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H H S Department of Health and Human Services
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Severity of Need (SON) Index - Process - Panel Areas of Concentration

The four panels were organized according to the IOM’s conceptualization of the four SON components. Below is a chart listing the variables in each component and a brief explanation of each.

Panel: Area Characteristics

Area characteristics refer to structural characteristics of an area that make the care of HIV/AIDS more resource-intensive in one area than another. The primary example of this is disease burden, which refers to the number of HIV-infected patients in an area. All other things being equal, areas with many infected patients will require more resources than areas with few. However, fundamental questions exist regarding how to measure disease burden. Other structural differences that may affect the need for Ryan White Program funding include the type of health care staff available in an area, physician availability, the availability of services to those who need them, the number of people living in poverty, and an area’s urban/rural composition.

Area Characteristics

Disease burdenCommonly measured by the incidence or prevalence (point or period prevalence) of a disease
HIV incidencePriority 2007 Ryan White Program allocation formulas used estimated AIDS prevalence to quantify disease burden
HIV/AIDS prevalenceIncluding HIV burden estimates in Ryan White Program allocation formulas would be likely to shift funds to recently infected populations and away from areas with established epidemics
HIV to AIDS Case Ratio, and or disease stage informationThe quality of HIV data is not consistent across States and EMAs; uniform methodology for data collection unavailable

Defined by the CDC based largely on symptoms (e.g., AIDS-defining clinical conditions such as pulmonary tuberculosis, or recurrent pneumonia) or CD4+ cell counts (AIDS case surveillance definition CD4+ cell count < 200)

• Resource needs for patients in care vary significantly by disease stage; recently infected individuals generally require fewer resources than infected individuals at later disease stages
Poverty & economic considerationsPoverty status (typically reported as average per capita income or percentage of population below the Federal poverty level [FPL]) in an area is likely to affect available resources in calculating total resource needs
Measures collected from the censusProvides county-level information which grantees typically report in quantifying severity of need (e.g., estimating the size of special populations and reporting socioeconomic needs)

Disadvantage: Census data are not specific to HIV/AIDS
FPLMeasure updated annually by Census Bureau to estimate the number of Americans living in poverty (differs by number of persons in family unit)

Commonly used to determine eligibility for programs such as Head Start, National School Lunch, Food Stamps, etc.

HRSA/HAB asks grantees to provide estimates of the no. of people living at or below 300 percent of FPL (majority of estimates come from Census data or State Health Departments)
Urban/ruralHighly affected urban areas defined by EMA status (population greater than 50,000 with more than 2,000 reported AIDS cases within the last 5 years) – Part A grants created to provide immediate relief to urban areas overwhelmed by concentrated case loads


Panel: Patient Coverage and Need (for Services)

Patient coverage and need for services refers to estimates of the medical care available to patients and the level of need that infected patients have for services. These include both measures of the number of people already in care (Estimated Patient Load); indicators of unmet need, such as waiting lists for ADAP services or proxy measures for poor access; and social area analyses of basic needs for medical services.

Patient Coverage and Need (for Services)

Estimates of persons in care/not in careThree HIV populations addressed by Ryan White Program: undiagnosed and not in care; diagnosed and not in care; diagnosed and in care. Efforts typically have focused on diagnosed populations. The number of undiagnosed people not in care is difficult to estimate without HIV incidence data

Estimates from the literature suggest between 42 and 59 percent of all people with HIV/AIDS are not in regular care
Unmet needsTypically defined as eligible individuals not receiving care for HIV/AIDS – can include support services such as case management in addition primary medical care (which generally includes access to highly active antiretroviral therapy [HAART])

May be quantified using findings from the HIV Cost and Services Utilization Study (HCSUS), which included questions on use of HAART drugs and needs related to income assistance, housing, home health care, mental health care and alcohol/drug treatment
ADAP waiting listADAP provides funding primarily for medications, but it also supports treatment adherence counseling and purchases private insurance with prescription drug benefits

Financial eligibility requirements and drug coverage varies across States – increasing treatment costs and State budget shortfalls have forced many States to implement restrictions such as enrollment caps, limits on access to antiretroviral treatment, and expenditure caps

