Limits on Your Options for Medical Care
Your options for medical care will depend on where you live. The kind of care specific to HIV infection is likely to be better in a big city: most big cities offer many options for treatment of HIV infection.
Smaller cities and rural areas are likely to offer fewer options, and the physicians in these areas are less likely to be familiar with HIV infection. This is because most of the people who became infected in the early stages of this epidemic lived primarily in large cities like New York, San Francisco, Los Angeles, Miami, and Washington, D.C.; disproportionately fewer people living in smaller cities and rural areas were infected. As a result, physicians who trained or who practice in small cities or rural areas often lack experience in treating HIV infection.As a consequence, when people with HIV infection who live in small cities and rural areas want medical treatment or periodic consultation about medical treatment, they often travel to the nearest physician or clinic specializing in HIV infection (see below, under “Choosing a Physician”). Some people also travel to more distant clinics or physicians to get the anonymity they cannot get locally.
The options for medical care may be substantially fewer for people who are in managed care organizations or HMOs, for people receiving Medicaid, and for people who have limited financial resources and no health insurance. Managed care organizations or HMOs and city health clinics offer medical services that vary in quality, some very good and some not so good. Large urban areas have federal funds from the Ryan White Act to provide medical care and support services for people with HIV infection. The range of services offered and the quality of those services are both variable. Most people served under this act are uninsured or underinsured and have limited financial resources.
Managed care organizations or HMOs are networks of service providers that contract for all the health care of their subscribers. These organizations provide comprehensive services—but to be profitable and competitive, they prefer to have healthy subscribers who don’t need health care. Conditions like HIV infection that are chronic and expensive to treat are avoided when possible, and quality services tailored to the specific needs of people with HIV are rare. These organizations may also limit access to any component of health care that is expensive: hospitalization, laboratory tests, radiology procedures, or consultations with specialists. Some organizations are exceptions to these rules, so the person with HIV infection may be lucky, or may need to search them out. Some organizations do not allow patients to see physicians other than those physicians who participate in that organization, or do so only on a case-by-case basis. People enrolled in those organizations therefore have no choice in what specialists they see. The organization can also limit the hospitals people may be admitted to.
The process of selecting among medical options begins with finding out what your finances allow and what publicly funded resources are available. This disease is expensive, and managed care organizations or HMOs, insurance plans, and Medicaid will each pay for some things and not for others. Many insurance plans especially restrict the outpatient services they cover. Medicaid covers a broad range of services but reimburses physicians at so low a rate that most physicians refuse to accept patients paying through Medicaid. Many employers offer a choice between joining a managed care organization or HMO or being reimbursed by the insurance company, and you may be able to switch back and forth as your needs dictate. In any case, you need to know your options. You can begin by finding out what your organization, insurance company, or government medical assistance will allow (see chapter 9), and then discussing these issues candidly with your physician or with a social worker.