Confronting AIDS Directions for Public Health, Health Care, and Research (1986) / Chapter Skim
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5. Care of Persons Infected with HIV
5. Care of Persons Infected with HIV
Pages 139-176
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From page 139... ...
HIV infection is a new condition, but the associated opportunistic infections and cancers occur in other situations.
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From page 140... ...
Most physicians have not yet treated persons infected with HIV. However, physicians in all areas need to be aware of signs and symptoms of HIV infection so that early diagnosis can be made, enabling all infected individuals to receive prompt care and counseling to reduce transmission.
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From page 141... ...
No single system of inpatient care will work equally well in all hospitals. Factors that influence the optimal system of hospital care include the type of hospital, the patient mix (as between homosexuals and IV drug users)
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From page 142... ...
Outpatient medical care of AIDS patients must take into account the multidisciplinary medical nature of the disease, the many psychosocial difficulties experienced by patients, and the social setting in which the disease occurs. For hospitals dealing with appreciable numbers of patients with HIV-related disease, outpatient care is best delivered through a dedicated AIDS clinic.
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From page 143... ...
Community-Based AIDS Care The real power of coordinated AIDS care plans is found in the integration of hospital and outpatient care with those facets of patient care based in the community (Abrams et al., 19861. Community-based care can be broadly defined as care occurring at a patient's residence to supplement or replace hospital-based care.
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From page 144... ...
In addition to relatively straightforward assistance in performing daily activities, AIDS patients at home often require more sophisticated and specialized nursing intervention. For instance, patients may require IV hydration because of persistent fevers, sweats, and/or diarrhea; they may need IV antibiotics for the treatment of AIDS-associated opportunistic infections; or they may require parenteral narcotics for the control of pain.
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From page 145... ...
· For areas with a high incidence of HIV infection, where the financial impact of AIDS on health care systems will be great, attention should be given to the development of AIDS-dedicated outpatient clinics. These units should have a stab of pertinent medical specialists, generalists, nurses and nurse practitioners, and specialists in psychosocial problems.
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From page 146... ...
. · Representatives of existing agencies and health care providers should organize AIDS care groups to coordinate presently fragmented efforts.
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From page 147... ...
Because extended care facilities, in almost all cases, refuse admittance to patients with AIDS, dementia will lead to extended use of acute care hospital beds unless alternatives are found. Most mental health professionals have the training and expertise to help patients with dementia.
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From page 148... ...
This situation must be remedied. Moreover, chronic care facilities are often reluctant to accept patients with AIDS either because of the patients' medical requirements or because of fears of contagion (Cassens, 1985; Christ et al., 19861.
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From page 149... ...
Although cost-efficient self-help groups are valuable for many, they are not applicable for all; some individuals have unique problems or are too concerned about issues of confidentiality to participate in a group process. In addition, public and private organizations have been sluggish in responding to the psychosocial needs of these individuals, in part because the epidemic has been largely confined to homosexual men and IV drug users.
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From page 150... ...
Especially in patients with mild ARC, the health care provider must encourage appropriate, but not excessive, use of medical facilities. Needs of Patients with Subclinical HIV Infections Patients with HIV infection but no clinical symptoms are often referred to as being "asymptomatically" seropositive.
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From page 151... ...
Clinicians can counsel homosexual men about the need to practice safer sex, or they can use the psychological distress experienced by an IV drug user as a catalyst to promote rehabilitation for this disorder. However, resources for IV drug users such as methadone maintenance clinics have become increasingly limited, and referral for such care may be difficult until appropriate resources become available (see Chapter 41.
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From page 152... ...
Recommendations The committee believes that the following measures would help in planning for the provision of effective psychosocial interventions for those affected by HIV infection: · The efficacy and cost-effectiveness of various psychosocial interventions should be assessed for seropositive and seronegative populations, for those with psychopathological reactions to having AIDS or ARC, and for those who are not in high-risk groups (e.g., family, friends, caretakers, the general public)
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From page 153... ...
Standard precautions against exposure to blood and body fluids are prudent and will protect health care workers (Public Health Service, 19851. A second implication of society's obligation to provide care for persons infected with HIV has ramifications for both health care providers and the health care system.
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From page 154... ...
The necrologic complications and dementia frequently associated with HIV infection underscore the need to determine early in the course of the illness the patient's wishes in regard to respiratory assistance, cardiopulmonary resuscitation, admission to intensive care units, and other forms of aggressive therapy. At San Francisco General Hospital, for example, physicians are encouraged to discuss "Do not resuscitate" orders with patients within 72 hours of admission.
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From page 155... ...
COSTS OF HEALTH CARE FOR HIV-RELATED CONDITIONS The direct health care costs resulting from HIV infection include those attributable to the following: · pre-test and post-test counseling associated with serologic testing · detection of infection by serologic testing and confirmation · monitoring of asymptomatic infected individuals · diagnosis of the range of conditions associated with ARC and AIDS and their treatment, including ambulatory care, inpatient acute care, chronic care in hospices and custodial facilities (e.g., for dementia) , and the various forms of extensive outpatient support The cost of treating manifestations of HIV infection in any particular case will vary with the marked differences in signs and symptoms and length and severity of illness among various patients.
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From page 156... ...
There is evidence that at certain acute care hospitals, the real costs of inpatient treatment for an average episode of opportunistic infection among AIDS patients may have declined over time. Among the explanations for such a decline are diminished use of private hospital rooms for isolation, increased training and experience of physicians and nurses, increased use of separate inpatient facilities dedicated to AIDS care, and earlier discharge to home or other health care facilities.
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From page 157... ...
