Kaiser Daily Health Policy Report
Association of American Medical Colleges Proposes Ban on Pharmaceutical Company Gifts to Physicians, Staff, Medical Students
New York Times Examines Debate Over 'Dental Therapists'
Los Angeles Times Examines 'Exodus' of Specialists From Southern California Emergency Departments
Hospitals Increasingly Requiring Upfront Payment for Services To Reduce Bad Debt
Missouri Senate Endorses Subsidized Health Coverage Legislation for Low-Income Working Residents
Michigan Senate Health Committee Chair Discusses Health Insurance Proposals
Health on the Hill from kaisernetwork.org and CQ
CQ's Carey Looks at Genetic Anti-Discrimination Measure, Legislation To Block Medicaid Rules Implementation, FDA Hearings
Election 2008
Wall Street Journal Examines Presidential Candidate Proposals to Address Health Care Costs
[Apr 28, 2008]
Presidential candidates Sens. Hillary Rodham Clinton (D-N.Y.), John McCain (R-Ariz.) and Barack Obama (D-Ill.) each have announced proposals that seek to reduce health care costs, but "it is unclear how many of the candidates' ideas could actually make a dent in the rising cost of care," the Wall Street Journal reports.
According to the Journal, the candidates have proposed similar initiatives to address health care costs, including: providing consumers with more information to allow them to consider the cost and quality of medical treatments when they make health care decisions; promoting the use of generic medications and health care information technology to help reduce costs; and some form of medical liability reform.
McCain also has proposed to replace a tax break for employees who receive health insurance from employers with a refundable tax credit for the purchase of private coverage and to allow the purchase of health insurance across state lines -- both of which he maintains would promote competition among health insurers and reduce costs.
Gail Wilensky, an adviser to McCain, said, "The real answer is we don't know" whether the proposals from the candidates would reduce health care costs. She added that the alternatives include price controls and controlling the spread of new technology, which "gets real ugly real fast." Robert Reischauer, president of the Urban Institute, added, "Everybody is talking about the same kinds of things, but they are very difficult to do," adding, "If we started on the campaign trail right now, you'd be lucky to see the product of that in seven to 10 years, if everything was meshing right" (Meckler, Wall Street Journal, 4/28). Cost of Proposals
Health care and other proposals from each of the candidates could "significantly swell the budget deficit and increase the national debt by trillions of dollars," the New York Times reports.
According to the Times, Clinton and Obama have acknowledged that their proposals "would be costly but have outlined how to pay for them," although "some fiscal monitors say they may be relying on overly rosy projections of how much savings their proposals would actually yield." Clinton has estimated that her health care proposal would cost about $110 billion annually, and Obama has estimated that his plan would cost as much as $65 billion annually.
McCain has "spoken vaguely about making entitlement programs like Social Security and Medicare less costly for the government" to help finance his health care and other proposals, the Times reports (Rohter/Cooper, Times, 4/27). Forum
Health care advisers to each of the candidates on Thursday at a forum hosted by the National Federation of Independent Business discussed proposals by the candidates to expand health insurance to more residents and reduce costs, CQ HealthBeat reports.
Douglas Holtz-Eakin, a policy adviser for McCain, said, "Rising spending on health care has been the biggest threat to the system. ... It is the reason we find employers dropping coverage" (Cooley, CQ HealthBeat, 4/25). He added, "We are paying far too much for the outcomes we get" (Wall Street Journal, 4/28).
Katherine Hayes of the Clinton campaign said, "It's really heard to get a handle on cost without addressing coverage," adding, "You can't open up the door (to tell) insurance companies that they have to take everybody ... if some people can wait until they're sick to enter the health care system."
Kavita Patel, an adviser to Obama, said that Obama and Clinton have "very similar" health care proposals, although the Obama plan would not require all residents to obtain health insurance (CQ HealthBeat, 4/25).
 A webcast of the forum is available online at kaisernetwork.org. McCain To Deliver Health Care Speech
McCain on Tuesday plans to deliver a major policy speech on health care at the H. Lee Moffitt Cancer Center & Research Institute in Tampa, Fla., according to his campaign, the Tampa Tribune reports. McCain spokesperson Jeff Sadosky said the speech will focus on the cost of health insurance, "which Sen. McCain feels is the root issue for the health care crisis as a whole," as well as the need to focus on preventive care and other issues (March, Tampa Tribune, 4/26). Opinion Piece
"For the last month, news media attention was focused" on the Pennsylvania Democratic primary, but, "as in the rest of the country this political season," information "about the candidates' priorities, policies and principles" on health care and other issues "too often did not make the cut," Elizabeth Edwards, wife of former Democratic presidential candidate and former Sen. John Edwards (N.C.), writes in a New York Times opinion piece. She writes, "Did you, for example, ever know a single fact about Joe Biden's health care plan?" adding, "But let me guess, you know Barack Obama's bowling score."
