Federal and state funding for drugs pushed to limit
Priority No. 1 is how to lower costs
State money that currently goes to pay for protease inhibitor therapy for AIDS patients may begin to evaporate in the coming months as rising demand for the drugs outstrips available funds.
"This is a week-by-week and day-by-day struggle," says Andy Epstein, RN, MPH, director of HIV Health Services for the AIDS bureau in the Massachusetts Department of Public Health in Boston.
Since July 1996, more than 500 new patients have enrolled in the state’s AIDS drug reimbursement program in what could easily become a budget problem, Epstein says. Funding for protease inhibitor treatment is supplied through the Ryan White CARE Act, federal legislation named after a young person who died of AIDS. Federal dollars supplement state funds.
In 1996, Massachusetts asked for and received an additional $1 million to help pay for protease inhibitor therapy. Epstein says her office has requested an additional $3.1 million in state funding for this year. "It is difficult to predict how much money will be needed," she says. "We think some patients are waiting to see how others do on the drugs. We may be in the second wave of enthusiasm but it is too early to tell."
Lawmakers want to balance budget
All members of the state legislature must approve the supplemental funding for AIDS therapy in Massachusetts. Although Epstein says lawmakers are supportive of drug treatment and pleased with the results of protease inhibitors, they also are concerned about balancing the budget. Sooner or later the funds will dry up, she predicts.
Epstein says an additional cost of the AIDS therapy for states and regional health departments will be the increasing need for social service infrastructure. Successful treatment will mean that many more patients will need a stable living environment, and the need for public housing may therefore increase, she says.
Many states are assigning more public funds for home health and home care. The Massachusetts Department of Public Health funds nursing care through the state’s 18 visiting nurse associations, Epstein notes.
But an even larger question of resource allocation looms, warns Dean Kauffer, LCSW, MSW, a social worker at Horizon Hospice in Chicago. The state of Illinois recently added $10 million in supplemental funding for protease inhibitor therapy to the state budget. Still, Kauffer worries about what may happen to homeless patients, legal immigrants, and patients with a psychiatric history who seek protease inhibitor therapy.
States, hospices trying to get drugs cheaper
Kauffer and Epstein say access to protease inhibitors has not been a problem for these patients so far. But both are troubled by the possibility that it may become an issue in the near future. "If these patients stay on public aid, they should be able to access the drugs. But if they are discharged from hospice and have no home to go to, they may soon become afloat and jeopardize their health benefits," says Kauffer.
Kauffer and Epstein say states and hospice providers are responding to this problem with two efforts to decrease the cost of protease inhibitor therapy. Horizon House is working with other area hospices and the state hospice organization to lobby manufacturers of the drugs to lower the costs. And Epstein says representatives from her department have met with other state and territorial AIDS directors to explore how the federal drug purchasing program can be used to decrease the purchasing costs of antiretroviral drugs. "Getting these drugs cheaper is a top priority for our department," she says.
The high cost of drug therapy also places a huge responsibility on hospice physicians and case managers to make sure the drug regimen is followed by patients, experts say. "A lot of money will be wasted if we don’t properly educate patients about using these drugs," cautions Michael Wohlfeiler, MD, assistant medical director of VITAS Healthcare Corporation in Miami. He urges hospice providers to develop written information for patients on how to take the drugs.
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