The Social Impact of AIDS in the United States (1993) / Chapter Skim
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3 Health Care Delivery and Financing
3 Health Care Delivery and Financing
Pages 46-79
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From page 46... ...
In addition, as health insurance premiums have escalated by 20 percent or more annually in recent years, employers have sought to contain costs by either reducing the value of the insurance coverage offered employees or by reducing the coverage provided for dependents. At the same time, insurance firms increasingly act unilaterally to avoid high (or "catastrophic")
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From page 47... ...
The funds easily available for health care in the 1960s and 1970s, as Medicare, Medicaid, and private health insurance coverage paid charges as billed with few controls over services or rates, are now more constrained. Limits on Medicare and Medicaid reimbursement rates, the increasing reliance of private insurance plans on various types of managed care and administrative constraints on physician practice decisions, and new attention to areas such as medical devices and equipment are fundamentally changing the practice of medicine.
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From page 48... ...
The connections between HIV disease and homosexuality, intravenous drug use, poverty, and racial or ethnic minority status contribute to this difficulty. For example, if physicians are disinclined to care for AIDS patients, is it because they fear AIDS?
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From page 49... ...
Consider cryptococcal meningitis, a fungal infection of the central nervous system, which eventually attacks 10 to 15 percent of AIDS patients (non-HIV-infected people also occasionally contract the disease)
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From page 50... ...
These wards have come to be accepted by physicians and patients alike, despite some initial misgivings that such centralization of care could further stigmatize patients, scare away health care workers, reinforce apprehensions about HIV transmission in a health care setting, and isolate the ward from the rest of the hospital. Disease-specific wards are not unprecedented.
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From page 51... ...
A study of 257 AIDS patients at 15 California hospitals, for example, found a significantly lower in-hospital mortality rate for Pneumocystis carinii pneumonia at the hospitals with more experience treating the disease (Bennett et al., 1989~. The authors of the California study suggested three possible options: creating regional centers, promoting rapid but carefully monitored increases in the experience of low-volume hospitals, or providing focused educational efforts for facilities with little experience with AIDS.
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From page 52... ...
Many nursing homes have been reluctant to care for AIDS patients, citing the fears of other clients, inexperience with managing infectious disease, and lack of adequate reimbursement. Administrators of long-term care facilities have been reluctant to admit gay or intravenous-drug-using patients, who are typically younger than the rest of their patients.
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From page 53... ...
Thus, the fiscal environment and the desire of AIDS patients to remain outside the hospital have converged to favor greater use of nonhospital facilities. Another beneficiary of more aggressive nonhospital care has been the growth of high-technology home care.
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From page 54... ...
In the Ryan White Comprehensive AIDS Resources Emergency Act of 1990, case management was recognized as a primary service under Titles I and II and an optional service for early intervention under Title III. Even with this strong encouragement, the concept of case management remains somewhat unclear, and its benefits remain, in large part, unevaluated.
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From page 55... ...
for AIDS care: no single medical discipline encompasses all the skills and training necessary to treat the wide spectrum of clinical manifestations of HIV disease (Bartlett, 1988; Cotton, 1988~. The American Board of Internal Medicine entertained and rejectedthe notion of creating a new specialty for HIV care.
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From page 56... ...
The chronic nature of HIV disease has meant a radical change in the practice of many infectious disease specialists, who now often serve as primary care physicians for patients with HIV disease. In the years just prior to the lIIV epidemic, there were concerns about a projected oversupply of physicians in most medical specialties, including infectious disease." In the late 1970s the president of the Infectious Disease Society of America said (Petersdorf, quoted in Bartlett, 1988:101: "Even with my great loyalty to infectious diseases, I cannot conceive of the need for 309 more infectious disease experts [the number taking the boards that year]
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From page 57... ...
Nurses Assessing the impact of AIDS on the supply of nurses is somewhat more problematic, although hospitals, nursing homes, and other institutional health care providers are currently experiencing staffing problems, and the National Commission on AIDS (1990) identified a shortage of nurses as an obstacle to improved care of AIDS patients.
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From page 58... ...
loosen the tight association of nursing care with 'women's work' through the conspicuous number of male nurses who are engaged in the clinical care of AIDS patients. At San Francisco General Hospital and in other AIDS-dedicated units where multidisciplinary models of care have been developed to integrate physical and psychosocial care both in and out of the hospital, nurses have played a key role.
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From page 59... ...
A growing body of literature has emerged to quantify the frequency of needlestick injuries, the risk of seroconversion following a single needlestick from an infected patient, and the cumulative risks of practice over the course of a career in particular subspecialities or geographic locations (see Gerberding et al., 1990; Henderson et al., 1990~.5 In May 1987 a report by the Centers for Disease Control (1987b) documented HIV infection in three health care workers who were exposed to HIV-infected blood through abrasions in the skin or splashes to mucous membranes.
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From page 60... ...
Other studies of urban hospital emergency rooms have revealed disturbing rates of HIV infection (e.g., Kelen et al., 1989~. Attempts are being made to monitor health care workers' attitudes toward infection control and to define sources of risk (Gerberding and Schecter, 19911.
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From page 61... ...
