experience with HIV and the capability to take new patients” (Ashman and Conviser, 1998; Kaye and Cardona, 2002).

At this time there are no formal guidelines for determining whether a physician is qualified as a specialist in HIV care, and there is substantial debate about whether a generalist or a specialist for HIV/AIDS provides higher quality care (Lewis, 1997; Zuger and Sharp, 1997; Laine and Weinberg, 1999; Valenti, 2002). However, it is widely accepted that experience counts. There is evidence that physicians with more experience treating HIV have better patient outcomes (Levi et al., 2003; Gerbert et al., 2001; Stone et al., 2001; Kitahata et al., 1996). Research also shows that more experienced providers are more likely to provide care that is in accordance with rapidly changing HIV treatment guidelines (Kitahata et al., 2000; Brosgart et al., 1999). Moreover, the longer a physician has been treating patients for HIV infection and the higher the volume of these patients in the physician’s regular practice, the higher the physician’s confidence in assessing patient status, prescribing treatment regimens, and inter-

BOX 4-3
Variation in Medicaid Programs: Prescription Drugs

Joe’s bipolar disorder adds yet another dimension to his already complex AIDS care. It would not be unlikely that Joe would be prescribed three drugs for bipolar disorder as well as three antiretroviral medications and an opportunistic illness prophylactic. The three medications that Joe takes to control his bipolar disorder would be covered at various levels. In New York, Joe would face no copays and no limits on the number of prescriptions. In Florida, mental health drugs are excluded from the limit of four brand-name prescription drugs and there are no copays, so here Joe also would face no restrictions. If he lived in Georgia, Joe would be within the five-prescription drug limit (in treating only his bipolar disorder), but would face a copay of 50 cents to $3 per prescription, forcing him to spend as much as $9 a month on drugs. If Joe lived in Texas, there are two possibilities. If he lived in an area where managed care is available and he chose to enroll, then he would face no limits and no copays. If he lived in a county where managed care is unavailable—as it is in most counties—then prescription drug treatment for his bipolar disorder would exhaust his drug benefit of three prescriptions per month.

To receive all of his medications, Joe might have to find coverage from other sources. In Texas, Joe would need to rely upon the AIDS Drug Assistance Program (ADAP) to fill the gap between his needs and Medicaid coverage. In Georgia, Medicaid has a five-drug limit and ADAP has a waiting list; Joe would need to either pay for two of his prescriptions out-of-pocket—an unthinkable expense considering his income—or go without, choosing between treating his HIV infection or his bipolar disorder.

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