AIDS specialists central to capitated AIDS plan
New drugs and treatment options mean that well-managed AIDS patients lead longer, healthier lives. Yet the care of these patients remains very complex. Johns Hopkins Health Care in Baltimore recently took a bold step and launched a capitated AIDS care program for Medicaid-eligible adults using AIDS specialists as primary care providers.
"The stakes are very high for AIDS patients," notes Patricia Engblom, RN, MA, administrator of the AIDS capitation program at Johns Hopkins Health Care. "Mismanagement can cause resistance to the virus that affects the patient forever. Mistakes are many. By using the AIDS specialist as the primary care physician, we feel we’ll get the best, most effective outcomes."
To determine the capitated per patient rate, Johns Hopkins relied on an extensive database started in 1989 that includes clinical and psychosocial data on AIDS patients. It then linked with the Maryland Medicaid program for cost information and Medicaid payment data. "We used the data to carefully determine costs for patients at all stages of the disease," Engblom says. "We know the cost per patient per month based on their viral load demographics, and we averaged it."
Eligibility criteria for the Johns Hopkins "Moore Options" program include:
• AIDS diagnosis per the 1993 definition by the Centers for Disease Control and Prevention in Atlanta;
• 22 years of age or older;
• Baltimore city resident;
• eligible for Maryland Medicaid.
"Studies have shown that for complex patients such as AIDS patients, experienced physician specialists deliver improved outcomes and more cost-effective care," Engblom says. The Moore Options program provides patients with access to all of Johns Hopkins HIV specialty services. In addition, Moore Options participates in clinical trials that offer patients access to the latest therapies. (For more information on new protease inhibitor cocktails, see Case Management Advisor, Sept. 1997, pp. 154-156, 161.)
Community Medical Alliance, another capitated Medicaid plan in Boston, also has implemented a capitated program for AIDS patients that uses a nurse practitioner/physician team approach to care, with the majority of primary care visits occurring in the home.
The capitated rate for the Community Medical Alliance plan was $4,487 per patient per month for end-stage AIDS patients in 1996, says Robert J. Master, MD, president and medical director of Community Medical Alliance. Plan services include primary care, home health visits, durable medical equipment costs, long-term care, and mental health services. The plan does not include transportation, oral pharmacy, or personal attendant care. (For more on Community Medical Alliance plan eligibility requirements and services, see pp. 185-186.)
The Moore Options AIDS capitation program includes the following services:
• outpatient primary care;
• outpatient specialty care;
• inpatient care;
• social work services;
• home health care, including infusion services;
• both inpatient and at-home hospice care;
• outpatient pharmacy services;
• preventive dental and vision care;
• emergency care and ambulance service;
• transportation;
• 24-hour RN telephone support.
For at least this first year of the program, Engblom says the cost of protease inhibitors is not covered under the capitated plan. "There just wasn’t enough historical data on the new drugs, yet," she says. "We need more information about the efficacy and the cost before we can add protease inhibitors to the capitated program." The capitated plan also does not cover the cost of quantitative HIV virology tests.
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