Geoffrey F. Joyce

Expenditures for the Care of HIV-Infected Patients in the Era of Highly Active Antiretroviral Therapy

BACKGROUND The introduction of expensive but very effective antiviral medications has led to questions about the effects on the total use of resources for the care of patients with human immunodeficiency virus (HIV) infection. We examined expenditures for the care of HIV-infected patients since the introduction of highly active antiretroviral therapy. METHODS We interviewed a random sample of 2864 patients who were representative of all American adults receiving care for HIV infection in early 1996, and followed them for up to 36 months. We estimated the average expenditure per patient per month on the basis of self-reported information about care received. RESULTS The mean expenditure was

Effect of Insurance on Mortality in an HIV-Positive Population in Care

1,792 per patient per month at base line, but it declined to

Cost Sharing, Family Health Care Burden, and the Use of Specialty Drugs for Rheumatoid Arthritis

1,359 for survivors in 1997, since the increases in pharmaceutical expenditures were smaller than the reductions in hospital costs. Use of highly active antiretroviral therapy was independently associated with a reduction in expenditures. After adjustments for the interview date, clinical status, and deaths, the estimated annual expenditure declined from

Increasing Costs of Urinary Incontinence Among Female Medicare Beneficiaries

20,300 per patient in 1996 to

The effectiveness of covering smoking cessation services for medicare beneficiaries.

18,300 in 1998. Expenditures among subgroups of patients varied by a factor of as much as three. Pharmaceutical costs were lowest and hospital costs highest among underserved groups, including blacks, women, and patients without private insurance. CONCLUSIONS The total cost of care for adults with HIV infection has declined since the introduction of highly active antiretroviral therapy. Expenditures have increased for medications but have declined for other services. However, there are large variations in expenditures across subgroups of patients.

Combination antiretroviral therapy and improvements in mental health: Results from a nationally representative sample of persons undergoing care for HIV in the United States

As policymakers consider expanding insurance coverage for individuals infected with human immunodeficiency virus (HIV), it is useful to ask if insurance has any affect on health outcomes and, if so, whether its magnitude has changed with recent efficacious but expensive treatments. By using data from a nationally representative cohort of HIV-infected (HIV+) persons receiving regular medical care, we estimate the impact of insurance on mortality in this population. A naïve single-equation model confirms the perverse result found by others in the literature–that insurance increases the probability of death for HIV+ patients. We attribute this finding to a correlation between unobserved health status and insurance status in the mortality equation for two reasons. First, the eligibility rules for Medicaid and Medicare require HIV+ patients to demonstrate a disability, almost always defined as advanced disease, to qualify. Second, if unobserved health status is the cause of the positive correlation, then including measures of HIV+ disease as controls should mitigate the effect. Including measures of immune function (CD4 lymphocyte counts) reduces the effect size by approximately 50%, although it does not change sign. To deal with this correlation, we develop a two-equation parametric model of both insurance and mortality. The effect of insurance on mortality is identified through the judicious use of state policy variables as instruments (variables related to insurance status but not mortality, except through insurance). The results from this model indicate that insurance does have a beneficial effect on outcomes, lowering the probability of 6-month mortality by 71% at baseline and 85% at follow-up. The larger effect at followup can be attributed to the recent introduction of effective therapies for HIV infection, which have magnified the returns to insurance for HIV+ patients (as measured by mortality rates).

The impact of state policy on the costs of HIV infection.

OBJECTIVES To examine the impact of benefit generosity and household health care financial burden on the demand for specialty drugs in the treatment of rheumatoid arthritis (RA). DATA SOURCES/STUDY SETTING Enrollment, claims, and benefit design information for 35 large private employers during 2000-2005. STUDY DESIGN We estimated multivariate models of the effects of benefit generosity and household financial burden on initiation and continuation of biologic therapies. DATA EXTRACTION METHODS We defined initiation of biologic therapy as first-time use of etanercept, adalimumab, or infliximab, and we constructed an index of plan generosity based on coverage of biologic therapies in each plan. We estimated the households burden by summing up the annual out-of-pocket (OOP) expenses of other family members. PRINCIPAL FINDINGS Benefit generosity affected both the likelihood of initiating a biologic and continuing drug therapy, although the effects were stronger for initiation. Initiation of a biologic was lower in households where other family members incurred high OOP expenses. CONCLUSIONS The use of biologic therapy for RA is sensitive to benefit generosity and household financial burden. The increasing use of coinsurance rates for specialty drugs (as under Medicare Part D) raises concern about adverse health consequences.

Mental Health Status and Use of General Medical Services for Persons with Human Immunodeficiency Virus

PURPOSE We measured the financial burden of urinary incontinence in the United States from 1992 to 1998 among women 65 years old or older. MATERIALS AND METHODS We analyzed Medicare claims for 1992, 1995 and 1998 and estimated spending on the treatment of urinary incontinence. Total costs were stratified by type of service (inpatient, outpatient and emergency department). RESULTS Costs of urinary incontinence among older women nearly doubled between 1992 and 1998 in nominal dollars, from

Sex and Race Differences in the Association Between Statin Use and the Incidence of Alzheimer Disease

128 million to

A Socioeconomic Profile of Older Adults With HIV

234 million, primarily due to increases in physician office visits and ambulatory surgery. The cost of inpatient services increased only slightly during the period. The increase in total spending was due almost exclusively to the increase in the number of women treated for incontinence. After adjusting for inflation, per capita treatment costs decreased about 15% during the study. CONCLUSIONS This shift from inpatient to outpatient care likely reflects the general shift of surgical procedures to the outpatient setting, as well as the advent of new minimally invasive incontinence procedures. In addition, increased awareness of incontinence and the marketing of new drugs for its treatment, specifically anticholinergic medication for overactive bladder symptoms, may have increased the number of office visits. While claims based Medicare expenditures are substantial, they do not include the costs of pads or medications and, therefore, underestimate the true financial burden of incontinence on the aging community.