• youth are the population moving most quickly into managed care. This population as a whole and those with or at risk for HIV/AIDS have unique and complex needs requiring a broad array of multidisciplinary medical and support services. Many of the managed care organizations (MCOs) may not have the experience or expertise necessary to work with low-income populations or populations with the complex medical and social needs of those with HIV. They also may not have experience working with multiple public and private providers to assure access to specific services.

Some of the problems encountered by persons with HIV enrolled in MCOs include reduced access to specialty care providers, including HIV specialists; reduced access to specific drug formularies and specific services; clinical decisions with the appearance of cost as the dominant factor; limitations placed on the information providers can provide; and insufficient time to meet with providers. Relationships need to be built with the type of providers that adolescents seek out—teen clinics, school health clinics, community family practice sites, and family planning clinics. More time is needed to gain experience providing HIV specialty services and to build systems that can monitor and evaluate the quality of care in the managed care setting and provide oversight. One strategy that some states have chosen is to carve out specific services or populations, such as those with disabilities, so as to ensure a focus on the multiple and special needs of the population.

  • Medicaid managed care arrangements compete for public providers and private community-based providers serving the uninsured and publicly insured. Before the advent of managed care, these providers were frequently the only providers for the poor or nearly poor patient. Reimbursement from Medicaid for eligible populations gave these providers the ability to cross-subsidize the uninsured or underinsured patient (Davis, 1997). Medicaid competition is threatening the ability to support services to those without adequate insurance coverage. In addition, "many public hospitals and … providers of care to the poor with a mission to render care to the uninsured are being sold to private, for-profit organizations without a comparable mission to provide uncompensated care" (Wehr et al., 1998).

The movement towards managed care has important implications for all those served, particularly for those who have a high level of need. Work is in progress on the national level to establish a patient's bill of rights for managed care settings and to establish oversight mechanisms that include monitoring and evaluation.

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