State rejects publication of HMO doctor list, won't mandate HIV care standard
Clinton plans $11 billion cut in Medicaid
Mouse study links cancer to AZT use during pregnancy
AMA reaffirms support for mandatory HIV testing
Poor P.I. compliance increases HIV RNA
Court allows testing of dental patients
FASTFAX is available by fax in the 215 and 610 area codes at no cost, by mail anywhere for $20.00 per year, by calling 215-545-6868, and by E-mail to drfair@critpath.org. Sources for some information in this issue include American Medical News, Bloomburg Business News, Journal of AIDS and Human Retrovirology, Journal of the American Medical Association, Philadelphia Inquirer, Wall Street Journal, Washington Post.
Gorton said that the only mechanism for identifying a Medicaid HMO doctor who will care for a person living with HIV/AIDS is for a Medicaid recipient to contact Benova, the company which received a $12 million contract from the state to counsel Medicaid beneficiaries in obtaining information on the state's new HealthChoices program, which officially begins on February 1st. Benova, he said, will give patients the phone numbers of the HMOs so they can ask them individually for information on AIDS care providers.
Coalition members pointed out that the system proposed by Gorton violates the basic principle of the Benova contract, which says that the organization will be able to provide sufficient information to allow a Medicaid client to choose the right HMO for their care. Benova has been criticized for its failure to develop a mechanism to assist Medicaid recipeints with HIV/AIDS.
Meanwhile, at least one HMO has revealed that it keeps a special list of its HMO doctors, but said that DPW had encouraged it not to release the information publicly. Other HMO representatives said that they are concerned that publishing the data would open them to a flood of people living with HIV/AIDS joining their plans, with negative economic impact on their bottom lines. Under existing Medicaid capitation rates, care for people with HIV/AIDS virtually guarantees a financial loss for the HMO they join.
HealthChoices, which requires all Medicaid recipients to join special Medicaid HMOs and eliminates the current "fee for service" program, will be required for all families receiving Aid to Families with Dependent Children benefits in February. SSI recipients and other disabled individuals will be required to join the plan in July.
Gorton also told the Coalition that the state would not require a common, specific standard of HIV care to be followed by each of the HMOs. He said that such a requirement might be a "double-edged sword" because it would allow the HMOs to ignore future treatment advances. Coalition members pointed out that they are seeking a minimum standard that would be consistently updated as treatment methods changed.
HMOs will be expected to develop their own standard of HIV care, Gorton said, but the details of each standard would not be mandated by DPW.
Meanwhile, an informal committee of local AIDS specialists and physicians participating in the four HMOs of HealthChoices was scheduled to meet last week to begin discussing the nature of such a standard of care as well as the definition to be used by the HMOs with regard to how a doctor is classified as a "specialist" in HIV care. A second joint committee, an advisory group comprised of people living with HIV/AIDS, is scheduled to begin meeting in early February.
In a related matter, Pennsylvania Welfare Secretary Feather O. Houstoun has unveiled a plan detailing how the agency would implement vast changes required by state and federal law.
The 27-page plan includes many expected features, including a five-year lifetime limit on welfare benefits and a requirement that recipients work at least 20 hours a week after two years of receiving benefits. The plan calls for escalating sanctions. Recipients will lose all benefits after the third time they refuse to work.
One surprise cut affects welfare mothers who have been able to keep up to $50 a month in child support without losing part of their cash-assistance grant. Under the new rules, any welfare mother who gets child support will see a drop in cash benefits.
"Pennsylvania's state plan reflects Gov. Ridge's commitment to reform the welfare system by encouraging personal and parental responsibility and promoting self-sufficiency through work while preserving safeguards for those who can't help themselves," Houstoun wrote in a letter announcing the plan.
Advocates immediately criticized the plan, which is now open for public comment, saying it was fragmentary and left many items to be worked out, such as how thousands of recipients were to find work in areas where job losses have been substantial.
Cheri Honkala, the unpaid director of the Kensington Welfare Rights Union, said the plan would hurt all workers by flooding the market with low-wage earners.
