AIDS care at 5 HMOs questioned


State health officials plan to review medical records from five health maintenance organizations being paid to care for Medicaid patients with AIDS, after hearing that the HMOs were making mistakes that AIDS specialists say could cause avoidable deaths.

The problems ranged from misreading test results to failing to give the correct medicine.

Specialists said children and adults with AIDS who are enrolled in HMOs have suffered unnecessarily, developed avoidable complications and landed in the hospital. Other Medicaid patients with AIDS have been discharged from the hospital without adequate follow-up because it took so long to get an appointment with their HMO physician.

This issue is made more urgent by plans to move the half-a-million state Medicaid patients into HMOs.

The problems were discussed at a March meeting of local AIDS physicians and social workers, along with officials from the state Department of Health and Mental Hygiene and the state's AIDS Administration. While several people present refused to comment, minutes from the meeting obtained by The Sun were confirmed as accurate by three participants.

Lawrence P. Triplett, director of the state's Medical Care Finance and Compliance Administration at the Maryland Department of Health and Mental Hygiene, said tracking individual cases is difficult because of confidentiality issues, but the state wants to determine how the patients are being treated.

"We've heard some concerns from both sides of the fence," Mr. Triplett said last week. "We don't have any conclusions of absolutely what the problems are."

But at the March meeting, which was organized by the AIDS Administration to discuss these issues, specialists who routinely see these patients said the problems are clear. In many cases where HMOs referred AIDS patients to them, the doctors said they discovered serious inadequacies in treatment. They blame the limited experience of HMO physicians with HIV and acquired immune deficiency syndrome, a field in which even specialists say they have difficulty keeping up with changes. According to the minutes, physicians attending the meeting said this inexperience may have caused some children to die unnecessarily.

Physicians also said there may have been preventable transmission of the human immunodeficiency virus from mother to child, because some HMO obstetricians and gynecologists appeared not to follow national guidelines on HIV testing, counseling and prescribing of a drug that has been shown to reduce transmission.

"There's a real time element and a real balancing act in what you do and when you do it," Dr. Nancy Hutton, director of the pediatric HIV program at Johns Hopkins Children's Center, said last week.

"It's difficult to have everybody in the community be up to the speed," added Dr. Hutton, who attended the meeting. "I think the physicians in the HMOs are very interested in doing the best job. I don't know how much time and staff support they have."

But HMO officials defended the care they provide, saying they have case managers and other staff to make sure patients with AIDS and HIV are getting proper care.

"We believe that for people with chronic and catastrophic illnesses, it only makes sense to have them treated by people who specialize with that disease," said Hanita Schreiber, senior vice president of medical services at Chesapeake Health Plan, one of the five HMOs that contracts with the state to care for patients on Medicaid, the federal-state health program for the poor and disabled.

For Marylanders with AIDS, the quality of care in Medicaid is crucial, because 40 percent of these patients are on Medicaid, and 60 percent of all people with AIDS will be on Medicaid at some point during their illness.

But because of the rising cost of Medicaid, officials are increasingly relying on HMOs. A form of managed care, these health plans use a "gatekeeper" physician to control and coordinate medical care.

Already, a quarter of the 467,000 Marylanders on Medicaid are enrolled in HMOs. Pending federal approval, state health officials are planning to put the entire Medicaid population into HMOs as early as next summer.

When moving these Medicaid patients into HMOs, one of the major concerns is whether HMOs -- which typically treat healthier, privately insured populations -- are prepared to deal with the problems of Medicaid patients, who often face as many social issues as medical ones. Medicaid patients, for instance, often are illiterate, may not have a telephone or transportation, and as a group are sicker than the general population.

Dr. Liza Solomon, the new director of the Maryland AIDS Administration, said her office has only anecdotal reports, so it is difficult to quantify the extent of the problems. While her agency has no regulatory authority, she said she is trying to bring together all the players to work on solutions.

"I think the HMOs have been surprised at the complexity of the medical problems they've confronted. I think they haven't been ready," said Dr. Solomon. "They're going to have to come up to speed quickly if they're going to care for people with complex medical problems."

Other physicians at the meeting refused to comment because they feared it would jeopardize their hospitals' efforts to get contracts with HMOs and other managed care plans. Increasingly, that is the way for hospitals to get patients.

But Larraine Bernstein, administrator for the Division of Child, Adolescent and Family Health for the Baltimore City Health Department, attended the meeting and confirmed the minutes were accurate.

"What was being said really came from the heart. These were both physicians and nurses and social workers who work directly with the families and who were frustrated with the system," said Ms. Bernstein.

"It wasn't that they were against the concept of HMOs. Their specific concern was these kids -- and that the children's quality of life could have been improved if their illness was being treated in a more aggressive manner," she said.

According to the minutes, children with HIV and AIDS are also missing necessary primary care such as immunizations and well-child visits. And a local pharmacist who works with many Medicaid patients, Don Schumer of Penn-Dol Pharmacies, says HMO patients who come in with prescriptions for expensive AIDS medicine often face delays as long as a week while the HMO approves it.

But HMO officials said they are giving AIDS patients good care.

At Total Health Care, for instance, a case manager handles AIDS cases and physicians are sent to the University of Maryland for monthly updates on HIV issues. The HMO's officials also said that pregnant patients with HIV get the proper medication, and they have physician consultants on staff to assist physicians who have questions on judging X-ray or test results.

Officials at Chesapeake Health Plan, which contracts with physicians in the community, said they have not received any specific complaints from the state.

Prudential Health Care Plan's officials said they have become the first and only HMO in the Baltimore-Washington area to be granted full accreditation from the National Committee on Quality Assurance, which evaluates managed care plans around the country.

Officials at Columbia Medical Plan, which operates outside of Baltimore, said they have very few AIDS patients. Officials at the remaining Medicaid HMO, Optimum Choice, did not return telephone calls.

But health officials in Baltimore, where half the state's Medicaid population lives, say something must be done. "In a city where there is perhaps more expertise in the area of AIDS than almost any other place in the country, it's unconscionable that children with AIDS, perhaps our most vulnerable of all populations, are being either denied services or having services unnecessarily delayed," said Dr. Peter Beilenson, city health commissioner.

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