HMOs, Health Insurance: More Problems

AIDS Treatment News, Oct 20, 2000 by John S. James

Many San Francisco patients who see physicians at Davies Campus of California Pacific Medical Center, in the heavily gay Castro area of the city, will need to change doctors on November 1--due to insurance changes triggered by the ongoing incentive to drive expensive patients out of insurance plans, by targeting the doctors who treat them. The immediate problem is that the one IPA (Independent Practice Association, an intermediary between the doctors and the HMOs) willing to serve the physicians with many HIV patients at the Davies Campus is going out of business. A few of the HMOs will contract directly with the physicians--but usually on unworkable terms which pay for persons with HIV or AIDS as if they were healthy young adults, essentially guaranteeing that the physician will lose money on every such patient.

It is well known that HIV patients live longer if they receive care from an HIV specialist than from a general physician--and that the high-quality specialist care actually costs less, because it avoids unnecessary hospitalization and other expenses. But even though insurers know well that specialist care is both better and cheaper, they also know that they can save even more money by denying it, so that seriously ill patients will find their health plan unsatisfactory and go elsewhere if they can.

In September of this year a California bill, AB 2168, to require that California HMOs offer care from physicians who have "demonstrated expertise" in treating AIDS, was signed into law. But some experts fear that this bill does not have teeth, because today there is no legal way of establishing what this "expertise" means, as HIV care is not formally recognized as a medical specialty at this time. Efforts to define such a specialty are ongoing.

Meanwhile, changes at Blue Cross of California and other plans--changes that are especially harmful to patients with serious illnesses including HIV--were described in a recent article by Dan Aiello in the Bay Area Reporter.

Clearly the system is not working when insurers have incentives to provide worse treatment (even when better treatment would cost less) to drive expensive patients away, or limit medical costs arbitrarily.

William Owen, M.D., a leading HIV physician at the Davies campus, prepared information on how California patients can contact their insurance company, their employer, and state officials about problems affecting them; such pressure will help the movement for reform.