The long-awaited state plan will officially take effect on March 3rd.
Richard Weishaupt, an attorney with Community Legal Services, said the state plan so far fails to include many suggestions that advocates had been pressing for. Weishaupt and his colleagues have urged the agency to create one welfare program solely with state funds that wouldn't be subject to federally ordered, five-year limits on benefits. Such a program would give the state more flexibility in responding to individual needs.
"We should do what we can to avoid the one-size-fits-all approach," Weishaupt said. "Requiring everyone to work even if they're a 67-year-old grandmother is probably not the way to go."
Under the law, the Welfare Department can exempt 20 percent of clients from work rules and other limits. Houstoun said, however, that it was premature to pick all categories of recipients who would be exempted, because social conditions could change so much in five years. She said the welfare department had already created a variety of incentives. Half of a recipient's earned income already can be disregarded when determining cash assistance. Recipients can also own a car worth up to $1,500, she said.
Asked about creating a strictly state-funded welfare program, Houstoun said she hadn't dismissed the idea. But she said it is controversial because many in Congress think it is a thinly veiled attempt to skirt the federal law's guidelines.
The department will release a plan in late February that will revamp the child-care system, she said.
Clinton plans $11 billion cut in Medicaid
In his 1998 budget, President Clinton will propose a spending cap for the first time for Medicaid, administration officials said this month. The cap would limit the growth in spending for Medicaid to the growth rate of the gross domestic product (GDP), which is a tally of the nation's economic production.
The proposed cap means that per-capita Medicaid spending may grow no faster than the nation's per-capita economic output, before adjusting for inflation. Such a cap would likely limit Medicaid's growth to between four percent and five percent a year.
The President intends to ask Congress to squeeze at least $11 billion -- and perhaps twice that amount -- from Medicaid over the next five years. In addition to the cap on Medicaid spending, the administration will ask for cuts in disproportionate share hospital payments.
Clinton proposed the Medicaid cap over the objections of senior members of his own party, who view the limits as undermining the open-ended nature of Medicaid. Democrats, including Reps. John Dingell (MI) and Henry Waxman (CA) and Sen. Bob Graham (FL), are urging the White House to drop the idea of a cap on Medicaid spending. They contend that a cap would save much less money now that the growth of Medicaid has slowed. They also say that while the proposal would have been an acceptable alternative to the Medicaid block grants proposed last year by the GOP, such a plan to dismantle the program is no longer on the table, so a cap is unnecessary.
"Liberal Democrats and advocates for the poor do not want any more (such) cuts," one administration official told the Los Angeles Times. Other likely critics include state governors worried about the prospect of a decreasing contribution from the federal government. Republicans on the other hand, are likely to be pleased by what they've called Clinton's "effort at fiscal discipline."
In his budget, Clinton is assuming that Medicaid will grow by about 7.5% annually for the next five years, a level that is $55 billion less than the administration predicted last year. Clinton wants to ensure that the Medicaid program does not return to the explosive growth of the late 1980s and early 1990s. While Medicaid spending rose an average of 15% a year from 1985 to 1995, the growth of the program slowed to an average of 7.9% a year between 1992 and 1996, and increased just 3.3% last year. Reasons for the decline include greater use of managed care (such as the new HealthChoices program in Pennsylvania), a drop in medical price inflation, a decline in the growth of Medicaid enrollment and a federal crackdown on ploys used by states to shift costs to the federal government. However, it is unclear if the savings can be sustained over a long period. Government actuaries are fearful that Medicaid's costs could rise sharply by the year 2000 and beyond. As a result, the real impact of the cap could come in future years.
Court rejects resumption of privileges for HIV+ MD
An HIV-positive surgeon who sued Mercy Health Corporation after his clinical privileges were suspended has been denied his request to have his privilege to practice surgery restored by a federal trial court in Pennsylvania.
