published by We The People Living with AIDS/HIV of the Delaware Valley, Inc.
Doctor, director fired at Neumann over AIDS patient care
Congress increases 1997 AIDS funding; immigration provision deleted
NY moves ahead on Medicaid HMOs; Maryland may delay
Study shows Famvir reduces herpes
Doctor, director fired at Neumann over AIDS patient care
Robert Capone, Director of HIV Services, and Dr. Daryl Jackson, Medical Director of NuVision Health Management's AIDS program at Neumann Medical Center, were abruptly terminated last week after they confronted the CEO of Neumann, Joseph Hare, about what they called "questionable treatment of AIDS patients" by nursing staff.
Capone, a person living with HIV, is a member of the city's HIV Commission, which sets priorities for AIDS programs throughout the five-county area. He also serves as Treasurer of We The People Living with HIV/AIDS, the nation's largest regional coalition of people living with HIV and AIDS.
He is the second person living with HIV who serves on the city's HIV Commission in as many weeks to face employment problems. Ted Kirk, the chairperson of the Commission, was denied long-term disability benefits by CNA insurance company and his employer, COMHAR, because his AIDS diagnoses was considered "a pre-existing condition."
"I can't believe it," Capone said on his termination. "I have to admit that when NuVision recruited me for the position I was concerned that they might only be in it for the money, but they assured me that good patient care was top priority. I guess I should have trusted my intuition, because these people obviously have no concern for patient care. I told them up front that my primary concern was quality care for people with AIDS and that I did not oppose anyone making money so long as they provided the care that they promised."
NuVision Health Management is a new company owned and operated by Rev. George Anderson, Jasper Baxter, and Dennis Baxter, who also own NuLife, which operates two drug and alcohol detoxification units at Parkview Hospital and JFK Memorial Hospital in northeast Philadelphia.
The detox units have been criticized in the past for what advocates have called "recycling" patients through the two units as soon as they are Medicaid eligible for readmission.
Capone said that the problems began the week of September 14, when Neumann admitted its second patient to the NuVision unit.. During the course of the patients' seven-day stay, Capone said, he received "at least a half dozen complaints" from the patient, a family member, and even from NuVision's office manager regarding the way the patient was treated.
The complaints were primarily about attitudes from various nurses. Both the patient and a family member termed the nurses' attitudes as "nasty," he said. Capone said that NuVision's office manager, Greta Marshall, confirmed the complaints, telling him that when she asked a nurse for a blanket for a shivering patient, the nurse refused.
Capone said that Marshall eventually took a sheet from an unoccupied bed and gave it to the patient.
Dr. Jackson, the medical director of the program, said that his concern rose when he was pressured to discharge patients early. "It was ridiculous," he said. "I was being paged 6-7 times a day for one patient. They kept asking me when I was going to discharge him, where was he being discharged to, they were in a big hurry to get him out."
Dr. Jackson said he also became worried about the ability of the Neumann nurses to provide appropriate AIDS care when he noticed that several nurses entered a patient's room as though he were in isolation, in gloves and mask, even though such precautions were not necessary. "When I asked one nurse why she was doing this she responded that she was just practicing universal precautions. I reminded her that the patient was not contagious but she still kept on the mask. I then reported the incident to Rob."
Dr. Jackson said that on the day of discharge he had to tell a nurse to change a patient prior to his leaving, because when the family member asked for help to change him because he had defecated, she was told that they could change him at the personal care facility that he was being discharged to.
"By this time I was really upset," Capone said. "I informed George (Anderson) of the situation and told him that I was going to bring my concerns to the Director of Nursing at Neumann, Allan Funtanella. "Over the next two days I called and visited his office several times. I was told he was unavailable. I left my pager number and explained that it was urgent that we speak about patient care. He never returned my call.
"The next day however, I was informed by Greta (the office manager) that the assistant director of nursing was looking for me. I went to her and when I tried to express my concerns she became annoyed and defensive. I called George Anderson and said that we needed to meet with Joe Hare (Neumann's CEO) because I was not satisfied with this response and I was hoping to enlist his assistance in resolving the matter," Capone continued.
"The meeting was scheduled for Wednesday afternoon Sept. 25. It was me, Dr. Jackson, Rev. Anderson, and Joe Hare. I explained everything to Mr. Hare. Then Dr. Jackson expressed his concerns. Then, rather than ask how we could rectify the situation, Hare became irritated and defensive. He went on to say, 'Hypothetically , when you have a director of a program who doesn't have a degree trying to tell a nurse how to do her job you have to expect some resistance.'"
Capone said, "I responded that not only have I been living with HIV for eight years, I have also been providing care to people with HIV for over 4 years, and that I didn't need a degree to determine when someone wasn't being treated with basic human dignity and respect."
Capone said that Hare went on to "hypothetically" describe a new physician at a hospital arrogantly telling nurses how to do their jobs. Hare said, Capone reported, that in the four years that he has been at Neumann he has only received 5 patient dissatisfaction letters.
