Managed Care Problems: San Francisco Hearing Set for May 13
The San Francisco Board of Supervisors has scheduled a hearing May 13 into complaints that Brown & Toland, the dominant physicians' practice association in the city, has excluded the seven gay doctors who see 90% of the HIV patients at the former Davies Medical Center (now the Davies campus of California Pacific Medical Center), which is located a short walk from the center of the heavily gay Castro district--while inviting seven non-gay colleagues in the Davies Medical Group to join. The excluded doctors include some of the leading HIV specialists in the city; and without membership in Brown & Toland, it is often difficult or impossible for an independent San Francisco physician to be reimbursed by HMOs and other health insurance plans.The practice association has denied "that any physician has been denied membership into Brown & Toland on the basis of sexual orientation or on the basis of their patient population having HIV" (quoted in "AIDS Redlining Charged," by Mike McKee, in the May 3 issue of The Recorder, a legal newspaper in San Francisco). For background, see that article (http://www.law.com/jsp/ca/index.jsp; select Archive, then search for 'Toland'). AIDS Treatment News has reported on this controversy in issue #311, January 22, 1999 ("New Healthcare Economics Threaten HIV Specialization, Patient Choice, & Quality Care"), and #313, February 19, 1999 ("San Francisco: New HMO Problems Threaten Access to Care"). For a different look at Brown & Toland and its contributions toward establishing standards for health care, see AIDS Treatment News #278, September 5, 1997, and #280, October 3, 1997).
The May 13 hearing, intended to allow the issues to be explored in a public forum, has been scheduled for the Public Health and Environment Committee; for meeting information, call Greg Hobson at the Board of Supervisors, 415-554-4441.
Comment
The larger issue is that capitated managed care (where the health plan pays a fixed amount per patient per month, regardless of how much care they turn out to need) creates powerful incentives to ditch expensive patients and the doctors who treat them--especially in the case of a disease like AIDS, which is in fact a specialty but is not formally recognized as such. Independent practice associations (IPAs) like Brown & Toland can be caught in the middle, because they must negotiate with health plans seeking the lowest possible cost.
It is known that patients with HIV disease have substantially better survival when they are treated by expert physicians.1 Forcing experts to close their practices or leave their specialty seriously threatens access to quality care.
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.
