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August 6, 2007 |
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IN THIS ISSUE
Editor's Column: Compared To What?
Medicaid
Drug Security Measure Could Cost Docs
Pontiac
Hospitals Link Services
Congress Approves Kid's
Program: $35 Billion, 5 Years
House Approves Rx Drug Imports
Economists
Say High Spending, Doc Salaries Linked
Giuliani Pushes Free Market HC Solutions |
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Editor's Column: Compared To What?
By JOSEPH WEISS, MD
A study in Health Affairs ( Health Affairs Nov-Dec 2006
w555-ff) on primary care practices in four other countries --
Australia, New Zealand the Netherlands and United Kingdom -- offers
information valuable to us in Southeast Michigan.
The study found that in these four countries the use of
Information Technology (IT) by primary care doctors averaged 90
percent (US physician average 28 percent). The technologies included
not only the electronic medical record but electronic prescribing,
electronic access to laboratory results and to the medical
literature. In addition the physicians used IT to generate lists of
patient diagnoses, pharmaceutical drug use, and to remind patients
about dates for preventive care or maintenance treatment. That usage
rate was 80 percent vs. US rate of 37 percent.
Case management reached 81 percent in the United Kingdom.
The US rate is 36 percent. After-hours coverage, in which patients
do not go to an emergency room but are seen by a physician or a
nurse, averaged 90 percent in the four countries; in the United
States that rate is 40 percent.
Finally, a poll of the doctors in the four countries asked
the question: “How often do you think your patients experience
difficulty paying for prescriptions?” The doctors estimated nearly
20 percent. The same question in a poll of U.S. physicians elicited
the response of 51 percent.
American physicians can explain some of these discrepancies.
We have no governmental support or financial assistance to pay for
IT let alone to help us maintain or upgrade it. Our patients have no
waiting for tests or surgery; no one surpasses us in these services.
But the difference between ourselves and our colleagues
abroad has meaning to us. At the least we should:
(1) urge Congress for money for IT (2) change our attitudes
about after hours coverage; that is, reconsider our evening phone
message: “if you think this is an emergency go to the hospital”; and
(3) reassess our indifference to case management.
At the most, we should learn more about how physicians
elsewhere in the world work their practice. As Emerson said: “Our
best ideas come from others.”
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Medicaid Drug Security Measure Could
Cost Docs
In what may end
up being regarded as a misguided attempt to prevent fraud, federal
legislators have seen fit to bury a costly and cumbersome
prescription drug security measure in an Iraq War spending bill. The
provision would require that Medicaid prescriptions be
electronically submitted or written on special tamper-resistant
pads. If that isn’t alarming enough, the effective date for the new
policy is Oct. 1, 2007.
The move is
intended to inhibit drug seeking individuals from filling fraudulent
prescriptions – especially for narcotics -- through the Medicaid
program.
“Michigan already
has the Michigan Automated Prescription Service (MAPS) to track this
information in a way vastly superior to the use of tamper-resistant
pads,” said Colin Ford, MSMS state government affairs director. “In
fact, MSMS along with the Michigan Hospice and Palliative Care
Association helped fight an amendment to the bill creating the MAPS
program that would have required these pads be used in Michigan.
“Many states
already a provision for these pads as part of their state law.
However, since Michigan does not, this would be an additional burden
on the physician and the pharmacist. Therefore, MSMS is asking that
the law not apply in Michigan and, at a minimum, that the
implementation be delayed.”
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Pontiac Hospitals Link Services
In what has
been described as a possible prelude to a merger, North Oakland
Medical Center and St. Joseph Mercy Hospital, both in Pontiac, have
agreed to refer baby deliveries from North Oakland to St. Joseph
Mercy. As part of the deal North Oakland will close its neonatal
intensive care and pediatrics units.
North Oakland
intends to open a 40-bed acute-care for patients too ill for nursing
home care, but who don’t need the full hospital services.
According to a
report in the Detroit News, 366-bed North Oakland, which is operated
independently, incurred a net operating loss of $10.4 million last
year; 428-bed St. Joseph Mercy, owned by the Catholic health system
Trinity Health experienced growing patient volume and finished in
the black with revenues of about $14 million.
Under North
Oakland Medical Centers' affiliation with St. Joseph Mercy Oakland,
North Oakland will cut operating costs, in part through better
purchasing arrangements. Independently operated North Oakland will
close its neonatal intensive care and pediatrics units and refer
patients to St Joseph. Baby deliveries will take place at St.
Joseph, which is part of the larger Catholic health system Trinity
Health.
While a merger
is unlikely soon, owing to North Oakland’s reluctance to being
acquired and its $38 million in construction debt from the 1980s,
future consolidation is not out of the question, the News reported.