According to Edwards, "[I]t's not as if people didn't want this information," but few "people even had the chance to find out about Joe Biden's health care plan before he was literally forced from the race by the news blackout that depressed his poll numbers, which in turn depressed his fundraising." Such "shallow news coverage" allows residents to "ignore issues and concentrate on things that don't matter," Edwards writes, adding, "If voters want a vibrant, vigorous press, apparently we have to demand it" by "talking calmly, repeatedly, constantly in the ears of those in whom we have entrusted this enormous responsibility" (Edwards, New York Times, 4/27).
Coverage & Access
Association of American Medical Colleges Proposes Ban on Pharmaceutical Company Gifts to Physicians, Staff, Medical Students
[Apr 28, 2008]
All 129 U.S. medical schools should not allow pharmaceutical and medical device companies to provide food, gifts and travel to physicians, faculty members and students, according to a report released on Sunday by the Association of American Medical Colleges, the New York Times reports. According to the report, drafted by a task force formed by AAMC in 2006, such "forms of industry involvement tend to establish reciprocal relationships that can inject bias, distort decision-making and create the perception among colleagues, students, trainees and the public that practitioners are being 'bought' or 'bribed' by industry." Roy Vagelos, a former Merck CEO, chaired the task force, which also included the CEOs of Pfizer, Eli Lilly, Amgen and Medtronic.
The report recommends that medical schools "strongly discourage participation by their faculty in industry-sponsored speakers' bureaus," in which physicians receive payments to promote the benefits of medications and medical devices. In addition, the report recommends that medical schools establish centralized systems for the acceptance of medication samples from pharmaceutical companies or develop "alternative ways to manage pharmaceutical sample distribution that do not carry the risks to professionalism with which current practices are associated." Medical schools also should audit independently accredited medical education seminars led by faculty members "for the presence of inappropriate influence," according to the report.
Most medical schools follow the recommendations of AAMC, although they can decline to adhere to them. According to the Times, only a "handful of medical schools presently bar faculty members from serving on speakers' bureaus, so if this recommendation is widely adopted, it could transform the relationship between medical school faculty and industry, and it could change substantially the way medical education is routinely delivered." Many medical school faculty members have opposed restrictions on participation in speaker bureaus, as well as limits on medical samples from pharmaceutical companies. Comments
Rob Restuccia -- executive director of the Prescription Project, a not-for-profit group that seeks to prevent conflicts of interest in medicine -- said that the recommendations in the report would change medical education. He said, "Most medical schools do not have strong conflict-of-interest policies, and this report will change that."
Vagelos said that the recommendations in the report likely will face opposition from some medical school faculty members. In addition, he said, "The outcome of this for the industry is that those companies that are strong in science will always be welcome at medical colleges, and others won't."
Pfizer CEO Jeffrey Kindler and Eli Lilly CEO Sidney Taurel -- both members of the task force -- in the report wrote that they oppose the recommendation to restrict participation by medical school faculty members in speaker bureaus. They wrote, "We continue to believe that these types of programs, which are subject to clear regulations regarding their content, can be worthwhile educational activities."
David Beier, an Amgen senior vice president, wrote a letter that endorsed the recommendations in the report but questioned some of the language "because we have a different view about the accuracy concerning representations about the motives of the participants in industry-academic interactions."
Ken Johnson of the Pharmaceutical Research and Manufacturers of America said that the group will review the report. He added, "Providing physicians -- and medical students -- with timely, accurate information about the medicines they prescribe clearly benefits patients and advances health care throughout the United States" (Harris, New York Times, 4/28).
 The report is available online (.pdf).
New York Times Examines Debate Over 'Dental Therapists'
[Apr 28, 2008]
The New York Times on Monday examined the debate over a program in Alaska that uses "dental therapists" to provide care to Alaska Natives who lack access to dentists.
Under the program, after dental therapists receive two years of "intensive training" at the University of Alaska-Anchorage, they can perform routine tooth extractions and fill cavities. Patients who need root canals and complex extractions must be referred to dentists. Dental therapists must be supervised by a dentist, either onsite or offsite through documents and X-rays. The therapists, who are allowed to practice only in Alaska and only on Alaska Natives, are paid about $60,000 annually -- one-half to one-third dentists' typical incomes -- through a federally funded program that provides dental care to 136,000 Alaska Natives throughout the state. The program, which aims to have 100 fully trained dentists on staff, so far has only 75 participants, and "the number of vacancies is growing," according to the Times. According to Ron Nagel, a dentist and a consultant for the Alaska Native Tribal Health Consortium, dental therapists are a less-expensive option to provide dental care for people who otherwise might not have access to it.