The surgeon had told the director of surgery at Fitzgerald Mercy Hospital, which is owned by Mercy Health Corporation, that he was HIV-positive in 1991, at which time he was encouraged to stop performing surgery and to notify his former patients that he was infected. Mercy was granted permission to inform the surgeon's past patients of his HIV status and sent out 1,050 notices. The company also suspended the surgeon's clinical privileges to perform invasive procedures unless he documented the patient's awareness of the fact that he had HIV.
Mercy Health Corporation sponsors Keystone/Mercy Health Plan, one of the four HMOs which will be providing HIV care under the state's new HealthChoices program.
The surgeon sued Mercy under the Rehabilitation Act of 1973 and the Americans with Disabilities Act, and both sides filed for partial summary judgment. The court ruled that the surgeon had not proven that performing surgery did not pose a significant risk to his patients. The court held that, while the risk of transmitting HIV during surgery was low, it would not decline to hear the case because the possible consequences were catastrophic.
Mouse study links cancer to AZT use during pregnancy
New evidence that the offspring of mice given high doses of AZT during pregnancy are at risk for cancer has raised concerns among federal health officials about the use of the drug for HIV-infected pregnant women.
Health officials say that for now, pregnant women infected with HIV should continue taking the drug, which has been shown in several studies to significantly reduce the transmission of HIV to infants.
High doses of the drug caused cancer in the baby mice, and pregnant women take much lower doses, said a spokesman for the National Institute of Allergy and Infectious Diseases. No cases of cancer have been found in the children of women who took AZT during pregnancy.
In response to the findings, the National Institutes of Health assembled a panel of AIDS and cancer experts to develop guidelines on the use of AZT during pregnancy.
Following a day-long meeting, the NIH panel overwhelmingly restated support for the U.S. Public Health Service guidelines which encourage AZT use in the treatment of HIV-infected pregnant women and their babies to reduce the risk of HIV transmission from mother to baby. The panel concluded that the theoretical risks represented within the one NIH study were far outweighed by the significant known reduction in risk of transplacental transmission of the virus as a result of treatment with AZT. In addition, the panel recommended continued evaluation of these data as well as a re-evaluation of the programs currently in place to provide ongoing monitoring of children born to mothers who were treated with AZT.
"Evaluation of these mice data should continue to try to better understand whether these hypothetical risks have relevance to human beings as very little is known about the reliability of the mouse model system in predicting human transplacental carcinogenicity," said Lynn Smiley, M.D., International Director, Antiviral Clinical Research at Glaxo Wellcome.
"What we do know is that treatment of HIV-infected pregnant women, and their babies, with AZT has dramatically reduced the numbers of infants born with this infection," said Dr. Smiley. "The discovery in 1994 that treatment with AZT could reduce the risk of perinatal transmission of HIV still stands as one of the most significant achievements in HIV/AIDS research."
In addition, children born to mothers who were treated with AZT in the landmark AIDS Clinical Trials Group study 076 have been followed for up to four years and no cancers have been reported. These children will be followed to age 21.
Meanwhile, a European research team has reported "a strong association between mother-to-child transmission of HIV-1 and a high maternal viral RNA load in plasma at delivery."
Dr. O. Coll and colleagues of Ciudad Sanitaria Vall d'Hebron, in Barcelona, and others at Utrecht University in The Netherlands, evaluated 67 HIV-1-positive women during pregnancy and delivery at two university hospitals. The team monitored the subjects for HIV-1 RNA, p24, CD4 cell counts, and also measured tissue culture infectious doses. HIV-1 infection was subsequently confirmed in 17 of the 69 children born to these women.
Dr. Coll's team found that "...[v]iral load was the main contributing factor for HIV-1 vertical transmission." No significant differences in the rate of vertical transmission appeared to be associated with route of maternal HIV transmission, treatment or no treatment with AZT, mean gestational age, duration of ruptured membranes or means of delivery, vaginal or cesarean.
The Spanish group says that this is the first large study to uncover "...a strong association between transmission of HIV-1 from mother to child and a high maternal viral RNA load in serum at delivery." And although the study was retrospective, Dr. Coll believes the results were not biased by a retrospective approach and that the data are in agreement with results of previous studies.
