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Health Chairs Project Spring Meeting 2002Summary of Speakers' CommentsSession 1: Centers for Disease Control and Prevention
Session 2: Substance Abuse and Mental Health Services Administration
Session 3: National Cancer Institute
Session 4: Agency for Healthcare Research and Quality
Session 5: Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration)
Session 6: Health Resources and Services Administration
View this file in Adobe Acrobat (PDF) format. Session 1: Centers for Disease Control and PreventionDr. James Marks:Chronic diseases and related risk factors are the most common causes of death. Two thirds of all deaths are related to cardiovascular disease and cancer. The chief causes are tobacco, poor diet and lack of exercise. Cardiovascular Disease: Heart disease is the leading cause of death in every state and in every racial and ethnic group. There is no group for which it's not No. 1. There was a decline in mortality rates for stroke among black and white men between 1972 and 1994, but the white rate is dropping more quickly than for blacks, so the relative disparity grows. Most of the disparity is shifting to people in their younger years. Regionally, the rate of cardiovascular disease deaths is much higher in the South. But even for those in the state with the lowest rate, Utah, it's still the number one cause of death. How many cardiovascular deaths can be explained by smoking, exercise, diet and stress? About two thirds of differences among states are due to modifiable risk factors. This means it's not how fast ambulances are and not how good coronary care units are. Two thirds of the difference is due to population risk factors that are completely modifiable. Cancer: Regarding cancer, we are seeing a declining annual average death rate: lung cancer -1.8 percent; prostate cancer -2.6; colorectal cancer -2.1. Among women, breast cancer is down -2.3, although lung cancer is up +1.1, so lung cancer is still going up in women. Men and women's lung cancer rates are now the same. Lung cancer [among women] is an epidemic. Most women don't realize they suffer more deaths from lung than breast cancer, even though only a fourth of women smoke. The public doesn't realize that a woman's chance of daying of lung cancer is four times greater than dying of breast cancer if she smokes. Mammography use has experienced a strong increase in use in all states. This is one of the real successes of last decade. In California, adult smoking prevalence has declined at twice the U.S. rate, and youth smoking fell 43 percent from 1995 to 1999. California is only the state to see a decline in lung cancer deaths among women, and 30,000 fewer deaths from heart disease, equaling $8 billion in health cost savings. Nearly every state that made a serious effort to fight tobacco saw real declines. Price is important to get lower-income people to stop smoking. Colorectal cancer screening is still at an early stage. There was almost no change in use from the mid-1980s to the mid-1990s. There has been no systematic effort to educate the public and providers. We in public health and you in the states have to help to get the word out: 50 percent of colorectal cancer deaths can be prevented with early screening. Obesity & Diet: Most state health departments are weak in this area. Most states have no program aimed at nutrition among adolescents and adults, yet the growth in obesity rates in all 50 states is the most striking epidemic we have seen in the chronic disease arena. It's not genetic. It's not due to drug companies taking drugs off the market - the first effective drugs have arrived. It's not due to a lack of low-fat choices: Lean Cuisine, Healthy Choice are growing in sales. Cholesterol has declined. We know that rats fed regular diets don't gain weight, but offer them a buffet and they gain. We have seen a 50 percent increase obesity since 1985, and it is due to an imbalance between eating and what we do. The more hours of TV watched, the more likely a child will be obese. That does not count video games or computer time. In 1970s, we never saw a case of type II diabetes in a kid. Oakland saw the first in 1979; now it sees two to five per week. Sports teams are better today but fewer kids are involved. Diabetes follows obesity like night follows day. It's a second epidemic related to the first. We see a 50 percent increase in adults. The rates are faster among those in their 30s, up 70 percent, though 20 percent of folks over 65 have diabetes. Diabetes has an impact on circulation and is the leading cause of blindness, kidney failure and amputations. The science is very good - if you control glucose, you lower the rate by a third New York set up networks to remind diabetics to check their feet, to check blood sugar, to get screenings - and it saw a 25 percent drop in amputations. The message is to prevent diabetes Seventeen million live with it and 17 million have elevated blood sugar. Diet and activity kept 60 percent from moving on to full diabetes and are twice as effective as drugs. Diet and exercise are the only things that worked for those over 60 and had some convert back to normal. Session 2: Substance Abuse and Mental Health Services AdministrationCharles Curie:In talking to patients in state hospitals, to consumers in drop-in centers, to clients in rehab or residential programs, I hear three things. Scientific