Physicians With Private HIV Practices ‘Struggling’ to Stay in Business, Blame Low HMO Capitation Rates

As many people with HIV are living longer due to antiretroviral drugs, a "growing number" of primary care physicians who specialize in HIV treatment are being forced to close their practices due to increased costs and low reimbursement rates from insurance companies that do not classify HIV treatment as a specialty, the New York Times reports. In San Francisco, many HIV physicians report that their annual income has dropped from the $110,000 to $120,000 range five years ago to the $70,000 to $90,000 range today, although they continue to work about 60 hours per week. Some have been forced to abandon their practices. Most physicians blame their decreasing revenues on managed care, especially health maintenance organizations that pay primary care physicians a flat capitation rate for every patient in their practice, regardless of their patients' health conditions, but reimburse specialists such as cardiologists at a higher rate per patient. Most HIV patients receive care from primary care physicians who receive the same fee -- sometimes as low as $5 a month -- for an HIV patient whom they see routinely as they do for a relatively healthy patient who comes in once or twice a year.

Complex Treatment Regimens Force Cutbacks
Such low rates have prompted some physicians to turn away many new HIV patients, and increasingly complicated treatment regimens that require more extensive monitoring and more expensive lab work have forced many doctors to cut back on the number of patients they do see, the Times reports. "The medical management of these patients has become increasingly complex, so physicians are unable to see as many patients," leading to decreased incomes, Julia Hidalgo, president of Positive Outcomes, an Annapolis, Md.-based consulting firm specializing in the financial ramifications of HIV, explained. If reimbursement rates "do not increase to address the level of complexity and frequency of visits, clinicians are not going to be able to break even," she added. Two groups of HIV physicians are working on developing criteria to establish HIV as a specialty practice to receive higher reimbursement rates, but there is no indication that HIV will be officially accepted as a specialty "any time soon," the Times reports. Health insurance groups say it is "up to doctors to negotiate the best rates for themselves with insurance plans," but acknowledge that the capitation system was developed for doctors who treat a variety of patients. Bobby Pena, a spokesperson for the California Association of Health Plans, said that the current system "does make for an interesting dilemma if you have doctors who call themselves primary care but are taking a large percentage of specialty patients. I don't know that anybody has come up with the best answer for that" (Tuller, New York Times, 11/6).