HIV Practices Face Grim Financial Times

As new drug combinations are helping HIV-infected people live longer, a growing number of doctors treating them are struggling to keep their practices afloat, largely due to changes in health care financing. "I loved the private practice, but I could see the handwriting on the wall," said Dr. Jeff Goodgame, who left his Miami practice two years ago and joined Pfizer in New York as a researcher.

In San Francisco, some physicians with large HIV practices estimate that their annual incomes have dropped to the $70,000 to $90,000 range, from $110,000 to $120,000 five years ago, even as some work more than 60 hours a week. "There's a large number of doctors leaving private practice in this fairly small city," said Dr. Stephen Becker, one of San Francisco's leading AIDS doctors. Becker blames managed care -- especially health maintenance organizations -- for the problem.

HMOs pay primary care physicians the same flat monthly fee, called a capitation rate, for every patient, healthy or sick. Specialists are reimbursed at a much higher rate. Many HIV patients, however, get almost all of their treatment from a primary care physician, who may receive as little as $5 a month for patients -- whether they have HIV or the common cold.

As a result, many doctors are hesitant to take HIV-infected patients, at least those covered by HMOs. "It's getting harder and harder to refer people to doctors who will accept them," said Tim Teeter of the San Francisco AIDS Foundation. "The medical management of these patients has become increasingly complex, so physicians are unable to see as many patients," said Julia Hidalgo, president of Positive Outcomes, a consulting firm that specializes in the financial aspect of HIV. Dr. Howard Grossman, a New York primary care physician, said his HIV patients make up about 40 percent of his practice but take up to 90 percent of his time.

One alternative is for the medical profession to formally recognize a specialty in HIV medicine, which could put pressure on insurers to provide higher reimbursement. Yet health insurers say that it is up to the doctors to negotiate the best rates for themselves with insurance plans.

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