Confronting AIDS Update 1988 (1988) / Chapter Skim
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5. Care of Persons Infected With HIV
5. Care of Persons Infected With HIV
Pages 93-122
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From page 93... ...
In the face of an epidemic, administrators, researchers, practitioners, and policymakers alike are being forced to reconsider how medical care is provided in this country- both in clinical and fiscal terms and to seek solutions to the social and ethical quandaries that have surfaced during the process. Confronting AIDS outlined a model of patient care comprising appropriate inpatient services for those most acutely ill and comprehensive outpatient care operating at the interface of hospitals and communitybased agencies.
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From page 94... ...
Yet effective discharge planning is often a problem for AIDS patients: gaps in health care financing, combined with a lack of federal, state, and community resources to provide the appropriate array of services, frequently result in disruption in the continuity of care and an increasing burden for public agencies. Since the publication of Confronting AIDS, there has been progress in improving care for patients with HIV infection and AIDS.
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From page 95... ...
Pediatric AIDS further disrupts families that may be already weakened as a result of parental drug abuse or HIV infection (Boland, 19871. Approximately 75 percent of children who develop AIDS are infected perinatally; about 80 percent of perinatally infected children come from families in which one or both parents are IV drug abusers (Curran et al., 19881.
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From page 96... ...
The committee recommends that skilled nursing facilities or nursing homes providing inpatient long-term or hospice care be made available to AIDS patients who require these service~for example, through the construction of AIDS-dedicated facilities or by offering incentive payments to facilities that are willing to accept AIDS patients. HEALTH CARE PROVIDERS Although health care providers continue to enter the field of AIDS patient care, they are not being recruited at a rate commensurate with the epidemic's growth.
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From page 97... ...
Despite its dire nature, the risk of contagion is not as great, the modes of HIV transmission are known, and the risk to health care workers can be minimized through the prudent use of infection control procedures (Gerberding and the University of California at San Francisco Task Force on AIDS, 1986~. Occupational Risks Although the probability that a health care provider will acquire HIV infection on the job is low, it is not zero.
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From page 98... ...
Some surgeons have refused to care for patients without the reassurance of a seronegative test status; a few prominent surgeons have publicly announced that they will not treat AIDS patients (Gruson, 19871. Among health care workers in general, there appears to be increased concern about the risk of treating HIV-infected patients; there is also a growing willingness to question their ethical obligation to treat such patients.
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From page 99... ...
Moreover, actual risks are not distributed uniformly across all health professions, nor are perceptions of risk or duty consistent among health care workers.
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From page 100... ...
In one instance, a Cook County, Illinois, physician battled his hospital administration to be allowed to continue to practice medicine following his AIDS diagnosis; in another, a Mesquite, Texas, pediatrician was forced to close his private practice after a local newspaper disclosed his seropositive status, even though medical experts affirmed that he represented no danger to his patients. Serologic testing of health care workers to prevent HIV transmission raises concerns similar to those surrounding the prospect of routine screening of other populations (see Chapter 41.
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From page 101... ...
Adherence to universal blood and body fluid precautions by seropositive health care providers should serve to further minimize any risk of HIV transmission to patients (CDC, 1987b; American College of Physicians and the Infectious Diseases Society of America, 19881. Should serologic testing programs for health care workers be developed in the future, such programs ought to apply the same principles used to develop screening for other populations (see Chapter 41.
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From page 102... ...
In addition to expanded postgraduate AIDS training, medical students and other health professions students would benefit from curricula that incorporate specific information about the diagnosis, prevention, and treatment of HIV infection and AIDS, as well as from clinical experience in the care of HIV-infected patients. Several areas need particular emphasis: (1)
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From page 103... ...
Other factors that contribute to increased stress include the youth of the patients, the stigma attached to the disease, prejudice against high-risk groups, lack of medical knowledge and experience in treating HIV-related conditions, the physical and mental deterioration often associated with the disease, and the frequent fatalities. Health care workers need opportunities to share and examine the fears they confront daily in caring for AIDS and HIV-infected patients.
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From page 104... ...
As in other areas of concern about AIDS, we must rely on the limited power of estimates and projections to describe current circumstances and plan for future health care needs. Direct Costs of Care for AIDS Patients The direct costs associated with AIDS include personal medical care expenditures (hospital services, physician inpatient and outpatient services, outpatient ancillary services, and nursing home, home care, and hospice services)
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From page 105... ...
