Health Business Blog

The Hearts & Noses Hospital Clown Troupe provides professionally trained, volunteer clowns to hospitalized children and also provides training to hospital clowns from around the US and the world.

It’s a great organization and you can read more about it here. I’ve been on the board for several years and took over the chairmanship a year ago.

If you’re looking for a worthy end of the year (or start of the year donation), please consider a tax-deductible donation.

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In Nursing crisis looms as baby boomers age, CNN Money repeats a well-known story: there are unlikely to be enough nurses to take care of people as they age. Nursing schools can’t keep up with the demand and trouble awaits. We’ll face a shortage of 260,000 RNs by 2025, we’re told.

I don’t really believe it’s such a big deal.

There are two good solutions to the problem, and they aren’t mutually exclusive:

1. Increase the recruitment of nurses from abroad
2. Substitute technology for labor

The first option is already in effect to some extent. But anti-immigrant attitudes and rules limit the number of non-US nurses here. There are also an ethical considerations; when nurses from middle income countries like South Africa and Thailand come to the US, it creates a shortage of nurses in those countries. Some of those shortages are filled by bringing nurses from poor countries to middle income countries. That leaves the poor countries bereft at a time of tough challenges such as HIV and TB.

The second solution essentially means replacing at least some nurses (or some of their functions) with technology, including robots. A lot of things nurses do will be doable by machine, if not this year then certainly by 2025. These robots will take many forms, but one could certainly be as a “personal medical assistant” that handles most mundane functions. It could check vitals, provide encouragement, remind patients to take their medications, and go beyond those tasks to other areas, such as playing games, cleaning the house, making food, and even engaging in pleasant conversation.

This technology trend shouldn’t encounter too much resistance from nurses, who after all should still have plenty of opportunities for employment.

The nursing workforce issues are real, but they provide opportunities for innovation, not cause for panic.

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It’s interesting to be in late 2009 and see e-visits described as a “disruptive innovation” that “the medical establishment is fighting.” I first started working on e-visits almost 10 years ago, consulting to RelayHealth (then Healinx). It’s a sensible concept, fairly straightforward to implement, efficient, and effective for certain situations. Yet growth has been slow. Part of the issue is that it’s health care we’re talking about, where innovation tends to be retarded when it involves changing physician practices. Another, related problem is that there’s no great financial incentive for the physician or patient to make a change. Health plans that do cover e-visits often charge the same co-pay for patients as for in-person visits, even though they often reimburse physicians at a lower rate.

My guess is that over the next decade we’ll see e-visits become common. Why?

1. Adoption will follow the typical S-shaped curve, and we’ll soon get to the steep climb almost regardless of other changes
2. More patients and physicians will simply expect to communicate online, as they do in every other area of their personal and professional lives
3. Payment systems will evolve to support e-visits, rather than penalize them
4. Adoption of electronic systems in physician offices in general will enable e-visits
5. Supporting technologies will evolve and emerge. These include remote monitoring, higher bandwidth, personal health records, and mobile applications

Enjoy the next decade and don’t expect things to change too quickly.

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Check out the latest edition of Grand Rounds, hosted this week by Teen Health 411.

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Per Lofberg was appointed president of CVS Caremark’s pharmacy benefit management business this morning, and traffic to the Health Business Blog had a minor spike. Turns out a search for Per Lofberg on Google brings up my interview with him from early 2009 among the first few results.

Just for the heck of it I decided to check the popular search terms bringing people to the blog today, something that’s easily done with Statcounter, the free website statistics service I use. Sure enough, about a third of the last five hundred searches that led to the blog were for “Per Lofberg” or some variant thereof.

I eyeballed the other terms, and they divide into a few main areas:

• Health business  –including several seeking information on Practice Fusion‘s business model (they have a free, web-based EHR)
• Policy –not surprising, given the current health reform debate. Nursing homes in reform seems a popular one today
• Medical tourism –this was a topic I used to cover a lot
• Some other David Williams –I guess I shouldn’t be too offended when searches for topics like “Dr. David Williams quack” or “Dr. David Williams scam” lead people to my site. Still, I wonder who this guy is (could be more than 1)
• Consumer — such as “can cell phones cause autism,” “port wine stain ivf”, “truth about generic drugs” and “cvs forcing people off lipitor”

To me (and perhaps only to me) this is interesting information. There were, however, a few somewhat concerning searches from what appear to be patients. For example (with typos preserved):

• “accidental ingestion of lsd while on oxycontin maintenace”
• “i have no healh insurance and are having chest pains what do i do”
• “buy black market percocet with no membershipfees”
• “situation who may worsing patient to worse in e.r”

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This is the transcript of my recent podcast interview with Qliance’s Dr. Garrison Bliss.

