Managing Medicare's HIV caseload in the era of suppressive therapy

Objectives. The 1996 introduction of antiretroviral medications changed Medicare's role in providing HIV care. We analyzed Medicare's patient database in an effort to document the new HIV therapies' effects on expenditures and outcomes. Methods. We examined the medical billing records of a 5% national Medicare sample from 1997 through 2003. The cohort was stratified by year and categorized by age, race/ethnicity, gender, and Medicare status. Population summaries were categorized according to presence of major chronic diseases and HIV-related conditions. Results. The number of Medicare beneficiaries with HIV increased from 42520 in 1997 to 76500 in 2003, whereas mortality among this group fell by 35%. HIV-associated infections declined by as much as 43% (mycoses). Heart and liver disease and diabetes increased by more than 50%. Adjusted annual per person Medicare expenditures fell 28%; expenditures were 49% higher for Blacks than for Whites. Conclusions. Improved HIV medical management has led to fewer deaths and has shifted treatment toward chronic care. However, successful management is complicated by conditions that have not been historically linked to HIV and whose effects vary according to race/ethnicity.