Physician reimbursement and retention in HIV care: Racial disparities in the US South

Abstract

Fewer than 60% of Americans diagnosed with HIV are retained in care, with racial disparities. Addressing structural barriers to care may improve outcomes along the HIV care continuum, such as retention, and promote health equity. We examined the relationship between physician reimbursement and retention in HIV care, including racial differences. Data included person-level demographic information and administrative claims (Medicaid Analytic eXtract, 2008-12), state Medicaid-to-Medicare fee ratios (Urban Institute, 2008, 2012), and county characteristics for 15 Southern states plus District of Columbia. The fee ratio is a standardized measure of physician reimbursement capturing state variation in Medicaid relative to Medicare physician reimbursement, which is largely consistent across states. We used generalized estimating equations to assess the association between physician reimbursement ratio and retention in HIV care (≥2 claims for physician visits, antiretroviral prescriptions, or CD4 or HIV RNA viral load tests >90 days apart in a calendar-year). We also evaluated an increase in the fee ratio to parity, where Medicaid and Medicare physician reimbursement are equal. Stratified analysis assessed racial differences. The sample included 55,237 adult Medicaid enrollees living with HIV (179,002 enrollee-years). Enrollees were retained in HIV care for approximately three-quarters (76.8%) of their enrollment-years, with retention lower among non-Hispanic Black (76.2%) versus non-Hispanic White (81.3%, p<0.001) enrollees. A 10-percentage point increase in physician reimbursement was associated with a 4% increase in the odds of retention (aOR 1.04, 95% CI 1.01, 1.08). In stratified analysis, increased physician reimbursement was significantly associated with retention among non-Hispanic Black but not non-Hispanic White enrollees. At parity, predicted retention was 81.1% (80.0%, 82.1%) and 80.4% (79%, 81.7%) of enrollment-years, overall and for non-Hispanic Black enrollees, respectively. Higher physician reimbursement improves retention in HIV care, particularly among non-Hispanic Black individuals living with HIV, and could be a structural mechanism to promote racial equity in retention.