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Congress Approves Kid's Program:
$35 Billion, 5 Years
The Senate late last week voted 68-31 to approve legislation (S
1893) that would reauthorize SCHIP and expand funding for the
program by $35 billion over five years, the
Wall Street Journal
reports (Lueck, Wall Street
Journal, 8/3). Two independents, 18 Republicans and
all 48 Democrats voted to pass the measure, with the 31 opposition
votes coming from Republicans (Pear,
New York Times,
8/3). The Senate would need 67 votes to override a potential
presidential veto (Alonso-Zaldivar,
Los Angeles Times,
8/3).
Sen. Debbie Stabenow (D-Mich.)
said, "As lawmakers, we have a moral obligation to provide health
care coverage for the millions of uninsured children. Health care
should be a right, not a privilege, and covering every child is an
important step toward this goal."
“The American Medical Association applauds the US Senate for passing
legislation that will protect the health of America’s kids,” said
Ron Davis, MD, AMA President and longstanding WCMSSM member. “The
Children’s Health Insurance Program Reauthorization Act will help
millions of American children who currently rely on CHIP, and the
many more who are eligible for the program, but not yet enrolled.”
SCHIP expires on Sept. 30. The
Senate Finance Committee in July finalized an agreement on SCHIP
reauthorization that would increase five-year funding for the
program from $25 billion to $60 billion by raising the federal
cigarette tax from 39 cents to $1 per pack. Under the plan, the 6.6
million children currently enrolled in SCHIP would continue to
receive benefits, and an additional 3.3 million children could be
enrolled in the program (Kaiser
Daily Health Policy Report, 7/31).
“America’s doctors urge Congress to finalize this legislation before
CHIP expires…Congress must preserve access to health care for both
America’s kids and seniors,” said Dr. Davis. “The AMA strongly urges
the conference committee to include in the final legislation the
House provisions in the CHAMP Act (HR 3162) that stop steep Medicare
cuts to physicians.”
A White House spokesperson said President Bush's previous veto
threat would stand, despite the large margin of support in the
Senate, according to the
Journal (Wall
Street Journal, 8/3). The White House said the bill
"goes too far in federalizing health care" (New York Times,
8/3).
The House on Wednesday voted 225-204 to approve its reauthorization
legislation (HR
3162), which would increase SCHIP funding by $50 billion over
five years and make changes to Medicare (Kaiser
Daily Health Policy Report, 8/2).
HHS Secretary Mike Leavitt said that Congress was jeopardizing
health care for children by passing bills that "the president will
have no choice but to veto" (New
York Times, 8/3). However, if conference committee
members can reach a bipartisan agreement, the White House might
"have to back down on its veto threat," according to some senior
Republicans, the Los Angeles
Times reports.
Senate Finance Committee ranking member Chuck Grassley (R-Iowa)
said, "I hope to be able to talk to the president and just show how
common sense dictates not vetoing this" (Los
Angeles Times, 8/3).
Conference Committee
The bill now goes to conference committee, and negotiators will have
"a formidable challenge in trying to work out differences" between
the two bills, according to the
New York Times.
Democratic leaders' "strong commitment to the issue ... virtually
guarantees" that the committee will reach a compromise before Sept.
30, when the program is set to expire, the New York Times
reports. However, it is unlikely that a compromise bill would be
acceptable to Bush (New York
Times, 8/3).
The House version of the bill includes a larger expansion of the
program, along with revisions to Medicare that include cuts to
private Medicare Advantage plans and a reversal of a scheduled cut
to physicians' Medicare reimbursements. The House and Senate
versions also differ in the size of the tobacco tax increase, with
the Senate supporting a 61-cent increase and the House supporting a
45-cent increase.
House and Senate lawmakers acknowledge that the Medicare provisions
in the House bill, "intended to piggyback their way into law on the
popularity" of SCHIP, will "complicate negotiations," according to
CQ Today
(Wayne, CQ Today,
8/2). The Journal
reports that the House-proposed level of cuts to MA plans "is
unlikely to survive the Senate" (Wall
Street Journal, 8/3).
Senate Majority Leader Harry Reid (D-Nev.) said that it would be
difficult for the Senate to approve a bill expanding SCHIP above $35
billion. Noting that the Senate legislation was drafted with
bipartisan support, Reid said, "It is the compromise, and I think
that is our figure," adding, "We're encouraged to move to conference
with the House, and we're happy to work with them to try to get
something we can sell over here" (Johnson,
CongressDaily, 8/3).
Senate Finance Committee Chair Max Baucus (D-Mont.) said, "What's
going to happen in conference? I have no idea." He added that the
bills "are really two different animals, and when that happens,
generally some other solution presents itself. ... There are all
kinds of ways to do things around here" (Lengell,
Washington Times,
8/3).
