S.F. Leads the Way in Coping With Cost of AIDS

American cities--almost all of which are or will be caught up in the human and economic devastation of AIDS--are being urged to look here for a lesson in how comparatively inexpensive compassion can do better than high-tech, big-bucks medicine.

The San Francisco approach, a major national foundation argues, may save public health departments, hospitals and other health centers across the country from the economic calamity imposed by treating victims of AIDS--acquired immune deficiency syndrome.

The people who run the first-of-its-kind AIDS unit at San Francisco General Hospital say that there is a larger message in this, too--one that may eventually alter some of the basic U.S. philosophy of medical economics, which seems to say that the most expensive type of treatment is always the best.

Grants Program

The economic lesson to be exported from San Francisco is this, according to the Robert Wood Johnson Foundation, which on Thursday announced in Washington that it is putting up $17.5 million in grants to 10 cities to develop their own financially sound AIDS treatment programs:

Nationwide, according to the federal government’s Centers for Disease Control in Atlanta, the first 10,000 cases of AIDS have cost $1.4 billion in medical care costs, alone--an average of $140,000 each. But in San Francisco, the cost has been held to $29,000 per case through greater use of non-hospital facilities and an altered perception of AIDS here that has made it possible to develop a humane community response to its victims instead of simply locking them away to die in intensive care units, with ventilator tubes in their throats.

A California Department of Health Services analysis of AIDS costs in the state made somewhat different computations for San Francisco’s costs-per-case, finding the total costs for the final 18 months of AIDS victims’ lives to be from $52,000 to $74,000 here and between $70,000 and $109,000 in Los Angeles County. The statewide cost-per-case was between $65,000 and $110,000, the state agency found.

San Francisco combines a special inpatient AIDS unit at San Francisco General with a network of 20 different organizations that work together to plan treatment programs for AIDS victims that emphasize out-of-hospital services ranging from hospice care to house cleaning.

With 1,800 AIDS cases reported so far, San Francisco has the second-highest total in the country--after New York, which has reported 5,224 cases. Los Angeles, with 1,384, will probably pass San Francisco this year in the total number, AIDS experts here say. Statewide, California had tallied 3,793 cases as of the end of January.

But the cost differences between the rest of the state and country and San Francisco are pronounced, no matter how the calculations are made. Dr. Philip Lee, director of UC San Francisco’s Institute for Health Policy Studies, said local health officials have been able to prevent AIDS from bankrupting the local health system because “they responded to it as if it was a disease, with people who deserved treatment, instead of (as if) the victims were just a stigmatized population.”

It is that message that Lee, who is also president of the San Francisco Health Commission, and Dr. Mervyn Silverman, former San Francisco director of health, went to Washington to deliver Thursday at a news conference sponsored by the Robert Wood Johnson Foundation. Lee will serve as chairman of the foundation’s national advisory committee for the new program to help cities find ways to control the cost of treating AIDS and Silverman will be project director.

In an interview here earlier this week, Lee said he thinks the growing panic over just the financial implications of the AIDS epidemic--as well as the syndrome’s spread to almost every state and city of any size in the country--has finally made the time ripe for major changes in the way AIDS victims are treated.

“When San Francisco put its first money into AIDS, there were fewer than 50 patients,” Lee said, noting that the epidemic here traces to as early as 1983. “Nationally now, I think there is more interest and willingness to learn (from what San Francisco has done) because of the increased numbers (across the country). One of the important things (in the struggle to change the perception of AIDS and its victims) is to dispel the myths about the high costs of this problem.”

“There . . . is a unique opportunity here to do something that has proven difficult to achieve in American health care--create improved and expanded health services that actually cost less,” noted Drew Altman, vice president of the foundation that is providing the money for the new national program.

‘Best Possible Response’

“Finally, liberals and conservatives and spenders and budget cutters alike should all find strong reasons to support these projects. For AIDS patients, for the taxpayer, for health care institutions and for a fearful public, a specialized citywide program emphasizing out-of-hospital care is the best possible response to this disease.

“It is appropriate to call AIDS this nation’s No. 1 public health priority. Though other diseases claim more victims, no disease in recent history has created so much fear or strained our ability to respond.”

To Silverman, who served as city health director for 7 1/2 years before stepping down last year, what may be most important in the new program is the model, based on San Francisco’s response to AIDS, that can be created for dealing with what amounts to public health emergency situations. “Really, if anything positive comes out of the AIDS crisis,” Silverman said in an interview in his home in the Haight-Ashbury district, “it is that this is how we ought to look at all chronic diseases.

“What we do in this society (in any situation like this) is use the most expensive (treatment) modality.”

The foundation will accept proposals for the grants from public or private agencies in each of the largest 21 cities in the country, a group that ranges in population from New York to Baltimore and includes San Francisco, Los Angeles and San Diego here in California. Grants of up to $1.6 million each will be available to successful applicants among the 21 cities except for New York, Los Angeles and San Francisco, where new or existing programs will be able to get as much as $2 million each. Winners will be announced later this year.

