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Health care delivery for HIV patients an 'emerging crisis'
  By Bob Roehr
Sep 7, 2006, 14:14
Saag says Medicare reimbursement for treating patients not enough for health care providers to survive
Dr. Michael Saag speaks about HIV treatment during a national forum for HIV care providers meeting in Washington.


Dr. Michael Saag speaks about HIV treatment during a national forum for HIV care providers meeting in Washington.
The average Medicare reimbursement per patient, per year for treating a person with HIV is $359. And that is not enough, according to some health care providers.
"That covers physicians, nurses, rent, utilities, social workers, you name it. How are we [providers] supposed to survive?" Dr. Michael Saag said during a national forum for HIV care providers meeting in Washington on Aug. 30.
He said the figure was calculated from records at the HIV clinic that he leads at the University of Alabama at Birmingham.
"One can't make it as an HIV care provider - unless they are lying and cheating - with that reimbursement," Saag said. "You won't see many HIV docs doing HIV private practice care five years from now. It will all be in publicly funded clinics."
Saag called the situation "an emerging crisis in health care delivery for HIV - patients not being able to get access to care."
Drawing on data from his clinic over the last 10 years, since the introduction of "highly active antiretroviral therapy or HAART, Saag calculated that the average patient with a CD4 count less than 50 costs $36,532 a year to treat. The average patient with 350 T-cells or more costs only $13,885.
The cost of HAART is relatively constant across the CD4 counts, Saag said. The big difference is the expense of other medications, he said.
Saag said about half of the people who started HAART with a CD4 count of 50 or less died within eight years.
"Only those people who start with CD4 counts above 200 are gaining the genuine benefit of what I hope is a normal life expectancy from HAART," he said.
The median CD4 count of a patient appearing for the first time at the clinic in Birmingham is 150; three-quarters have less than 200 CD4 cells, the doctor said.
He said the one exception is pregnant women who have median CD4 count of 400. That is because opt-out testing for HIV is offered to all pregnant women as part of standard medical care.
Those statistics have made Saag a proponent of increased testing.
The Centers for Disease Control and Prevention, after much public discussion, is expected to announce a new set of guidelines later this month that would make testing for HIV a more routine part of regular medical care in all settings.
The anticipated changes continue to draw opposition from some corners of the AIDS advocacy community over fears the new standards will lead to inadequate counseling and linkage to HIV services.
Existing grants and contracts for HIV counseling and testing, which support operations for many community-based AIDS service organizations, are likely to shrink or disappear under the new policy.
Saag said that expenditures for physician and clinic costs are less than 2 percent of the annual total expenditures for health care for an HIV patient. But, he asked, "What good are medications if there are no providers to provide care?"
"Treating a patient with HIV is hard to do well, and it is easy to mess up," Saag said. "You need educated, well-versed practitioners. If they aren't there, the medications are going to be misused and we are going to have a health care crisis of resistant virus that you can't imagine."
Funding for the Ryan White CARE Act has been largely flat over the last four years, with almost all of the increases going to the AIDS Drug Assistance Program. Saag said that is because "almost all of the lobbying effort has come from pharmaceutical companies, who are saying, 'We are providing medicines. We'd like to get paid for it.' There has been nobody from the care providers standing up on Capitol Hill saying, 'We're providing service; we'd like to get paid for that.'"
Saag said that his clinic has been flat-funded for the past seven years, except for a 2.6 percent cut in funding last year.At the same time, his clinic has seen a 60 percent increase in patient volume over the last five years, as well as salary increases and new lab tests the clinic has to pay for.
"We run an annual deficit of $1.1 million. How are we supposed to survive?" he said.
Saag predicted that wider testing will result in an 50 percent increase in patient volume over the next year to 18 months.
"Who is going to take care of these folks?" he said. "We're at capacity; we're beyond capacity."
Saag said there is a "safety net made up of the fabric of health care providers who give a damn," and that safety is abused.
"When people come to my clinic and can't get medicines, social workers, nurses, sit on the phone with Medicare Part D prior authorization, into the wee hours of the night, because they give a damn," Saag said.
"We are abused. We are taken advantage of by a system that doesn't recognize what is holding this country's health care delivery together. It is simply health care providers who give a damn. And God help us when those folks burn out and leave," he added.
Jeanne White, the mother of teen AIDS patient Ryan White whose plight put a different face on AIDS for many Americans in the last half of the 1980s, also attended the conference. She pointed out that during her son's six-year battle with HIV, it was access to drugs that was the problem.
"Ryan couldn't get access to drugs. They were not available," Jeanne White said, praising the LGBT community and ACT UP for the role they played in getting access to medications.
"We have the drugs now," she continued. "But people need to be paid. ... I don't know what it is going to take to raise our voices again. But we have to do it."
Frank Oldham, executive director of the National Association of People With AIDS, called for "a rebirth of advocacy, but with all of us as partners because of the way that the epidemic has changed."
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