surveys indicate the same three things people need to recover and to stay recovered. They boil down to: I need a job; I need a safety, someplace to live; and I need a date on weekends, the opportunity to have relationships with special people, families, to be connected. Those three things shape our thinking about what are we trying to achieve in the lives of people with addictive disease and with mental illness. Treatment is important. We need state-of-the-art medications. The psychotropic meds available today are alleviating symptoms beyond what we could ever imagine. But while treatment is essential, we also need to give folks a life and an opportunity to succeed in the community. When there are failures, typically it's because those three things I mentioned weren't addressed. If they find a safety, someplace to live and a connection to people, through churches, through social groups, if they end up dating somebody, if they end up reconnecting with their families, they're going to succeed. Years ago, drugs and alcohol were part of mental health and alcoholics were thrown into state hospitals and inappropriately treated. Today we understand recovery and drug and alcohol treatment. But we need to think about mental health and substance abuse being part of public health. One way we're doing that is by including substance abuse and mental health on the list of leading health indicators of Healthy People 2010. Mental health and addictive disorders are responsible for one fifth of all disability. The World Health Organization tells us depression is the second leading cause of lost capacity and lost lives in the U.S. and countries with similar economic status. That's also been documented in the Surgeon General's 1999 Report on Mental Health. Diagnosable mental illness affects 44 million adults; of those, 22-23 percent are over 21 years of age and more than 20 percent are children and youth ages 9 to 17. One in 10 children has a diagnosable, serious emotional disturbance or conduct disorder, and many end up in juvenile justice. Many aren't making it in school and end up being "the headaches" of the system. Too many people experience both mental health and substance abuse: as many as two thirds of those with a lifetime addiction also experience at least one mental disorder and over 50 percent of those with a lifetime mental disorder also have a lifetime history of one addictive disorder. Even seven years ago, mental illness and substance abuse were a small specialty subpopulation. Today we're finding up to half of the people coming to our doors have a co-occurring mental illness and addictive disease. There's a window of opportunity when young teens, those that may develop a mental illness, begin to turn to drugs as a form of self-medication. The addiction takes hold then and the mental illness isn't diagnosed until later on. President Bush talked about a 14-year-old young man who began using drugs in his teen years, became addicted, in and out of treatment, in and out of trouble, a history of not getting a life. At age 30 he was diagnosed as bipolar. Once diagnosed, he got on the right medications and the addictive disease began to take care of itself and the mental illness was being controlled. Sixteen lost years of a life. Co-occurring disorders are real. The Surgeon General found that two thirds of adults with mental disorders don't get any help. Only one in five of the children or youth with serious emotional disturbances get care in the mental health sector. Of grave importance are the numbers of children growing up in families in which substance abuse is taking place. A family is the No. 1 risk protective factor for a child's decision to start using drugs. So we know more today in prevention. One message we're trying to send through our Center for Mental Health Services is that all parents should spend at least 15 minutes a day, one on one, with their children. That communicative factor can be significant. We have the science to demonstrate that's effective. But we can't succeed in ending drug abuse if we don't meet the treatment need. We know dollars spent for mental health and substance abuse services really work. Treatment for substance abuse reduces drug abuse. The rates of use a year after treatment are half those for the year before treatment. Criminal activity is reduced as a result of treatment by 2/3 to3/4 depending on what program you're looking at. Research shows that rates of abstinence from drug abuse run up 40 percent to 60 percent because of treatment and treatment intervention. The criminal justice interface is something I can't stress enough. In Pennsylvania, we found 90 percent of the individuals in prison had a drug and/or alcohol issue, comparable nationally to the surveys that we've seen. Out of the 12 percent or prisoners who are considered mentally ill, 90 percent had a co-occurring drug and/or alcohol disorder. Over 50 percent of individuals in prison were under the influence of drugs or alcohol at the time of arrest. By preventing or treating substance abuse, we lower other collateral costs, such as those associated with HIV/AIDS. Again, I talked about the criminal justice system and also the child welfare system. Studies have found that treating pregnant, drug-abusing women, actually resulted in a net savings in post-delivery treatment costs of over $4,600 per mother and child. We can either pay now or pay later. Just as in the corporate