Managed care for AIDS patients: is bigger better?
BACKGROUND
Medicaid provides funds for the majority of AIDS-related health care services in the United States. In an effort to stabilize steeply rising Medicaid costs, managed care programs are replacing traditional fee-for-service Medicaid services.


OBJECTIVE
To assess the impact of patient volume on the quality of care received by AIDS patients within a state's Medicaid managed care system.


METHODS
Cohort study of AIDS patients who were enrolled in Medicaid at any time from July 1997 through December 1998. Patient charts were reviewed and abstracted. Additional information on the AIDS patients' mode of exposure, date of AIDS diagnosis, and vital status were obtained from the state's HIV/AIDS surveillance database.


METHODS
All known AIDS patients enrolled in the Maryland Medicaid managed care program were eligible. A total of 1052 of 1585 patient records were reviewed and analyzed.


METHODS
CD4 and viral load tests; preventive health care including screening for sexually transmitted infections; placement of tuberculin purified protein derivative (PPDs); hepatitis B and C screening; vaccination for hepatitis B; vaccination for pneumococcal pneumonia; Papanicolaou test screening; medication utilization including receipt of antiretroviral therapy and prophylaxis against Pneumocystis carinii pneumonia; case management services; and mortality.


RESULTS
Health care quality indicators were examined by comparing the performance of clinical sites that saw a low volume of Medicaid AIDS patients per site (1-15 patients), a medium volume (16-100 patients), and a high volume (101-500 patients). High-volume sites performed better on virtually all quality indicators. There were few differences in performance between low- and medium-volume sites. High-volume sites experienced a greater number of patient deaths; this was true after adjusting for potential confounders such as age, use of antiretrovirals, time since AIDS diagnosis, appropriate laboratory monitoring, and hospitalizations.


CONCLUSIONS
Variations in quality of care for AIDS patients were observed in a statewide managed care system. These variations existed despite provisions to ensure quality care such as an enhanced payment system for managed care organizations providing services for AIDS. High-volume sites were more likely to adhere to Public Health Service guidelines and may offer the best opportunity to provide high-quality AIDS care.
Solomon
Liza
L
Maryland Department of Health and Mental Hygiene, AIDS Administration, Baltimore, MD, USA. liza@toad.net
Flynn
Colin
C
Lavetsky
Georgette
G
D000163:Acquired Immunodeficiency Syndrome / Q000150:complications* / Q000175:diagnosis / Q000628:therapy*; D000328:Adult; D018791:CD4 Lymphocyte Count; D005260:Female; D006509:Hepatitis B / Q000175:diagnosis; D006526:Hepatitis C / Q000175:diagnosis; D006801:Humans; D008297:Male; D008329:Managed Care Programs; D008396:Maryland; D008484:Medicaid; D065006:Papanicolaou Test; D022242:Pneumococcal Vaccines; D011020:Pneumonia, Pneumocystis / Q000188:drug therapy / Q000517:prevention & control; D011314:Preventive Health Services; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D016019:Survival Analysis; D014374:Tuberculin Test; D014626:Vaginal Smears; D019562:Viral Load
D022242:Pneumococcal Vaccines