Mercy confirms closure of Betak
HCFA demonstration set; Dierkers cancels meeting with advocates
Study questions HIV impact on CD4 cells
US to protect doctor fees under HMOs
Modified Bactrim may increase effectiveness
Mercy Health Corporation confirmed this week that its West Mt. Airy personal care home for persons living with AIDS is no longer able to accept admissions in order to eventually close the personal care home. "The residents who currently reside at the home will continue to live there until comparable living arrangements are identified," Mercy said.
The imminent closure of the facility, embattled since its opening in 1992 as both a skilled care and personal care facility, was reported in fastfax last week.
In October 1995, the City's Health Department asked Mercy to work with them to develop a plan to ensure the continuation of operations at the AIDS facility, then known as Betak, because it was in a dire financial situation. Mercy began to provide services in the home last January, and entered into an interim contract with the City as of July 1, 1996, to operate the facility until September 30.
On July 1, as part of plans to ensure continuation of services for the most ill of the Betak residents, Mercy opened a new skilled nursing facility at Girard Medical Center/North Philadelphia Health System. Girard Medical Center currently maintains 54 skilled nursing beds; one-third of these beds are now specifically designated for people with AIDS. The Girard Medical Center skilled nursing facility will remain open and continue to accept referrals, Mercy said in its statement.
Operations of the personal care facility from July 1, 1996, through September 30, were funded by the Department of Public Welfare, Mercy and the City in anticipation that adequate permanent financial funding could be secured. The City, in consultation with Mercy, submitted a proposal to the Pennsylvania Department of Public Welfare which was not approved.
Critics of Mercy's proposal to DPW noted that Mercy was asking for $1.6 million in additional funding for operating the personal care boarding home than was currently provided under existing reimbursements and grants. The daily, per-patient cost of care at the Mercy facility for personal care services for residents was $110 -- only $16 less than its reimbursement rate for its skilled nursing beds.
Mercy has also been criticized for what have been termed "extraordinary" overhead and administrative costs for its personal care facility, which Mercy said needed 64 employees for an average residential census of 25 people.
As at Betak -- the former name of the facility when it was operated as a skilled/personal care home by Lutheran Home at Germantown -- many of the residents at the home also were relatively healthy, and did not require the intensive services that would bring in higher income from reimbursements, said some advocates. The $2.5 million debt on the old Betak facility also drove up operating costs, advocates said.
In its public statement, Mercy said that it has operated the personal care facility since October 1st at its own cost without public funds, resulting in an $800,000 loss to the corporation.
"The City is actively exploring a number of alternatives to ensure that services comparable to those offered by the Mt. Airy home are maintained," said Estelle B. Richman, Health Commissioner, City of Philadelphia. "We are committed to that goal and the State continues to work with us to identify a solution." Source said that negotiations with other potential providers are promising, although it is unlikely that a future provider will continue to provide personal care services at the costly West Mt. Airy facility.
Under active consideration is a proposal which would open several smaller nursing homes located in areas which could serve both city and suburban residents without requiring them to travel as far from their families and neighborhoods as was necessary when a resident was admitted to the West Mt. Airy site.
Mercy has advised its current residents that they will not be inappropriately placed and that they expect it to take between 60 and 90 days for new placements to be made. Case managers and AIDS advocates have charged that there are not appropriate placements available for those residents who actually require intensive personal care services, and that some residents may be forced into independent arrangements that will endanger their health, or placed in homeless shelters -- already overcrowded because of the cold weather.
Plato A. Marinakos, President of Mercy Health Corporation, said he was "deeply disappointed" at the failure of DPW to provide the resources needed for AIDS care at the facility.
"Many people invested a great deal of knowledge, expertise and heart trying to develop a model that would continue to serve those with this devastating illness while maintaining its long-term financial viability. Unfortunately, the health care environment makes it financially impossible to maintain the current residential personal care program in West Mt. Airy."
Mercy will continue to have full financial responsibility for the personal care home in West Mt. Airy until living arrangements have been secured for all current residents, Mercy said.
The Mercy personal care home is the largest such facility dedicated to people with AIDS in the region. Other facility specifically designed for AIDS care include Calcutta House in North Philadelphia, Gift of Mary House in Delaware County, and Rainbow Home in Reading, each of which has no available beds and waiting lists for their services.
The meeting had been scheduled as a follow-up on a meeting in Harrisburg in mid-November at which Dierkers had pledged to rapidly take steps to publicize the names of physicians covered under HealthChoices, the state's new Medicaid managed care program, which is currently enrolling Medicaid recipients and is to begin operation on January 1st. Dierkers had also pledged to strengthen the ability of people with HIV/AIDS to choose AIDS specialists as their primary care physicians, and to appoint a staff member to handle complaints about the enrollment process.
"Obviously she hasn't done what she said she'd do and didn't have the guts to tell us face to face," said one activist who showed up for the meeting, which was canceled less than two hours before its starting time.
Meanwhile, a coalition of AIDS service organizations, people with HIV/AIDS and advocates, led by ACT UP Philadelphia, has set a demonstration to include civil disobedience, at the Philadelphia regional office of the Health Care Financing Administration (HCFA), which must grant a waiver to DPW before HealthChoices can be implemented. Virtually all AIDS service providers and physicians in the region have joined with people living with HIV/AIDS in asking HCFA to force DPW to delay enrollment of people with HIV/AIDS in HealthChoices until adequate access to experienced physicians and an appropriate standard of care are in place.
