A Caring Alternative for AIDS Victims : Firms Offer In-House Service That Avoids Stays in Isolation Wards
When the early afternoon sunshine filters through the skylight, bathing the room in a cheery glow, the modest apartment Larry Foster shares with his two cats doesn’t look much like an isolation ward.
But that is exactly what the three-story San Francisco walk-up is for Foster, an AIDS victim who prefers being at home to spending endless weeks and months in a hospital.
Sipping inky-black espresso, Foster, who asked that his real name not be used, summed up both his plans to remain among familiar surroundings as much as possible and his desire for a quiet, dignified death when the disease runs its seemingly inevitable course.
“For me, I find being at home has a lot of dignity. I find it to be very humane and I find it to be healing, also,” he explained. “Home is comfortable and it’s someplace I feel safe. Mentally, that’s the biggest advantage to home care.”
While researchers struggle to find a cure for Acquired Immune Deficiency Syndrome, many of its victims continue to await death in lonely hospital isolation, tucked away at the edge of the world of the living.
But for other AIDS patients, like Larry Foster, non-hospital care is an attractive alternative to the AIDS ward.
Foster, 32, is one of about 100 AIDS sufferers who have been treated over the last three years by Caremark Inc., one of a growing number of for-profit companies and volunteer agencies that offer non-acute care at home in place of more expensive and often unnecessary hospital care. Products and services offered for in-home care of AIDS patients range from delivery of antibiotics to infusion therapy and full-time nursing care. Although Newport Beach-based Caremark ministers to 900 different diseases, including cancer, gastrointestinal ailments and Alzheimer’s disease, AIDS treatment has been a growing sideline for the company and others as the number of AIDS victims continues to rise. At about 17,000, the number of diagnosed AIDS patients remains fairly small. However, large numbers of people have been tested positive for the virus, but do not yet display symptoms of the disease. Moreover, because the disease may have an incubation period of several years, countless numbers of people may be infected, but do not know it.
As a result, suggests David Goldsmith, a health-care analyst with the San Francisco brokerage house of Robertson, Colman & Stephens, the demand for in-home AIDS care could mushroom within a few years.
“There is just an enormous number of people who have been diagnosed as having the AIDs antibody,” Goldsmith said. “I think it’s going to turn into a big market unless someone comes up with a vaccine.”
Placing subtle advertisements in medical journals, Caremark has relied mainly on referrals from doctors and hospitals for the AIDS patients it has treated, said James Sweeney, Caremark’s president and chief executive.
Caremark’s experience in providing in-home care positions it to be a leading provider of alternative AIDS care, but the company has avoided drawing much attention to its involvement with AIDS, because of the hysteria surrounding the disease.
“It’s a very, very hot issue now, not only in the press but in the medical industry as well,” Sweeney said in a recent interview. “The approach we’ve taken really is to not too strongly identify ourselves with AIDS because we don’t want to grab headlines.”
The AIDS virus cripples the body’s immune system, rendering it unable to combat disease. Its earliest symptoms usually include a long, unexplained illness, fever, weight loss and enlarged lymph glands. As AIDS progresses, its victims frequently suffer rare forms of skin cancer, lung infections and fungus growth in the mouth and throat.
AIDS sufferers, like most Caremark patients, receive infusions of various antibiotics or other medications to treat the numerous maladies that affect them. Also, because many AIDS patients’ suffer from chronic diarrhea, they often need intravenous nutritional therapy as well.
Less-Expensive Care
However, because AIDS patients usually require less attention and don’t live as long as many other Caremark patients, home care is generally less expensive for them than for many of the chronically ill patients the company cares for.
“They are not the most sick patients we take care of at home,” said Larry Watts, a Caremark spokesman who estimates that 40% of the people the company cares for suffer from cancer. “I would say that the cancer patients we have--who are on multiple drugs or who are advanced in age--really present at least as many clinical problems.”
AIDS is believed to be transmitted through sexual contact, sharing of contaminated needles by drug abusers, transfusions of blood or blood products, or infection from mother to child before or during birth. There is no evidence of AIDS being spread by casual contact.
A recent study by the Centers for Disease Control revealed that the average AIDS patient dies within 24 months of diagnosis and runs up nearly $150,000 in hospital bills during that brief span.
In the four major metropolitan areas where the majority of AIDS patients are concentrated--New York, Los Angeles, San Francisco and Miami--a day in the AIDS ward will cost between $800 and $1,000, with the burden often falling to Medicaid when patients are indigent.
While some AIDS patients are too ill to be anywhere but in a hospital, many experience periods of relative calm between acute episodes of illness. And because much hospital time is spent merely waiting for medication, home-based treatment can make a dent in the staggering cost of the disease.
Substantial Saving
Caremark said receiving its intravenous therapy at home can shave 40% to 60% off the cost of receiving such treatment in the AIDS ward, while Continental Health Affiliates Inc., an Englewood Cliffs, N.J., firm which offers integrated home-care services, claims savings of 33% to 50% over the cost of comparable hospital care.
“The cost savings are obviously very real,” said Dr. Paul A. Volberding, director of the AIDS ward at San Francisco General Hospital, which regularly utilizes various forms of in-home care. “It’s much cheaper to bring this kind of care to the patient at home rather than in the hospital, assuming that he doesn’t need acute care.”
Depending on how severe an individual AIDS patient’s condition my be, the level of care Continental offers can range from antibiotic infusion therapy and an occasional visit by a nurse to having one at a patient’s bedside full-time, said Cynthia Kubala, Continental’s vice president of home care.
