Association for Public Policy Analysis & Management

Background: HIV management guidelines recommend routine preventive care (RPC), but little is known about access to RPC, and potential disparities. Policies to reduce structural barriers to care may improve care outcomes, such as RPC, and health equity. We leveraged state variation in Medicaid physician payments to assess the association between state-level physician payments and receipt of RPC, including by race, in the US South.

Methods: We integrated person-level demographic information and administrative claims for health services (Medicaid Analytic eXtract, 2008-2012), state Medicaid-to-Medicare physician fee ratios (Urban Institute, 2008, 2012), and county and state characteristics for 15 US Southern states plus District of Columbia. The fee ratio reflects Medicaid physician payments relative to Medicare rates, which aim to reflect costs of care and typically exceed Medicaid payment rates. Outcomes included six clinically important, annually recommended RPC screenings for HIV management: lipid panel, glucose, sexually transmitted infections (syphilis, chlamydia, gonorrhea), and cervical cancer, defined as ≥1 claim for a given RPC screen per calendar year. We assessed the association between state-level physician payments and RPC screening using multivariable race-stratified logistic regression.

Findings: The sample included 54,893 Medicaid enrollees living with HIV, aged 19-64 years, non-dual eligible for Medicare and without any private insurance, and continuously enrolled in Medicaid ≥1 calendar year. The percentage of enrollees receiving RPC screening ranged from 20.5% to 63.5% for glucose and cervical cancer, respectively. Non-Hispanic Blacks were significantly more likely to be screened for four of the six outcomes compared to non-Hispanic Whites. A ten-percentage point increase in the fee ratio was significantly associated with a 6% (aOR 1.06, 95% CI [1.03–1.09]; chlamydia) to 30% (1.30, [1.27–1.34]; syphilis) increase in the odds of RPC screening (Table). The association of the fee ratio with RPC screening was positive and significant in five out of six outcomes among non-Hispanic Blacks, but only for syphilis among non-Hispanic Whites.

Conclusion: Higher physician payments are associated with increased RPC screening, primarily among non-Hispanic Blacks. Increasing state-level physician payments may improve RPC for HIV management. A nuanced understanding of factors that further explain differences in this relationship is needed.

Routine preventive care screening	Overall sample (N=54,893; PY=177,130)		Non-Hispanic Blacks (N=29,607; PY=95,078)			Non-Hispanic Whites (N=7,957; PY=24,956)
	Percent-screened	aOR (95% CI)	Percent-screened	aOR (95% CI)	Percent-screened		aOR (95% CI)
Lipid panel	43.6	1.12*** (1.09–1.15)	46.2	1.14*** (1.11–1.17)	53.4		1.01 (0.88–1.15)
Blood glucose	20.5	1.08*** (1.04–1.12)	23.3	1.07*** (1.03–1.11)	21.3		0.89 (0.76–1.07)
Sexually transmitted infections
Syphilis	38.6	1.30*** (1.27–1.34)	42.5	1.30*** (1.27–1.34)	42.5		1.22*** (1.07–1.39)
Chlamydia	23.4	1.06*** (1.03–1.09)	26.5	1.07*** (1.04–1.10)	21.1		0.98 (0.85–1.14)
Gonorrhea	28.6	1.11*** (1.08–1.16)	31.2	1.12*** (1.09–1.16)	29.6		1.13 (0.98–1.29)
Cervical cancer†	63.5	1.04 (0.83–1.31)	71.8	0.99 (0.77–1.29)	68.2		2.96 (0.91–9.61)

Abbreviations: N=Number of patients; PY=Number of enrollee person-years; CI=Confidence interval; aOR=Adjusted odds ratio

* p<0.05, ** p<0.01, *** p<0.001

†Restricted to female enrollees without an abnormal Pap test or cervical-cancer diagnosis.