ABLEnews Extra

                    Shutting Out the Sick

          As veterans of this echo know, CURE's opposition
          to euthanasia extends to its most virulent form,
          checkbook euthanasia.  Our early analysis of the
          managed care mills now replacing traditional
          fee-for-service medicine found that HMOs and
          other managed care schemes are prone to this
          profit-enhancing/patient-endangering practice.

          The evidence we found years ago in the back pages
          of medical journals is now reaching the front
          pages of daily newspapers like the San Francisco
          Examiner.  We shall continue to bring such
          significant news to your attention.
          
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At Davies Medical Center, a 4-year-old treatment center for HIV
patients sits empty most of the day. At the UC-San Francisco HIV
clinic, patients hear unfounded rumors that the clinic might close. In
an office on Castro Street, an AIDS specialist for 14 years considers
retiring.
   
Patients are being told they'll have to find new doctors, settle for
fewer tests and possibly face closure of one highly regarded hospital
that specializes in the disease.
   
It's not that the epidemic is over. Rather, AIDS patients have become
the first to feel the pressure by health plans on hospitals to count
pennies and meter care like never before. In managed care's drive to
compress health care costs, patients unlucky enough to be very sick--
and the doctors who care for them--believe they are being squeezed
out.
   
"This is like a game where everyone throws the hot potato--the
patient," says Dr. Myles Lippe, a veteran of the HIV epidemic who says
he'll be forced to retire if the situation doesn't improve. "My
practice is on the brink of being economically inviable."
   
Managed care rapidly is becoming the norm in California for employees
with paid health benefits. Under this system, hospitals and groups of
doctors acquire patients through contracts they negotiate with big
health plans.
   
The aim of managed care is to make medical services cheaper and more
efficient. But the sickest patients don't fit well into such an
equation. Doctors, hospitals, and economists who study the
managed-care industry say that high-cost groups such as people with
HIV, the elderly and cancer patients are being shut out of the system.
   
Doctors and hospital administrators say that managed-care companies
avoid contracts with physician groups that specialize in costly
patients. They say these companies turn care-giving into a maze of
negotiations over the proper specialists, drugs or lab tests. Most
importantly, doctors and hospitals complain, health plans pay far too
little for care.
   
For example, the Conant Medical Group, specialists in AIDS care, say
they collect $5 to $12 a month to treat AIDS patients, even though the
cost averages $100 a month.
   
"It becomes economically unfeasible to take care of patients," Lippe
said.
   
Managed-care companies defend their practices and say they are
prohibited by law from trying to avoid certain patient groups. But
they acknowledge that long-term care for serious illnesses presents
special problems to their profit-making formula.
   
Ellen Aliberti, project manager for long-term care for PacifiCare, one
of the state's largest health-maintenance organizations, said the
industry is realizing it will have to adjust its approach. Several
companies, including Cypress-based PacifiCare, Group Health of Puget
Sound and Sierra Health Services of Nevada, are creating programs that
recognize the higher cost of care for diseases that require long-term
care, she said.
   
"I don't think all HMOs are trying to run away," Aliberti said.
   
But most are, contends Greg Monardo, president of Davies Medical
Center.
   
Monardo has succeeded in negotiating just two HMO contracts after
talking to nearly a dozen health plans over the past 18 months.
   
He says Davies' reputation for excellence in HIV care has been the
deal-breaker.
   
"Their goal is to avoid expensive patients," Monardo said. He said
health plans fear that if Davies appears on a company's list of
hospitals, more HIV-positive people will sign up.
   
With fewer patients to treat, Davies is moving its skilled-nursing
facility for HIV, designed with great fanfare in 1991, into a smaller
space. Its infusion center also is likely to shrink.
   
The number of HIV patients it discharges dropped from 808 in 1989 to
374 in 1993.
   
The empty beds are taking a financial toll. Since last fall, the
hospital has laid off up to 19 managers and other staff members and
negotiated 23 early retirement packages. Hospital executives are
deciding now how many nurses should be laid off in July.
   