The Alaska program currently has fewer than 12 dental therapists practicing. However, some dentists who specialize in public health said the program should be offered nationwide to provide dental care to the about 100 million U.S. residents who cannot afford treatment, according to the Times.
The American Dental Association and Alaska Dental Society oppose the program, saying dentists -- who receive four years of postcollegiate training -- should be the only providers allowed to perform fillings and extractions. The two groups filed a lawsuit to block the program but dropped the suit last summer after a state court judge issued a ruling critical of the dentists. According to the Times, ADA officials say that they do not want patients to receive substandard care and note that dental therapists might not be able to handle emergencies such as uncontrolled bleeding that sometimes occur in routine procedures.
The Times reports that some dentists in public health programs say the groups are actually concerned about dental therapists becoming low-cost competition. According to a 2006 study by the Baylor College of Dentistry that compared the quality of about 600 procedures in more than 400 patients, the quality of procedures performed by dental therapists was no different from that provided by dentists (Berenson, New York Times, 4/28).
Los Angeles Times Examines 'Exodus' of Specialists From Southern California Emergency Departments
[Apr 28, 2008]
Specialists in Southern California have "abandoned emergency [departments] in droves" -- a trend that has exacerbated backlogs in EDs and affects both insured and uninsured patients, the Los Angeles Times reports. Mark Langdorf, ED director at University of California-Irvine Medical Center, said that physicians can handle about 80% of patients who come to the ED for care but that about 20% must be treated by a specialist. According to the Times, "That can mean hours on the phone trying to find a specialist or arranging a transfer to a larger hospital." Jim Lott, executive vice president of the Hospital Association of Southern California, said, "If the state of California's licensing and certification division came into our hospitals to examine whether we had all the specialists we say we do, they would shut down over half of the hospitals in Los Angeles County because we don't have coverage."
According to the Times, "The most obvious reason for the flight of specialists from emergency rooms is the surge of patients who have no medical insurance or who use Medi-Cal, which pays some of the lowest rates in the country." Medi-Cal is the state's Medicaid program. In addition, "It has become virtually impossible" for some people to find specialists in private practices, "so they turn as a last resort" to EDs, which are required to provide treatment under federal law regardless of ability to pay, the Times reports. The number of specialists "could grow even scarcer" if the state cuts Medi-Cal payments by 10% to reduce the budget deficit, according to the Times.
Lott said that other reasons specialists move away from EDs are that patients are often drunk or on drugs, there is a higher risk of being sued by an ED patient than a longtime patient and insurers limit physicians' ED payments. Lott also said that many specialists are "looking for a lifestyle that doesn't tie them to a hospital on evenings and weekends," adding, "Some of them you couldn't pay any amount of money to -- they just won't take the call."
One tactic some hospitals have used to gain more specialists is paying them stipends to be on call. However, Irv Edwards, former president of the California chapter of the American College of Emergency Physicians, said that it is a temporary solution (Engel, Los Angeles Times, 4/25).
Health Care Marketplace
Hospitals Increasingly Requiring Upfront Payment for Services To Reduce Bad Debt
[Apr 28, 2008]
The Wall Street Journal on Monday examined how some hospitals are "adopting a policy to improve their finances: making medical care contingent on upfront payments." According to the American Hospital Association, uncompensated care nationwide increased by 44% to $31.2 billion in 2006 from $21.6 billion in 2000. The "bad debt is driven by a large number of Americans who are uninsured or who don't have enough insurance to cover medical costs if catastrophe strikes," the Journal reports. Federal law mandates that hospitals provide emergency care, but the law does not cover conditions that are not immediately life-threatening, such as cancer. Even among people with adequate coverage, "deductibles and copayments are growing so big that insured patients also have trouble paying hospitals," according to the Journal.
Richard Umbdenstock, president of AHA, said that leaving bad debt unchecked could leave hospitals in financial ruin and hinder their ability to provide care. He said that hospitals prefer to talk about payment up front because "[a]fter, when it's an ugly surprise or becomes contentious, it doesn't work for anybody."
The Journal reports, "While the practice has received little notice, some patient advocates and health care experts find it harder to justify at nonprofit hospitals, given their benevolent mission and improving financial fortunes." Otis Brawley, chief medical officer at the American Cancer Society, said, "My greatest concern is that there are substantial numbers of people who need cancer care" and do not receive it, "usually for financial reasons."
The Journal profiled Lisa Kelly, who was diagnosed with leukemia in late 2006 and was asked to pay $105,000 up front for treatment at M.D. Anderson Cancer Center, which would not accept her limited-benefits insurance (Martinez, Wall Street Journal, 4/28).