IV drug users usually have underlying poor health when entering the hospital and tend to have a higher rate of opportunistic infections. Both IV drug users and pediatric cases tend to have longer hospital stays (cumulatively)
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From page 158... ...
Much less is known about the use of and the costs associated with outpatient clinics, physicians' offices, long-term care facilities, and home health services for AIDS patients. Costs of Care for ARC Patients and Seropositive Individuals Comprehensive calculation of the costs resulting from HIV infection would include not only those associated with AIDS but those associated with ARC patients and persons who are clinically asymptomatic but seropositive for HIV.
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From page 159... ...
In all likelihood, the $8-billion to $16-billion projection represents a low estimate for the total annual costs in 1991 associated with HIV infection. It does not include the costs associated with ARC patients and seropositive individuals and does not take into account the fact that many of the AIDS patients alive in 1991 may be receiving experimental therapies.
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From page 160... ...
AIDS patients often require more emotional support from nursing staff than do non-AIDS patients, as well as more direct patient care. AIDS patients also require more nursing care in intensive care units than do non-AIDS patients because of the frequent development of multisystem
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From page 161... ...
Collection of information can probably best be helped by the design and use of specific diagnostic categories for AIDS and HIV-related conditions. Studies of the costs and effectiveness of alternative forms of care need to distinguish among various manifestations of HIV infection, including Kaposi's sarcoma, opportunistic respiratory and gastrointestinal infections, and necrologic disorders.
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From page 162... ...
The National Center for Health Services Research and Health Care Technology Assessment (possibly in conjunction with other organizations e.g., the Health Care Financing Administration) should commission an appropriate group to provide advice on the minimal data collection requirements to evaluate care modalities in demonstration projects or major centers providing care.
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From page 163... ...
However, as of June 1986 no state had applied to the Health Care Financing Administration for the waivers necessary for such care to be covered through the Medicaid Program (Smith, 19861. The committee is concerned that pursuit of funding to support community-based care be a priority goal in the provision of health care for HIV-related conditions, including AIDS.
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From page 164... ...
A study by the California Department of Health Services (1986) of AIDS patients covered by Medi-Cal (the California Medicaid program)
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From page 165... ...
Private insurance covers a significant proportion of the costs for AIDS care, ranging from 13 to 65 percent in various hospitals (Scitovsky et al., 19861. Improving the Coverage of Health Care Costs Although many individuals have health insurance, 50 million Americans have inadequate coverage and 30 million under the age of 65 have none (Congressional Research Service, 19861.
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From page 166... ...
Department of Health and Human Services task force is currently examining various options for dealing with catastrophic health costs and incomplete coverage (Bower, 19861. Among the options under consideration are the following: · Expanding Medicare and Medicaid to serve a broader population or, specifically through Medicaid, offering otherwise ineligible persons the option of purchasing some form of catastrophic protection; · Authorizing "medical individual retirement accounts"; · Implementing catastrophic provisions in employee health insurance plans; · Providing federal subsidies for nonfederal catastrophic policies; · Providing low-cost, subsidized coverage to uninsured low-income and unemployed persons through state insurance pools; and · Imposing a small federal tax to allow state payment of catastrophic illness policies for persons incurring expenses exceeding 20 percent of family income.
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From page 167... ...
Issues that are emerging in relation to the financing of care for HIV-related conditions include the following: · Many affected individuals, particularly IV drug users, may have no health insurance. · Some individuals seeking health insurance coverage may be aware that their behavior has put them at risk for HIV infection, but may not wish to reveal this if it affects their likelihood of obtaining insurance.
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From page 168... ...
Many of the issues that arise in connection with financing AIDS care are not unique to it, but reflect problems inherent in the present system for financing care. These problems are posed at a time when federal and state governments and others are grappling with their respective responsibilities and the best mechanisms for meeting the health care costs of the poor, the uninsured, and the underinsured.
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From page 169... ...
Incentives to identify and exclude high-risk persons are not eliminated by laws that prevent discrimination in employment or insurance coverage. Even if screening tests specific for HIV infection were barred, and even if discrimination on the basis of sexual orientation were illegal, employers and insurers would still have strong incentives to screen persons by any imperfect means at their disposal.
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From page 170... ...
Thus, it is desirable that provisions for ensuring coverage of AIDS care costs be encompassed in a scheme that resolves general problems in financing rather than be AIDS-specific. There are a number of mechanisms available to deal with the problems faced by potential patients and insurers whereby last-resort coverage might be provided.
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From page 171... ...
Incentives to seek care are relevant not only to treatment of HIV infection but also to its prevention. In this regard, it is critical to examine ways in which the current system or any new system of health care financing might be modified to help persons at risk avoid infection.
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From page 172... ...
Some of these reflect generic problems with health care financing. There also exists the potential for high-risk individuals to be apprehensive about discrimination in employment or in access to health care insurance, which could adversely affect efforts to stem the spread of HIV infection.
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From page 173... ...
· Current financing mechanisms should be immediately and periodi cally examined to determine the extent to which they meet the costs of care for AIDS and ARC patients and their edect on incentives to provide care. Areas for attention should include the adequacy of hospital reimbursements by Medicaid for AIDS patient care; the appropriateness of eligibility periods; reimbursement for out-of-hospital care, hospice care, and home care; the use of diagnosis-related groups in reimbursement decisions; and coverage for home care not provided by nursing professionals.
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From page 174... ...
Unpublished draft paper. Baltimore, Md.: Health Care Financing Administration.
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From page 175... ...
1985. The clinical spectrum of the acquired immunodeficiency syndrome: Implications for comprehensive patient care.
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