GMHC Treatment Issues, Volume 10, Number 6/7 - June/July 1996
Gabriel Torres, M.D.

The goal of managed care is to contain costs by coordinating care through a "gatekeeper," a general practitioner who decides on all referrals for diagnostic services, specialists, emergency care and hospitalizations. Gatekeepers often receive incentives from the plans for minimally serving patients; thus they minimize the number and types of referrals they make. Many plans have gatekeepers without appropriate HIV expertise but nonetheless refrain from referring patients to HIV or infectious disease specialists offering state-of-the art HIV care.

Capitation also provides incentives for early detection and preventive care to avoid higher costs for serious illness, but managed care plans often lack adequate outreach and culturally appropriate health education and HIV prevention services. In addition, many plans limit their drug formularies, nutritional services or range of therapies offered to include only the least costly option. Such restrictions may pose problems for HIV-positive patients, who may not receive the best treatment for their particular condition or stage of illness.

There are various sorts of managed care organizations, including two types of health maintenance organizations (HMOs): the traditional staff or group model and the independent practice association (IPA). The staff or group model HMO employs salaried doctors serving only plan members. IPAs are HMOs that contract with independent doctors and hospitals to provide care for their enrollees according to treatment protocols, per-case fees and review and approval rules set by the plan. In both cases, care is prepaid and members are covered only when using HMO-designated providers and hospitals.

Preferred provider organizations (PPOs) offer enrollees a network of "preferred" providers who deliver care according to set fee schedules. The managed care company may review individual providers' treatment decisions, but PPOs do not control decision making as closely as HMOs. They reimburse providers according to negotiated rates by the service rather than through captitated payments. PPO members may choose out- of-plan physicians but will be forced to pay higher out-of- pocket costs for doing so.

Employers more and more are choosing managed care plans to cut costs even though such plans have been reluctant to cover "high risk" groups such as people with HIV. HIV-positive beneficiaries should educate themselves on the services provided by each plan. Some features that are left out may be important in managing HIV infection, including mental health and substance abuse coverage. It is also advisable to ascertain which medications, nutritional supports and alternative treatments are in the plan's formulary, as some therapies may have been "carved out" from the program, and to determine the HIV expertise of the network or HMO physicians. A plan's complaint and grievance procedures also are important should needed services be denied.

Patients insured under the Medicaid or Medicare programs also are experiencing a growing shift toward mandatory managed care plans, although many state Medicaid programs have little experience providing HIV care under this new type of system. Small pilot programs have been initiated in California at the AIDS Health Care Foundation and in Baltimore at the Johns Hopkins University. These trial programs have assumed full responsibility for managing of HIV-positive patients insured under Medicaid.

In New York State, a planning process has begun to develop Special Needs Plans (SNPs), under the auspices of the New York State AIDS Institute. The SNPs would coordinate HIV care through regional networks of providers who work in unison and share the risk. These networks will ensure that all needed services, including hospitalization, outpatient care, substance abuse treatment, home care, emergency care, hospice care, case management, clinical trials and nutritional services, come under the umbrella of a lead or group of lead agencies who shoulder the financial risk. Pilot SNPs implemented next year are expected to have safeguards to avoid the pitfalls found in traditional HMOs.

----------------------------- Physician Training Threatened

The results of the Kitahata study imply that the continuing training of physicians devoted to HIV care is crucial to their optimal management of patients. Recent Congressional threats to the funding of the Education and Training Centers (ETCs), the federal program to train medical professionals in HIV care, may affect the ability of many providers to receive state-of-the-art medical information. ETC training can improve practice patterns and result in better health care outcomes for AIDS patients. On-going advocacy in Congress is needed to continue to support funding for the ETCs as a vehicle for keeping physicians current on HIV treatment.

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