world we focus on quarterly bottom lines and we may make short-term decisions that make sense. Sometimes the longer-term decisions don't get made and those can be decisions that could be cost effective in the long run. I recognize the difficult position we're all in making these kinds of decisions. It matters what we pay for today and the services we support, the services you support with your state dollars, and that's why again, commitment to evidence-based [research] is very, very important. Session 3: National Cancer InstituteDr. Andrew C. von Eschenbach, MD:In 1989 I became a cancer survivor, with melanoma and two years ago I became a second time survivor with prostate cancer. So I come to this wonderful opportunity to be the director of the National Cancer Institute with a perspective on the importance of research; a clear and passionate belief and understanding of what we need to do with regard to enhancement and therapy; and a tremendous sense of urgency as to how important it is that we get it done. One thing I learned early in my career was that as a surgeon, a surgical oncologist, I didn't think I was God; I knew I was God. I quickly learned that the problem with cancer, no matter how good I thought I was, would never be solved by one discipline or individual. It is going to require a multidisciplinary approach and an interdisciplinary approach; we have to weave together expertise from a variety of disciplines to change the face of cancer and provide appropriate care. You cannot solve a problem you don't understand. So research has to be the foundation for progress. Collaboration and integration and needing to discover and learn have been principles that have formed and guided me. I want to talk to you about the importance of collaboration and cooperation, especially as it relates to integration of things that we are doing at the federal level and things on which you are working so to accomplish at the state and community level. The first thing is the unbelievable burden that cancer places on us as a society. One of every two men and one of every three women will learn during their lifetime that they have cancer. Over 1.3 million new cases of cancer will occur this year and more than a half million deaths. That is an enormous problem for us, an unbelievable problem as it relates to the world global burden of cancer. Because cancer is a global problem. But the solution is the destiny and the responsibility of this country because no other country has the resources, the capability and the talent to solve it. We are a country that's chosen to make an enormous investment in this problem beginning with passage of the National Cancer Act, which was signed by President Nixon in 1971, with the hope that we would quickly solve the problem much in the way we put a man on the moon. The problem was that we did not have the tools we needed. We didn't understand the problem, let alone how to eliminate it. But we have begun to understand the problem at the genetic, molecular and cellular levels and now we are poised at a new paradigm. The new paradigm, the new transition, is to move from the one that I grew up with, which was seek and destroy. Our approach to cancer was to find it and kill it. We are now poised to change that to a paradigm I describe as target and control. We now have the opportunity to develop interventions that can detect, treat and prevent the disease and we are challenged to take this new knowledge and translate it into interventions and make certain those interventions are delivered to patients, to people who need them most. We recognize now that the process of cancer, the way it develops and takes someone's life, is a series of well-defined steps, steps that have to do with how cells grow in an uncontrolled and unregulated fashion, how they invade the surrounding tissue and how they find access to the blood stream and spread to other parts of the body and then then grow in other areas. It's not until the metastatic expression of cancer occurs that we see the full lethal expression of cancer, or its lethal nature. We now have steps in which we can develop interventions. The idea is to think about cancer the way we think about a decathlon champion. To win the decathlon, you have to compete at a number of events. For cancer to win it has to do all those things. So we begin to think not about having to eradicate it or destroy every last cell but to control it at multiple steps. This opens up opportunities to create a new portfolio of therapies and interventions-drugs to stop the ability of a tumor to create or cause the body to form new blood vessels, to nurture it and support it. We have new interventions that were not available before that are part of this new paradigm. One thing we've learned about this process is that [cancer cells] cause the body to create new blood vessels, which bring oxygen and food to the tumor but also provide a pathway for the tumor to escape and get to another part of the body. That process is called angiogenesis and now, a number of drugs have been developed to interfere with that process. Thalidomide was so horrible with regard to birth defects because it did just that, it blocked the development of blood vessels. Interestingly enough, one other condition that affects 8 million Americans, is macular degeneration in the eye, the abnormal development of blood vessels that leak and hemorrhage. Drugs developed