State Watch
Missouri Senate Endorses Subsidized Health Coverage Legislation for Low-Income Working Residents
[Apr 28, 2008]
The Missouri Senate on Wednesday endorsed legislation that would expand health coverage to up to 200,000 low-income state residents, the AP/Kansas City Star reports. The Insure Missouri bill would expand health coverage to workers with incomes below 200% of the federal poverty level, and beneficiaries would have to contribute $1,000 annually into their savings accounts for use toward deductibles. The state would subsidize insurance premiums. The legislation, which was proposed by Republican House leaders, was based on a failed proposal of the same name by Gov. Matt Blunt (R). The Senate will hold a second vote on the legislation before it moves to the state House (AP/Kansas City Star, 4/23).
Michigan Senate Health Committee Chair Discusses Health Insurance Proposals
[Apr 28, 2008]
Michigan Senate Health Policy Committee Chair Tom George (R) on Thursday recommended that lawmakers take action on three provisions intended to manage Michigan's individual insurance market, including some proposed by Blue Cross Blue Shield of Michigan, the Detroit Free Press reports. About 322,000 state residents between ages 18 and 64 have individual policies -- "a growing number of whom are forced to buy their own insurance as they lose jobs or as employers drop workplace health benefits," according to the Free Press (Anstett, Detroit Free Press, 4/25).
BCBS estimates that the individual health insurance market could grow to 25% of all policies sold in the state in the next seven years. BCBS, the state's insurer of last resort, has recommended creating a high-risk insurance pool that would spread the risk of covering people with medical problems among other insurers (Anstett, Detroit Free Press, 4/24). BCBS claims the pool would limit for-profit companies from "cherry-picking" the healthiest patients and leaving it to cover the sickest residents.
Representatives from several consumer advocacy groups appeared before the state health committee on Wednesday and said a high-risk insurance pool would increase insurance premiums for the self-insured and make coverage unaffordable for those who need it most (Rogers, Detroit News, 4/24).
On Thursday, George said only policies that have the most support and will provide the greatest benefit to the consumer should be adopted. He said that the state should implement stronger protections for consumers purchasing coverage and that BCBS should be allowed to increase rates more easily, as commercial insurers are able to do. In addition, he recommended a three-year study to research the state individual insurance market.
State Senate Majority Leader Mike Bishop (D) on Thursday met with representatives of BCBS, private insurers and Michigan's HMO organization, Aetna, to "broker a compromise" over the various proposals. Representatives from BCBS and Aetna's Michigan division confirmed the meeting but declined to provide details of their discussion with Bishop (Detroit Free Press, 4/25).
Health on the Hill from kaisernetwork.org and CQ
CQ's Carey Looks at Genetic Anti-Discrimination Measure, Legislation To Block Medicaid Rules Implementation, FDA Hearings
[Apr 28, 2008]
Mary Agnes Carey, associate editor of CQ HealthBeat, examines Senate approval of genetic nondiscrimination legislation, House passage of a measure to block implementation of new Medicaid rules and hearings about FDA's need for increased inspection resources in this week's "Health on the Hill from kaisernetwork.org and CQ."
According to Carey, the Senate voted 95-0 to approve legislation that would prohibit employers and insurers from using any genetic screening test results when making employment or coverage decisions. The House has approved a different version of the measure, but the chamber is expected to pass the Senate version, Carey says. President Bush is expected to sign the bill.
Carey also discusses legislation approved by the House that would block for one year the implementation of several new Medicaid regulations proposed by the Bush administration. The House passed the bill with enough votes to override a presidential veto. Senate Majority Leader Harry Reid (D-Nev.) has put the measure on a fast-track process, which eliminates committee consideration and brings the bill straight to the Senate floor. HHS Secretary Mike Leavitt has indicated that there likely will be opposition to the measure in the Senate, and some Senate Republicans have voiced support for the Medicaid rules.
Lastly, Carey discusses House and Senate committee hearings about FDA efforts to protect the nation's drug supply. At the hearings, lawmakers asked FDA officials how much additional federal funding the agency needs to increase overseas drug inspections. Carey says FDA officials made the case that a broader overhaul of the agency's efforts to track and inspect international production of drugs was just as necessary as increasing the number of FDA inspectors abroad. They also stressed that drug makers should be held more responsible for the quality of the ingredients manufactured overseas and that FDA needs to have a comprehensive database of those manufacturers to help track possible problems. Carey adds that debate over this issue likely will continue for much of this year.
 The complete audio version of "Health on the Hill," transcript and resources for further research are available online at kaisernetwork.org.
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