AIDS Treatment News Issue #280, October 3, 1997
John S. James

Until recently, medical care was usually provided on a fee- for-service basis, with doctors or medical groups being paid separately for each visit or procedure; the more treatment they did, the more they were paid. Managed care uses a different payment system, called capitation, with doctors or medical groups being paid a fixed amount per month per patient, no matter what their care actually costs. Since each treatment prescribed takes money from the bottom line, the incentive to treat more was replaced by an incentive to treat less. Managed care is controlling medical costs; but a central challenge now is how to make it work properly for patients with HIV or other serious and expensive illnesses.

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AIDS TREATMENT NEWS: How did the Brown & Toland HIV treatment program develop?

Dr. Becker: At California Pacific Medical Group (which recently merged to form Brown & Toland), we were looking at a high prevalence of HIV disease in San Francisco, and a high prevalence of HIV-infected individuals in our contracted health plans. So in 1993 we were asking how we would manage what was a growing HMO population of HIV-infected individuals. The issues of quality were very important, the cost was very high, and we were concerned about patient satisfaction and physician burn-out. How were we going to deal with the pressures in a responsible fashion?

A number of physicians got together: myself, Robert Bolan, Jeremy Berge, Lawrence Goldyn, and Alison LaVoy. I assembled this group because we were among the more active HIV doctors who had a fair number of HMO or managed-care patients. There was nothing special about the group; it just seemed like a good place to start.

We decided to build an intervention program based on two overall concepts. One, we would insist that care be given by an HIV-expert physician. Two, we were going to include a care manager. "Care manager" is a term we originated, which has now been taken over by the HMO industry, so everybody is called a care manager. It is different from a case manager, which had the implication of somebody saying "No" to you. The care manager is an HIV-experienced field nurse, who has additional training and understands case management, managed care, and home health.

We looked at different models. A couple companies had services like this; the best known was Clinical Partners. We did not like that model, and developed a model with the company then known as Homedco, which later became Apria Health Care. So our medical group went into a joint venture with Homedco-Apria, who provided the care managers; our medical group provided the doctors, and we built an intervention program based around teaming up the care manager and the HIV doc. Patients would be jointly managed in many respects by the care manager and the physician.

In the beginning it was clear how poorly coordinated the HIV services were. For example, case managers; if you were an HIV-infected patient in an HMO, you often had a case manager who would call you up and not do very much. The medical group had a case manager, who also didn't do very much. If you came into the hospital, there was a case manager there. If you went to the skilled nursing facility, there was a case manager there. If you went on to a hospice, there was a case manager there. So there could be five case managers for one patient. They all took one piece of the patient, but nobody took the whole. We said, get rid of all these case managers. We are going to have one manager; they will know the patient from early on, and follow them through the spectrum of their illness, regardless of the site of their care. We teamed the physician and care manager with a social worker, a nutritionist, and a pharmacist.

We built this model around certain protocols we developed; for example, how do you treat CMV disease? How to tell when somebody should be given that second or third round of anti- lymphoma treatment? Are there predictors that a patient will not do well? How did we decide who needed hospice? Why do some physicians throw drugs after drugs after drugs in patients who are dying, and others can pull back and talk to the patient about what is the best quality of life? We analyzed what our approaches were and came to a certain level of consensus.

We talked through these and came up with a series of protocols. We enrolled a hundred patients in a pilot program; we found it worked very well. The doctors were happy, the patients were happy. We found that our quality was much better, and we found that our economic utilization was better. So we expanded the program, and brought in more of the doctors with many HIV patients.

With managed care, it is not enough to be just a good doctor; you must be a good doctor, and also do it in an economical fashion.

In the fee-for-service system, it was to the doctor's or the medical group's advantage to see the patients very frequently; the industry term is "churning." Historically, it does not matter what specialty, when doctors are paid fee for service, they see patients more often. When doctors have procedures to do and they are paid separately to do those procedures, they do more of them --including, several years ago, HIV-related infusions. Many HIV doctors gave lots of infusions in those years; they would do infusions in their office, where they could charge a lot, instead of doing it at home when it would be safe and more convenient for the patient to do so.

Many patients who are doing well on the current combination regimens do not need to come for visits as often as they did before. I can review their laboratory work -- not T-cells and viral load, but the tests to make sure they are not having adverse effects from the medications. I don't need them here to look at a set of laboratory tests, all of which are OK. I can look at the labs and call the patient. Getting out of the mindset of bringing patients in and churning through visits is part of what managed care brings. You must not push this too much, at the expense of health or safety. But the doctors that didn't get sucked into the churning, doing things just to enrich themselves, are the same good doctors who will not keep patients away because they get more money by doing so.