for cancer are now being applied to macular degeneration and are having exceptional early results and will be applicable to millions of patients. Those drugs could never have been developed just in the context of the eye for macular degeneration. They could have only been developed in cancer where we had models and could do the experiments. The point is to remind us that an investment in cancer research can pay dividends with regard to cancer but also to an array of chronic diseases. The other take-home message I want to convey is what incredible horizons are within our grasp. One thing clinicians have recognized for decades was that prostate cancer preferentially spreads to the bone, just like breast cancer tends or lung cancer tends to go to the brain. We have known as clinicians for a long time that cancers from certain organs have the specificity to metastasize to other sites. We knew that, we've observed that, but we didn't understand how that could happen. We're seeing overall new cases of cancer beginning to stabilize and actually decrease in some areas, though there are some tumors for which there are still increases occurring, particularly, lung cancer in women and melanoma overall. So we still have a lot of work to do. We are seeing downturns in mortality, or death rates from cancer; 6 percent overall. The problem is this progress has not been uniform. There still remain problems with regard to progress among certain populations, such as minorities and the economically underserved. Part of the agenda of the National Dialogue on Cancer was to look at the implementation of state cancer plans, a program initially championed by former Pennsylvania Governor Tom Ridge. Governor Roy Barnes from Georgia became a collaborating partner and has created the state cancer plan initiative, and it now is something that's embedded into your own state health department programs through CDC funding mechanisms. The National Dialogue is providing the platform for these plans to be developed and the National Governors' Association is bringing state health leadership together to look for best practices and begin to understand how these programs can be implemented so we cover the entire spectrum of the delivery of cancer services. Session 4: Agency for Healthcare Research and QualityDr. Carolyn Clancy, MD:I'm going to provide a brief overview of AHRQ and then Gregg Meyer, who directs our Centers for Quality Improvement and Patient Safety, will talk to you about the states' role in improving patient safety. Helen Burstin, who directs the Center for Primary Care Research, will discuss AHRQ's efforts in making sure the health care system is part of the response to a bioterrorist event. Dr. Lisa Simpson will talk about Medicaid and SCHIP. The mission of the agency is to support, conduct and disseminate research that improves access to care and the outcomes, quality, cost and utilization of health care services. The research we sponsor provides information to improve health care decision making-in other words; what works, either clinically or from a policy perspective. We support research to strengthen quality measurement and improvements and research that identifies strategies to improve access to care and foster appropriate use of services and reduce unnecessary expenditures without doing harm. To emphasize where we fit in: NIH focuses on basic biomedical research and clinical trials, or what works under ideal conditions. The Centers for Disease Control and Prevention focuses on public health and community interventions. We focus on the effectiveness of health care services and delivery. Our work is patient-centered and not disease specific because many patients, unfortunately enough, have more than one condition, so you have to treat the entire patient. We have a unique roll in focusing on cost effectiveness. What are the tradeoffs between quality, outcomes, access and cost? If you think about health care expenditures going up, these tradeoffs are increasingly important. Effectiveness research focuses on actual daily practice, not the ideal situation of a clinical trial. It's clear we face challenges in the quality of care being provided. We have a gap or a chasm between the high-quality care that could be provided and what most people actually get. How can we help states? We support research to improve or inform policy decisions. How can drug prices be reduced without unanticipated consequences? We supported a study showing that a drug cap for Medicaid beneficiaries has the unanticipated consequences of increasing nursing home and hospital admissions and worsening health status for some. We need help from you letting us know the right questions and making information available in a timely and useful way. Next year, we're going to issue the first annual report on the quality of care in this country. We don't have a national benchmark and this report is going to provide that and we're very excited about that. We're also going to provide a report on disparities in health care. The reports will be closely linked, since it's hard to think about reducing disparities without thinking about that as an important part of the overall quality challenge that we're facing. Dr. Gregg Meyer, MD:How many saw the report from the Institute of Medicine called "To Err is Human"? The report, released in November 1999, made everyone aware of a problem the medical profession recognized for some