"The discussion at this point became heated and Mr. Hare stated that he could no longer work with Dr. Jackson," Capone continued. "At this point both Dr. Jackson and myself left the room. We went back to the clinic and about ten minutes later Rev. Anderson came and I asked if I was fired and he said no."
The next day, however, Capone said he met with Rev. Anderson and was informed that Hare had decided he could no longer work with Jackson or Capone, so NuVision would have to "sever its relationship with" Capone because he had alienated NuVision's "customer."
Capone said he told Rev. Anderson that "if you really care about people with AIDS you would pull the program out of Neumann." Rev. Anderson replied, according to Capone, that he had to "look at the bigger picture."
"I have other business arrangements with Neumann that I can't jeopardize," Capone quoted Rev. Anderson as saying. Capone said he was promised two weeks severance pay and no medical coverage.
Capone said that he had also been suspicious because he had always been compensated in cash, with no clear record of payment of his federal, state and local taxes, or of payment of unemployment taxes. He said that Rev. Anderson was unable to confirm that the legally required taxes were paid, and suggested instead that Capone apply for unemployment benefits on the basis of his previous job.
"So here I am a person with HIV who only tried to assure decent care for other people with HIV and AIDS, out of work and uninsured, punished for trying to do the right thing." Capone concluded.
After weeks of intense advocacy and negotiations, an additional $25 million for HOPWA was included in the final FY '97 VA/HUD Appropriations Bill, AIDS Action said. The additional money will be used to expand the program to new communities as well as to guarantee "level" funding for cities which have been in the program for some time, including Philadelphia. Philadelphia receives approximately $1.3 million from HOPWA for AIDS housing programs in southeastern Pennsylvania and southern New Jersey.
The additional $25 million for HOPWA will come from "recaptured" savings in another HUD account, making a total of $196 million available for HOPWA in FY 97. However, the additional $25 million for HOPWA is dependent on HUD "collecting" the recaptured funds as they become available and assigning them to the HOPWA account. Thus, depending on how quickly HUD thinks the $25 million in recaptures will become available, the FY '97 HOPWA formula may be run initially on a total of $196 million, or, if recaptures are expected to be slow in coming, run the initial formula on a base of $171 million and do a supplemental formula process for later in the year for the additional $25 million.
AIDS Action said it will be pushing HUD to run the initial funding formula based on $196 million rather than the $171 million. This will help to make sure that grantees know, up front, what funding levels to expect and can plan accordingly.
AIDS Action said it was proud that it succeeded in getting Congress and the Administration to do "what many thought was impossible" -- namely, to find $25 million more in the "unbelievably tight" HUD budget for HOPWA. "Now we need to urge HUD and the Administration to make these additional funds available as quickly as possible, so that grantees can move on with their work of providing housing services to people in need," the group said in a statement.
In other action, the FY '97 Omnibus Consolidated Appropriations bill was also approved by the Congress and signed by the President. The bill increases funding for AIDS prevention, care and research by over $365 million. After marathon negotiations over the weekend prior to the bill's passage, and what AIDS Action called "strong leadership from President Clinton and heroic efforts by Rep. Nancy Pelosi (D-CA)" and others, an additional $100m above the President's recommended funding levels was secured for the Ryan White CARE Act to help pay for new drug therapies and provide other care services.
Funding levels for 1997 in the various AIDS categories are as follows:
Prevention: Prevention programs received an increase of $33 million over FY 1996 for a total of $617 million. This increase is targeted for previously unfunded prevention programs identified through the HIV prevention community planning process. Those programs could not be funded last year since prevention programs had been cut by $6 million from FY '95 to FY '96.
Ryan White CARE Act: Funding for the Ryan White CARE Act was increased by $239 million, bringing total funding for the CARE Act to just under one billion dollars. All titles of the CARE Act received increases in funding for FY '97, including an increase of $115 million exclusively for AIDS drugs through the AIDS Drug Assistance Program. Funding for the AIDS Education and Training Centers has now been fully restored to the FY '95 level of $16 million.
AIDS Research: The National Institutes of Health received an overall increase of 6.8%, which includes an additional $94 million for AIDS research. The contentious issue of the consolidated appropriation for AIDS research was settled through compromise language which empowers the Directors of NIH and the Office of AIDS Research (OAR) to determine the level of AIDS research per Institute in accordance with the AIDS research strategic plan. The compromise also grants the OAR up to 3 percent transfer authority throughout the fiscal year to respond to changing research needs and priorities.
Medical care for immigrants protected
Meanwhile, AIDS Action reported that "hateful" provisions of the immigration reform portion of the appropriations bill passed by Congress were removed in the final legislation. The provisions that would have denied legal immigrants and undocumented persons access to publicly-funded HIV testing and care services. Provisions which would have rendered legal immigrants who utilize more than 12 months of public assistance benefits deportable were also removed from the final bill.
Unlike a similar plan set to start in southeastern Pennsylvania in January, the New York system will allow for the creation of "special needs managed care" plans for people living with HIV and other populations.
