Spitzer Mulling Managed Care in AIDS Cases

The Spitzer administration is considering a move to impose mandatory managed care enrollment among Medicaid patients who are infected with HIV or AIDS.

Since the late 1990s, more than 65,000 HIV and AIDS patients enrolled in the state's Medicaid program have been exempt from a push to enroll beneficiaries in managed care plans.

Because the Spitzer administration is facing a $4 billion budget gap, the issue has taken on a greater urgency of late. The administration has indicated a need to curb health care spending, and in particular its Medicaid budget, which is the highest per capita nationwide.

Spitzer officials stressed that mandatory managed care enrollment for HIV and AIDS patients, a plan still in its nascent stages, may offer a better value for Medicaid dollars.

"One reason we want to start a discussion is because the data we have, across the board for Medicaid managed care, shows that enrollees are getting better care than in fee-for-service" plans, the state's Medicaid director, Deborah Bachrach, said in an interview.

She stressed that cost is not the only factor driving discussions. "We can't make a decision without looking at cost savings," she said, adding: "We can't just look at cost. What is the care we're buying?"

Still, such a proposal is likely to rankle many AIDS advocates. More than 172,000 New Yorkers are infected with HIV or AIDS, with the largest concentration living in New York City.

"Simple mandatory enrollment in Medicaid HMOs is not any kind of magic bullet," Michael Kink, the legislative counsel of Housing Works, which opposes mandatory managed care for HIV and AIDS patients, said. Mandatory enrollment has "the potential for large-scale disruption of the HIV care system," he said.

Since the late 1990s, certain populations, including those infected with HIV and AIDS, were exempt from a drive to enroll Medicaid patients in managed care plans. In recent years, however, state lawmakers have lifted some exemptions on people with disabilities and those suffering from mental illness.

Currently, some 10,000 HIV-positive beneficiaries are enrolled in Medicaid managed care plans. Among the general population, about 2.5 million of the state's 4.2 million Medicaid beneficiaries are enrolled in managed care plans.

In describing their concerns, AIDS advocates questioned whether HMOs could handle their needs, and whether there are enough physicians specializing in HIV and AIDS to accommodate an influx of 65,000 patients.

"For this population, it needs access to medicine and doctors who know what they're doing," Matthew Lesieur, the director of federal affairs at the New York AIDS Coalition, a group representing nearly 200 community-based HIV and AIDS organizations, said.

A central question is whether HIV and AIDS patients would need to enroll in existing Medicaid health plans for people with HIV and AIDS, known as HIV Special Needs Plans. Currently, three plans operate in the state, but they are available only in New York City. Some advocates raised questions about the ability of the plans, which currently have 2,500 members between them, to absorb an influx of members.

"Our special needs program would definitely need to expand its provider network in order to be responsive to large numbers of people who would choose us," Doug Wirth, the president and CEO of VidaCare, a New York City company that offers an HIV Special Needs Plan, said. The company currently has 75 primary care physicians and 3,000 specialists in its network. It has roughly 550 members.

Finally, patients also expressed a desire to choose their health plans, with some saying managed care plans could not provide the range of services they need.

"Why should it be mandatory?" a 45-year-old woman who has been living with AIDS for 10 years, Shirlene Cooper, said. "By right, I should be able to choose whether I want managed care or not, and I do not."