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Transitioning from Categorical Support for Clinical HIV Testing in the District of Columbia to a Stronger Reliance on Third Party Reimbursement: A Case Study Open Access

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Newly enacted provisions outlined through the Affordable Care Act (ACA) may substantially expand health care coverage in the United States and require or incentivize third party payers to offer reimbursement for preventive services that receive a Grade A or B rating from the United States Preventive Services Task Force (USPSTF). Using a qualitative case study approach, this study sought to gain a better understanding of the challenges and facilitators that primary care clinics providing HIV testing in the District of Columbia (DC) may encounter as they transition away from dedicated support through external grant funding and implementation support to a stronger reliance on coverage through third party reimbursement (TPR). Since the release of the 2006 Centers for Disease Control and Prevention recommendations for routine HIV testing, the DC Department of Health (DOH) has provided substantial support for the implementation of HIV testing through the provision of free rapid test kits to implementing sites. Because of this support, most sites have not actively sought out third party reimbursement. An implementation science framework guided the study's exploration of the factors and processes that may contribute to moving through this transition and achieving the sustainable implementation of HIV testing in DC. An embedded case study design was utilized that incorporates three sub-units of analysis including: DC government representatives, reimbursement stakeholders, and DC DOH-supported primary care providers. Data was collected through document review and interviews. Purposeful sampling was used to identify key informants and their organizational affiliations at the appropriate sub-units of analysis. Four primary care clinics were selected based on three criteria: number of clinic patients, availability of dedicated resources for HIV testing, and testing models and their implications for billing and reimbursement. The study found support for its initial propositions. Key informants were knowledgeable and held favorable views about a shifting resource environment resulting from decreased public funding and expanded health care coverage through ACA. However, when it came to the transition away from categorical support for HIV testing from HAHTA to a stronger reliance on TPR, clinical informants perceived this transition less favorably. This sentiment resulted from challenges they encountered in trying to seek TPR to sustain their testing programs. Barriers to a successful transition to a stronger reliance on TPR included policies and procedures related to TPR, resource constraints, organizational factors, and communication between stakeholders. Third party reimbursement barriers largely had to do with testing strategies that were not compatible with current third party policies and procedures. Specific challenges included current categorical support, staffing models and use of non-credentialed providers, bundled reimbursement rates, and inadequate reimbursement. Key recommendations resulting from this study include: 1) Assessment and Expansion of FQHC Coverage of Preventive Services; 2) Expansion of coverage for testing by non-credentialed providers; 3) Increased requirements for DC Medicaid MCOs; 4) Update for Medicare's national coverage determination for routine testing; 5) Expansion of HAHSTA's support to explore ways to facilitate reimbursement for rapid HIV testing; 6) Improved communication between stakeholders; and 7) Ongoing clinic assessment of TPR.

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