The program the foundation hopes applicants will model their proposals after is based in a cheery, freshly painted 20-bed unit on the fifth floor of San Francisco General Hospital. Simply called 5-A, the unit was the nation’s first inpatient ward devoted specifically to AIDS cases.

There were 12 patients in 5-A earlier this week, but it was operating at less than capacity only because the unit has recently been expanded and some redecorating and addition of equipment remained to be completed. They were all men, some with breathing tubes in place--almost all of them essentially certain to die, either this time in the hospital or in the next few months.

Cliff Morrison, San Francisco General’s assistant director of nursing and the person who developed much of the hospital inpatient and outpatient AIDS program, said the average length of stay in the unit is 11.4 days per patient--a significantly lower figure than the national average of 31 days in the hospital, and as much as 50 days in New York. Some patients are hospitalized several times.

In a statewide analysis by Lee’s group, researchers found total average hospital time in San Francisco AIDS cases of 35 days versus a national average total hospital time of 167 days computed by the Centers for Disease Control in the study that concluded $1.4 billion had been spent on the first 10,000 patients. The same CDC study said that, because AIDS patients are young--most are 25 to 49--and still in their most productive working years, the total financial toll in earning years lost, disability payments and other costs may have exceeded $4.8 billion for the first 10,000 patients.

Morrison said that when San Francisco General first started seeing AIDS patients, it was common to send many of them to intensive care units--the most high-cost services in any hospital--where they would be given the most technologically advanced life-support treatment even though many of them would die within a few weeks, no matter what was done for them. Quickly, Morrison said, hospital officials realized that, for comparatively young people who remained fully aware of their surroundings while connected to the complex medical machinery of the ICU, the terror of the treatment was doing far more harm than good.

What evolved as a result, Morrison said, was a markedly different approach in which ICUs are used only under unusual circumstances.

San Francisco General AIDS patients, Morrison said, are encouraged to manage their own cases and participate in all decisions about their care. They may choose to be designated as so-called “no code” patients on whom no emergency resuscitative measures would be taken, he said, or they may elect to receive complex lifesaving treatment.

A major change that has resulted in San Francisco is that, before the San Francisco General-based AIDS program began, most AIDS victims died in ICU beds. Today, the majority of patients choose to have only palliative care and die outside the hospital, often in far more comfortable and familiar surroundings. Morrison said 80% of the victims die through the natural, terminal progression of their diseases. The suicide rate among AIDS victims, Morrison said, has declined.

Many of the rooms in the AIDS unit have extra beds so lovers, friends or family members can stay overnight with patients--a practice that is actively encouraged. Flowers adorn the nurses’ station at the middle of the unit and teddy bears and other personal effects are common in patient rooms.

There have been few, if any, fears for the safety of hospital workers or volunteers, said Lee, Silverman and Morrison, because part of San Francisco’s approach to AIDS has been a public education program to emphasize that the disease cannot be spread by casual contact between people. It is, public health authorities agree, a difficult virus to pass on and can be transmitted only through sharing needles to inject drugs, many types of homosexual sex and other activities in which body fluids like blood and semen are mixed.

The special AIDS unit has a waiting list for its 33 staff openings and is supported by a large corps of specially trained volunteers.

The most important part of the San Francisco program, said Morrison, is the network of mostly private, outside organizations that work with the hospital staff, providing such things as hospice services, emergency housing, meal preparation, house cleaning, laundry assistance and transportation to AIDS victims who are out of the hospital.

In all, there are 20 community and public organizations involved in the collaborative program to deal with AIDS--all of them oriented to finding ways to deal with AIDS patients in the community, resorting to hospitalization only when no other step can be safe or effective. Morrison holds weekly discharge planning meetings with representatives of all of the groups involved so the management of each case can be discussed in detail, with an eye to choosing the most compassionate programs available.

Not surprisingly, he said, the most humane treatment often turns out to be the least expensive--especially since the death rate from AIDS remains nearly 100% and expensive hospital techniques often accomplish little more than postponing the inevitable.

“The only way that you can do something like this is to plan for it,” Morrison said. “You can do it if you can put aside all the other (emotional) issues about AIDS. (In a sense,) the reality is that there are no issues with AIDS. We’ve created the problem by our inability to respond to AIDS unemotionally.

“AIDS is the essence of all the problems with health care today. AIDS is the No. 1 issue in health care today. If we can’t deal with it, we can’t deal with anything. The bottom line is we can deal with it.”

San Francisco officials realized as early as three years ago, Morrison said, that, simply in terms of patient welfare, a pervasive public attitude had to be changed about AIDS victims that, in many cities, seems to express the preference that they die--as quickly as possible.

Though they suffer from diseases that have a link to their life styles, Morrison and Lee agreed, AIDS victims are little different in that respect than cigarette smokers who have contracted cancer or obese people who have heart attacks after lifetimes of overindulgence in food and drink.

“People live longer when they know they are being taken care of,” Morrison said. “The health care system (in many places) is (still) saying, ‘I hope you die.’ That is pretty pervasive.

“I think health care in this country has gone crazy. I hope history never lets us forget how we’ve treated AIDS. We’ve had all this emphasis on ‘cure’ but we’ve forgotten about ‘care.’ ”