time but had not confronted head on: America has a major problem with our health care system in terms of lapses of safety and people losing their lives in hospitals. Each year, according to the report, 44,000 to 98,000 Americans die in hospitals because of lapses in safety or medical errors. The medical profession had public debates about whether the number is right. But whether it's 15,000, 44,000, 98,000 or 200,000, I don't care. because everybody agrees on one fundamental point, and that is it's too many. I want to know what that rate is but we're not there yet in the science. We need to begin work right now and every provider audience I've talked to has agreed with that. The problems are systemic. The traditional way we've handled safety problems has been to name, blame, shame and train. We've been doing that for a long time and it doesn't work. The data are clear: we have too many problems to rely on that approach. We need a systemic approach. For example, every single day patients get the wrong medications or the wrong dosages because a hand- written prescription is misinterpreted. What's the solution? The solution is not to give doctors handwriting classes or to give pharmacists classes in reading messy handwriting. I see patients every week and write many prescriptions and in the last nine years I never had a single patient with any difficulty in a prescription being misinterpreted. Why? . I enter my prescriptions over a computer in the military health system. It's about taking handwriting out of the equation. It's the system stupid! In the last year, 6 percent of Americans say they have personally been affected by a medical error, by a lapse in safety. In health care, that's called an incident rate. How many times has this happened over the last year? To my knowledge, the only condition with an incidence rate greater than 6 percent in the general public is the common cold. Influenza, maybe, in a really bad year, but year to year it's the common cold. So this is as common in people's perceptions as the common cold. This is why the public gets it and why they're knocking on all your doors and writing those letters telling you, get out there, fix it. What you see as policymakers is the tip of an iceberg. For example, many of you have dealt with wrong-site surgery-a patient having the wrong leg amputated, for example. I ask all of you to remember those incidents are just the tip of the iceberg. Those are rare events but underneath them is a huge number of events that never come to our attention because the injury is minor, or we just get lucky - we recover, or we have a close call, a near miss. The take-home point is illustrated by driving. How many people here in the last six months have been involved in an accident that was fatal or near-fatal to somebody involved? How many people have "almost" been involved in an accident that could have been fatal? If you're from Washington, D.C. and drive on the Beltway, that's a daily experience. We can learn as much from those times when something bad almost happens as when something bad does happen. We don't have to wait for the body bags to tackle the problem of medical errors. If we took the opportunity to capture all that information about close calls, we could learn from it and keep from having to confront that ugly underside of the iceberg. We think of two types of errors: active, when somebody does something, when a doctor interacts with a patient, and latent, the delayed consequences of rules or policies. Here's an example: the Titanic, the world's largest cruise liner, was unsinkable. But in 1912 on its maiden voyage it went down. Part of that story is they were trying to set a crossing record, going into an area known as an ice field and the captain pushed the ship to break that record. They hit an iceberg and sunk. That was an active error, the captain making a decision. But there were also latent errors. The owner, Bruce Eshme, decided two months before the Titanic sailed to have a promenade deck so that paying passengers could walk around, rather than add 1,500 lifeboats to get passengers off the boat in case it sunk. Who is responsible? Who should we name, blame, shame and train for that problem? You need to focus on the sharp end, that individual who pushed that boat too hard, but also on the blunt end. Patients in intensive care units not getting proper care - they're dying because they're getting hospital-acquired infections. Part of that is people not washing hands but there's an organizational or policy decision around staffing that's also had a role there. There are examples how we can improve this dramatically and one comes from Paul O'Neill, who before he was Secretary of the Treasury, ran Alcoa Aluminum. Alcoa Aluminum is a dangerous business. They take big rocks out of the ground, grind them up, melt [the substance] in red-hot cauldrons, roll it into sheets of metal, punch it out into cans, put it on trucks and ship it out. O'Neill said even though Alcoa Aluminum's safety record was better than most, 'We are going to get to zero. We are going to have zero fatal and disabling errors," and he did it. He focused on system solutions, on how to make things safer. Whenever he saw a sign that said "caution" or "beware," he asked, "Why is that sign here? That sign says somebody didn't think enough about the worker to design this factory safely. Let's redesign that area to make it safe so we don't