HIV/AIDS: A niche MCOs avoid?

Know whom to approach to gain business

Contrary to popular belief, managed care is not everywhere. In fact, there are some who believe managed care organizations (MCOs) have been downright negligent in their outlook on certain diagnoses. By looking to provide care in such areas, it’s likely you could expand your business without having to become an expert in the complexities of managed care contracts — if you know who to approach.

"Managed care organizations don’t care about patients who have HIV," says Jesus Llanes, MD, a family practitioner and the president of LYVEMED, an independent medical group that recently opened a pair of HIV/AIDs treatment centers in South Florida after realizing patients were being left out in the cold by managed care. "Of 17 contracts we used to have, we are down to only a couple of contracts."

Llanes says he and Alberto Alea, MD, an infectious diseases specialist and vice president and medical director of LYVEMED, reduced their managed care contracts because of the way MCOs wanted to treat HIV patients.

"They want an HIV or an infectious diseases specialist to see these patients only on consultation when the primary care physician wants to refer the patient," says Llanes. "But if these patients are going to receive proper treatment, the HIV specialist should be the primary care physician. MCOs don’t want to do that because it’s much cheaper for them to have people who don’t know what they’re doing treat them."

Llanes notes that MCOs save money by minimally treating patients using little more than prophylaxis and sometimes AZT with a consultation with an infectious disease specialist. When the patients become sick, they are sent to hospice.

Llanes says patients get a wide range of medical services at the LYVEMED centers, including IV therapy.

"Infusion is very important to patients with HIV," he says. "When AIDs complications such as retinitis develop, that requires infusion."

Most of the infusion is provided in the medical center by the staff nurses, who are both LPNs and RNs. Llanes used to treat most patients in the home but is hesitant to do so with certain new drugs.

"Vistide is a drug I am very afraid of giving in the home since you have to give the patient a lot of hydration: one liter before the Vistide, then you infuse the Vistide and give another liter of hydration," he says. "On top of that, they have to get other medicine to go along with it. This drug can be so nephrotoxic that we have to be extra careful. This is a drug I would not give with home care because nobody is going to pay for a nurse to sit there for six hours."

However, LYVEMED patients receive everything from chemotherapy to total parenteral nutrition in the home, but Llanes says LYVEMED does not choose the home infusion agency.

"We usually leave it up to the hospitals to make the arrangements," he says. "Because of all the problems with kickbacks, we don’t ever want to have to answer questions regarding that, so we have decided to stay away. When we are approached by an infusion company, we refer them to the hospitals or people like South Florida AIDS Network," which case manages many of LYVEMED’s patients.

So take note that if your area has such clinics, the clinics themselves may not be the only targets you should market to. Consider groups that cater to individuals with the disease or any hospitals or care providers that may not have their own home infusion agency.

Llanes notes that the centers have not been marketed to the general public. Instead, LYVEMED is directing its marketing to physicians, combining education with marketing. LYVEMED presents conferences and HIV/AIDS updates at different hospitals, in addition to working with pharmaceutical companies where they give lectures on HIV treatment and diagnosis and other aspects of the disease.

"That way, people can get a grasp of the problems of HIV, they learn a little bit about diagnosing and treatment, and what the problem is in the community, and they get to know us and find out there are a couple of people in the community that can treat this diagnosis," says Llanes.