Table 2.

Themes Describing how Payers Influence Cardiovascular Preventative Care in HIV

Theme	Description	Patient Quote	Provider Quote	Implications for HIV Primary Care
Power of the Purse	Payers exert significant control over the in clinic delivery of cardiovascular preventative care and the at-home self management of preventative behaviors	“I moved here three and a half years ago. Previously, my HIV doctor was also my primary doctor. The insurance systems out there allowed that. When I moved here, the insurance systems don’t allow that. They force you – my HIV doctor was going to be my primary, but the insurance coverage forced it that I had to have a primary.” – Male PLWH, 24 years living with HIV “Cost can be a factor [in taking cardiovascular medications] and fighting the insurance company can be a factor.” – Female PLWH, 17 years living with HIV	“Oh, insurance. No. 1. Insurance. Insurance companies make it very difficult. I think they try, when they’re trying to tell you what’s better for the patient rather than the doctor dictating it. That’s frustrating” –Female Social Worker, 6 years HIV experience	• Clinics receiving Ryan White HIV/AIDS Program funds may need additional interventions to increase awareness about the importance of cardiovascular disease prevention in HIV • Enhanced communication between commercial insurers, patients, and clinical staff may result in more effective implementation prevention strategies • Expanded access to cardiovascular disease prevention tools for PLWH can help mitigate their increased risk • HIV and primary care providers should consider working together to develop new models of value-added care tailored to the needs of PLWH
Relative Value Units pressures may disincentive CVD Prevention	Health systems organized around relative value units (RVUs) experience pressures that may disincentivize CVD prevention efforts by HIV specialty care provider		“And so, things that make our job more difficult, I think are the sort of business side of medicine that most people recognize throughout the world, or at least the United States, that is the bureaucracy” –Male Physician, 20 years HIV experience	• Deem a higher value for comprehensive prevention services provided by the HIV team • Stronger consideration of bundled preventative service, perhaps through the annual wellness visits, in HIV clinics • Consider de-emphasizing and de-coupling RVU generation from providers’ annual performance
Grant funding can be a double-edge sword in CVD prevention	Grant-based services enable locally-tailored CVD prevention strategies but are limited by the funder’s timeline, priorities and requirements	“We do have other groups here. You ask your doctor and they can give you instructions. We used to have X. It used to be on Main Street. But the one here in closed.” - Male PLWH, 6 years living with HIV	“Because one of the priorities in quality improvement that our funders have seen is that youth aren’t getting in to – they’re not getting virally suppressed, so they’re not getting into care, taking their meds, they’re the vulnerable population right now.” Female Social Worker, 4 years HIV experience	• Holistic evidence-based cardiovascular health initiatives can be better integrated, and consistently funded, into HIV clinics • Proposed sustainability plans should include how the team will engage with payers to facilitate the long-term integration of prevention initiatives