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House Approves Rx Drug Imports
The House passed legislation late last week permitting the
importation of relatively inexpensive prescription drugs from places
such as Canada, Australia and Europe.
The measure was enacted as legislators passed a $91 billion spending
measure that will pay for farm subsidies and nutrition programs for
the budget year beginning Oct. 1.
The bill, which passed by a 237-18 vote, faces a promised veto from
President Bush because of its price tag. The administration also
opposes the drug importation provision.
The wide-reaching measure is the last domestic spending bill to pass
the House. It contains nearly $1 billion more than requested by the
president. But the overall measure is more than $10 billion below
comparable costs for the current budget year because it does not
contain farm disaster aid and reflects lower crop subsidy costs due
to the good farm economy.
The administration "strongly opposes" the drug provision, which
would permit individuals, wholesalers and pharmacists to import
lower cost U.S.-made and FDA-approved prescription drugs from Canada
and other countries.
The White House says there is no system in place to protect
consumers from counterfeit or unsafe drugs, but an administration
policy statement stops short of an outright veto threat.
"I understand the intention to lower drug prices to the seniors,
that is critically important," Rep. Mike Rogers, R-Mich., told the
Associated Press "What we're doing is throwing open the gates to
every (drug) counterfeiter in the world."
A move supported by drug companies to strike the drug importation
provisions from the bill failed by a vote of 283-146.
Supporters of the idea say it would save consumers great sums by
allowing them to purchase U.S.-made medications from other countries
where they often sell for much lower prices than in the U.S. Under
current law, consumers are permitted to buy a 90-day supply in
Canada.
Overseas, drugs can cost two-thirds less than they do in the United
States, where prices for brand-name drugs are among the highest in
the world. In many industrialized countries, prices are lower
because they are either controlled or partially controlled by
government regulation.
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Economists Say High Spending, Doc Salaries Linked
Many health care economists maintain that the "partisan fight" over
whether to "force cuts in prescription drug prices and insurance
company profits" to expand health insurance to more U.S. residents
is a "distraction from a bigger problem: the relatively high
salaries paid to American doctors, and even more importantly, the
way they are compensated," the
New
York Times reports. Salaries for U.S. physicians
are two to three times higher than salaries for physicians in other
industrialized nations. According to surveys conducted by medical
practice management groups, U.S. physicians on average have annual
salaries of $200,000 to $300,000, and specialists on average have
annual salaries of more than $400,000. Physicians in Europe in 2002
on average had annual salaries of $60,000 to $120,000, according to
a survey conducted in 2004 by the British government.
In addition, most U.S. physicians "are paid piecemeal, for each test
or procedure they perform, rather than a flat salary," which
provides them with "financial incentives to perform procedures that
further drive up overall health care spending," the
Times reports.
Physicians also receive limited reimbursements for preventive care
and "cognitive services," such as research into alternative
treatments or advice provided to patients that does not involve
medical treatment.
Alan Garber, a practicing internist and the director of the
Center for Health Policy at Stanford University, recommends that
U.S. physicians receive flat annual salaries, as well as bonuses
based on the health of their patients. Peter Bach, a pulmonary
physician at
Memorial Sloan-Kettering Cancer Center and a former senior
adviser to
CMS, said, "I don't have a view on whether doctors take home too
much money or not enough money. The problem is the way they earn
their money" (Berenson, New
York Times, 7/29).
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Giuliani Pushes Free Market HC Solutions
The United
States "can reduce costs and improve the quality of care by
increasing competition" and by "empowering patients and their
doctors," presidential candidate and former New York City Mayor
Rudy Giuliani (R) wrote in a
Boston Globe
opinion piece. He added, "We can do it through tax cuts, not tax
hikes." According to Giuliani, the Democratic presidential
candidates support a "government-mandated model that looks for
inspiration to the socialized medical systems," but "[i]nstead of
being more like Europe, we need to be more like America."
The United States "has the best medical care in the world," but the
health care system "is being dragged down by decades of
government-imposed mandates, wasteful bureaucracy and massive
distortions in the U.S. tax code," Giuliani wrote. "We need to begin
by bringing fairness to the tax treatment of health care," Giuliani
writes, adding that the current tax code system "penalizes millions
... who pay for insurance on their own and receive no tax benefit."
He recommends implementation of his
proposal to provide U.S. residents with tax deductions to
purchase individual health insurance.
In addition, Giuliani recommends caps on non-economic damages in
medical malpractice lawsuits, adding, "Doctors and nurses who have
devoted their lives to helping others are relocating or leaving the
practice of medicine altogether because they literally can't afford
the insurance against frivolous lawsuits."
He concluded, "The future of America's health care system lies in
free-market solutions, not socialist models. ... That's the American
way to reform health care" (Giuliani,
Boston Globe, 8/3).
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