The Economics of

HIV-Experienced Physicians

Dr. Becker: Bed days per thousand is an HMO industry measure. It is the number of hospital bed days per one thousand enrolled patients. For a "commercial" population (people between the age of 1 year and Medicare eligibility), the number of bed days per thousand should be about 150 to 180. In 1994 our program used about 2000 bed days per 1000 enrollees. In 1995 it was 1700; we were beginning to do more treatment out of the hospital. Then starting in late 1995 and into 1996 we had a big decrease, 1700 down to about 1200. Our experience is similar to what Peter Ruane in Los Angeles presented at the Retroviruses conference earlier this year; Gabe Torres published similar data from experience in New York. In the first part of 1997 the figure is down even further, to about 600 to 700 bed days per thousand.

But if you break down our data by physician experience, you can see that for the less experienced physicians, bed days per thousand changed very little from 1995 to 1996. The huge fall in the bed days is actually from the HIV-expert physicians, who had about a two-thirds drop. They had 591 bed days per thousand; but the non-HIV-expert physicians, whose patients were not enrolled in our intervention program, had about 1500 bed-days per thousand. So there is almost a three- fold difference between these two groups. We are preparing these results for publication. It is important to understand that you can do this within managed care, while absolutely maintaining the quality of care.

I believe some of the differences are because we are using opportunistic infection prophylaxis better. We know from a study we did a year before that 100% of our patients who should have been on PCP prophylaxis were on it, while only 50% of patients managed by a non-expert HIV physicians in San Francisco in 1995 were receiving PCP prophylaxis. Ninety six percent of our patients received appropriate MAI prophylaxis, vs. 9% of the patients of the non-expert physicians. We used antiretroviral combinations earlier, we started using protease inhibitors earlier, our knowledge of natural history is better.

And I think we are better about planning for terminal care when necessary. In that 1995 study, we looked at the percentage of patients with CD4 counts below 200, who had a durable power of attorney for health affairs included in their charts. It was one sixth the number with the less experienced physicians than with the experienced physician group. We studied many other differences as well. With the exception of treatments like infusion -- our program's doctors used more infusions, because they had sicker patients -- the less experienced doctors actually used more services.

A number of people have published on the superior quality of care outcomes from the expert vs. the non-expert physician; we found that as well in our analyses at Brown & Toland. But this is the first time to my knowledge that anybody has been able to demonstrate superior resource utilization among an HIV-experienced physician group.

The audience that needs to know this is the managed-care companies, the IPA executives, the people who are in a position to insist that HIV-infected patients be seen by expert doctors. For whatever reasons, there are many patients who do not come to the acknowledged HIV experts -- who stay with their doc of ten or 15 years because they have a good relationship, even when that physician may not know enough about HIV.

Managed care permitted the development of this kind of HIV intervention program; these figures provide an evaluation. We have the evidence now at Brown & Toland, where HIV is acknowledged as an area deserving much attention in managed care. It is an integral part of every contract that Brown & Toland negotiates with every health plan, that there be specific carve-outs, or provisions, for HIV, in some fashion or another.

ATN: That would include expert physicians, and allowing them to do certain things, like double protease?

DR. Becker: Right.

ATN: To what extent has Brown & Toland achieved this with all the insurance companies it is negotiating with?

DR. Becker: Not all, but most of them. Brown & Toland is a big entity -- it is like the elephant that can sit anywhere it wants. It is hard for the insurance companies, if they want to be in the San Francisco market, not to deal with Brown & Toland. Because of its size, it has a lot of weight, and can say that there are certain standards we must have.

It also helped that this is San Francisco, and the advocacy community is as potent as it is. Kaiser has an HIV advisory board, and HealthNet does, and PacifiCare does; that is an acknowledgment of the strength of the community, and the role the community can play in developing policy.

It is not that I am advocate for managed care. Managed care is here, and is not going away. I think that the community, including patients and doctors, have one of two ways they can go with it. They can flail against it, but it will not go away, or they can try to force it to work as responsibly as it possibly can. We have been successful because we have a big medical group, and we have a number of doctors who have been insistent on making sure that the quality is high.

I spoke to Susan Dooha, of Gay Men's Health Crisis -- she was very concerned, because in many parts of the country, where the doctors are not organized into large medical groups, they do not have the negotiating power, the club if you will, to bang the insurance companies. They have not been able to negotiate good contracts, they cannot get the expert doctors on the panels, and the formularies have been restrictive. That has not been our experience here, but it certainly has happened elsewhere.

I hope that the San Francisco experience can be a model for other communities as well. I hope too that success with HIV in managed care can be translated to other serious and chronic illnesses. The strength of a collaborative physician and patient organization, one that at a minimum is created on a regional basis, may be the most effective means of assuring quality care for those with HIV. The national networks of HIV/AIDS providers now forming hold potential to ensure that such quality exists.

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