Implementing Rapid Initiation of Antiretroviral Therapy for Acute HIV Infection Within a Routine Testing and Linkage to Care Program in Chicago.

Growing evidence suggests that rapid initiation of antiretroviral therapy for HIV improves care continuum outcomes. We evaluated process and clinical outcomes for rapid initiation in acute HIV infection within a multisite health care-based HIV testing and linkage to care program in Chicago. Through retrospective analysis of HIV testing data (2016-2017), we assessed linkage to care, initiation of antiretroviral therapy, and viral suppression. Of 334 new HIV diagnoses, 33 (9.9%) individuals had acute HIV infection. Median time to linkage was 11 (interquartile range [IQR]: 5-19.5) days, with 15 days (IQR 5-27) to initiation of antiretroviral therapy. Clients achieved viral suppression at a median of 131 (IQR: 54-188) days. Of all, 69.7% were retained in care, all of whom were virally suppressed. Sites required few additional resources to incorporate rapid initiation into existing processes. Integration of rapid initiation of antiretroviral therapy into existing HIV screening programs is a promising strategy for scaling up this important intervention.

Managing the unmanaged: a case study of intra-institutional determinants of uncompensated care at healthcare institutions with differing ownership models.

STUDY OBJECTIVE: This study presents a case analysis of how 3 urban medical centers with differing ownership models, within 1 metropolitan area, ration access to uncompensated care to uninsured patients. METHODS: Data was triangulated from 3 sources: hospital financial reports by service line for a fiscal year, a survey of 292 self-pay patients, and the self-pay policies and practices of clerical personnel described in a previous publication. RESULTS: Although the public, for-profit and not-for-profit institutions used different strategies for managing self-pays, there were also commonalities in the experiences indigent patients reported. The public institution provided the broadest access to the largest percentage of self-pay patients but offset the burden with the most successful prepayment and collection practices. The for-profit site obeyed federal regulations mandating emergency care but severely curtailed other services, and the not-for-profit limited assess (but not to the extent of the for-profit) and pursued collection (but not to the extent of the public). At all sites, actual practices by clerical staff often diverged from institutions' written self-pay policies. The probability of being turned away because of inability to pay ranged from 0% to 40% with front line personnel exercising considerable discretion on a case-by-case basis. CONCLUSIONS: Large institutional providers balance their particular social and legal obligations with strategies to limit access and optimize prepayment and collection. Stated policies generally do not reflect the practices of personnel. Uninsured patients are forced to navigate a capricious system that manages them as a liability rather than as a legitimate client.

Essential medical issues related to HIV in dentistry.

Management of HIV infection has progressed dramatically since the disease was first recognized, to the point that HIV infection is now considered a chronic condition. Some of these new approaches in management are related to the strides that have been made in understanding the pathogenesis of this condition. Such changes in medical care may also affect the provision of oral health care. Dental providers must therefore be aware of current management practices. This paper reviews current approaches to managing HIV-related disease.

Avoiding free care at all costs: a survey of uninsured patients choosing not to seek emergency services at an urban county hospital.

The purpose of this case study was to understand why many uninsured patients opt not to make use of a free public hospital when it is available, instead seeking emergency department care at sites where they will be billed for the services they receive. One hundred fifty seven uninsured patients were interviewed over an 8-week period at three emergency departments that bill for services near a county hospital that provides free care. Data was gathered on income, health status, and credit history. Subjects were also asked if they had previously sought care at the county hospital and, if they had, how satisfied they were with the quality of care and with the wait time. Seventy two percent of the subjects reported household incomes of <$20,000, 48% reported they were in fair or poor health, and 33% said they were unable to pay at least one medical bill at the site where they were seeking care. 65% reported they had previously received care at the county hospital, and of these 61% said they were not-too-likely or not-at-all likely to return. In a regression analysis, experience with wait time correlated with subjects willingness to return, whereas their satisfaction with quality, their income, problems with debt, and reported health status did not. Access involves more than geographic proximity and affordability. Excessive wait times can deter even patients who are poor, in ill health and in debt from making use of services that are intended for their benefit.

Rationing access to care to the medically uninsured: the role of bureaucratic front-line discretion at large healthcare institutions.

BACKGROUND: Medically uninsured patients seeking nonemergency care are not guaranteed access to services at most healthcare institutions. They must first register with a clerk who could require a deposit and/or payment on an outstanding debt. OBJECTIVES: This study examines the factors that influence whether nonmedical bureaucratic staff sign in or turn away uninsured patients who cannot meet prepayment requirements. RESEARCH DESIGN: The study was conducted at a for-profit, a not-for-profit, and a public healthcare institution in a metropolitan area. The authors explored the relevant policy environment through interviews with senior administrators and a review of documents pertaining to the management of self-pay patients. Then they examined how policies affecting access were implemented through in-depth, semistructured, audiotaped interviews with 55 front-line clerical personnel. RESULTS: At all 3 institutions, policies were ambiguous about what to do when uninsured patients cannot afford required prepayments. Seventy-one percent of staff reported they do not turn patients away; the remainder stated that on occasion they do. A variety of rationales were provided for how decisions are made. Those with the lowest-level positions were significantly more likely to be sympathetic to indigent patients and less likely to report turning patients away. CONCLUSIONS: Consistent with other studies of front-line bureaucracies indicating that low-level personnel who interface with clients make discretionary decisions, particularly when organizations pursue potentially conflicting priorities, this preliminary investigation found that nonmedical personnel play a significant role in decisions affecting access to care for medically indigent patients.