov/clinic/uspstf07/hiv/hivrevup.p
df
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2007 Focused Evidence Update for USPSTF

• With regard to prevalence-based testing, the 2005
  USPSTF recommendations cite the 2001 CDC
  threshold of 1, though recent cost-effectiveness
  studies suggest that a significantly lower
  threshold may be appropriate.
• A persistent challenge for prevalence-based
  testing is that local prevalence data are often
  not available for practicing clinicians. One
  approach could be for clinicians to institute
  routine testing unless local prevalence data is
  available to guide further testing a strategy
  advocated by the 2006 CDC recommendations.

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2007 Focused Evidence Update for USPSTF

• By eliminating the need for risk assessment or
  local prevalence information, universal testing
  is theoretically less burdensome for clinicians
  and easier to put into practice, though studies
  assessing implementation of routine opt-out
  testing in low-risk, low-prevalence settings are
  not yet available.
• Another potential effect of routine testing is to
  decrease the stigma associated with HIV screening
  and misperceptions about who may be at risk.
  However, the acceptability of routine testing and
  rates of test uptake in low- or average-risk
  adults and adolescents has not been evaluated.

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Why Grades Matter

• Medicare Improvements for Patients and Providers
  Act of 2008 Public Law 110-275
• Effective January 1, 2009, CMS may add Medicare
  Part B coverage of "additional preventive
  services" if the Secretary determines through the
  national coverage determination that these
  services are
• (1) Reasonable and necessary for the prevention
  or early detection of illness or
  disability.
• (2) Recommended with a grade of A or B by the
  United States Preventive Services Task
  Force.

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Why Grades Matter

• CMS established new G codes to bill for HIV
  screening of Medicare beneficiaries (April 5,
  2010)
• G0432 Infectious agent antigen detection by EIA
  technique, multiple step method, HIV-1 or HIV-2,
  screening
• CMS will cover HIV screening a maximum of once
  annually for Medicare beneficiaries at increased
  risk for HIV infection under the guidelines of
  the USPSTF
• Claims should be submitted with the following
  diagnosis codes
• When increased risk factors are reported, V73.89
  other specified viral diseases as primary,
  V69.8 other problems related to lifestyle as
  secondary
• When increased risk factors are not reported,
  V73.89 as primary only

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Why Grades Matter

• Health Care Reform
• SEC. 2713. COVERAGE OF PREVENTIVE HEALTH
  SERVICES.
• (a) IN GENERAL.A group health plan and a health
  insurance issuer offering group or individual
  health insurance coverage shall, at a minimum
  provide coverage for and shall not impose any
  cost sharing requirements for
• (1) evidence-based items or services that have
  in effect a rating of A or B in the current
  recommendations of the United States Preventive
  Services Task Force

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Why Grades Matter

• U.S. Office of Personnel Management
• FEHB Carriers follow the USPSTF recommendations

- July 1, 2008
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Outcomes of counseling and one-time screening for
HIV infection after 3 years
Excerpted from Screening for HIV A Review of
the Evidence for the U.S. Preventive Services
Task Force. Ann Intern Med. 200514355-73.
NNS no. needed to screen NNT no. needed to
test NNC no. needed to counsel
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Base-case Assumptions for Outcome Tables
Excerpted from Screening for HIV A Review of the
Evidence for the U.S. Preventive Services Task
Force. Ann Intern Med. 200514355-73.
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• The American College of Physicians used the AGREE
  (Appraisal of Guidelines Research and Evaluation)
  instrument to evaluate guidelines from the U.S.
  Preventive Services Task Force and the Centers
  for Disease Control and Prevention.
• Guidance Statement 1 ACP recommends that
  clinicians adopt routine screening for HIV and
  encourage patients to be tested.
• GuidanceStatement 2 ACP recommends that
  clinicians determine the need for repeat
  screening on an individual basis.

Ann Intern Med. January 2009150 (no. 2)1-7
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USPHS Treatment Guidelines Dec 1, 2009

• Antiretroviral therapy should be initiated in all
  patients with a history of an AIDS-defining
  illness or with a CD4 count lt350 cells/mm3 .
• Antiretroviral therapy is recommended for
  patients with CD4 counts between 350 and 500
  cells/mm3. The Panel was divided on the strength
  of this recommendation 55 voted for strong
  recommendation and 45 voted for moderate
  recommendation.
• For patients with CD4 counts gt500 cells/mm3, the
  Panel was evenly divided 50 favor starting
  antiretroviral therapy at this stage of HIV
  disease 50 view initiating therapy at this
  stage as optional.

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Treatment and Prevention

• Numerous observational studies support the use of
  ART for prevention.
• Definitive data for the effect of ART on
  transmission await the outcome of HIV Prevention
  Trials Network (HPTN)052/AIDS Clinical Trials
  Group (ACTG) 5245.
• Numerous Test and Treat models feasibility
  study with HPTN065 Test and Link to Care plus
  Treat
• San Francisco Health Department endorses
  immediate treatment April 5, 2010

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Conclusions

• Insurance reimbursement is most often linked to
  treatment recommendations and USPSTF grades.
• Treatment and public health recommendations
  increasingly coincide for HIV.
• It is time to revisit the strength of evidence
  for HIV screening that is not linked to risk.

The findings and conclusions in this presentation
are those of the author and do not necessarily
represent the views of the Centers for Disease
Control and Prevention