erosexual community? Would it protect the rest of the country? Would it protect the drug user community? Mr. THOMPSON. Since I know that both you and I spent time serving in the South Bronx, we know that that is not the case, that the complications of the drug community and IV drug use is not simply a matter of needles, clean or dirty. It is a matter of a very complicated set of lifestyles compounded by drug use that can simply not be addressed by making needles available. It is a much more complex social problem than that in the IV drug user community as well as among homosexuals. Mr. SCHEUER. Let me address one question to Dr. Boufford about the experience of New York. Why is it that New York seems to have the preponderance of the Nation's sufferers from AIDS as well as death from AIDS but has been so slow to develop the far less expensive and far more humanitarian treatment of AIDS in terms of home health care and hospices? Dr. BOUFFORD. I think that part of the reason is that the current reimbursement system has really always historically focused on inpatient services, and New York State has had a limit on long-term care facilities for all patients, which is exacerbated in situations like this. New York City has taken a major responsibility on itself, in providing very extensive home care and hospice services to patients in New York City, but most of that has been through tax levy funds because of the inadequacy of reimbursement for many of these services. Mr. SCHEUER. That is something that this committee ought to address itself to, Mr. Chairman, and I look forward to working with you on that. Thank you very much. Mr. WAXMAN. Thank you very much, Mr. Scheuer. You are representing hospitals. You are hospital administrators. You are not representatives of the Centers for Disease Control or public health agencies, and although how to stop the spread of this disease is obviously on all of our minds, as I indicated in my opening statement, even if we could stop the spread of AIDS, starting today, there would be at least 45,000 more Americans who will develop AIDS from infections they already have. Now, we all hope we will stop the spread of this disease and we are looking for any way to do that. But the reality for you as hospital administrators is you are going to have those AIDS patients in your hospitals. You have to give them care. Somebody has got to pay for that care, and it is appropriate for us to ask the questions who is going to pay. It is not going to be the insurers, it is going to be the taxpayers. Are we going to ask the hospitals to do it, and absorb the costs? Are we going to ask the patients to pay? And if they don't have the money, who will pay for them? This is a very difficult question. I think you have given us some sense of the problem and other witnesses this morning will give us some other perspectives as well. I don't know that any of us have answers. Thank you very much for participating in this hearing. Our next witness is Dr. Ann Hardy, an epidemiologist, Surveillance and Statistics Section, AIDS Activity, Center for Infectious Diseases, Centers for Disease Control. Dr. Hardy, we are pleased to have you with us. We are looking forward to your testimony. We would like to have you keep your oral presentation as close to 5 minutes as possible, and we will have all the written testimony in the record. Could you be sure the microphone is on. Dr. HARDY. I think it is. STATEMENT OF ANN M. HARDY, DR. P.H., EPIDEMIOLOGIST, SUR- Dr. HARDY. Mr. Chairman and members of the subcommittee, I first want to thank you for giving me the opportunity to speak today. Since AIDS was first recognized in 1981, over 14,000 cases have been reported to the CDC. Because AIDS is such a serious disease and affects a relatively young population, its potential economic impact is great. My coworkers and I have developed estimates of certain aspects of this impact for the first 10,000 reported cases of AIDS in the United States. These estimates include estimates for expenditures of hospitalization and estimates of resources lost due to disability and premature mortality. First let me point out that the data available to make the necessary calculations for these estimates were limited, and often based on small samples of patients, but they represent the best, and often the only, data that could be obtained. These data were extrapolated to the 10,000 patients to get national cost estimates. Because of these limitations, the cost figures should be viewed with a certain amount of caution, and are best used as broad estimates. Hospitalization expenditures were calculated by multiplying the estimated total number of hospital days for the 10,000 cases by the estimated average daily hospital charge for AIDS patients. Data available to determine total hospital days included the average length of hospital stay for AIDS patients, which was available from three surveys, one done in San Francisco, one done in the municipal hospitals in New York City, and one done in Philadelphia. This figure was used to estimate the duration of the first hospitalization for AIDS. To estimate rehospitalizations, we used the percentage of time hospitalized after the initial hospital stay from a study published by the New York City Health Department. For the purpose of our calculations, we used a median survival from AIDS diagnosis of 56 weeks. We estimated that the 10,000 AIDS patients would require approximately 1,678,000 hospital days. Again let me point out that since the data used to arrive at this estimate involved hospitalizations that occurred between 1981 and 1984, we urge caution in projecting lengths of hospital stay for future patients. To estimate expenditures for hospital care of AIDS patients, the hospital days were multiplied by $878, which was the average daily charge for AIDS patients admitted to an acute care hospital in