This is a slightly smaller fraction than is proportional to their number in the population at large. The attention to occupational risk for health care providers has overshadowed the fact that many more health care workers have become infected off the job, through unprotected sex or intravenous drug use.
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From page 62... ...
In July 1991, largely as a result of the Bergalis case, the CDC published new guidelines reiterating the need for strict adherence to universal precautions and infection control procedures (Centers for Disease Control, 1991~. The guidelines also stated that health care workers who perform "exposureprone invasive procedures" should know their HIV status.
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From page 63... ...
and Health and Human Services Secretary Louis Sullivan (Gautier, 1991~: the "informed consent" provision in the CDC guidelines requires that HIV-infected health care workers disclose their seropositivity to prospective patients undergoing exposure-prone, invasive procedures.8 On August 16, 1991, the CDC had announced the initiation of a process to develop a list of exposure-prone, invasive procedures to serve as a guide for local review bodies. Although the CDC anticipated completing the development of such a list by November 15, 1991, in order to clarify what it wanted states to do, a November 4 meeting revealed widespread discontent among the medical and public health community with CDC's approach (Altrnan, 1991~.
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From page 64... ...
Many health care workers have seemed to overlook the danger of hepatitis, while expressing serious concerns about HIV. Reluctance to treat patients with HIV disease has been documented, at least to a certain extent, in a number of surveys:
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From page 65... ...
A 1987 survey of second-year medical students revealed that 7% thought they should be allowed to decline taking a history from a patient with AIDS; 14% thought they should be allowed to refuse to examine such a patient; and 32% felt they should be able to decline to draw blood (Imperato et al., 1988~. 65 Answers to hypothetical questions on surveys do not necessarily reflect what health care workers actually do when put to the test.
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From page 66... ...
Federal laws provide stiff fines for "dumping" unstable patients on other facilities. Although anti-dumping laws may help ensure safe patient transfer, they do not guarantee that patients with HIV disease will receive the services of any particular institution.
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From page 67... ...
Another market exists for medical devices. Increased costs are associ ated with the barrier protections adopted by hospitals as a means of minimizing health care workers' contact with blood and body fluids.
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From page 68... ...
This development is the result of a "push" the desire of payers and hospitals to find lower cost ways of administering intravenous therapy and a "pull" the preference of many AIDS patients to be at home rather than in a hospital. Some companies, however, have come under criticism for their high prices, a reflection of the consumer activism that exists in other areas of the system (Green and DeStefano, 1991)
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From page 69... ...
First, the per-patient costs for AIDS-related medical care have been dropping. Most estimates now place direct lifetime medical costs between $40,000 and $50,000.~° The reduction is attributable to several developments: greater medical familiarity with the disease; more aggressive outpatient management of traditionally inpatient procedures, such as transfusions and lumbar punctures; effective outpatient regimens for such diseases as Pneumocystis carinii pneumonia and cryptococcal meningitis; and the availability of largely volunteer-based social service supports that allow management of sick patients at home and in less costly institutions than hospitals (Arno, 1986; see also Chapter 61.
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From page 70... ...
They have included enhanced Medicaid reimbursement for AIDS care, in New Jersey and New York (Rango et al., 19901; creation of AIDS centers with core funding in New Jersey, New York, and California (Williams et al., 1990~; and regional centers for people with HIV disease in Maryland and Massachusetts (Smith et al., 1990~; and, a number of states have obtained waivers of Medicaid regulations from the Health Care Financing Administration, allowing them to provide medical and other services not usually covered by Medicaid.
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From page 71... ...
In some areas, such as New York City, growing numbers of HIV and AIDS patients have put severe strains on already beleaguered public and university teaching hospitals. Other local health care systems, with fewer cases and smaller inpatient hospital censuses, have been better able to absorb the influx of people with HIV disease or AIDS.
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From page 72... ...
The multifaceted impact of AIDS has meant that any financing reforms in response to the epidemic have tended to be of a piecemeal, tinkering-around-the-edges nature, rather than wholesale or systemic. The HIV epidemic may also be having an impact on the training and recruitment of physicians and other health care workers, but the number of confounding variables makes it difficult to sort out the impact of HIV disease on the attitudes and behaviors of health care professionals.
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From page 73... ...
8. Congress held hearings on the issue of HIV in health care settings, and in July 1991 the Senate voted 80-18 for an amendment that would have mandated prison terms of not less than 10 years or fines of up to $10,000 or both for HIV-infected health care workers who knew they were seropositive but failed to notify prospective patients before performing invasive procedures (Gautier, 1991)
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From page 74... ...
Orthopedic surgeons' attitudes and practices concerning treatment of patients with HIV infection. Public Health Reports 104:121-]
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From page 75... ...
(1988) Update: acquired immunodeficiency syndrome and human immunodeficiency virus infection among health-care workers.
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From page 76... ...
(1989) Human immunodeficiency virus infection in emergency department patients: epidemiology, clinical presentations, and risk to health care workers: The Johns Hopkins experience.
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From page 77... ...
National Commission on AIDS (1992) Preventing HIV Transmission in Health Care Settings.
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From page 78... ...
(1990) The association of syphilis with risk of human immunodeficiency virus infection in patients attending sexually transmitted disease clinics.
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From page 79... ...
American Journal of Public Health 81:79-84. Zuger, A., and S.H.
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