David Williams: This is David E. Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Dr. Garrison Bliss. He’s co-founder and Chief Medical Officer of Qliance Medical Management.  Dr. Bliss, thanks for your time today.

Dr. Garrison Bliss: My pleasure.

Williams: What is Qliance?

Bliss: Qliance is a primary care focused medical practice.  We are currently located in Seattle and Kent, Washington. Our purpose is to completely remake the concept of primary care in such a way that we have a self-sufficient, highly effective patient centered health care system that can cover roughly 80% of what people need for medical care during their lifetimes and that will not require insurance as an infrastructure in order to survive.

Williams: I’ve seen you refer to your model as a direct primary care medical home.  What are the elements of that? How does it differ from a “patient centered medical home,” a term that is used often these days?

Bliss: The patient centered medical home is a description of a kind of primary care that intends to be all inclusive, that provides both basic health care requirements for people in terms of urgent care, but also it provides the kind of care that will allow people to continue to be healthy throughout their lives.  The purpose of that kind of an arrangement is to evolve a kind of care that doesn’t simply deal with the moment-to-moment needs of people who are acutely ill, but also to provide the preventive care that they will require and to reduce the probability of illness going forward.

The direct practice concept may or may not involve that kind of a medical home design, but the concept of direct practice is that physicians work for their patients both as a practical matter and as a financial matter. The money that pays for your primary care comes from the patient.  Now the patient may not be the ultimate source of that money; employers could pay their employees money that the employees could then expend on whatever primary care provider they wish to spend it on. But the general concept of direct practice is that we work for our patients.

We know that we work for our patients.  We don’t work for their insurance company.  We don’t work for their employer.  We don’t work for their government.  And when you start with that basic financial structure, it changes the nature of what the care is going to be like.  In an insurance driven system in which you do not work directly for your patient, the patient is an opportunity to bill an insurance company and the design of the care has increasingly been built around the idea of creating charges. If you want to make a living as a primary care physician in the United States, if you simply saw patients and examined them and wrote prescriptions on their recommendations you would actually not be able to make a living.  For most physicians in the United States that simply wouldn’t be a viable alternative. You would be seeing 35 – 45 people a day in order to make a living, which is largely what has happened in this country.

But if you really want to be more effective, what you do is you do more x-rays in your office, you do in-office laboratory work that would make money.  You would refer to the CT scanner in your building, of which you are going to be a part owner.  You would refer to your friends in your big clinic who are specialists so that your group would do well and then they would support you in return.  So, there are all kinds of financial repercussions of insurance driven systems that we are trying to avoid in the direct practice movement.

Williams: You have some fairly large claims of cost savings.  I don’t mean just for the primary care component, but for overall health care costs if somebody signs up for your model.  Can you walk me through the magnitude of savings and what they come from?

Bliss: Primary care accounts for a very small percentage of the budget in health care.  It’s probably under 5% even though roughly 80% of what happens is going to happen in a primary care office, and it’s the old 80/20 rule. In medicine it may be even 90/10: that 80% of the work generates 20% of the cost.  In our case it’s probably less than 10% of the cost that generates 80% to 90% of the cost.

In order for us to have a meaningful impact on health care costs, the way that we can do that is by reducing the amount of use of downstream high tech, highly expensive innovative health care.  It turns out that that’s not so difficult.  The reason why we are using so many emergency rooms, for instance, is that primary care is almost defunct in this country.  People really can’t get in to see their doctor in a timely fashion so they get sicker until they have to go to the emergency room, because that’s the only option left.

The number of emergency room visits has been increasing.  The number of emergency room doctors has been going up. The amount of dollars per visit to an emergency room is enormous relative to the number of dollars for a visit to a primary care physician to accomplish the same thing.  The complexity of a visit to an emergency room is much greater because the emergency room doctor never met you before, generally has no chart on you, and has to treat you as if you were a brand new patient: do a complete work-up and usually a tremendous amount of laboratory work and often much more imaging. If we can avoid emergency room visits –and my projection is that we can reduce emergency room visits by something between 20% and 50% by simply having a functional primary care office, then we can make a huge dent in the cost of health care.