As of December 15th, individuals scheduled for HealthChoices coverage on January 1st will be assigned a Medicaid managed care plan of the state's choosing, if they have not made a selection of their own by that time. People with HIV/AIDS have complained that they are unable to choose a plan because they don't know which doctors on the plan's panels of primary care physicians are competent in AIDS care.
The mandatory enrollment deadline applies to all people living with HIV disease, except for those who are disabled and receiving Social Security benefits.
"This is the place and the time where we must put power behind our demands." said Paul Davis of ACT UP. "There has been a reasonable amount of press on this issue which has exposed Health Choices for the criminal fraud that it will be. An unprecedented array of activists have struggled long and hard on this issue and have consistently been right and smart. It has not worked. The state and federal officials who must bear responsibility for the program are moving forward."
We The People and ACT UP are encouraging the executive directors of organizations that serve people with AIDS to step forward and volunteer to risk arrest at the demonstration, which plans an act of nonviolent civil disobedience. "The kind of pressure and respectability [agency directors] can bring to bear for this fight is different that what ACT UP alone can muster," Davis said.
New information found in the blood cells of HIV-infected people may force scientists to reconsider some of the basic facts about how the virus affects the immune system, researchers report in the journal Science.
It has been shown over the past few years that HIV infection targets certain critical immune system cells, called CD4 or T-cells, for destruction. The immune system tries to replace these killed cells as fast as possible to keep from being compromised.
Ultimately, these CD4 cells are thought to become exhausted and die, resulting in a progression from HIV infection to full-blown AIDS. Treatment is aimed at boosting production of
CD4 counts and survival is usually associated with higher CD4 levels.
But after looking at a component of the cells called telomeres, researchers from the Netherlands are proposing that HIV simply slows down the rate of production of new CD4 cells.
According to this theory, the decline in CD4 counts seen in people with AIDS before HIV treatment and the subsequent rise in cells counts after treatment may indicate that treatment is restoring the ability of the CD4 cells to function, not helping to generate new cells.
Dr. Katja C. Wolthers and colleagues from the Central Laboratory of the Netherlands Red Cross Blood Transfusion Service in Amsterdam examined blood from nine healthy people and nine HIV-infected people. They then examined the telomeres, which provide information about how many times a cell has replicated.
CD4 replication in both groups was similar, indicating that people with HIV did not have the rapid turnover of CD4 cells that one would expect them to have.
Wolthers suggests that HIV may slow down the flow at the tap, making it appear as if the cells are being killed and replaced when they may simply be hampered in their immune system activity.
US to protect doctor fees under HMOs
As Americans on Medicare and Medicaid switch to managed-care health coverage, the Clinton administration is moving to protect doctors from being penalized, as many are now, for referring patients to specialists.
Officials of the Health and Human Services Department are completing regulations to take effect January 1st that designers say will prevent doctors from having to choose between sending a Medicaid patient to a specialist or possibly losing reimbursement money.
Penalties often come in the form of refusal to reimburse the physicians for the visits that led to the referral, or for diagnostic tests or other expenses associated with it. Some plans withhold reimbursement in amounts equal to the cost of referrals, if a physician's referrals cost more than 25 percent of his annual payment from the HMO.
The new rules take on special importance, given the huge growth in the number of Medicare and Medicaid recipients who now receive medical treatment through managed-care systems.
Almost 12 million Americans on Medicaid are treated through HMOs, 140 percent more than in 1993. The 4.5 million Americans on Medicare treated through managed-care represent 87 percent more than in 1993. Just in the past month, more than 100,000 Medicare recipients switched to managed-care health coverage.
The new government rules require HMOs to provide insurance for physicians, thus guaranteeing that the physician would receive his expected reimbursement even if he finds himself making numerous, costly referrals to specialists.
The new regulation marks the second time this year that HHS has tackled the delicate issue of the HMOs' relationships with physicians, rewarding or penalizing them based on the type of service they provide.
In March, the department ruled that managed-care organizations cannot reward doctors for limiting services to the elderly and the poor under Medicare and Medicaid. The agency also said this month it is writing rules to strengthen appeals rights of Medicare beneficiaries who disagree with medical care decisions by their HMOs.
The results of the study were published in the Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology.
The formulation of this drug contains five parts SMX to one part TMP, lead investigator Dr. Monique Brun-Pascaud of Hospital Bichat-Claude Bernard in Paris said. In the current study, Dr. Brun-Pascaud assessed the efficacy of various doses of TMP and SMX, used alone and in combination, in a steroid-treated rat model.
She found: "For prophylaxis, the reference regimen of 20 mg/kg TMP plus 100 mg/kg SMX was effective. Reduced doses of SMX (5 and 20 mg/kg) effective against PCP were effective against toxoplasmosis, provided the TMP dose was increased to 100 mg/kg." This reversed ratio of components, however, was not effective for curative treatment.
Dr. Brun-Pascaud concludes these results provide a basis for altering the TMP-SMX ratios when used as prophylaxis for PCP and toxoplasmosis, and this may be especially useful for HIV-positive patients with poor tolerance to sulfonamides.