It wasn't too long ago that AIDS patients were shunned by many hospitals.
With universal healthcare coverage a dead issue, at least for this year, and nearly 30% of AIDS patients uninsured, hospitals today continue to struggle with cost-effective care for the disease. And despite changing attitudes in society, some hospitals still have biases against caring for AIDS victims.
But healthcare providers are overcoming the stereotypes and, at the same time, developing less costly alternatives to inpatient care.
As just one example of the changing methods of care, MODERN HEALTHCARE has learned that an "HMO-style" approach designed for people with the AIDS virus could be available early next year, paving the way for capitation.
"The disease can be mainstreamed, and there's an increased willingness to do that like we haven't seen in recent years," said Renslow Sherer, M.D., director of the Cook County HIV Primary Care Center, part of 932-bed Cook County Hospital in Chicago. "I do like to think the learning curve of AIDS is well on its way toward providing more care."
Such care will be needed, as AIDS has already claimed more than 220,000 American lives and its virus, HIV, has infected more than 1.1 million Americans, with no cure in sight.
Early problems.In the years immediately after the discovery of AIDS, hospitals sought grants-many of them minuscule in terms of today's healthcare dollars-to develop in-house AIDS programs.
The 18 cities with the largest AIDS caseloads were losing more than $400 per day on AIDS patients two years ago, according to the National Public Health and Hospital Institute in Washington.
The early hospital AIDS programs began with the onslaught of the disease in the early 1980s and didn't have federal money.
At 415-bed St. Mary Medical Center in Long Beach, where the number of AIDS and HIV cases is second in California only to San Francisco's, the Comprehensive AIDS Resource Education Program was started with a $40,000 grant in 1987 from the hospital's corporate sponsor, Sisters of Charity of the Incarnate Word.
"If you just take that money and begin educating people, you will be off to a good start," said Seth Ellis, vice president of 415-bed St. Mary. "Fear is such a barrier to care. If you're so scared to provide care, you won't be able to give compassionate care, and what kind of care is that?"
St. Mary's program focuses on individual patient-care plans. It involves frequent monitoring and reassessment, and weekly case conferences. The program has prevented medical and psychosocial crises, and proved to be cost-effective through everything from its clinic to home care to volunteers assigned to each patient's case, Mr. Ellis said.
Hospital days decline.Prior to enrollment in St. Mary's program, about 84% of the program's clients had at least one hospitalization. The average length of stay was 32.2 days. The year after their enrollment, only 49% of the same clients were hospitalized, and the average length of stay was down to 8.5 days.
Today, St. Mary's patients classified as having "HIV with major related condition" have an average length of stay of six days. Nationally, HCFA calculates an average of 11.8 days.
With 250 patients now enrolled, St. Mary's AIDS program has a budget of $1.1 million.
St. Mary's program received $800,000 this year from the federal Ryan White CARE Act of 1990, which gets its name from the Indiana schoolboy who contracted AIDS through a blood transfusion and later died.
"Hospital-based outpatient care is a key component of effective AIDS care, and that's why Ryan White only allows the money to be used for outpatient purposes," said Steve Young, acting chief of HIV services at the federal Health Resources and Services Administration, which administers the Comprehensive AIDS Resources Emergency Act, known as CARE.
Funding on rise.Healthcare providers are able to tap CARE now more than ever, as Congress tripled the appropriation for the program to approximately $660 million for fiscal year 1994, compared with $220 million in CARE's first year, fiscal 1991.
CARE, which represents the largest dollar investment made by the federal government for the provision of services for people with the AIDS virus, is allocated through four titles: Title I, for hard-hit metropolitan areas; Title II, for states to allocate through their health departments; Title III, for early intervention; and Title IV, for children, women and families' programs.
CARE is ready-made to alleviate hospitals' budgets for underinsured and indigent AIDS patients. CARE money is generally used when healthcare providers have exhausted all other forms of payment-private insurance, Medicaid or Medicare.
Nearly 30% of all AIDS patients have no insurance, so costly treatment for AIDS patients typically comes from hospitals' budgets for uncompensated care, HRSA said. The costs for treating a person with the AIDS virus from diagnosis until death are estimated at $150,000 to $160,000, according to the Physicians Association for AIDS Care.
But efforts are being made to incorporate patients with the AIDS virus into managed-care settings.
At Northbrook, Ill.-based Caremark International, a company that provides AIDS and HIV services to more than 6,000 patients, a managed-care product for AIDS patients is being worked on, the company's top executive confirmed.
"This will be a first," Caremark's chairman and chief executive officer, C.A. Lance Piccolo, told MODERN HEALTHCARE. "It will be a capitated model. We will be doing this for HIV and dialysis."