need a caution sign." Going through steps that included adequate resources, recognizing solutions come from unexpected areas and having a culture of safety allowed them to get to zero. Another example is naval aviation. Naval aviation in the 1940s and '50s was quite dangerous. I'm from the Air Force and I would never land in a plane on a moving air strip, but the Navy does that all the time with carriers. They extruded a systems approach that got them to the point where naval aviation improved its safety record dramatically. Health care can do the same. We have to attend to that sharp end, what providers are doing, and the blunt end, our policies. We want to build partnerships. We are a small agency but we want to be the mouse that roars and the way that we do that is to work in partnership with others and states are important, because they have unique levers. We want you to implement some of our products. We'll make them freely available to you. We want you to maintain the momentum. What safety has done is to make many people crystallize their thinking not just on that tip of the iceberg that we call safety, but health care quality in general and we think that we need to build on that momentum. You can get updates on our work in safety by going to our web site. Dr. Helen Burstin, MD, MPH:One of the main things we heard over and over again about bioterrorism was that health care systems needed help to respond and to know whether they were ready. We've developed a survey tool to help hospitals assess how prepared they are to deal with mass casualties. That will be available soon on our web site at no cost to any hospitals that would like to use it. We've also developed models for health system response. One is a model to look at how to do mass prophylaxis. If 9/11 had been a bioterrorist event, how would you get to all the people who needed antibiotics? If they all came into the emergency department, it would be deluged. There is no way it could take care of those people. We've developed a community-based prophylaxis model and are field testing it with support from the Department of Justice to see how it works, using community nurses to do this work, not overwhelming our health care systems. One of our primary care research networks is doing work in Indiana using electronic medical records that cross clinics and hospitals and connects them to the public health department. Some clinicians say, "I don't know how to contact the public health department if I see a patient with a reportable illness." If these systems aren't connected in real time, public health departments are at a huge disadvantage. They're not getting the information they need about important public health threats. How do we promote clinician readiness? In a bioterrorism event, most folks are going to go to their primary care provider. You're going to have a funny flu, a cough, something a little unusual. You're not going to think this is an emergency. The first anthrax case in D.C. in a postal worker was diagnosed by his primary care provider who said, "This just doesn't feel right. There's something here that's off," and who then sent the patient to the ER, saying it may be anthrax. As we think about health services and health system research needs, this is different than the work we've been hearing about from other players on bioterrorism preparedness; this issue of linkage is critical. The CDC and we have been thinking about how to make this work more collaboratively. The subject of surge capacity in hospitals comes up a lot. Over the decade, the number of hospitals and hospital beds has decreased. If you think about a surge in the event of a bioterrorist event or even a bad influenza outbreak in a given state or locality, you can see how difficult it is to have capacity in hospital beds available. As for ERs, a huge issue with so many of our emergency departments already on diversion on a regular basis is to imagine what it would be like if there were thousands of casualties coming in at once and the impact on the hospitals and health systems. Surge capacity will be critical not just from the perspective of hospitals but in terms of the long-term impact of these illnesses. Many folks reported long-term hospitalizations; long-term needs for home rehabilitation. We need to think about across the full spectrum of care: long-term care, home care, emergency departments and hospitals. One last issue we need to think about is that there area lot of downstream benefits, the more communities are prepared for bioterrorism. Again, the more systems are in place on a daily basis, the more ready they'll be in the event of a bioterrorist attack. Dr. Lisa Simpson, MD:Areas of high concern related to Medicaid and SCHIP include children with special health care needs, who are the highest cost and highest users of services, SSI or Title V programs and minority children, whom we know we have significant disparities in access and quality. A few key findings: Many children covered by SCHIP experienced interruptions in coverage and state redetermination requirements were associated with large disenrollments. One state, Florida, which has a passive reenrollment process, had more children experiencing uninterrupted coverage: 5 percent of children disenrolled at redetermination vs. 50 percent for Oregon. If you look over enrollment in SCHIP over 24 months, you see that in New York, 53 percent of kids are enrolled at 