In addition, if we can prevent hospitalizations by taking care of people in the office before they’re massively ill, we can make a huge dent.  There is some initial data from one primary care organization called MDVIP that they can reduce hospitalization rates by 50%.  We know that in projects that have been done in places like North Carolina; there was a Medicaid project that was done with a medical home design, that they could reduce their overall health care costs by about 11%, and that is not with a particularly sophisticated primary care system.

The way we’re approaching the problem at Qliance is by creating not just a primary care medical home, that is we do primary care preventive care, but also by having the hours extended. We’re open 12 hours a day Monday through Friday and we’re open on Saturdays and Sundays, which is when a lot of that emergency room traffic happens.  So if you have a cough and a fever you can come here.  We’re equipped to handle that problem.  If you have an asthma attack we can manage it.  If you have a kidney stone, you can come here and we can do all the basics that need to be done and you can avoid $3,000 to $4,000 in charges.  In addition, if you come to us, since you’re paying on a monthly fee basis for our care, your out of pocket cost is almost zero to come here as opposed to $3,000, $4,000, or $5,000 in emergency rooms.  So that’s how we intend to change the downstream cost configuration and I think that there is a very high probability that we can do that.

Williams: That certainly sounds exciting.  I noticed the way that you’re structured financially you’re really just capturing the revenue from the primary care side and then advising people to get a wrap around insurance policy. But at least from what you described, if you’re successful in your current model, the ones that are going to make serious money from this are the people that are providing those wrap around insurance policies and are not going to have to pay out very much on your patients.  Have I got that right?

Bliss: We are not an insurance policy. Let’s look at just the hard dollar savings for an employer who decides to buy a high deductible health plan plus Qliance for their employees. The high deductible health plan itself, if you go from $1,000 deductible to a $2,500 deductible, you’re often saving as much as 50% on premium alone. Even if you spend all of the deductible, so even if the employer decided that they were going to provide an HRA for instance, and they were going to cover all of the deductible that the employee might have to pay for that $2,500 deductible, they still will save about 20% on the cost of their health care even if every employer spends the entire deductible every year.  So that’s serious hard dollar savings that you could do regardless of what we do with downstream costs.

Williams: What happens if you have a patient that can’t be taken care of well in primary care and they really do need to have more specialist involvement or hospital involvement?  Do they lose the benefit of your model?

Bliss: Actually not.  The question is where is the edge on that.  If they have to go to the hospital obviously they are in that system. We are not an insurance company, so you need that insurance to cover you for the very high cost items and that’s the best use of insurance.  We’re not advocating getting rid of insurance all together, we’re just advocating having it become actual insurance again instead of a financing system for all of health care.

The problem that happens now is that once you leave the hospital you have no real primary care infrastructure to walk into: someone to manage your hypertension and your diabetes, someone who can follow up on your infection and make sure that if you’re having problems and not recovering that something is done about it so you don’t end up back in the hospital.  That system does not really exist in a very robust fashion in the United States, in part because we made a decision many years ago that we weren’t going to pay for primary care, at least not pay enough for it so that it would be survivable and functional.

We can do a lot for patients even if they end up in a complex system.  We can also manage a lot of chronic care issues.  You may want to see your specialist once a year for your heart disease, but we can certainly help manage your congestive heart failure.  If you’re having problems with chest discomfort, we can find out whether that’s something that requires a cardiologist or whether that’s something simpler and more manageable at our level, so we can also make sure that you get to a specialist who is going to treat you efficiently and effectively.

We can begin to make use of fairly significant data in this country.  It’s collected mostly by insurance companies and generally ignored, but there’s a lot of information available about which specialists and which hospitals provide the highest quality and the lowest cost.  Since many of our patients are paying a chunk of this money out of pocket, they want to know that and we’re happy to help provide that information for them.

