New Healthcare Economics Threaten HIV Specialization, Patient Choice, & Quality Care

Even in San Francisco, changes in managed care during the last few years have forced many of the leading HIV physicians to spend much of their time in non-HIV care in order to support their HIV practices, or to take other work and stop seeing patients altogether. Elsewhere in the U.S., the loss of expertise in HIV care may be even more severe. While the specifics are complex, the basic problem is that many private health plans do not want expensive patients, and use grossly inadequate reimbursements to discourage the doctors who would attract them. Persons with HIV are far more affected by this problem than those with cancer, diabetes, or other similarly expensive diseases, because unlike HIV they are recognized as requiring care within a traditional medical specialty.

One way for health plans to underpay HIV specialists is to claim that HIV disease treatment is part of primary care, which all their physicians can do--and then pay only the healthy adult capitated rate (often about $8 per month) for all office visits the HIV or AIDS patient may need. ('Capitation', the basic element of managed care, means that physicians are paid a set amount per patient per month, regardless of how much care they turn out to need.) The doctors are expected to make up their losses on each patient with HIV by also caring for many more patients who are healthy enough to need only minimal medical care. The result of paying only the healthy-patient rate is that physicians who tend to specialize in HIV are penalized, since they will lose money on all these patients, and have few others with whom to make up the loss.

The issue here is not limited resources, but perverse incentives. It is well known that HIV-experienced physicians have much better survival and other outcomes than inexperienced physicians; a major report published March 1996 in the New England Journal of Medicine found a 31% to 44% lower risk of death with experienced HIV physicians, after adjusting for other risk factors.1 The medical consequences of discouraging specialization are well known.

But also it is becoming clear that quality care from HIV specialists is not more expensive, and sometimes less so, than care from inexperienced physicians who are more likely to make costly mistakes. Therefore, the policies which make it difficult or impossible to specialize in HIV care do not save money for the healthcare system overall. Instead, they result from a "race to the bottom" in which each particular health plan can save money by creating prohibitive disincentives for physicians to offer the kind of quality care which could save lives--and which would also lead to "adverse selection" of more expensive patients into that plan, because they are attracted by the high quality of care.

No health-insurance plan could get away with saying that cancer, for example, should be treated by primary-care physicians, instead of oncologists. But HIV care--for varied reasons, including the stigma which has surrounded AIDS and still remains, although less acknowledged today--has developed as a specialty in fact, without the protection of formal recognition within medicine as a whole.


Managed Care and IPAs (Independent Physician Associations)

Doctors can sometimes restrain managed-care abuses by organizing into IPAs (independent physician associations). But whether IPAs care much about the problems of HIV specialists is likely to depend on the politics of where they are located. In San Francisco, the largest IPA by far is Brown & Toland, which has been a leader in defining protocols for high quality and cost-effective HIV care (see "HMOs and Quality Care for HIV--Interview with Stephen Becker, M.D., AIDS Treatment News #278, September 5, 1997). Most of the country will not be as fortunate.

Brown & Toland--which began in January 1997 as a merger of the IPAs of two major hospitals, University of California San Francisco and California Pacific Medical Center--has the clout to negotiate contracts which can force health-insurance plans to provide medically appropriate care--including viable reimbursement for HIV care. It insists on controversial exclusivity provisions (a physician in Brown & Toland cannot also be in other IPAs, for example), and includes so many physicians in San Francisco that health plans which refused to deal with it, and therefore could not list any of these physicians, would be handicapped in selling their services to employers. Brown & Toland has made it possible for some HIV specialists to remain in practice in San Francisco and be available to patients through their health plans.

But some of the major HIV physicians in San Francisco cannot join Brown & Toland, because of action against it by the U.S. Federal Trade Commission, which suspects it of violating antitrust laws. Because of the FTC action, which started well over a year ago, only a limited number of physicians can join Brown & Toland; particularly affected have been doctors who were already in other IPAs which they would have had to leave due to the exclusivity. This FTC action is part of a long-existing Federal policy of aggressively using antitrust laws to prevent physicians from unionizing effectively--a policy with mixed results today because it prevents physicians from curtailing abuses of managed care.

[In a different case, unrelated to HIV, on January 14, 1999 St. Luke's Hospital sued California Pacific Medical Center, charging that it used an exclusive contract with Brown & Toland to require physicians to admit lucrative patients to CPMC instead of St. Luke's, despite higher costs at CPMC, according to the San Francisco Chronicle ("2 S.F. Hospitals Battle Over Antitrust Lawsuit," by Tom Abate, page C2). St. Luke's accepts a disproportionate share of the poor--about half its patients are low income--and has remained independent; the larger, commercial medical systems do not want poor patients. "Cherry picking" of St. Luke's privately insured patients by CPMC, a unit of the huge Sutter Health System, could leave St. Luke's with mostly Medicaid patients, which are reimbursed at less than cost, threatening the hospital's survival.]

HIV specialists in San Francisco who cannot join Brown & Toland have difficulty being accepted by private health-insurance plans, since these doctors would attract expensive patients; therefore most patients cannot see these doctors under their employer-provided health plans. Or the doctors may be accepted but paid only for primary care (the healthy-adult capitated rate), meaning that they lose money on every patient and have to support their HIV practice by other work.

Compounding the problem is that many PPO (preferred provider organization) health plans have suddenly been discontinued in San Francisco, forcing patients into HMOs (or into health systems such as Kaiser, if offered by the employer). PPOs allow patients greater choice, since they can go outside of the plan and see any doctor, although at lower reimbursement than if they use doctors in the plan. Also, PPOs are usually less aggressive than HMOs in dictating what treatments will be covered. Recently many employers have discontinued their PPO plans to save money, and patients have had to leave physicians with whom they had a long-standing relationship (or not use their healthcare coverage and pay out of pocket, which few can afford to do).


The Larger Picture

In most of the country the situation is worse than in San Francisco or other centers of AIDS medicine, as usually there will not be enough physicians interested in HIV to get a powerful IPA or other medical organization to negotiate with the health plans on their behalf. Unless solutions are found, physicians will be discouraged from developing expertise in HIV care just because of how managed care is organized--even when there is plenty of need, and a market for their expertise would otherwise exist. Patients who want to get care from specialists will have to leave the area, when such care should be available locally.

Even in San Francisco, despite the strength of the AIDS community, there has been remarkably little public discussion of these problems--even as leading HIV specialists have been forced out of private practice or sometimes out of medicine, while the number of people living with HIV and AIDS continues to increase. AIDS activists have learned the intricacies of clinical research, but often had little interest in the details of the organization or disorganization of medical care. Part of the problem has been the great complexity of the de-facto healthcare "system" in the U.S., and the great differences between states and cities in the arrangements people have invented to get by. There has also been some misguided sentiment that these problems belong to physicians alone--even when patient choice and quality of care is threatened due to clear "redlining" of people with HIV and AIDS by health-insurance organizations.

There are potential solutions--from public exposure and pressure against specific abuses, to establishment of official standards of HIV care which health plans cannot ignore with impunity, to joining with other advocates for broader healthcare reform. A first step is to maintain an open and vigorous discussion of what is happening now, and options for doing better in the future.

Note: AIDS Treatment News will continue to cover the impact of managed care on access to HIV-experienced physicians. You can help by bringing problems and other information to our attention.


References

1. Kitahata MM, Koepsell TD, Deyo RA, Maxwell CL, Dodge WT, and Wagner EH. Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival. New England Journal of Medicine. March 14, 1996, volume 334, number 11, pages 701-706. Also note comment and discussion in the New England Journal of Medicine, August 1, 1996.