Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA.
Department of Psychology, University of Virginia, Charlottesville, VA, USA.
AIDS Res Ther. 2024 Nov 19;21(1):83. doi: 10.1186/s12981-024-00674-9.
With access to and uptake of pre-exposure prophylaxis (PrEP), the United States can prevent new HIV infections. To end the HIV epidemic, health insurance plans must facilitate access to comprehensive preventive care benefits. Since plan benefit designs vary considerably by plan, it is difficult to systematically determine plans that facilitate and restrict preventive services for PrEP.
We applied an unsupervised machine learning method to cluster 17,061 Qualified Health Plans offered to individuals. We examined the clusters to draw conclusions about the types of benefits insurance companies tend to group together in plans. Then we analyzed the geographic distribution of those clusters across the United States to assess geographic inequities in access to HIV preventive care.
Our method uncovered three cohesive clusters of plans. Plans in Cluster 1: the least restrictive cluster, facilitate access to preventive care using copays over coinsurance on almost all benefits; Cluster 2: the moderately restrictive cluster, plans cover HIV prevention benefits with copays but restrict access to general health benefits with coinsurance; and Cluster 3: the most restrictive cluster, plans cover almost all benefits using coinsurance. Overall, increased prior authorization requirements tend to accompany reductions in out-of-pocket costs. Examining the geographic plan distribution, states with at least one rating area where at least 75% of plans offered are in the most restrictive cluster included: Georgia, Illinois, Missouri, Oklahoma, Texas, Virginia, and Wyoming.
Insurance plan design is complex. To address the ambitious call to end the HIV epidemic in this country, plans should also take into account both public health and health equity factors to create plan designs that ensure access to critical preventive services for people who need them most. Addressing the growing disparities in PrEP access along racial and ethnic lines should be a national priority, and federal and state insurance regulators as well as insurance plans themselves should be part of the conversation about how to ensure people who would benefit from PrEP can access it. Better state/federal regulation of plan design to ensure access is consistent, equitable, and based on clinical recommendations will reduce the variability across plan designs.
随着人们获得并使用暴露前预防（PrEP），美国可以预防新的 HIV 感染。为了终结 HIV 疫情，健康保险计划必须为全面预防保健提供便利。由于计划福利设计因计划而异，因此难以系统地确定促进和限制 PrEP 预防服务的计划。
我们应用无监督机器学习方法对向个人提供的 17061 个合格健康计划进行聚类。我们检查了这些集群，以得出关于保险公司倾向于在计划中组合在一起的各种福利类型的结论。然后，我们分析了这些集群在美国各地的地理分布，以评估获得 HIV 预防保健服务方面的地理不平等现象。
我们的方法揭示了三个凝聚力较强的计划集群。在集群 1 中，计划限制最少，几乎所有福利都通过共同支付而不是共付额来促进预防性保健的获取；集群 2：中等限制集群，计划通过共同支付来支付 HIV 预防福利，但通过共付额来限制一般健康福利的获取；集群 3：限制最多的集群，计划几乎全部通过共付额来支付。总体而言，增加事先授权要求往往伴随着自付费用的降低。检查地理计划分布，至少有一个评级区的至少 75%的计划属于最严格集群的州包括：佐治亚州、伊利诺伊州、密苏里州、俄克拉荷马州、得克萨斯州、弗吉尼亚州和怀俄明州。
保险计划设计复杂。为了实现结束该国 HIV 疫情的雄心勃勃的呼吁，计划还应考虑公共卫生和健康公平因素，制定确保最需要的人获得关键预防服务的计划设计。解决 PrEP 获取方面日益扩大的种族和族裔差异应成为国家优先事项，联邦和州保险监管机构以及保险计划本身都应参与关于如何确保从 PrEP 中受益的人能够获得 PrEP 的讨论。更好的州/联邦计划设计监管，以确保获取的一致性、公平性和基于临床建议，将减少计划设计之间的差异。