We’re working right now trying to incorporate that kind of information into our referral patterns so that our patients are not simply paying the highest price for the lowest quality product out there when they’re outside of our office.  We can also provide them with cash discounts; it’s another way that we can help people who are not in our office getting our care, but are interfacing with the rest of the universe of health care. We can negotiate with laboratories, for instance.  The laboratory we work with provides two prices for lab work.  There is the retail price, which is what everybody else pays who has insurance.  If you’ve ever had lab work done, you know that the bill goes out, the insurance company cuts the bill by 50% and then pays some portion of it and the patient pays the difference.  We have another price, which is the negotiated price, a cash price.  If the money is paid directly through us to the lab company they don’t have to bill, they don’t have deal with the insurance company, they don’t have to deal with the discounting. They’re paid cash up front then we can get a price that’s 50% to 75% less for our patients who want to pay cash. Often that’s below their co-pay.  Even for insured patients, it turns out to be a deal that they want to do.  There are many ways in which we can start to help our patients get better care, get a better deal, whether or not they have an insurance company involved in the financial dealings.

Williams: We’ve talked quite a bit about the benefits to patients and to employers, but it sounds like there is probably also an interesting value proposition in it for primary care physicians themselves. What does this practice look like to a physician who may go into a primary care practice?  Is Qliance an attractive place to practice?

Bliss: I like to say that we have built the Ark for primary care physicians.  Right now, given the finances of primary care, you are probably a loss leader in a large clinic that keeps your around because you refer to the people who do make money in the clinic. You are expected to see 35 to 45 patients per day and you’re paid on production, meaning that the more you mill people through the office, the more money you make. The more efficient your care is, the less money you make, so you try to avoid talking with your patients on the phone or e-mailing your patients because no one gets paid for that or at least not enough to make it worth while.

You end up in this financial system that actually makes your medical care worse. And although primary care physicians are actually quite famous for the fact that money is not their chief motivator (they’ve gone into the least financially rewarding part of health care), it’s unpleasant and difficult for them to see every day that not only are they making less money than all of their colleagues, but they’re not able to practice medicine the way they want to practice medicine.

They’re not able to spend the time with patients that they need to.  So we’ve created an environment in which the shortest visit time is 30 minutes.  You have a full hour to do a physical exam on a patient and often more if you need it.  No one is paid for production here.  You’re paid to keep your patients happy. You’re paid to meet our quality guidelines. If your panel size is somewhere between 500 and 800 patients, which is what we’re aiming for here, that’s roughly a quarter to a third of what the average primary care doc in the United States is seeing. If you do a good job of it then you will make as much money as you will make in any of these other systems and you will have the reward of doing it right and the pleasure of being a real doctor in a functioning health care system.

So we think that this is a great place for primary care doctors to come. So far we’ve had no great problem finding doctors of very high quality who want to come and try out our way.  We know that there is a huge shortage.  It’s in the 40,000 physician range or higher.  It depends on how you calculate it.  There are going to be problems finding physicians eventually as we grow, but we’re hoping that more and more doctors will want to go into primary care because all of the sudden it becomes not only rewarding in terms of the care itself, but also it’s finally rewarding in terms of the pay scale that we will be able to afford and also the lifestyle.

Our doctors are going to be working 40 hour work weeks, not 80 hour work weeks, and they’re not going to spend the weekends catching up on their paperwork for the last five days.  There are a lot of things that we can do here that will make this much more attractive for physicians as well.

Williams: Last question:  what is the Direct Primary Care Coalition and what are you seeking to achieve with it?

Bliss: The Direct Primary Care Coalition was an attempt to identify and band together the direct practice in the United States.  There has been a movement probably for the last 15 years in the United States to create monthly fee design practices of one kind or another, but the direct practice is one of those variants. So not to get too arcane about this, but when you’re in a monthly fee practice, you can charge your monthly fee and charge insurance for everything that you do so that your patients’ insurance will pay for all the medical care and then they pay you a monthly fee on the side for access, or you can simply have a monthly fee for primary care and the insurance company is not involved and they don’t pay anything for the care itself.  Direct practices are of the latter variety.

We were trying to identify who those practice are and get them organized so that they can participate in the debate that’s going on in Washington D.C. right now and also begin to look at creating networks. So if our patients are traveling, they’ll be able to go to a similar practice and we may be able to make some arrangements so their financial costs will be a minimum if they’re out of state.  But mostly we want to have like-minded physicians and groups be able to talk to each other and know where we are.  So that was the impetus behind creating the coalition.

Williams: I’ve been speaking today with Dr. Garrison Bliss, co-founder and Chief Medical Officer of Qliance Medical Management.  Thanks again.

Bliss: Thank you very much.  It was a pleasure.