ADAP Supplemental Awards: 3% of ADAP funds earmarked for States with severe need (defined by FPL, medical eligibility, or a lack of access to or availability of drugs/health care)
Regional variations in needIOM Committee estimated preliminary models (termed social area analysis) of patient need (in addition to receipt of HAART) as a function of area characteristics, using data from the Census and HCSUS

Persons reported more needs if they lived in areas with fewer college-educated persons, fewer general practitioners, and more medical specialists
Need for core servicesNeed for specific Ryan White Program-funded services that have been termed “core services,” which include primary medical care, medications, and other primary healthcare services. However, the list of core services could be substantially shorter than the list of all services that Ryan White Program programs currently provide.
Hospital discharge dataMay be used to indicate unmet need in that hospitalization may be avoidable with adequate primary care. Hospital discharge data can also be used in active reporting (along with death records and other administrative data) to identify previously unreported cases based on HIV/AIDS-related discharge codes


Panel: Patient Characteristics

“Patient characteristics” refers to aspects of people infected with HIV that are expected to influence resource needs. For example, poor and uninsured HIV/AIDS patients are likely to require more Ryan White Program-funded services than more affluent patients. The presence of comorbid conditions such as TB, substance abuse, hepatitis C, and mental health problems likely make caring for HIV/AIDS patients more resource-intensive. The age of the epidemic in a geographic area and the distribution of patients among disease stages are also likely to affect resource needs, given the different medical complications associated with different stages. Concentrations of patients with high-risk characteristics may also lead to increases in cases in the future.

Patient Characteristics

Patient characteristics related to needHCSUS study: Persons with HIV on Medicaid or uninsured, along with women and racial/ethnic minority groups, did more poorly on a variety of access measures than individuals who were privately-insured, male, or white
Socio-demographics (race/ethnicity, gender, age)Area socio-demographic characteristics likely to be related to HIV resource needs as identified by the IOM Committee in preliminary analyses include: Percentage of the population that is African American, foreign born, living in urban areas, living in poverty, and college graduates
Co-morbiditiesMain co-morbid conditions include: TB, syphilis, gonorrhea, hepatitis C, injection drug use, other substance abuse, mental illness, homelessness

Large variation in the source, validity, reporting period and definitions used by EMAs to document co-morbidities (e.g., homeless during the past year vs. month)

Estimates largely reported among the general population instead of the HIV-infected population due to data limitations
Risk factorsServing a large poverty-stricken IDU population with high rates of no insurance may be more costly than having an affluent largely MSM population with great health benefits.

States often require documentation of associated risk factors in case reporting – completeness varies across States


Panel: Associated Costs

Associated costs refer to elements that make medical care more costly in one area than in another. These primarily include regional differences in the cost of medical services but may include other factors as well, such as State Medicaid reimbursement rates and information on the proportions of people with and without health insurance.

Associated Costs

Regional variations in costTotal cost of providing comparable care across areas may vary geographically due to differences in wage rates for health care workers, local costs of medical supplies and per capita income

Costs also may vary depending on levels of efficiency in providing care and economies of scale (e.g., areas with concentrated case loads or established epidemics)

Adjusted Average Per Capita Cost: controversial measure used by Medicare to adjust capitation rates for regional variations in cost
Resource needsDefined as the product of disease burden and cost of care minus available resources
Estimation based on health system qualityResource needs = (Disease burden * Cost of care) – Available resources
Availability of healthcare resourcesStructural measures (e.g., measures which address the characteristics or resources – training, supplies, staff, etc. – of an area or organization) thought to be associated with the quality and cost of care. The effects of staffing mix, physical surroundings, and availability of services on care are poorly understood
Physician shortage dataHealth Provider Shortage Areas (HPSA). Defined as a geographic area, population group, or medical facility that HHS determines to be served by too few health professionals of particular specialties. Physicians who provide services in HPSAs qualify for Medicare bonus payments. HPSA information is county-specific and may be used in analyses to account for general availability of medical personnel in an area
Insurance coverageHRSA/HAB asks grantees to provide estimates of the number of people without insurance, including those without Medicaid insurance
Medicaid generosityThe level at which State Medicaid programs currently provide benefits for HIV/AIDS services