24 months but during those 2 years, 27 percent have experienced a period of disenrollment, so that there is some turning on and off of insurance. What that means for each state is different because the question is, are people disenrolling to become uninsured or to become privately insured? We're starting to get results that help us understand what happens with these programs. Another finding that's coming out of studies looking at utilization of dental care in Alabama, Georgia and Florida is that dental care is a huge issue for publicly insured children but that their utilization is lower than for those who are privately insured. We know that children's use of dental care is highest between ages 6 and 11 but in these public programs in these three states, the rates are still lower than recommended. The question is, is this necessary care? It's really much needed services and significantly, a large number of these children are getting emergency or restorative care. So we're not even looking at recommended, preventive services for children. One study looked at high-risk preterm babies who are big costs in hospital care. Looking at all children's health, the big costs come from those sick babies who were born too small and too early and need to be cared for in a tertiary quaternary NICU. Does it make a difference if you go to a NICU that has a larger number of patients that sees a high volume of patients because in the last 20 years there is a proliferation of these neonatal intensive care units in states. What we found was that mortality outcomes are better if you're in an NICU that sees more children. This is a broader volume outcome relationship we're seeing throughout adult and child health services and hospitals, but this is one specific example that relates to mortality in pediatrics. Session 5: Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration)Thomas Scully:Before I came to this agency I was the biggest HCFA hater of all time. The agency was insular and needed a shake up badly, even though it has a great staff. One of the first things that Secretary Thompson did was to change the name to the Centers for Medicare and Medicaid Services, and that has helped a lot. But Medicare and Medicaid patients still don't have a clue what these programs are all about. One major initiative is giving good information to seniors about Medicare to help them with the choices they need to make. We're now financing an $80 million education campaign. CMS has bought full-page ads on nursing home consumer information in eight states because we have real quality of care problems in many of our nursing homes. There is a core federal and state responsibility to put out good data on hospital quality. Another problem we have addressed is communication with states that often found difficulty in getting straightforward answers to their questions. At CMS headquarters in Baltimore, we have assigned one contact person for each region and two for every state. We have begun Open Door Policy Forums to open up the process and let anyone get their questions answered. We also hired two Wall Street analysts to write reports on the financial health of various industries we finance. We did one on the managed care industry, which showed that private plans participating in the Medicare + Choice market are getting killed. We did one on nursing homes, which showed that they are climbing out of their hole and that Medicare has been propping up that industry, while most are getting killed on Medicaid. The most recent report on hospitals found some are doing great, and some are doing poorly. Let me discuss some political concerns. Regarding pharmaceutical coverage under Medicare, the one thing clear to me is that the Medicare Catastrophic Coverage Act of 1987 should never have been repealed; it offered a good drug benefit, and it's a shame we don't have it. The Bush Administration is totally committed to getting a drug bill passed by the Congress this year. RBRVS - [Resource Based Relative Value Scale, Medicare's physician payment formula] - may get blown up this year. Physicians are facing a -5.6 percent update. That is because they were overpaid $66 billion in 2000 and 2001 and now that overpayment is being recaptured. It will be -4.5 percent next year. I am certain Congress will fix this. There will be a Medicare bill this year if only because of the problems with physician payments. On access, the conversation has been much lower key. The President included $89 billion for refundable tax credits, while the Kennedy-Hatch approach wants the SCHIP model. Everybody wants progress this year. We could lower the number of uninsured by about 5 million. We yell a lot about this every year but nothing happens. The Medicaid program is much more screwed up than Medicare. We have 50 sets of rules and financing. It covers most long-term care. And there is almost no national conversation about it. The program has a totally irrational and unfair funding base. There is no connection between the statute and the actual match rate states receive. Mississippi is in crisis and gets a match rate of 78 percent; Alabama, because of upper payment limits, gets 92 percent. What's fair? Why should I give a better deal to Illinois than to Indiana? These are much bigger structural problems than Medicare. On waivers, the key issue is budget neutrality and OMB, especially if Congress appropriates no new money. I am a huge