Caremark executives wouldn't comment further.
A managed-care model.In Los Angeles, the 120 physicians who are part of the Physicians Association for AIDS Care are developing a managed-care model with 230-bed Midway Hospital that is designed to standardize AIDS care and lower costs by some 25%. The plan is similar to St. Mary's in assigning a case manager to each AIDS patient and working to head off certain expensive AIDS treatments such as tube feeding, which can cost $30,000 to $40,000 per hospitalization.
The effort by Physicians Association for AIDS Care and Midway is gaining the attention of private insurers, which two years ago were reimbursing the hospital $2,000 to $4,000 per patient, executives said. Since then, reimbursement has dropped steadily.
"Financially, all of these facilities that are going full speed ahead with their AIDS units when (private) reimbursement is declining are getting on the wrong end of the bus," said John Fenton, Midway hospital's CEO. "A lot of insurers come in and ask us for discounts."
Effective new AIDS outpatient facilities are expected to contract with other hospitals and pursue managed-care ventures.
In Chicago, Cook County Hospital and Rush-Presbyterian-St. Luke's Medical Center are building a $30 million outpatient center that will save Cook County Hospital, a public tax-supported facility, some $6 million annually in unnecessary hospital costs. The project will be financed through a private fund-raising blitz, and state and federal money.
Once completed in 1997, the Cook County/Rush Health Center will take on all staff and 2,600 patients of Cook County's HIV Primary Care Center, Dr. Sherer said.
Funds are still being raised for the center, which will eventually contract with other Chicago-area hospitals for AIDS care. Projected revenues aren't available, but Cook County executives expect it to be profitable and project about 100,000 visits per year from 12,000 patients.
"Clearly, in some communities there is some more choice and greater willingness to provide care," said Jeff Levi, a Washington-based healthcare consultant and former director for public policy at AIDS Action Council.
Prejudice still prevalent.But Mr. Levi also said widespread and harsh discrimination persists against people with AIDS.
There's still an unwillingness on the part of providers, particularly in less-populated areas, to promote any services for AIDS victims.
As one example, David Barker, M.D., resigned in July as director of the new Nesset HIV Center at Lutheran General Hospital in Park Ridge, Ill., accusing the hospital of not advertising the center's services.
But Lutheran General said its patients at Nesset appreciate the privacy. "We don't go out and get publicity," said Lutheran General spokeswoman Della Burns. "We get patients through physician referrals."
Nesset last year earned a $40,000 grant through CARE. Dr. Barker now works at Cook County's AIDS unit.
"There's still an attempt to find indirect ways to screen out people with HIV or to screen out those providers who might have a large load of HIV patients," Mr. Levi said. "Providers aren't actually recruiting AIDS patients."
But providers need to be prepared for AIDS care, since it permeates all areas of the population.
Virus hits many.Dr. Sherer said that like the public at large, healthcare providers need to realize the AIDS virus isn't just a disease afflicting homosexuals. Of Cook County's 2,600 patients with the AIDS virus, the majority are women, children, injection IV drug users and people who contracted it through blood transfusions, Dr. Sherer said.
Those healthcare providers that don't see a humanitarian responsibility in caring for AIDS patients may change their tune when they look at the bottom line.
In less-populated areas where AIDS care isn't as prevalent, patients are still coming into emergency rooms. "In Illinois communities like Rockford, Kankakee and Elgin (all smaller cities), there needs to be a special capability," Dr. Sherer said.
Rural hospitals with 50 beds or fewer typically have about $50,000 set aside for indigent care. But that would be exhausted if the hospital had one or two AIDS patients in one year, said David Berry, chairman of the University of Nevada Las Vegas Department of Health Care Administration and the author of several books on rural healthcare.
The national Centers for Disease Control and Prevention estimates there are some 14,000 AIDS cases in less-populated areas with populations of less than 50,000. While those AIDS cases account for only 6% of all AIDS cases nationally, the rate of increase is three times faster than in urban areas.
The looming AIDS crisis in rural areas is yet another reason for rural providers to pursue cost-effective managed care and contract relationships with tertiary facilities that can handle AIDS patients.
"We learned early every patient isn't going to need the same care at the same time," said St. Mary's Mr. Ellis. Since there is no cure for AIDS, "the one thing you do know about AIDS patients is that level-one patients are going to become level-three patients."
With more money being funneled to AIDS care through programs such as CARE, some executives are concerned about misuse of the new funding streams.
"With the amount of money available at an all-time high, a lot of providers are jumping on the bandwagon," Mr. Ellis said. "You can drive around Long Beach and see billboard advertisements for AIDS healthcare. But you're not going to be successful without developing full systems."