AIDS Clinic Works to Limit Costs : Health: Operators say their managed, preventive program offers quality care while holding down expenses. They are also improving options for members of minority groups.

There was a time when Barry Lubo felt perfectly welcome at the private medical group that used to treat him for AIDS.

“I must say I felt very watched over when I had health insurance,” he said. “Every little thing was tested.” But when Lubo lost his health insurance and went on Medi-Cal, things changed.

Lubo recalled the sting of humiliation when the receptionist called out: “How do you intend to pay?” Not only did the doctors seem to lose interest in him as a patient, he said, they even lost his lab reports. A friend who is a nurse told him that was not a good sign.

“They were definitely after the money,” the retired hairdresser said.

Now, Lubo visits a novel community-based clinic in Hollywood operated by the AIDS Healthcare Foundation, where he can undergo sophisticated testing or obtain drugs such as AZT or epotein alfa. The atmosphere is more comfortable, the attention is more personal and the quality of care seems “very competent,” Lubo said.

Such testimonials are heartening to health officials trying to find a better way to manage the crisis in health care expenses. After one year of operation, the clinic is showing encouraging signs of providing cost-effective, quality care for persons afflicted with a virus that is now estimated to infect more than 1 million people in the United States.

The clinic, housed on the fourth floor of Hollywood Presbyterian Hospital, served 952 patients in its first year. To foundation President Michael Weinstein, the patient enrollment is one sign of success. “People are voting with their feet, and a significant proportion are coming here,” he said.

Foundation officials also contend that their clinic has improved health care options for members of minority groups who are less likely to have insurance. More than 55% of the patients have been minorities, including 349 Latinos, 174 blacks, 10 Asians and four American Indians. Sixty-two patients have been women. The clientele includes people who have health insurance, people on Medi-Cal and immigrants who do not qualify for public assistance.

The clinic was created by the same group, then known as the AIDS Hospice Foundation, that in 1988 established the 25-bed Chris Brownlie Hospice in Elysian Park, the nation’s largest residential hospice and the first licensed in California. The foundation, created largely by gay activists, now has two more hospice facilities in the works.

Just as the foundation persuaded county supervisors that a hospice would be a more humane and cost-effective way of caring for AIDS patients near death, it persuaded officials that its HIV clinic would provide similar benefits by emphasizing individual case management and preventive medicine, in contrast to the episodic treatment that is typical in county hospitals.

“It’s not to say the county isn’t providing good care. There’s a lot of good people there,” said Juan Ledesma, director of the clinic.

But in county hospitals, Ledesma said, doctors who see patients infrequently are more apt to order extra tests and prescribe expensive drugs.

“Everyone here is more attuned to what our limitations are. We try to manage things more efficiently,” he said.

For example, by more closely monitoring patients, Ledesma said, foundation doctors are able to prescribe less expensive medications that are just as effective as drugs such as AZT in preventing the onset of illness. In some instances, the less expensive medicines are more appropriate, depending on the patient’s condition.

“If they need a Cadillac medicine, they’ll get a Cadillac medicine.” Ledesma said. “But if there’s a Hyundai medicine that will do the same thing, we’ll give them that. We have to be conscious of a bottom-line budget.”

Foundation officials, while acknowledging that such comparisons are complicated, contend that state records show that the average outpatient costs for 73 Medi-Cal patients in their clinic during 1991 was $377 per patient per month, compared to $1,150 in county facilities.

State officials dispute both figures. The higher number reflects a projected cost for 1992 that includes an estimation for the increased use of a highly expensive drug, epotein alfa. A more reasonable estimate for the 1991 outpatient Medi-Cal costs to the county is $670 per patient, said Bob Ruderman, an actuary with the state Department of Health Services.

Ruderman also said one year is not enough time to render definitive judgments about the cost-effectiveness and quality of any such program dealing with AIDS.

Yet, for all those caveats, state officials say they fully expect the foundation to provide significant savings because of the emphasis on case management and preventive medicine.

“I want to say very confidently that clinic can do very well containing costs,” said Sandy Pierce, chief of program development and health systems financing for the state Department of Health Services.

“We would expect case management to save money. I would be very surprised if they couldn’t save the state a lot of money,” said Ruderman. Under pilot programs in San Mateo and Santa Barbara counties that emphasize “managed care” for AIDS patients, outpatient costs averaged $460 per month for Medi-Cal patients, in contrast to the $670 in Los Angeles County, Ruderman said.

State officials are considering the foundation for a new program that would create a kind of health maintenance organization for people with the AIDS virus, Ledesma said.

Not all of their patients may be so pleased with their care, but Lubo, who was hospitalized twice in 1989, is encouraged by the fact that he has not spent a night in the hospital since he enrolled at the clinic nearly a year ago.

He and another man, named Patrick, agreed that the atmosphere is friendlier in a clinic established and run by members of the gay community. At another facility, Patrick said, the staff was “insensitive.”

“You can come here as a gay person and still feel comfortable. You can still have your dignity,” said Patrick, who is one of the clinic’s 10 Asian-American clients.

He asked that his full name not be used. To do so, he said, might jeopardize his health insurance coverage.