AMA reaffirms support for mandatory HIV testing
While members of the American Medical Association agreed by a close vote in June to support mandatory HIV testing for pregnant women, the group reaffirmed the decision by a wider margin at a recent meeting. A committee of the AMA wanted to reverse the decision, on the grounds that the group's general policy holds that a patient is entitled to consider a doctor's recommended care, but that "patients may accept or refuse any recommended treatment." Voluntary HIV testing of pregnant women continues to be supported by the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and other medical groups.
Dr. William R. Jones pointed out that the AMA also supports mandatory testing for people who donate blood, breast milk, organs, semen and ova, as well as for immigrants and military personnel, noting that HIV should be "depoliticized" and treated like other infectious diseases.
HIV returns when therapy ends
In the first case of its kind, San Francisco doctors report that the potent combination of anti-viral drugs that turns down HIV apparently does not turn it off.
The finding by doctors treating an unidentified San Francisco man suggests treatment of the disease may be a long-term endeavor -- and eradication still an elusive goal.
The experiment, unpublished in peer-review medical journals but reported on Sunday's "60 Minutes," is thought to be the first, albeit limited, test of viral eradication.
"That one case tells us that you shouldn't declare the ball game over when you do a biopsy and don't see any virus," Dr. Anthony Fauci, director of the National Institutes for Allergy and Infectious Disease, told "60 Minutes."
"Virus can exist at very low levels, perhaps beneath the level of detectability," Fauci said. "It would be a good thing if the virus were not detectable, but that doesn't mean it's not there."
Activists like Mike Martin Delaney of Project Inform were not surprised at the news.
"These drugs are not a cure, not an eradication," Delaney said. "If you take someone off therapies, of course you see a rebound (of the virus)."
Poor P.I. compliance increases HIV RNA
Even brief periods of low compliance with protease inhibitor monotherapy in HIV-positive patients are associated with increases in plasma HIV levels, according to researchers from Stanford University.
In a letter published in the Journal of the American Medical Association, Dr. Terrence F. Blaschke and colleagues report that they observed wide intragroup variations in response in a study of 40 patients with HIV-1 infection who received one of two saquinavir regimens requiring a six-times daily dosing. The development of resistant mutations did not explain the variability. Dr. Blaschke evaluated the subjects to see if "...decreased patient compliance with this intensive
regimen could explain the observed variation in viral responses." Drug-taking behavior was monitored using medication container caps that recorded the time of opening and closing on a microchip.
The team found that when patient compliance with the dosing schedule decreased, plasma HIV RNA levels increased subsequently. "The possible association between the transient increases in plasma RNA level and the subsequent development of mutations is intriguing but inconclusive," they write.
"Given the reality that perfect compliance is unlikely in any setting," Dr. Blaschke suggests that "...the relationship between drug-taking behavior...should be examined thoroughly in clinical trials and in therapeutic settings, using compliance monitoring combined with frequent virologic studies."
Court allows testing of dental patients
A Pennsylvania court has ruled that a dentist did not violate the law by refusing to treat the parents of a patient with advanced HIV infection until the parents were screened for HIV, according to an article in AIDS Policy & Law.
In the case of Cook v. Wirtz, a court of common pleas ruled that a "...legitimate request for medical information by a healthcare provider is not proof of discrimination under the state's Human Relations Act," the article continued.
Judge Eunice Ross ruled that the plaintiffs had not shown that Dr. Paul Wirtz had actually denied them care, and that the dentist's request for HIV testing was "not unreasonable" because the couple had a "...high-risk exposure..." to HIV. The Cooks had cared for their dying son without knowing that he had AIDS.
Meanwhile, a federal court in North Carolina recently rejected the employment discrimination claim made by an asymptomatic HIV-positive man. The case marks the first time a court has ruled that HIV infection is not a disability. Fernando J. Cortes had sued a McDonald's restaurant, but the court ruled that he had not proved his claim that "he had a physical impairment that substantially limited a major life activity."