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Expert oversight essential for treatment programmes - part 7 of 8
Ian Sanne, Chris Barker and Alizanne Cheetham. 17 June 2003. Business Report. Republished courtesy of Independent Newspapers (Pty) Ltd.
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Offering free antiretroviral drugs to HIV-positive employees is economically viable - but only if the treatment works. High-quality treatment is not just a prerequisite for ensuring that productivity costs are saved, it is essential to ensure that costs are not doubled. This is where many businesses are doubling the cost of HIV/AIDS on their bottom line.
In week two of this series (available on www.FutureForesight.com), we compared the cost of an employee's declining productivity for the duration of advanced HIV/AIDS with the costs of that employee's treatment. If antiretroviral treatment for HIV is started early, the employee can continue to work normally, without exceptional productivity losses, for years.
The argument is that the cost of the treatment is less than the cost of a chronically unwell employee, as long as the treatment keeps the employee healthy. This week we explore the risk of double dipping: paying for treatment without seeing the benefits of improved health. (A previous article covered the issue of paying for treatment only after incurring productivity losses.)
Well-meaning employers who buy minimalist treatment programmes will not see the savings. FutureForesight has conducted audits on firms that have been treating for several years. The results are alarming, and the reasons for this are clear. Companies sign up with a service provider - seemingly large, but with appallingly thin medical expertise. The provider subordinates the scripting process to general practitioners (GPs), offering to check the scripts and patient welfare.
In reality, the GPs are not skilled enough to write the scripts; they are expected to do so within the limited patient time their practice can afford. The checking process either doesn't exist or cannot cope with the need for repeated interaction with each and every patient. In 41 percent of the cases studied, the patient's therapy is inadequate to start with. And without someone to pressure the patient into regular updates of the script, 32 percent of all the scripts become invalid within a year or two.
High-quality antiretroviral treatment for HIV/AIDS works. Anecdotal evidence, like that of the recent Spirit of Comrades award given to an athlete on treatment who had been bedridden the year before, is supported by the data from international studies. The experience of a large South African telecommunications firm is that HIV-positive employees on treatment take less sick leave than their HIV-negative colleagues.
But treatment showing this kind of result is not easy to secure. In the first place, treating HIV is not always straightforward. Drugs are prescribed in triple combination, and the doctor has to take into account side effects and reactions with other medications.
The level of expertise required is a couple of years' full-time, hands-on training, and continued learning in the rapidly changing field; GPs with such experience simply don't exist.
In fact, UNAIDS says we need six GPs for each 1 000 patients to cope with HIV - but we have only 1.3 GPs per 1 000 patients, let alone experts. The complicated nature of the scripting process means an average visit for an HIV-positive patient could take up to 50 minutes, compared with 20 minutes for an average HIV-negative patient. Any GP who accommodates a meaningful proportion of HIV-positive patients will dramatically decrease the number of patients seen and destroy the practice's economics. It is unfair to expect GPs to carry this time burden.
Finally, patients are required to have their scripts updated every three to four months, due to problems with rapidly developing resistance associated with non-compliance. When the patient is not followed up and offered a comprehensive chronic support system, he or she tends to miss doctor's visits and continues taking a failing regimen of drugs. For the company, this means absenteeism and productivity losses, while the cost of the medication continues.
More alarmingly, on a public level, HIV-positive individuals on a failing regimen run the risk of transmitting resistant strains. Quite simply, the burden of patient management cannot be left in the hands of doctors alone. Only vets manage patient scheduling and GPs cannot be expected to co-ordinate the volumes involved in addition to their normal activities.
The results of all this show in double dipping. The accompanying chart best illustrates this. An untreated HIV-positive employee would normally get ill and die, costing the company lost productivity in the process.
A poorly managed patient will start treatment (ideally before incurring productivity losses), but the treatment will fail for any of the above reasons.
At some stage the patient will realise that something is wrong and will go back to a doctor. The script will be changed, lifting him or her back to a productive state again. This can happen as many as seven times with locally available drug regimens.
Each dip will affect the company an average of 50 percent of the normal death impact (a crude estimate by FutureForesight based on patient audits).
A single badly managed patient has the potential to triple the productivity impact of an unmanaged patient (six dips of 50 percent over seven script changes), while simultaneously incurring the treatment costs.
It is easy to see how companies we have audited are managing to double the impact of HIV/AIDS beyond the initial projections. So how does this all get solved in a workable yet affordable solution? An employer needs to look for three mechanisms offered by the management service provider, all of which are currently on offer to the market.
First, the service providers need to link directly with GPs taking care of providing the patient script. This requires sophisticated levels of interaction, as the script can only be written based on the GP's assessment of the patient's clinical status. It is simply not acceptable for the provider to expect the GP to write the script, and then pass a "rewrite" verdict.
Second, high-quality treatment can come only from HIV experts. While there are about 40 doctors in the country considered to be HIV experts, there are as many as 200 doctors prescribing antiretrovirals.
Employers must ensure that their service provider links the experts directly to the treating doctors of the employees.
While the treating doctor can offer an initial script, the experts can ensure it is safe and optimal, and ideally use this as an opportunity to train the doctors. Accompanying the improved script with detailed explanations and building the relationship with doctors are ways to achieve this.
The full version of this article can be downloaded on the righthand side of this page |
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