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Primary care in the US is badly broken. Physicians complain they are like hamsters on a wheel, trying to generate enough fee-for-service revenue to pay the bills. That leads to short appointments, less follow-up, and dissatisfaction on the part of physicians and patients. It’s no wonder that not a lot of medical students are intent on entering primary care.

A number of attempts are being made to address the concern. Some physicians have started “concierge” practices that charge a fee on top of insurance payments. Others have affiliated with or sold their practices to larger health care systems, which subsidize primary care in order to bring in profitable referrals for imaging, surgery, etc. There is also a shift toward different payment models such as capitation, Promtheus, and the Patient Centered Medical Home.

Qliance Medical Management, Inc. has a different approach, which it calls “direct primary care medical homes.” These practices charge a monthly subscription fee for unlimited access to comprehensive primary, preventive and chronic management care. I really like the concept and its focus on the patient as the primary customer and user of the service. The company claims its approach can reduce overall health care costs by over half. If true, this could be the wave of the future.

In this podcast interview with Dr. Garrison Bliss, co-founder and chief medical officer of Qliance, we discuss the details.

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David Williams interviews Dr. Garrison Bliss of Qliance Play Now | Play in Popup | Download

In the USA Today, Dr. Marc Siegel, an internist in New York, attacks the US Preventive Services Task Force for its “simplistic” approach and seemingly disapproves of evidence-based medicine. (Task-force thinking doesn’t deliver my kind of medicine.)

It’s interesting to see how Dr. Siegel practices:

Today, I use my own checklist based on 20 years in practice. When my female patients are younger than 21 and sexually active, I refer them to a gynecologist for a yearly pelvic examination and a Pap test. At 40, I order a mammogram as well. All patients over 50 are sent for a colonoscopy. Elderly patients are prone to both depression and falls, so I screen them for these issues.

Unfortunately, in my examination room of the near future, my hands may be tied. I will want to order the same screening tests and procedures, but I might need another checklist of the services that my patients can’t receive because Medicare or private insurance will no longer pay for them.

Sounds like common sense. But what is the basis for this checklist? How did Dr. Siegel determine the age 21 cut-off? How about age 40? Is he rationing care to people who don’t fall into those groups? How does he define elderly? Has his checklist changes over the years?

And what about doctors with less than 20 years of experience? What checklist should they use when they get into practice or after 5 years?

Should everyone have the same checklist?

I have sympathy for Dr. Siegel’s Marcus Welby-style approach, but it sounds like whining to me.

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Republicans have been accused –quite fairly in my opinion– of trying to kill health reform under the guise of improving the approach and making it bipartisan. A major complaint is that the bill isn’t deficit neutral. In other words, it might cost money.

Health reform in 2009 was always mainly about increasing access to health insurance, not saving money, so it’s hardly surprising that there’s a price to be paid for that achievement. But I’m not unsympathetic to the idea of a better, leaner reform bill that focuses on costs.

In my opinion, a good place to focus would be reforming Medicare, starting with the repeal of Part D prescription drug coverage. As Princeton economist Uwe Reinhardt puts it in a letter to the editor in today’s New York Times:

[I]n 2003, barely out of the recession of 2000-2, President George W. Bush and his then Republican Congress passed the Medicare Modernization Act of 2003, a huge new entitlement. Unlike serious attempts to make the current health reform deficit-neutral, however, the entire cost of the Medicare drug bill simply has been deficit-financed since the inception of the program in 2006. Current projections are that the legislation will add in excess of $1 trillion to the federal deficit over the period 2010 to 2019…

There is something quite untoward for people who went along with that glaring fiscal irresponsibility to now belatedly discover the virtue of fiscal probity.

One suggestion would be to limit Medicare spending to the amount of funding paid for through the Medicare payroll tax. That would cut the Medicare budget by about 50 percent. Seniors would receive a much-reduced subsidy on Medicare premiums. Better yet, the subsidies would be income and wealth based.

The remainder of the money now spent on Medicare could be used to bring everyone else into coverage, including the millions of working people who pay for Medicare through payroll and income taxes, but lack health insurance for their families and themselves.

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This is the transcript of my recent podcast interview with National AIDS Fund President and CEO Kandy Ferree.

David Williams: This is David E. Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Kandy Ferree, President and CEO of the National AIDS Fund.  Kandy, thanks for speaking with me today.

Kandy Ferree: You’re very welcome.  Thanks for having me.

Williams: Kandy, what is the National AIDS Fund?

