Magazine article The Advocate (The national gay & lesbian newsmagazine)

Mismanaged Care

Magazine article The Advocate (The national gay & lesbian newsmagazine)

Mismanaged Care

Article excerpt

The move to push Medicaid recipients into managed-care programs has AIDS activists up in arms

When city welfare workers reported to their offices in south Philadelphia on February 3, they were greeted by more than 100 chanting, placard-waving AIDS activists. First the demonstrators blocked the streets with a sit-in. Then they commandeered the welfare agency itself, tossing piles of HMO registration forms onto the floor and trampling them.

The incident was just one in a rash of demonstrations organized to protest a policy that is forcing all Medicaid patients in Pennsylvania into health maintenance organizations. Intended as a cost-cutting measure, the mandatory move of patients into HMOs began February 1 and is expected to be completed in July. The problem, according to AIDS activists, is that the managed-care approach employed by HMOs includes built-in incentives that can result in poor-quality care for people with AIDS.

Other states are eyeing similar mandatory programs, which could affect as many as half of all people with AIDS, since that's the proportion believed to rely on Medicaid. "It's a huge, frightening problem that's rearing its head all around the country," says Jeffrey Crowley, associate executive director of the National Association of People With AIDS, a Washington, D.C.-based advocacy group. Activists fear that HMOs may seek to restrict access to specialists or to expensive drugs and other therapies for AIDS patients. There is also concern that some HMOs may seek to avoid signing up people with AIDS because of their higher medical costs.

Under managed care, health care providers are reimbursed at a flat rate for every patient they enroll, regardless of the type of medical attention received. By contrast, Medicaid has traditionally been a "fee for service" program, meaning that doctors and hospitals are paid according to the services they provide as well as the number of people served.

So far only two states--Tennessee and now Pennsylvania--require all Medicaid patients, regardless of their condition, to sign up for an HMO. At least 17 states enroll some portion of their disabled Medicaid patients in HMOs, but many offer special exemptions for patients with severe needs, such as people with AIDS.

AIDS activists argue that w en HMOs care for chronically ill patients with intensive and expensive medical needs, they should be paid additional rates to compensate them for their extra care. Otherwise, they say, people with AIDS will represent too high a financial risk for both doctors and HMOs.

"From the history we know about HMOs so far, there is a lot of anecdotal evidence that people who are the most expensive to treat will be cut back on or cut out if there isn't some sort of fair compensation plan in place," says Bruce Flannery, executive director of the Pennsylvania Coalition of AIDS Service Organizations, a statewide association of AIDS agencies.

In Minnesota most disabled Medicaid patients are slowly being phased into mandatory managed-care programs--but with special provisions for compensating HMOs that care for the most expensive patients. "Moving people into managed care without providing risk adjustment for special-needs patients will create huge problems," warns Virginia Weslowski, supervisor of the Health Economics Program at the Minnesota health department. …

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