and individuals with substance abuse disorders and mental illness face unequal access to newer drug therapies (Andersen et al., 2000; Celentano et al., 2001; Palacio et al., 2002; Kahn et al., 2002). A delayed access to new standards for care is troubling because HIV therapies evolve rapidly. Any lag in the receipt of new therapies or adherence to new guidelines compromises the reduction in morbidity and mortality that access to appropriate medical care early in the disease can ensure.

Under Medicaid, two specific program elements—provider accessibility and reimbursement—interfere with access to quality care. Some Medicaid beneficiaries with HIV disease encounter difficulties finding providers and more specifically, experienced providers, who are willing to take them on as patients (Tuller, 2001; Levi and Kates, 2000; CMS, 1999). One reason is financial; adequate reimbursement has been consistently asserted as necessary to ensuring beneficiary access to health-care services, and low reimbursement rates have been shown to affect access to care for Medicaid beneficiaries. Federal law provides states with considerable discretion in determining the amount Medicaid will reimburse for services provided to beneficiaries on a fee-for-service basis (Kaiser, 2001). Reimbursement for HIV care in both fee-for-service and Medicaid managed care settings does not always reflect the cost of providing care that can be time consuming and resource intensive (Bartlett, 2002; Menges et al., 2002; Norton and Zuckerman, 2000; Conviser et al., 2000). Low reimbursement rates have been suggested as a factor contributing to inferior patterns of care for some Medicaid enrollees with HIV/AIDS (Shapiro, 1999). It is instructive that the Medicare program, where reimbursement rates are set nationally at a higher level than Medicaid rates, has consistently higher physician participation, better patient access, and easier patient referrals than Medicaid (MedPAC, 2003).

Findings:

  • A major shift in the delivery of services, from inpatient hospital and end-of-life social support to outpatient and chronic care, occurred with the discovery of HAART and treatment of HIV/AIDS as a chronic disease.

  • Two-thirds of HIV care takes place in physician offices, community hospitals, and clinics.

  • The delivery of HIV care in rural areas may be compromised if physicians lack the expertise that comes with providing care to greater numbers of HIV patients.

CARE Act programs, specifically designed to serve those with HIV disease and to fill the gaps left by Medicaid programs, also encounter difficulties in providing care. Access to HAART and primary care, for



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