Ferree: The National AIDS Fund is a national non-profit organization.  We’ve been around for a little over 20 years. Our primary purpose is to marshal resources from corporations, foundations and individuals and direct those resources out to the communities and programs that are most impacted by HIV and AIDS.

Williams: In a recent survey you indicated a pretty shocking number of 640,000 people with HIV in the U.S., but who are not in care.  Can you tell me about that number and how it breaks down?

Ferree: The survey research was commissioned by Bristol Meyers Squib and iss largely based on numbers that the CDC estimates.  There are approximately 1.1 million people in the United States living with HIV and AIDS, and based on the number of people that are in care across the country, the estimates are that approximately 640,000 people of that 1.1 million are not in care.

That breaks down in a number of ways: for example about one quarter to one third of people with HIV in this country are estimated to not even know that they are HIV positive because they haven’t been tested. Those are numbers from the Centers for Disease Control and Prevention.  Then the balance of the folks who are not in care aren’t in care for any number of reasons.  One might be that, up to this point they have not fit within the guidelines for accessing treatment.  In other words, they haven’t had a T-Cell count or a Viral Load or the clinical manifestations that would suggest that they needed to be in care.  Although I’m not the expert on those guidelines, there has been some new recommendations that people actually start treatment much earlier.

For those people who are actually within the guidelines for treatment, the survey shared two main findings.  The first was that people living with HIV often say that they are not in care because of societal personal factors, things like: fear, stigma, and discrimination. Potentially substance use and that kind of thing as well, but mostly the societal things around fear, stigma, and discrimination surrounding HIV.  The other set of reasons why people often times aren’t in care are more structural; things like they may not have access to transportation, they may be in a rural community where there is not an infectious disease physician available to them, it may be a mom who doesn’t have child care and therefore can’t make the 30, 40, or 60 mile trip to go to the doctor and spend several hours away.

The purpose of the Positive Charge initiative is to address those barriers that people may be experiencing in a whole host of ways.

Williams: It seems as though providers and patients had some different ideas about the underlying reasons why people are not in treatment. You were touching on some of them there, but can you tell me about what some of those differences are and whether one group is more correct than the other?

Ferree: I don’t know that we can really say that one is more correct, although I think what you’re getting at is that there seems to be a fairly significant disconnect where physicians and health care providers had the perception that the reason that most people who should have been in care were not was because of things like substance abuse or they simply did not want to be adherent to their medication regimen. But in fact, what we learned from people living with HIV is that while those factors do influence a small number of people, the vast majority of people living with HIV who are not in care actually reported that it was more of the societal matters; things like they were afraid to disclose their status.

They were afraid that if they did come forward about their HIV status, particularly if they lived in a rural community, if everyone saw them going to the “AIDS doctor” then they would potentially be discriminated against.  So the important thing is not that one is right or wrong, but certainly the report of people living with HIV is very real and that’s their experience. What we hope will come out of this survey is that health care providers will begin to better understand what the real barriers are and then can work with an AIDS service organization and other social service providers to help break down those barriers that can and help get people into treatment and keep them there.

Williams: One of the things that appeared to be major issue for patients was a concern or fear about side effects of HIV medications. Are those fears borne out in practice? Are there mechanisms in place to address those concerns?

Ferree: You’re absolutely right.  Side effects was one of the main concerns that people living with HIV indicated was a barrier for them. Back in the early days when we only had drugs like AZT the medications had a lot of side effects. People still believe that that’s the case.

That’s not to say that the current medications don’t have side effects.  Some of them certainly do, but it varies from one person to another what side effects they might experience. I think the important thing for people to understand is that compared to the past, the side effects are much more manageable and people don’t have to take nearly as many drugs as they used to.

We now have combination therapies that may be one pill or two pills whereas 10 or 15 or 20 years ago, people might have had to take 20 or so pills a day. So the treatments have made such great advances, but I think it’s important for folks that if they do have questions that they can get treatment information from their physicians and from lots of other organizations out there that can provide treatment information including information about side effects and how to manage them.

Williams: What is the role that different parties can play in addressing this rather large issue of 640,000 people who are not in care?  You have mentioned the Positive Charge Initiative.  Can you describe that more?

Ferree:   Let me talk first about Positive Charge and then I’ll talk a little bit more about the role of other players.  Positive Charge is designed to target 13 really highly impacted communities across the country that have significant populations of people living with HIV and where some of the estimates of people who are not in care are most significant.