Most studies have been confined to certain hospitals or geographic areas; thus, they may not be representative of all AIDS cases nor generalizable to other parts of the country.* Furthermore, in calculating the medical costs associated with AIDS, studies have excluded individuals with other manifestations of HIV infection and those who are seropositive but clinically asymptomatic.
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From page 106... ...
calculated the indirect costs associated with prevalent cases in 1986 at $7 billion, which is approximately seven times their estimate of personal medical care costs ($1.1 billion)
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From page 107... ...
Cost Implications of Projected AIDS Cases Total annual costs based on the projection that there will be 172,800 AIDS patients at any one time during the year 1991 (including a 20 percent adjustment for underreporting) are estimated to be $66.5 billion: $8.5 billion for personal medical care expenditures, $2.3 billion for nonpersonal expenditures, and $55.6 billion for indirect costs (Scitovsky and Rice, 1987b)
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From page 108... ...
New treatment regimens will undoubtedly influence health care costs or, more specifically, treatment costs. Whether such protocols will ultimately lower or raise medical costs is unclear.
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From page 109... ...
In New York City, municipal hospitals are crowded with IV drug abusers, a group that constitutes almost 60 percent of all AIDS patients hospitalized there (Sencer and Botnick, 19851. Research on Health Care Costs Confronting AIDS recommended that more information be gathered on all aspects of the costs of care for persons with HIV-related conditions and especially for those with AIDS.
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From page 110... ...
Other research initiatives currently under way should provide useful information regarding the costs and relative effectiveness of providing managed, comprehensive ambulatory and community-based services to people with AIDS and HIV-related illnesses. These studies include an evaluation of the Robert Wood Johnson Foundation's AIDS Health Services Program being conducted by Brown University's Center for Health Care Research with support provided by the foundation.
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From page 111... ...
HHS's Health Care Financing Administration has estimated that 40 percent of all patients with AIDS are served under Medicaid; in locations such as New York and New Jersey, the proportion may be as high as 65 percent to 70 percent. Medicaid now bears nearly 25 percent of the total medical care costs of AIDS, and this proportion could increase, depending on future epidemiological trends, in particular, the spread of HIV infection among IV drug abusers.
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From page 112... ...
Almost all insurance companies now refuse to insure individual health insurance applicants with AIDS; 91 percent * As discussed in Confronting AIDS, Medicare covers AIDS patients through its disability program, which is tied to the Social Security Disability program.
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From page 113... ...
In these states, private insurance companies can still protect themselves by writing policies that limit AIDS benefits or by refusing to sell health insurance to persons who reside in cities with high concentrations of AIDS cases (Bloom and Carliner, 19881. Alternative Financing Mechanisms to Improve Health Care Coverage In February 1988 the Institute of Medicine convened a meeting to examine the special problems associated with financing AIDS care and the inadequacies of the current health care financing system in the face of that task.
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From page 114... ...
Funds are distributed to the states in proportion to their share of all AIDS cases. To be eligible for drug reimbursement, individuals must meet state low-income standards, be ineligible for Medicaid or without private health insurance coverage, or live in a state whose Medicaid program does not cover zidovudine.
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From page 115... ...
A third modification involves the determination of reimbursement rates for skilled nursing facility or nursing home care. Reimbursement rates could be adjusted to reflect the costs of the spectrum of patient care.
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From page 116... ...
, the potential costs to Medicare make it an unlikely alternative. Develop an AIDS Federal Grant Program An AIDS federal grant program directing funds to the states allows the federal government to participate in the financing of care for HIV-infected and AIDS patients while also influencing what services are offered and how they are delivered.
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From page 117... ...
The Public Health Service Intragovernmental Task Force on AIDS Health Care Delivery has recommended that all state Medicaid programs and private insurers consider reimbursement for costly AIDS medical therapies once FDA has approved them for treatment under a special investigational new drug (IND) status called treatment IND (see Chapter 6~.
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From page 118... ...
1987. Patient safety and doctors with HIV infection.
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From page 119... ...
1988b. Update: Acquired immunodeficiency syndrome and human immunodeficiency virus infection among health-care workers.
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From page 120... ...
1986. Occupational risk of the acquired immunodeficiency syndrome among health care workers.
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From page 121... ...
1987b. Estimates of the direct and indirect costs of acquired immunodeficiency syndrome in the United States, 1985, 1986, and 1991.
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