In many cases, Kubala said, all a patient may need is assistance in performing routine tasks such as getting dressed in the morning. “From that point on, if the condition degenerates, as it usually does, we can move to a higher level of care,” she said.
For example, a registered nurse is on duty 24 hours a day keeping watch over Joseph Yale, a 36-year-old AIDS patient and Continental customer. Diagnosed last May, Yale returned to his Los Angeles apartment in September after spending several weeks in the hospital.
Rarely Leaves Apartment
He rarely leaves his apartment, except when undergoing radiation treatments for the cancerous skin lesions that nearly claimed one of his toes. Suffering intense pain, especially in his feet, Yale requires injections of a powerful pain-killer every three to four hours.
Reclining in the the hospital bed which now occupies his small bedroom, the soft-spoken Yale said that while there is always a nurse present, he has a greater sense of privacy and control over his own life than in the hospital.
“The first month I was home I felt as if I had strangers in my house all the time, but after I got to know them and they got to know me, they have become like family,” he said. “And in the hospital they are a little more regimented about when they give you medications or take blood. No one wakes me up at 4 in the morning to give me a sleeping pill here.”
At about $750 a day, the care that Yale receives represents a substantial saving for Blue Shield of California, according to Tiffany Collier, a Blue Shield claims processor, who said that paying for the home care was “a good decision.” By contrast, Yale’s two-month stay in an AIDS ward cost more than $900 a day.
Most insurance companies are willing to pay for hospital care of AIDS patients. But insurance coverage of in-home treatment is “more the exception than the rule,” said Herbert Goodfriend, an insurance analyst with Prudential Bache Securities of New York. Some insurers feel it is more difficult to keep track of the appropriateness of treatment that is administered in the home.
However, as the effort grows to control health-care costs, Goodfriend suggests, in-home care of AIDS patients likely will become more attractive to hospitals as well as insurers.
Psychological Benefits
But perhaps of greater importance than the cost savings, say medical experts and patients themselves, are the psychological benefits of being at home, particularly because AIDS sufferers are under a virtual death sentence.
“The impact on the person’s social setting is probably more important, because these are people with limited life expectancies,” said San Francisco General’s Volberding. “So, anything you can do to decrease their time in the hospital setting will be well received.”
In Foster’s case, for example, the intravenous treatments didn’t require him to remain in bed. Once the daily infusion of antibiotics was finished, he could maintain a normal routine, something that would have been impossible in the AIDS ward.
“In the hospital, you’re just waiting for your medication,” he said. “When I was in the hospital, if I needed to go to the bathroom, I still had to take my IV pole with me, so what’s the difference between doing it at home or at the hospital?”
Although the fear surrounding the disease has prompted many health-care workers to shun AIDS patients, Watts said treating AIDS patients has not been a “big deal” for Caremark’s nurses and technicians.
By contrast, Yale has gone through six nurses since beginning home care in September, two of whom were reassigned because they were afraid of AIDS, said Lyse Dandenault, Yale’s day-shift nurse. Dandenault, who is in charge of the other two nurses caring for Yale, said the Continental subsidiary she works for pays her a $2 an hour bonus for nursing an AIDS patient.
Although home-care is an alternative for some patients, health-care professionals and many patients agree that home is not the place for acute care.
System Was Devastated
At a robust 200 pounds, Larry Foster doesn’t look like the emaciated, skeleton-like creatures usually associated with AIDS. But, with his immune system devastated, it is only a matter of time before Foster succumbs to one or more of the rare diseases which already have claimed more than half of all AIDS victims.
While he won’t hesitate to return to the hospital should serious problems develop, such as another bout with a rare form of pneumonia which put him in the AIDS ward for 28 days last year, Foster said “it would only be until my doctor and I were comfortable enough for me to go home and finish my therapy.”
Yale, on the other hand, probably won’t go back to the hospital, despite his steadily worsening condition.
“Unless I have problems with severe bleeding or something they really can’t handle here, I’m inclined to stay home,” he said. “Hopefully at some point if the shingles go away and I don’t have as much pain, perhaps I won’t need 24-hour-a-day care and could get by with just a nurse’s aide coming by and helping with the house.”
While the number of persons diagnosed as having AIDS is expected to increase substantially during the near-term, AIDS patients still make up a relatively small percentage of the overall population. AIDS patients, said Caremark’s Watts, accounted for only about 1% of the company’s 1985 revenues and probably will not exceed 2% of the current year’s revenues.
Earnings Soared
During the fiscal year ended June 30, 1985, Caremark’s net earnings were $7.4 million, up sharply from $1.4 million a year earlier. Revenues for the year were $74 million, nearly double its $49.7 million in 1984 revenues.
“The problem is that despite the fact that there are some 16,000 AIDS cases, if you look at the number of patients outside of the metropolitan New York and Los Angeles areas, it’s not that big a market,” said Jules Marx, of the New York investment banking firm of D. H. Blair & Co.
Still, as the number of diagnosed AIDs cases increases, Caremark and Continental will step up their services for AIDS patients. Continental, which already operates a string of nursing homes in the East, plans to open an AIDS wing at one of its facilities, said Jack Rosen, Continental’s president.
Caremark’s plans to market its infusion therapy for AIDS patients have not been fully developed, but are likely to begin during the current quarter. More direct contact with the homosexual community, including assisting AIDS support groups and a forming a speakers’ bureau to pitch in-home care are among the approaches the company is considering.
Despite plans to increase its visibility in caring for AIDS patients, Sweeney said, Caremark will maintain its quiet approach to avoid appearing like an ambulance chaser. “I don’t in any way want to be dancing on the literal graves of some very sick people,” he said.
