In this cross-site evaluation of integrated HIV care and bup/nx treatment, we found that median monthly clinic costs were $136 per patient for labor and overhead and $8 per patient for toxicology analyses. This represents an incremental cost to the clinic of only about $22 per month compared with treating HIV-infected patients with an opioid dependence diagnosis who were not assigned to integrated care. In integrated care, however, there were fewer encounters with physicians and more encounters with nonphysician providers, whose services are less expensive but also less likely to be billable to third party payers. This finding reinforces the critical role played by bup/nx coordinators in integrated care models described elsewhere17
and the need to obtain funding for their services.
All patients in integrated care do not remain on bup/nx continuously. In this study, we found the monthly cost of bup/nx was about $209 per patient at current prices, somewhat higher than a recent national estimate of $166 per prescription in 2007.18
The bup/nx patent recently expired,19
so future costs may be lower if generic bup/nx becomes available. If incremental HIV clinic costs are $22 and bup/nx prices remain unchanged, the total additional cost of $229 per patient month still compares favorably with monthly per patient costs reported elsewhere for office-based ($238) and methadone clinic-based ($159-$486) methadone maintenance treatment adjusted to 2008 US dollars.20,21
Paradoxically, with fewer billable physician encounters, HIV clinics may actually receive lower reimbursement from third parties using these models of integrated care. However, there were wide variations among sites in the number of encounters, reflecting differences in program design and implementation. The funding for this project allowed sites to use integration approaches without regard to third-party reimbursement and different approaches might be designed to maximize reimbursement. Up-front expenditures for clinics were relatively small, consisting primarily of provider time spent on training. Ongoing training support may also be required and is available without charge through a national mentoring program.22
Integrated care also requires additional patient visits to the clinic, especially during the early phases of bup/nx treatment. For some patients, these requirements may be a barrier to participating in integrated care, even though they can incur similar or higher costs for off-site outpatient substance abuse treatment.23
Programs should consider providing financial and nonfinancial incentives to address these barriers, such as transportation reimbursement, meals, or other incentive programs.24,25
A limitation of this study is that we only calculated costs incurred at HIV care sites because we were unable to collect utilization data for substance abuse care provided elsewhere for most sites. This means that we are unable to determine potential savings from integrated care to third-party payers and state agencies currently paying for substance abuse care in other settings. Using patient self-reports, we were also unable to identify offsetting cost savings from integrated care elsewhere in the health care system. We might have been able to identify more cost savings if we had access to clinical data systems. For example, Barnett26
found total costs of care were lower for bup/nx versus methadone in the first 6 months of care in the Veterans Health Administration, with no significant differences in costs in subsequent months. This result was attributable to significantly lower use of ambulatory care services (defined as substance abuse/mental health and other ambulatory care) and fewer inpatient days. In addition, potential long-term health system savings from better HIV care outcomes 27,28
and better screening and treatment of comorbid medical conditions3–5
could not be measured in this study. Although we were also unable to identify cost offsets in the criminal justice system or due to increased employment, these savings have been found in other studies of opioid dependence treatment.29
There are several other limitations to this study. The increase in labor and overhead costs associated with integrated care may have been understated because our analysis was based on care initially received. Some patients not initially receiving integrated care subsequently received this care during the follow-up period. Moreover, initial group assignment was not randomized at the majority of sites, so patients with lower costs may have been assigned to integrated care. These factors may also have limited our ability to detect cost offsets from patient-reported data.
On the other hand, bup/nx integrated care was supported with dedicated funding and may have been more intensive and expensive than would occur elsewhere, especially because site funding levels were fixed and enrollment at most sites was lower than anticipated. Costs may be lower in subsequent years if providers require less time with more patient experience; in addition, patients may require less additional time as they stabilize on bup/nx. Costs of inductions may also be overstated because at some sites re-inductions that required fewer resources were not reported separately from regular visits; had they been included the average induction costs would have been lower.
The wide variation among sites in provider utilization and costs, confirmed in multivariate analyses, indicates that the costs we report may not be broadly generalizable. HIV clinics will need to forecast their own costs based on the approach described here and then determine which of these costs would be reimbursed to project additional funding requirements. Our analysis does suggest that clinics may have the opportunity to approach third-party payers for assistance, in addition to traditional funders such as Ryan White CARE Act programs.
In summary, integrated HIV care and bup/nx treatment requires additional resources at the clinic level, including for nonphysicians and other providers acting as bup/nx coordinators whose costs are usually not third-party reimbursed. Even if overall costs do not increase substantially, implementing integrated care will require additional funding at the clinic level in addition to appropriate reimbursement for bup/nx drug costs. By forecasting service utilization and costs of integrated care, HIV clinics can determine the budget impact of implementing different treatment models and identify potential sources of funding.