The Bay Area Reporter - March 20, 1998
Mike Donnelly, ACT UP/Golden Gate Writers Pool

"The amount of time and energy you spent on those problems has increased," said Dr. Virginia Cafaro. David Senechek, a well-known San Francisco HIV doctor, also sees the newer AIDS drugs changing office visitations in his practice. "Some of my patients are on three different antiviral drugs and acyclovir and other prophylaxis drugs," he said. "With each new treatment change I prepare a written treatment plan for my patients."

No matter how time-consuming that work is, Senechek said most insurers will only reimburse him for 15-minute visits, when in reality office visits take at least 20 to 30 minutes. On top of that, he said, "The last three or four years I've seen an insurance rate drop of 70 percent. I've never seen an increase in that time."

Cafaro agrees. "Reimbursement [by insurance companies] has decreased," she said, at a time when her workload is getting more difficult. "Over the last two or three years the amount of people going into HMOs [as patients] has increased," she pointed out, "and at the same time the amount of paperwork, phone calls, pre-authorizations, refusal of medications, as they each come up with their own drug formularies, has increased." Also, she added, HMOs "have middle-man groups like Brown & Toland who manage a lot of HMOs in the city and they may have different policies from other HMOs, and you get caught up in that whole thing."

Although Cafaro's staff estimates making a dozen to 25 phone calls or faxes a day for authorizations, referrals, and drugs that are not on formularies, "for the extra amount of time you spend on phone calls and staffing, there is no reimbursement."

Senechek said he felt he was working in a "crisis budget" in his medical practice.

Dr. Lawrence Goldyn is also feeling a financial crunch, which he also attributes to insurance companies. "You don't get to negotiate rates," he pointed out. "You have to accept the rates that the HMOs and preferred provider organizations [PPO] give you." He thinks Brown & Toland allows "as good as any care in the city." A PPO provides expanded medical options over HMOs, in return for increased fees.

Other sources of income

In the last year two prominent HIV medical practices have folded under the pressure of finances. The Ursus Medical Group in San Mateo County serving most of the mid-peninsula closed down operation and many of their patients felt stranded. The Conant Medical Group had an abrupt halt to patient services in August of 1997, causing several weeks of disrupted medical care.

"Doctors are desperate to make ends meet because of the reimbursement rates dropping," Goldyn said. "I have a lot of medical school bills." When asked about all the problems of being a doctor in the HIV community he replied, "That's why I went to medical school, to be an HIV doc. I saw a need in my community."

There is no consensus on how to solve the problems now being encountered. One solution could be to create an HIV specialty. Specialists in cancer, cardiovascular problems, diabetes, geriatrics, and respiratory illnesses are compensated at rates higher than primary care doctors. Goldyn thinks that creating HIV as a specialty would create a hardship to the primary care doctors who see people with HIV/AIDS now, but Cafaro thinks that a system of grandfathering of the geriatric model into an AIDS model could be a solution. This geriatric system has primary care doctors who treat older patients becoming specialists because of recent care, rather than having to go back to medical school for further studies.

Joe Robinson, a consultant for HIV medical practices, also presents a possible solution in the prospect of a community-based nonprofit system in which HIV doctors come together with pharmacies, labs, and other services. This solution would take the participation of both doctors and community.

Some doctors currently attempting to make ends meet are accepting honoraria of about $1,500 for lectures here and in other cities, according to Robinson. Other doctors are looking to the people who have the money - namely the drug companies - and are providing a new model of clinical trial, which financially benefits their practices. One example is the "Observational Database Study" sponsored by Glaxo Wellcome Inc., being conducted at Potrero Hill Medical Group, in which the participants' medical information will be shared with the sponsor (as well as economic and quality of life information, according to the Patient Informed Consent). Cafaro came to the ACT UP/Golden Gate general body meeting on March 17 to talk about a "MEMS Cap study," and discuss her concerns about sharing information with the sponsor of the study.

Whatever the solution is to the problem of adequate reimbursement, we need to start working on it now. AIDS seems to be always in a crisis mode. Let's solve the problem before the next time a patient goes for a doctor's appointment and finds the doors locked.
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