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Physician Reimbursement and Retention in HIV Care: Racial Disparities in the US South
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Physician reimbursement affects care.
We found a positive and significant relationship between the physician fee ratio and retention in HIV care (Fig. 1). A 10-percentage point increase in the fee ratio was associated with a 4% increase in the likelihood of retention (adjusted odds ratio 1.04; 95% confidence interval 1.01 to 1.07). In stratified analysis, there was an association only among non-Hispanic Black enrollees (1.08; 1.05, 1.12).
One explanation for these racial differences is the manifold structural disparities inherently faced by Black individuals. Reduction in 1 structural barrier might disproportionately and favorably impact non-Hispanic Black than non-Hispanic White individuals living with HIV, who face fewer structural barriers. The removal of 1 structural barrier is likely to have greater weight for groups burdened by many structural barriers. Thus, our results may reflect a ceiling effect among non-Hispanic White enrollees, who had a higher proportion of their enrollment retained in care (81%) than non-Hispanic Black enrollees (76%). Increasing Medicaid physician reimbursement to parity may be a mechanism to narrow the gap in retention in HIV care between non-Hispanic White and non-Hispanic Black individuals living with HIV.
Retention in HIV care, and racial disparities in retention, could be mitigated by addressing structural barriers to care. We find that retention in HIV care is higher among enrollees living in states with higher Medicaid physician reimbursement, regardless of the definition of retention, enrollee payment type, and fee ratio type. Notably, this relationship occurs almost exclusively among non-Hispanic Black enrollees. Findings suggest that even modest increases in physician reimbursement may improve retention in HIV care.
Physician reimbursement is a structural factor that may impact the quality of care and health outcomes. Lower physician reimbursement is associated with worse appointment availability, longer waiting time, and lower probability of receiving care.8-11 Clinicians report low reimbursement as a barrier to HIV testing because reimbursement may not fully cover the time and care coordination required when delivering test results.12,13 Providing high-quality HIV care may similarly require substantial time investments relative to reimbursement levels, but the relationship between physician reimbursement and HIV care quality, including retention, has not been examined.
We examined the association between physician reimbursement and retention in HIV care and whether racial differences affected this relationship.

Retention in HIV care remains a national challenge. Addressing structural barriers to care may improve retention. We examined the association between physician reimbursement and retention in HIV care, including racial differences.
We integrated person-level administrative claims (Medicaid Analytic eXtract, 2008-2012), state Medicaid-to-Medicare physician fee ratios (Urban Institute, 2008, 2012), and county characteristics for 15 Southern states plus District of Columbia. The fee ratio is a standardized measure of physician reimbursement capturing Medicaid relative to Medicare physician reimbursement across states. Generalized estimating equations assessed the association between the fee ratio and retention (≥2 care markers ≥90 days apart in a calendar year). Stratified analyses assessed racial differences. We varied definitions of retention, subsamples, and definitions of the fee ratio, including the fee ratio at parity.
The sample included 55,237 adult Medicaid enrollees with HIV (179,002 enrollee years). Enrollees were retained in HIV care for 76.6% of their enrollment years, with retention lower among non-Hispanic Black (76.1%) versus non-Hispanic White enrollees (81.3%, P < 0.001). A 10-percentage point increase in physician reimbursement was associated with 4% increased odds of retention (adjusted odds ratio 1.04, 95% confidence interval: 1.01 to 1.07). In stratified analyses, the positive, significant association occurred among non-Hispanic Black (1.08, 1.05-1.12) but not non-Hispanic White enrollees (0.87, 0.74-1.02). Findings were robust across sensitivity analyses. When the fee ratio reached parity, predicted retention increased significantly overall and for non-Hispanic Black enrollees.
Higher physician reimbursement may improve retention in HIV care, particularly among non-Hispanic Black individuals, and could be a mechanism to promote health equity.

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