Specialist self-referral insurance policies and access to physicians with HIV clinical expertise: Impact on patient health-related quality of life and treatment expenditures

Health insurance that requires pre-authorization for the use of specialists has drawn criticism from HIV patients and their advocates, because of evidence that patients of specialist providers—defined by residency training or high HIV-patient volume—are at lower risk for death. It is unclear, however, whether patients who can self-refer actually have better access to specialists than do patients who need pre-authorization. Further, the impact of HIV specialty care on health-related quality of life (HRQOL) and treatment expenditures has not been examined. Analyzing data on a representative sample of 2,864 HIV patients in the United States, I found that approximately 52% of patients had some form of insurance coverage that allowed self-referral to specialists. In multivariate analyses, being able to self-refer was associated with having a physician who, according to patients, “mostly treated HIV” disease (RR = 1.11; 95% CI = 1.01, 1.21) at baseline, but the finding did not hold at follow-up interview. This type of coverage was also not associated with having an infectious disease specialist, a high-volume physician, or a high-volume infectious disease specialist in standard multivariate analysis. However, in stratified propensity score analyses, results suggested that patients with self-referral policies were more likely than others to have infectious disease specialists (RR = 1.19; 95% CI = 1.05, 1.32) and higher-volume infectious disease specialists (RR = 1.45; 95% CI = 1.16, 1.74) as a regular source of care. In multivariate analysis, having a physician who “mostly treated HIV” was associated with lower physical HRQOL. Treating the independent variable as endogenous in a two-stage least squares regression changed the sign of the coefficient to positive, but the corrected estimate was relatively imprecise (β = 1.00; 95% CI = −3.35, 5.35). Finally, having a physician who “mostly treated HIV” was associated with a marginal increase in total treatment expenditures that ranged from {dollar}1,530 at baseline to {dollar}3,194 at follow up. Insurance plans that allow HIV patients to self-refer improves access to physicians with HIV expertise, but it is unclear from this analysis whether having such a physician has an effect on physical or mental HRQOL.