CROI 2024 Abstract eBook

Abstract eBook

Poster Abstracts

1233 Estimated Costs of Eliminating Medicaid Prior Authorizations for Antiretrovirals in Washington State Matthew Golden 1 , Ryan Taketomo 2 , Ryan Pistoresi 2 1 University of Washington, Seattle, WA, USA, 2 Washington State Health Care Authority, Olympia, WA, USA Background: Medicaid is the largest insurer of persons living with HIV (PLWH) in the U.S. Some Medicaid programs use prior authorizations (PAs) to limit drug expenditures. In 2023, WA State eliminated PAs for antiretrovirals (ARVs). Methods: We modeled the impact of PA elimination on HIV treatment and pre-exposure prophylaxis (PrEP) costs, 2023-2027. All models used 2021 net drug costs reflecting costs minus rebates. PrEP models assumed a 10% annual increase in the number of PrEP users and evaluated the impact of annual declines in the relative percentage of PrEP users on TDF/FTC with compensatory increases in TAF/FTC use; some models assumed the percentage of PrEP users on cabotegravir (CAB) would increase 1% annually. We modeled 5 scenarios: 1) Base – no change in the percentages of PrEP users on TDF/FTC and TAF/ FTC and no CAB; 2) Stable change – 3.5% decrease in TDF/FTC and no CAB; 3) Accelerated change – 7% decrease in TDF/FTC and no CAB; 4) Stable change + CAB – 3.5% decrease in TDF/FTC and 1% annual increase in CAB; 5) Accelerated change + CAB – 7% decrease in TDF/FTC and 1% annual increase in CAB. For HIV treatment, we assumed a 2% annual increase in the number of PLWH on ART. Our Base Model assumed no change in the percentage of PLWH on different drugs. Our No PA Model assumed: 1) 18% annual relative increase in the percentage of PLWH on bictegravir/TAF/FTC; 2) the percentage of people on tenofovir/FTC taking TAF/FTC (vs. TDF/FTC) increases 9% annually; 3) CAB/ rilpivirine increases 1% annually; 4) no change in darunavir/cobisistat; and 5) use of other ART drugs decline in proportion to their 2022 use. To place costs in context, we estimated the number of PLWH who might be housed using money required to meet new ART costs; this estimate reflects local 2023 costs for emergency or temporary housing with 5% annual inflation. Results: The 5-year cost of PrEP in our Base Model was $28.7 million. Elimination of PAs increases that cost by $28.2 to $57.8 million. The annual cost of PrEP in 2027 was $9.5 to $20.1 million more in no PA models than the base model. Changes in HIV treatment will result in $63 million in new costs over 5 years. In our most costly scenario, elimination of PAs will cost $121 million over 5 years. This cost would pay for 5 years of housing for 817 PLWH, which exceeds the total number of unhoused PLWH in King County, WA. Conclusion: Elimination of Medicaid PAs will likely result in substantial new costs. Changes in drug formulary policy should consider opportunity costs.

1232 Increased Medicare Spending Among Beneficiaries With HIV in the 12 Months Prior to Death Jose F. Figueroa 1 , Ciara E. Duggan 1 , Jessica Phelan 1 , Florence Ebem 2 , Parastu Kasaie 3 , Luke Ang 2 , Keri N. Althoff 3 , E J. Orav 4 , Emily P Hyle 2 1 Harvard TH Chan School of Public Health, Boston, MA, USA, 2 Massachusetts General Hospital, Boston, MA, USA, 3 The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, 4 Brigham and Women's Hospital, Boston, MA, USA Background: Medicare spending tends to be disproportionately higher among beneficiaries in their last year of life. We currently lack empirical data on how spending differs among Medicare beneficiaries with HIV in the last 12 months of life compared with Medicare beneficiaries with HIV who survive 12 months. Methods: Using a 20% yearly sample of Medicare fee-for-service claims data (2016-2018), we identified beneficiaries with HIV aged 65 and older with Part D (prescription) coverage. We examined mean annual Medicare spending among beneficiaries with HIV who survive the calendar year compared with mean spending in the 12 months prior to death among beneficiaries with HIV who died, stratifying results by age group. After 1% winsorization, we calculated mean total spending, as well as mean spending across seven subcategories: direct medical treatment of HIV (excluding drugs); HIV-associated conditions and infections; mental health disorders; other medical spending; total drug spending; spending on antiretroviral therapy (ART); and spending on other drugs. Results: The study sample included 5,601 beneficiaries with HIV who survived the study period, and 706 beneficiaries who died. Mean annual Medicare spending was substantially higher among decedents in the 12 months prior to death compared to people who survived, with the largest difference observed among beneficiaries aged 65-69 ($126,969 vs. $55,662). Mean annual spending was higher among decedents with HIV (compared with survivors) across most subcategories, except total drug spending. Beneficiaries of all age groups who died had lower spending on ART ($23,256-$16,532 vs. $30,650-24,159) with the greatest decrease among older beneficiaries. Conclusion: In a national study of older Medicare beneficiaries with HIV and Part D, beneficiaries in their last year of life incurred substantially higher spending compared to survivors, particularly among younger beneficiaries. In contrast, ART spending declined markedly in the last year of life, especially among older beneficiaries, which suggests ART cessation at the end of life. These findings have important implications as the HIV population grows older, and a greater number of people with HIV receive healthcare coverage through the Medicare program at the end of life.

Poster Abstracts

CROI 2024 404