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. [The following file may be freq'd as CBE50604.* from 1:275/14; and other BBSs that carry the ABLEFiles Distribution Network (AFDN) and ftp'd from ftp.icdi.wvu.edu on the Internet. Please allow a few days for processing.] 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] Brought to you as a public service by ABLEnews. A Fidonet-backbone echo featuring disability/medical news and information, ABLEnews is carried by more than 500 BBSs in the US, Canada, Australia, Great Britain, Greece, New Zealand, and Sweden. Available from Fidonet and Planet Connect, ABLEnews is gated to the ADANet, FamilyNet, and World Message Exchange networks. (Additional gating welcome on request.) ABLEnews text files--including our digests Of Note and MedNotes (suitable for bulletin use) are disseminated via the ABLEFile Distribution Network, available from the filebone, Planet Connect, and ftp.icdi.wvu.edu. ...For further information, contact CURE, 812 Stephen St., Berkeley Springs, WV 25411. 304-258-LIFE/258-5433 (earl.appleby@emailworld.com)