The combination of the wider availability of outpatient care and the development of more effective clinical treatments is reducing the number of people with HIV or AIDS who need inpatient hospital or hospice care.
That decline, while good news from public health and individual patient standpoints, has had some negative financial implications for healthcare providers, particularly those that have geared up their operations for a greater flood of AIDS patients.
In some cases, providers have laid off workers or closed.
"The demand for beds is way down," said Dick Daly, chief executive officer of Clinical Partners, a San Francisco-based firm that specializes in disease management for AIDS patients. "We were filling eight beds a day in Los Angeles. Now we have none."
A survey of 500 Clinical Partners patients in Los Angeles indicated they are spending on average less than half a day in the hospital this year compared with two days in 1996 and four days at the beginning of the decade. Inpatient hospital admissions dropped to 94 last year from 161 in 1995 and are averaging four a month this year. Average length of stay decreased to 3.6 days last year from seven days in 1993.
Fewer patients are dying. Deaths in Clinical Partners' entire population dropped to 0.5% per quarter this year from 4% per quarter in 1993.
Hospitals in the San Francisco Bay Area, which have among the heaviest concentration of AIDS patients in the nation, also report lower inpatient census figures.
Dolores Gomez, associate administrator at San Francisco General Hospital Medical Center, said there is "a steady decline in the inpatient census" at her facility, although exact numbers weren't available at deadline.
The same is true at Stanford (Calif.) Health Services, where AIDS inpatient admissions in early spring were on pace to finish 36% below last year's admissions.
The story is similar elsewhere. The Greater New York Hospital Association, the major trade group for hospitals in New York City, reports the average daily census of AIDS patients at its member facilities dropped 26% to 1,402 in October 1996 from 1,886 in October 1995. The peak AIDS patient census was 2,353 in October 1992.
Doris Varlese, the association's general counsel, wouldn't attribute a specific cause to the decline. While she mentioned protease inhibitors-which when used in combination with previously available drugs have reduced traces of the disease to undetectable levels in many patients-she noted that the decline began before the drug treatment became widely available last year.
"It's difficult to ascertain what the possible causes might be. There has also been better managed-care utilization and better treatment of opportunistic infections," Varlese said. "When patients are hospitalized these days, they tend to be much sicker than they were a few years ago."
While the patients may be sicker, they are also spending less time in the hospital. According to the New York Academy of Medicine, a not-for-profit research and educational organization, the average length of stay for an AIDS inpatient dropped to 11.5 days last year from 12.7 days in 1995. In 1989, the average length of stay for hospitalized AIDS patients at New York City hospitals was 18.9 days.
A recent academy survey of New York City hospital executives found that many attributed the decline in inpatient utilization by AIDS patients to clinical developments, but they also cited managed care and the greater availability of outpatient services as key reasons (See chart).
"The need for care has not gone away," but the way it's being rendered has changed, said Ellen Parish, a health policy specialist for the academy.
But Parish added that the change in inpatient utilization has created another problem for hospitals. Medicaid reimbursement rates for outpatient care are much lower than for inpatient care, although the costs of outpatient care are extremely high.
In addition, Medicaid payment rules for outpatient care are far more complicated than the rules for inpatient care, adding to the money crunch, Parish said.
"When patients go to a clinic for treatment, they often will see several doctors, and under the (Medicaid) rules, (the clinic) can only get reimbursed for one visit," Parish said.
According to Crain's New York Business, a sister publication to MODERN HEALTHCARE, 231-bed St. Clare's Hospital and Health Center in New York lost $2 million in revenues from the decrease in AIDS inpatients last year and was forced to lay off 35 employees. It projects a $4 million drop in revenues this year. Other facilities, such as Beth Israel Hospital, also say they are losing revenues.
Similar problems are occurring on the West Coast. LAC-University of Southern California Medical Center, one of the busiest AIDS treatment centers in Los Angeles, is struggling to receive reimbursement for protease inhibitors through the state's AIDS Drugs Assistance Program, considered by many to be underfunded.
Established in 1987, the program subsidizes AIDS drugs for individuals with an adjusted gross income of up to $50,000 per year who lack private insurance and cannot qualify for Medi-Cal, the state Medicaid program. Anyone earning less than $30,960 a year, or four times the federal poverty level, receives the drugs free under the program.
Even though California Gov. Pete Wilson has proposed boosting ADAP's annual budget for fiscal 1998 to $83 million from $53 million, Ronald Kaufman, M.D., chief of staff for 2,000-bed LAC-USC, said simply kicking more money into the pot won't improve the program.
"Reimbursement from ADAP is a problem of timing," he said. "What happens is that new drugs get (Food and Drug Administration) approval and come onto the market, but they have yet to be approved for the ADAP formulary. Sometimes there's a lag of three to six months, and we don't have assurance that we will get paid anytime soon. But these can be life-changing drugs, and I feel we have a public responsibility for providing them at that time."
Kaufman added, "We do feel ethically bound to treat the patients, so we do it, even though it helps put the hospital in financial jeopardy."
But at least the hospital remains open. The AIDS Healthcare Foundation, Los Angeles' leading private foundation for treating the disease, recently shut down one of its three hospices and laid off some of the employees working at the facility. Most were transferred to other positions within the organization.
"We've seen a 50% reduction in the use of our facilities," said Michael Weinstein, the foundation's executive director. "We had to shut down a facility to cut our deficits. And the others are now more focused on a lower-level, residential type of care."