"Three years from now, if we can't make significant changes, we'll be
like the dinosaurs and die," Monardo said.
   
Fearful that they'll lose the security of seeing the same doctor year
after year in a clinic at the heart of the Castro, patients have begun
organizing against what they call "red-lining" by health plans.
   
"If we in this neighborhood were to wake up one morning and find
Davies gone, it would be devastating," said AIDS patient Brian
Christianson.
   
Davies' biggest problem may be that it can't offer a broad range of
services and wide geographic presence, according to Lisa Simonson,
senior health-policy researcher at the California Office of Statewide
Health Planning and Development. Its concentration on HIV, however,
makes the hospital even less attractive to HMOs, she said.
   
"There's a real spectre of adverse selection if a hospital is very
good at taking care of a bad disease," said Dr. Charles Saunders,
health care consultant for Electronic Data Systems, a data analysis
company in San Francisco.
   
AIDS is just the first area to feel the crunch, according to Saunders.
He said many health services considered necessary to the people of San
Francisco are anathema to a profit-making insurance plan.
   
UC-San Francisco treats many complicated medical cases as part of its
teaching program, which is inherently costly. San Francisco General
Hospital, which is affiliated with UCSF, has many patients with no
insurance, but offers world-class trauma care. California Pacific
Medical Center specializes in expensive transplant services and
maintains a residency program.
   
Chinese Hospital offers translation and educational services that
aren't typically included in health-plan cost calculations. Its
doctors treat a high percentage of elderly people who come in with a
variety of advanced illnesses.
   
The hospital barely broke even last year. It is considering developing
a special foundation and aims to rescue its 24-hour treatment center,
which loses about $900,000 a year, with a fund-raising push.
   
California Pacific Medical Center has managed to lure plenty of HMO
contracts even though it cared for 12 percent of San Francisco's AIDS
hospitalizations in 1993, about the same as Davies. But the hospital
lost about $4.6 million that year.
   
"The problem is we haven't adapted our practices quickly enough to
managed care," said William Aseltyne, vice president and general
counsel for California Pacific. He said the hospital is developing
alternative treatment settings such as home care and hospices with the
idea of becoming less costly without reducing quality.
   
But institutions trying to balance finances with their commitment to
care face difficult issues, said Dr. Harry Hollander, director of the
UCSF AIDS clinic.
   
He said the UC clinic is in no danger of closing, despite rumors of
its demise. Patients apparently fear the worst because of some fairly
dramatic changes taking place.
   
Early this year, the office consolidated with the infectious-disease
group next door and changed its name to the adult specialty clinic.
HIV specialists there will likely have to give over many of their
long-time patients to primary-care doctors, who aren't likely to refer
back patients because of the added cost.
   
Clinicians worry that an average 20 percent reduction in payments from
health plans will prompt the university to shy away from costly care.
One HMO that formerly paid as much as $1,100 a month to cover an AIDS
patient on a fee-for-service basis has switched to a flat rate of $100
per month per member.
   
"That is a huge hit. You can see where there's a disincentive to
signing up HIV patients," Hollander said.
   
Health plans pay nothing close to the real cost of HIV care, said Joe
Robinson, administrator for Conant Medical Group. Instead of cutting
back care, doctors there are paring their salaries and overhead. Dr.
Marcus Conant, head of the practice and also a dermatologist, stopped
taking a salary out of the AIDS side of his office two years ago.
   
Conant said health-maintenance organizations make it difficult to get
vital treatment tools such as a new DNA test that measures the amount
of HIV in a person's blood and an expensive antifungal agent to
protect patients with very weak immune systems against infection.
Referrals to specialists are difficult and doctors have no say over
which home health service or laboratory they're allowed to use, Conant
said.
   
"All of these things are turning doctors' practices into mills where
the pressure is to run patients through," Conant said.

[Health Plans Shutting Out Those Who Need Care Most, Sally Lehrman,
San Francisco Examiner, June 4, 1995]

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