The purpose of Positive Charge is to be a game changer.  A lot of times when people need to get access to HIV care, maybe they have problems with housing or transportation or other issues. What we’re challenging those communities to do who have been invited to apply is to come together as a group of organizations: AIDS service providers, medical providers, transportation, housing, all different types of organizations, and to submit a unified application to the National AIDS Fund, because we really believe that it’s that linkage and that continuum of care that’s going to make the difference for people with HIV.

What each community will propose, we won’t know yet; we will have to wait until those applications  come in.  Let’s say for example in a particular urban community they are targeting Latino men who have sex with men. Then we would expect whatever strategies they’re going to propose to implement would be able to specifically address the issues of that population.  If it happens to be rural African American women in Alabama, then we would expect that the issues in Alabama would be different than L.A. or NewYork City.  What we’re really proud about at the National AIDS Fund is our agility and flexibility to work with communities to tailor their responses and strategies to meet the needs of those populations.

On the broader question of what role different players can have, regardless of whether a community is part of Positive Charge or not, there are a couple of really key constituents. One are health care providers –by that I mean both infectious disease physicians (the HIV specialists) as well as primary care physicians, nurse practitioners, and others.  They all have a huge opportunity when people come into the emergency room or their general office to encourage HIV testing. A lot of times I think we’re missing people because we haven’t routinized HIV testing. That’s a huge opportunity for us to identify people who may not even know they’re positive.

Beyond that I think it’s back to the survey results. When somebody has tested positive it is important to encourage people –especially health care providers– to not make any assumptions about what someone’s barriers might be or not be. Somebody who is a middle class, apparently well educated and well organized may have some similar transportation barriers or housing issues that someone who may be perceived as poor or as not having as much education. The real key is to ask the person what their challenges might be and then try to work with them.

Then there are the social services providers; the AIDS service organizations, the housing providers, the transportation providers, etc.  They all have an opportunity to include HIV testing in their work. If they know that someone who is in their service area is living with HIV they can encourage them to get connected to care and to build linkages with other organizations. That way no matter where the person with HIV might come into the system, they can get linked to the other services that they might need.

Then finally I would say that society as a whole, we need to realize that a lot of times we are the problem. We still have a lot of fear. Because people are afraid of discrimination due to HIV, they may not choose to come out and get tested. That keeps people from getting  into treatment and then if they get into treatment later, they tend to not have as good of outcomes in their HIV treatment.  So I think as a society or coworkers or friends or family members, we just need to really think about how to be accepting and supportive of someone living with HIV.

Williams: What’s the magnitude of the Positive Charge Initiative?  I know you mentioned 13 communities.  Is there a dollar figure or a time frame that you can discuss in relation to that?

Ferree: We invited 13 communities to apply.  We are hoping that we get applications from all of them.  We expect that we will pick about six to eight of those.  The grant size for each of those six to eight communities will range from about $100,000 to $500,00 a year for each of three years. Then, based on the successes and presuming that we’re making progress, there is the potential that we would actually renew those grants for an additional two years.  So it’s at least a three-year initiative, potentially five.  The size the grant will be based on the complexity and the scope and the scale of the particular programs and strategies that those communities are proposing to us.

Williams: World AIDS Day was last week. What is the impact of a day like that? Did you have any involvement with it?

Ferree: Yes.  We try to do something around World AIDS day every year.  It reminds everybody at least once a year that there are 1.1 million people in the United States alone living with HIV and AIDS.  I think so often we forget.  We tend to think that HIV is only a problem in sub-Saharan Africa and Asia and the former Soviet Union.

The other thing about this year’s World AIDS Day was that the theme was about access to care all around the world. For us and the Positive Charge Initiative, it reinforced for us that we were doing the right thing, that access to care is a huge issue and utilization of care is a huge issue including in the United States. Hopefully we’ll raise that awareness, but I would also say that for us, every day is World AIDS Day.  Every nine and a half minutes according to the CDC another person in the United States becomes infected with HIV.  So even during this podcast, in the time that we had this conversation, at least one more person will have become HIV positive.

For us, every day is a day to be mindful about that.

Williams: I’ve been speaking today with Kandy Feree, president and CEO of the National AIDS fund.  Kandy, thanks for your time today.

Ferree: You’re very welcome.

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