Mismanaged care.The move to push Medicaid recipients into managed-care programs has AIDS activists up in arms armed for war; in a state of hostility.
See also: Arms
When city welfare workers reported to their offices in south Philadelphia South Philadelphia, nicknamed "South Philly," is the section of Philadelphia bounded by South Street to the north, the Delaware River to the east and south, and the Schuylkill River to the west. South Philadelphia is coterminous with the zip codes 19145, 19146, 19147, and 19148. 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 HMO health maintenance organization.
A corporation that is financed by insurance premiums and has member physicians and professional staff who provide curative and preventive medicine within certain financial, 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 according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. 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 The People With AIDS (PWA) Self-Empowerment Movement was a movement of those diagnosed with AIDS and grew out of San Francisco. The PWA Self-Empowerment Movement believes that those diagnosed as having AIDS should "take charge of their own life, illness, and care, and to minimize .
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 anecdotal evidence,
n information obtained from personal accounts, examples, and observations. Usually not considered scientifically valid but may indicate areas for further investigation and research. 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. "Part of the problem will be with HMOs' discouraging such patients from enrolling in their programs, and there's anecdotal evidence all across the country that that's happening. But the bigger problem is that health plans will become extremely reluctant to develop good networks to care for people with chronic conditions. They don't want to make themselves too attractive to people with expensive, chronic needs because they won't get compensated enough for taking care of these people."
Like most people involved in mapping out the future of Medicaid for people with AIDS, Weslowski believes the managed-care approach will eventually factor into every state program. "The question isn't if it's going to happen," she says. "The question is when it's going to happen and, more important, how it's going to happen."
In Pennsylvania, AIDS activists and advocates are still struggling with how best to cope with that harsh reality Harsh Reality are a little-known, proto-prog band born in Stevenage, Hertfordshire out of the remnants of the Freightliner Blues Band (formerly the Revolution) in the early sixties. . "Managed care is sort of an understandable evil," says Kevin Conare, the HIV-positive executive director of Action ADDS, the state's largest AIDS service organization. "We're not asking for the shutdown of HMOs. But there are a lot of important details that have to be worked out to protect people with HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. . We've had a lot of skirmishes over it," adds Conare, who along with other directors of Philadelphia AIDS organizations has been arrested in the series of demonstrations against the state's recent moves. "I think we're going to see a lot more skirmishes coming."
RELATED ARTICLE: Gore pushes for expanded access Expanded access refers to the inclusion of patients in a clinical trial for a new therapeutic treatment or chemical entity, where those patients would not satisfy the enrolment criteria for the scientific study in progress. to HIV drugs under Medicaid
Even since the first stories began to emerge about a revolutionary new class of AIDS drugs called protease inhibitors Protease Inhibitors Definition
A protease inhibitor is a type of drug that cripples the enzyme protease. An enzyme is a substance that triggers chemical reactions in the body. , skeptics have been asking one question: Who's going to pay? Therapy with the new drugs is costly--from $12,000 to $20,000 annually per person--and for people without health insurance or whose insurance doesn't cover the drugs, there are few options. The AIDS Drug Assistance Program, administered on a state-by-state basis, is severely underfunded un·der·fund
tr.v. un·der·fund·ed, un·der·fund·ing, un·der·funds
To provide insufficient funding for.
underfunded adj → infradotado (económicamente) : The ADAP ADAP AIDS Drug Assistance Program
ADAP Alcohol and Drug Awareness Program
ADAP Agricultural Development in the American Pacific
ADAP Airport Development Aid Program
ADAP Advanced Digital Antenna Production Working Group, a coalition of AIDS organizations and pharmaceutical companies, projects a shortfall of nearly $132 million for fiscal 1998.
Medicaid also covers protease protease /pro·te·ase/ (pro´te-as) endopeptidase.
Any of various enzymes, including the proteinases and peptidases, that catalyze the hydrolytic breakdown of proteins. inhibitors--but only for people who are indigent indigent 1) n. a person so poor and needy that he/she cannot provide the necessities of life (food, clothing, decent shelter) for himself/herself. 2) n. one without sufficient income to afford a lawyer for defense in a criminal case. or who qualify as disabled, which usually means they have full-blown AIDS. Yet the drugs are most valuable when given before a person becomes symptomatic.
Activists have been pushing for an expansion of Medicaid eligibility rules eligibility rules,
n.pl the conditions that define who may be entitled to dental benefits, when persons first become entitled to such benefits, and any provisions that determine how long an individual remains entitled to benefits. to make the new drugs available to people with asymptomatic HIV. They received encouragement April 9 from Vice President Al Gore, who said he supports the notion of such expanded eligibility at a meeting with the AIDS Action Council, a national AIDS advocacy group. In fact, Gore said, he has already asked the Health Care Financing Administration Health Care Financing Administration,
n.pr department in the U.S. agency of Health and Human Services responsible for the oversight of the Medicaid and Medicare benefit programs, including guidelines, payment, and coverage policies. to study the impact of such a move.
While the idea of expanding Medicaid might seem unrealistic in an area of budget cuts an spiraling medical costs, Gore emphasized the positive. "Our view is that getting these drugs to people earlier will not cost more in the long run," he told the crowd. Indeed, advocates say money spent on the drugs will show up as savings in treatment for those same patients later on.