Meanwhile, as Pennsylvania AIDS advocates seek a delay in the implementation of a similar program for people with HIV/AIDS because of numerous concerns about access and quality of care, the state of Maryland is considering delaying the start of its program because of nagging questions about its regulations and reimbursement.
In New York, Pataki said, "This legislation represents our commitment to insuring high quality and cost-effective health care for all Medicaid recipients. It finally gives New York the authority and tools to implement needed reforms of the nation's most costly Medicaid program."
New York's Medicaid program costs $25 billion a year; state officials expect the managed care plan to save about $1.5 billion over five years. The plan allows the state to certify "special needs" managed care plans for HIV-infected Medicaid beneficiaries and those who require psychiatric care.
The law also provides protections "against aggressive recruitment techniques," and mandates that "Medicaid recipients receive independent counseling on how a managed care
plan works before they sign up." All Medicaid recipients must be offered a choice of at least two plans.
In Pennsylvania, Medicaid recipients will be able to join one of five plans.
Meanwhile, "Maryland may have to delay implementation of its plan to switch Medicaid recipients into managed care plans to give more time to work out regulations," state Sen. Larry Young (D), chair of the state Senate Health Subcommittee, has announced. Health providers and advocacy groups are concerned that insurers and providers have not had enough time to review the still-incomplete regulations and reimbursement rates for Maryland's plan to begin moving Medicaid recipients into managed care on its target date of January 1, he said.
State health officials, however, contend that they are ready to begin the process.
"There's too much left to be done," said Bobbi Seabolt, a lobbyist for the Maryland chapter of the American Academy of Pediatrics. Seabolt explained, "Some managed care organizations are still forming and they have to send the rates to the providers, who need time to analyze them." Leigh Cobb, a representative for Advocates for Children and Youth, said, "We'd like more time to do education. The population doesn't have sufficient knowledge about this." Young said "he needs to think more about how a delay would work," but said that "he could have recommendations ready for next week's meeting of the joint committee of the Legislature that reviews recommendations." Young said, "I'd rather be slow and right."
HMOs, however, "are anxious to move ahead."
Martha Roach, executive director of the Maryland Association of HMOs, said that "overall, the health department has been responsive to a lot of our concerns, and is continuing to work with our remaining concerns." Barbara Shipnuck, deputy state health secretary, said she believes the state is on target for beginning enrollment January 1. "The number of issues has been reduced substantially, although some organizations that didn't get 100 percent of what they wanted will continue to try to get 100 percent. We believe we have a balanced set of regulations taking account of all the interests," she said. However, she added that the department would "study the implications of beginning the program later."
Study shows Famvir reduces herpes
Famciclovir (Famvir) is safe, well-tolerated and effective in significantly suppressing herpes simplex virus-2 (HSV-2) outbreaks among HIV-infected individuals, according to a recent study conducted at the University of Washington.
In the first phase of the study, approximately 80 percent of famciclovir recipients remained free from HSV recurrences compared to only 29 percent of placebo recipients. The findings were reported by Dr. David Koelle of the University of Washington Division of Allergy and Infectious Diseases at the 101st annual convention and scientific seminar of the American Osteopathic Association (AOA) in Las Vegas.
"HIV-infected individuals are known to experience frequent and troublesome genital herpes outbreaks," said Dr. Timothy V. Schacker formerly of the University of Washington and first author of the study. "Based on the results of this study, famciclovir is a well-tolerated and effective drug for suppression of HSV-2 in HIV-infected individuals."
This randomized, double-blind placebo-controlled study was conducted with 48 individuals infected with HIV and HSV. Using a crossover study design, patients were randomized to receive famciclovir (500 mg, twice daily) for eight weeks, followed by a seven-day washout period and then eight weeks of placebo. Similarly, patients who were initially randomized to receive placebo concluded the study with famciclovir treatment (500 mg, twice daily).
In a crossover analysis of patients successfully completing both arms of the study, famciclovir-treated patients experienced a significantly lower overall rate of HSV-2 shedding versus placebo (1.3 vs. 9.7 percent of days, respectively). The subclinical anogenital HSV-2 shedding rate (percentage days with positive culture and no lesions present) was also significantly lower in the famciclovir group (1.2 percent) than in the placebo group (6.3 percent). Furthermore, the percentage of days that HSV-2 shedding occurred and herpes lesions or symptoms were present was also significantly reduced during famciclovir treatment.
HIV-infected persons experience more frequent and prolonged episodes of anal and genital HSV-2 reactivation. Famciclovir appears effective in reducing the frequency and severity of these HSV reactivations in HIV-infected persons.
Famvir was cleared by the U.S. Food and Drug Administration to treat recurrent genital herpes in immunocompetent patients in December, 1995 and is also currently indicated for the treatment of acute herpes zoster (shingles). Famciclovir is being studied for the treatment of a number of other infections caused by the viruses belonging to the family of human herpesviruses in both immunocompetent and immunocompromised individuals. Studies are also in progress with this agent in the treatment of chronic hepatitis B virus infection.