In two separate initiatives to improve care for AIDS and HIV patients, it is physicians-not hospitals-who are leading the charge.
In New York City, an epicenter of the disease, physicians have formed the city's first independent practice association for AIDS patients and those infected with HIV, the virus that causes AIDS. HIV Independent Practice Association, a not-for-profit corporation representing 34 physicians who specialize in treating AIDS and HIV patients, recently signed its first contract to provide care to Medicaid recipients who enroll in Empire Blue Cross and Blue Shield's managed-care plan. The discounted fee-for-service contract becomes effective Jan. 1, pending state approval of the managed-care plan, and the intent is to eventually move to full capitation.
Nationally, physician groups and IPAs are negotiating with the Los Angeles-based consulting firm of Schwab, Bennett & Associates on development of a "national support organization" for AIDS and HIV doctors.
Unlike a medical service organization that integrates physicians and provides administrative services, the support organization would coordinate AIDS research and provide other services aimed at helping physicians do a better job managing patient care and make more money, said Stephen Bennett, a founding partner of the firm.
He is talking to groups and IPAs in six to eight "key markets," including Los Angeles and Washington, about investing in the service organization.
Physicians see these initiatives as logical responses to managed-care pressures.
"The basic premise is simple. We know doctors have got to get together," said Douglas T. Dieterich, M.D., chairman of the board of HIV IPA and a founding member of Liberty Medical, a four-physician group practice specializing in HIV care.
Unlike other patient populations, people with AIDS may need to see a physician monthly or weekly. At $10 per member per month, patient care would suffer, "so we needed to get together to negotiate better rates with insurers," he said.
HIV IPA was licensed under New York state not-for-profit healthcare regulations in January, said Kirk Lawson, the IPA's executive director. So far, most of the 34 IPA physicians have been hand-picked by its founders. But physicians have been calling the IPA seeking membership, Lawson said.
Within two months, membership is expected to swell to 50 to 60 physicians in a region covering New York City and counties north, Long Island, northern New Jersey, and parts of Connecticut.
Each member is being asked to contribute $1,500 to help capitalize the organization. In addition, HIV IPA intends to earmark an undetermined portion of future contract revenues for administrative purposes.
Organizers of HIV IPA say they have an advantage by being first in the market. The New York County Medical Society said it is not aware of any other physician groups or IPAs devoted solely to treating AIDS and HIV patients.
"What we're trying to do is empower our physicians to deliver the best care that they can to the HIV/AIDS population," Lawson said.
HIV IPA physicians have privileges at numerous hospitals in the metropolitan area. But by design, the group has no special affiliations with any hospital. Lawson said that will come, though, as physicians gain experience as a group and begin sharing information on the best hospitals for HIV and AIDS care. He said the IPA hopes to begin a dialogue with hospitals "right away."
"I think it's important to keep the focus and the control of the management of the disease in the hands of people who are devoted to increasing the benefits of reliable and accessible outpatient care," said James Braun, D.O., a founder of Liberty Medical and president of Physicians' Research Network, an organization of 250 physicians in the metropolitan New York area who treat HIV disease.
Having snared the contract with Empire, HIV IPA continues negotiations with three or four other insurers in the market on the premise that, one day, IPA physicians will be fully at risk for managing the care of AIDS and HIV patients.
"The sooner we can move to full capitation, the happier the payers will be," Lawson said.
And, although the HIV IPA has not applied for an HMO license, "that certainly would be a possible step" for consideration once the IPA gains significant experience serving a large population, he said.
HIV IPA is one group that is considering joining the national service organization that Bennett is forming. Bennett said the organization would be a "shared equity model" in which physicians hold an 80% stake.
The other 20% would be held by "strategic partners," such as pharmaceutical companies and other vendors.
Bennett's vision is to create an organization that, on a national basis, would coordinate research, attract research grants, develop an information system for data collection and case management, and create a disease management product.
"This is a manageable disease. It's screaming to be managed," Bennett said. "But we don't manage the care well." He hopes by linking participating physician groups nationally, collecting data and conducting outcomes research, the service organization may tackle that problem.
The organization also could provide a critical mass for national drug trials, he said.
Bennett, who is openly gay, said he is extremely sympathetic to the needs and concerns of AIDS physicians. "We want to be part of the system that improves outcomes for HIV," he said.