Costs and Funding
What are the costs to plan for and how will they be covered?
When it comes to expanding HIV testing beyond when clinically indicated, cost and reimbursement are among hospitals' major concerns. Grant funds can be important in getting a program off the ground and demonstrating early outcomes; however, if a program is to be sustainable, existing funding streams will have to tapped and perhaps redirected to support testing in the ED when it is effective. The next page provides possible sources to further explore for funding or in-kind support.
Potential Funding Sources
At present, third-party reimbursement policy for routine HIV testing is likely to be limited. For example, some public and private payers will reimburse an HIV test only when clinically indicated, therefore, ancillary services such as HIV counseling may not be reimbursable when conducted by someone other than a physician. Some payers may reimburse only one test, meaning that the screening test is reimbursed but the confirmatory test for a reactive result is not. Other potential barriers may be that reimbursement may not cover the full cost of the test. This is problematic when rapid HIV tests are more expensive than ELISA or Western Blot tests. A confounding issue may be EDs' ability to bill for the incremental cost of an HIV test when some EDs bill globally for services based on a diagnosis.
The good news is that many payers are reviewing their reimbursement policies for HIV testing. For example, New York's Medicaid Program has changed its reimbursement policy for rapid HIV testing in emergency departments (see yellow column to the right). Recently, America's Health Insurance Plans, the national association of health insurance providers, released a report for its constituents on the benefit of expanded HIV screening. According to the report, Humana, Aetna and Kaiser Permanente are reviewing their current HIV testing policies to provide more coverage for routine HIV testing.
State and local health departments
Health departments use their state, local and federal dollars to support HIV testing and prevention in a range of venues. These may include public sites, community-based resources, private health care providers, and emergency departments. While health departments may be well positioned to provide financial and in-kind support, some are bound by law to allocate a certain amount of funding to localities and specific programs. Others have found through pilot programs that there is greater testing volume and linkage to care when testing is conducted in EDs and have elected to channel funding to those efforts. Federally mandated community planning (funded through the Ryan White Care Act) and prevention planning councils (funded through CDC grants to states) may be important venues to make the case for redirecting these funds.
Regardless of the amount of funding they can provide, health departments are invaluable resources for the technical support they can provide, which can include laboratory services for confirmatory tests, training of ED-based testing staff, and centralized test kit purchase and distribution, among other support.
340B Drug Pricing Program
Public hospitals and other disproportionate-share hospitals are eligible for 340B drug pricing, which sets an upper limit on the price that drug manufacturers receive from covered entities for outpatient drugs. Prime vendors in the 340B program provide their products at further reduced rates. At present, the Uni-Gold Recombigen Rapid HIV Antibody Test is available through the 340B Prime Vendor Program.
Local Health Commissions, City Councils, Local Foundations
Tapping into local resources is a good approach to ensure the sustainability of efforts. In communities with high HIV prevalence, the case can be made to direct local resources to where there is great likelihood for testing a high volume of people and immediately linking them to care. Making the case to local governing bodies such as health commissions, city councils, and foundations will inform their decisions about how to allocate local resources for HIV prevention and testing throughout the community.
Some hospitals have successfully obtained funding from pharmaceutical companies to launch ED-based HIV testing programs. These funds have been used to pay for additional staff and equipment. These can be important early funds to launch the program, but it is unlikely that they will be sustainable over time.
Hospital administration can help launch the program by securing funding for staff (such as through development funds), directly funding program oversight, and paying for rapid test kits. Hospital administration can also help secure space, such as access to a workstation (desk, phone, fax machine, computer, file cabinets, copy machines, etc.) for administrative tasks and record keeping. If the test is run outside the laboratory, access to the ED's STAT lab or some other temperature-controlled space is required. Space needs are minimal - some sites have found space in unused closets.