Medical Care Systems

Medical care comes in two general types: managed care and fee-for- service. In managed care, an organization takes financial and medical re­sponsibility for your care. There are several types of managed care or­ganizations; the most common among people with HIV infection are health maintenance organizations, or HMOs.

With managed care organizations, the good news is that the orga­nization will provide all the medical care services without a charge be­yond the monthly fee. The bad news is that most organizations have their own networks of health care providers and facilities, so that op­tions for selecting health care providers or for choosing hospitals are lim­ited. This means that patients cannot pick their own doctors, or that they may not continue to see a doctor they had picked previously unless they pay for the service.

The driving force in these organizations is cost saving. Savings are often accomplished with three general tactics: (1) limitations on the availability of services, (2) reduced or capitated reimbursement for ser­vices, or (3) substitutions. The organization assigns a fee per patient per month. The fee may be a full cap, which covers everything; or a partial cap, which covers some services but not all; or subcapitation, which cov­ers some services done elsewhere. Substitution means an aide does the work usually assigned to a nurse, or a physician’s assistant does the work usually assigned to a physician, or a general practitioner does the work of a specialist.

In the battle to reduce cost, the highest priority is allocated to elim­inating hospital care, which is by far the most expensive component of the U.S. health care bill. Another tactic to reduce cost, called “cherry picking,” is for the managed care organization or HMO to enroll pa­tients who are unlikely to need medical services. Quality is neither rec­ognized nor rewarded. In fact, many HMOs provide financial incentives to physicians to avoid consultations, expensive tests, or expensive treat­ments.

People with HIV infection frequently need medical services and are seen by managed care organizations or HMOs as high risks. Many peo­ple with HIV infection will find themselves victims of cherry picking; if they succeed in enrolling in an organization, their access to services and to medical expertise may be limited. They may have particular difficulty finding experts in HIV infection, in part because no managed care or­ganization or HMO wants to be the selective referral source for patients who might be expensive to treat. Mental health services are especially difficult to find in these organizations.

Fee-for-service might also impose sharp limitations on medical care for people with HIV infection. There are three types of limitations: ac­cess to insurance, denial of payment for preexisting conditions, and lim­ited coverage for a diverse range of services. Most insurance companies limit the access of individual applicants who are considered high risks; acceptance in group policies through employment plans is much more readily available. Services covered are specific to the plan. All plans cover the high-priced item—hospitalization—but may have a cap, a co-pay, or a restriction on services. Coverage of other medical care services—includ- ing outpatient visits, pharmacies, home care services, and nursing home services—is quite variable. The most important plan for people with HIV infection is the pharmacy plan. HIV drugs now account for half the total HIV medical bill: the average HAART regimen costs $10,000 to $15,000 per year.

Medical care is provided by different kinds of people offering dif­ferent services in different settings. The providers of medical care are professionals: they are physicians, physician’s assistants, and nurse prac­titioners. The setting in which care is provided can generally be divided into two components: outpatient facilities and inpatient facilities. Out­patient facilities are individual physicians’ offices, clinics staffed by physicians who practice as a group, managed care organizations or HMOs, and public health department clinics. Inpatient facilities, which are primarily hospitals and nursing homes, are generally used by people who need more intensive care.

In recent years, because hospital care in the United States is now enormously expensive, there has been a growing demand for alternatives to hospitals. These alternatives now include chronic care facilities (like nursing homes), home care programs, day care centers, infusion centers, hospice care facilities and programs, and outpatient clinics. Some of the alternatives provide the services—including transfusions and other in­fusion services and same-day surgery — previously provided only in hos­pitals. Hospitalization in acute care hospitals accounts for about 15 to 20 percent of the total cost of HIV care. So for managed care organiza­tions or HMOs, these less expensive alternatives to hospitals are a high priority.

Financing for this complex network of resources varies: the prin­cipal modes of funding are Blue Cross-Blue Shield and other insur­ance companies, managed care organizations or HMOs, self-pay, and the government programs for assistance with medical bills (Medicaid and Medicare). Chapter 9 will discuss how to finance medical care— since financing is obviously a major factor in deciding which option to choose.

Regardless of which option for medical care you choose, it is im­portant to have

—a physician who has extensive experience with HIV infection;

—a close physician-patient relationship;

—the services of medical specialists as they are needed;

—the services of psychiatrists, psychologists, or support groups as they are needed;

—emergency medical services;

—a hospital with appropriate resources;

—such alternatives to hospital care as home therapy, chronic care facilities, and hospice care.

It is particularly important to have access to a physician or hospital or clinic that will provide the special medical resources and skills needed to treat people with HIV infection. The treatment of HIV infection is a fast-moving field: medical therapy now makes a substantial difference in the progress of the disease, and new treatments are continually being de­veloped. HIV care is now a specialty with its own research agenda, jour­nals, care programs, conferences, and experts. It is important for a per­son with HIV infection to have care from someone included in this HIV care network.