California Is Tightening Rules on HIV Care

Managed care plans in California will be required to refer HIV patients to doctors certified as AIDS specialists under regulations scheduled to take effect in July, making the state the first to impose this requirement on private health insurers.

Studies have shown that HIV patients fare best when treated by doctors who have experience with the virus. But there is no formal definition of what constitutes expertise in HIV, so health plans have generally been left to devise their own standards, which vary widely. The new regulations define a specialist as someone who has cared for at least 20 HIV patients in the past two years and has demonstrated an understanding of recent developments in the field through testing, continuing medical education or other means.

"We have to treat people with this disease on a par with other diseases," said Daniel Zingale, director of California's Department of Managed Health Care, which developed the new regulations. "If you have cancer, you see an oncologist. If you have HIV, you should get to see an HIV specialist." Managing HIV infection has become much more complicated since the advent of effective pharmaceutical "cocktails" six years ago.

Advocates for people with AIDS applaud the new rules and expect them to influence the debate in other states. Julia Hidalgo, president of Positive Outcomes, a Maryland-based consulting firm specializing in the economics of HIV care, said AIDS activists and doctors elsewhere would carefully monitor the situation. "If this appears to be expanding access to experienced HIV care, then I think both consumers and clinicians in other states will be able to take that experience to their own legislatures and point to it," she said.

The AIDS Healthcare Foundation, a Los Angeles-based organization that operates HIV clinics, sued PacifiCare Health Systems last year, claiming that the company was making it hard for patients to see knowledgeable specialists. "The patients would really have to jump through hoops to get an appointment, and there were people who ended up giving up," said Tom Myers, the foundation's general counsel.

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