Atlanta. The result was an estimated $1.47 billion in expenditures for hospitalization. In addition to the costs for health care, there are indirect costs from work loss from disability and premature mortality of AIDS patients. Based on data collected by the New York Health Department, we assumed that 86 percent of all AIDS patients would be unable to work from diagnosis until death, and that these patients would lose approximately 8,000 years of work due to disability at a cost of almost $189 million in lost earnings. The cost of premature death due to AIDS was calculated assuming all 10,000 patients would die prematurely from the disease. Using standard tables for potential future income by age at death, the economic loss in 1985 dollars from future earnings lost following the premature death of these 10,000 patients was calculated to be $4.68 billion. To express our findings in another way, we estimated that the average AIDS patient would be hospitalized for 168 days before eventually dying, with the resulting expenditures totaling $147,000 per patient. Each patient will also lose an estimated 10 months' potential working time and $19,000 in income due to disability. The loss per patient death in terms of future income is $470,000. Again, the figures that I have presented are estimates, since relevant data was available from only a few sources. For individual patients, costs will vary depending on a variety of factors, including the opportunistic diseases, the duration and frequency of hospitalization, and the geographic location of the patient. As more detailed information relative to costs is collected, improvements can be made in the cost estimates. CDC has recently contracted to determine the economic and financial implications of AIDS nationally, including the impact of recommendations for the prevention and the control of AIDS. Our estimate of $147,000 for the hospital care of each AIDS patient may be high in part because data on hospitalization after initial stay was available only from New York City, and hospital usage by AIDS patients there may be greater than by patients in other areas. It is important to note that there is potential for these expenditures to be reduced somewhat through means such as the development of more effective drugs to treat the opportunistic diseases and increased availability of out-of-hospital care. Also I should mention that other important health care expenditures such as home medical care and outpatient care could not be estimated due to lack of data. [The prepared statement of Dr. Hardy follows:] Statement of Ann M. Hardy, Dr.P.H. Surveillance and Statistics Section Center for Infectious Diseases Mr. Chairman and members of the Subcommittee: I am Ann H. Hardy, Dr.P.H., an epidemiologist in the AIDS Activity of the Center for Infectious Diseases, Centers for Disease Control, Public Health Service, Department of Health and Human Services. Thank you for the opportunity to discuss certain aspects of the economic impact of acquired immunodeficiency syndrome (AIDS) on the United States. Since AIDS was first recognized in 1981, over 14,000 cases including some 200 children, have been diagnosed and reported to the Centers for Disease Control (CDC). AIDS is a severely debilitating disease representing the severe end of the clinical spectrum of infection with a retrovirus termed HTLV-III or LAV. Patients with AIDS often require prolonged and repeated hospitalizations and the outcome of this disease is usually fatal. Over 90% of AIDS patients are between the ages of 20 and 49 years. Because AIDS is so serious and affects a relatively young population, its economic impact is great. Today I will discuss one set of estimates we have developed of this impact for the first 10,000 reported cases of AIDS in the United States. This work is the result of a collaborative effort involving Dr. Dean Echenberg and Ms. Kathyrn Rauch of the San Francisco Health Department and Drs. Meade Morgan, James Curran, and myself of the AIDS Activity at CDC. The economic impact for the 10,000 cases was measured in terms of expenditures for hospitalization after AIDS diagnosis and resources lost due to disability and premature mortality from AIDS. A summary of the formulas used to derive these estimates is given in the Appendix. The data available to make the necessary calculations were limited and often based on small samples of patients but represent the best and sometimes the only data that could be obtained. The data from these samples were extrapolated to the 10,000 cases to arrive at national cost estimates. Because of the limitations of the data these estimates could not be subdivided by such things as geographic area, patient characteristic, or type of opportunistic disease. The cost figures should be viewed with a certain amount of caution and are best used as broad estimates. Hospitalization expenditures were calculated by multiplying the estimated total number of hospital days for the 10,000 cases by the estimated average daily hospital charge for AIDS patients. Data available to determine total hospital days included the average length of hospital stay (used to estimate the duration of initial hospitalization) and the percentage of time hospitalized after the initial hospital stay. The average length of hospital stay was obtained from three surveys: o A survey of approximately 60 hospitalizations for AIDS that occurred over a 1-month period in the 15 acute care hospitals in San Francisco found an average stay of 12 days. O Another survey, conducted in the municipal hospitals in New York City, found the average length of stay to be 50 days for 67 AIDS patients identified in these hospitals during a 1-week period. Preliminary analysis of an ongoing follow-up study of AIDS patients in Philadelphia found an average stay of 31 days for 16 AIDS patients who died during their initial hospitalization. |