advocate of PACE programs that combine Medicare and Medicaid funding to keep seniors out of nursing homes. Assisted living is wonderful, but most people can't afford it. We don't have the ability to expand drug coverage or other benefits. Sue Rohan:Our mission is to be a liaison between all of CMS and elected officials and other officials in state and local government. We primarily deal with elected officials-representatives, senators, governors-but we also deal with state health officials, Medicaid directors, insurance commissioners and with intergovernmental associations such as NCSL and NGA, CSG, the Public Human Services Association, the State Medicaid Directors Association, the Association of State and Territorial Health Officials, insurance commissioners, units on aging, mayors, county and city health officials, along with advocate groups that represent beneficiaries. Anyone who is designated as a representative for your state, we work with them. If it's a request for a meeting with Mr. Scully or with our Medicaid director, Dennis Smith, or if it's a Medicare issue, we'll coordinate those requests. You can contact us directly and we can set up a meeting or get the appropriate people to talk about issues you're interested in. We also e-mail and fax things to keep everyone informed. Last week, we met with a delegation from the State of Washington. They were concerned about Medicare costs and that they were one of the lower- reimbursed states on Medicare. I attended a summit in Wisconsin on Medicare reimbursement, another state that feels disadvantaged in reimbursement rates. Helen Fredeking:Before the mid 1980s we were a claims processing and payment organization but after that and some lawsuits, the agency began to take responsibility for issues related to quality of care. Since then there's been growth in these initiatives. Peer review organizations moved from being organizations that looked at individual cases in hospitals to organizations focused on improving quality of care. Their new name is Quality Improvement Organizations. In the late '90s we moved to consumers and Mr. Scully has increased that effort to provide better information for consumers. I classify CMS's activities for improving quality in these categories. First is consumer information to educate consumers on making choices and where to get information. Second is provider improvement activities. Third is regulatory oversight, which includes survey and enforcement activities, and there are also policy initiatives. On consumer choice, since the late 1990s, CMS has been active in providing information for consumers. In the area of nursing homes, for example, a pilot state project initiated in April provided measures of quality for long-term and short-term stays. In home health we have an initiative to improve care. It's a demonstration project with the University of Colorado identifying and improving performance problems. They have been successful and can show improvements in outcomes. Over the next couple of years we expect that the QIO's will become more and more involved. Another issue is regulatory oversight. The federal definition for abuse in nursing homes or other settings like ICFMR's says abuse means willful infliction of injury and confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. There has been the same level of deficient findings found as a result of abuse and it's spread across the nation. It goes from less than 1 percent to about 6 percent. It hasn't changed that much over the years. But there's been a massive rise in the reporting of abuse. In about 1998, as the public and the Congress continued to be concerned about abuse and nursing home and ICFMR care, we realized that dropping into a facility now and then you would not run across somebody knocking somebody over the head. If we wanted to do a better job at preventing abuse we should look at the processes the facility has in place to make sure abuse is not happening. So in 1999, we put in guidelines and survey protocols focused on whether the facility had procedures and policies and had implemented them. Had they been doing criminal background checks, had there been training, were they training their staff, that kind of thing. As the surveyors went out, there was an increase in the kinds of deficient practices found. We're also developing quality of life indicators. For most people going to choose a nursing home or another institution, the number one thing on their mind is not pressure sores or pain management. They're most concerned about what we call quality of life, whether people respond, whether they're treated with dignity. That's hard to get a handle on in gathering information but we have a study by the University of Minnesota to develop performance measures for quality of life type issues. Theresa Sachs:We've been working on HIFA (Health Insurance Flexibility and Accountability) waivers since last year. The HIFA waiver is a way to make changes targeted to some Medicaid groups as opposed to needing to do it to everyone. We also allow adjustments in cost sharing by, for example, using unspent Title XXI for expansion populations. All proposals acted on so far have insurance expansion components. So far, two waivers have been approved, in Arizona and California. Both expand eligibility using unspent Title XXI funds, and Arizona also uses other Medicaid funds if needed. In Arizona, childless adults up to 100 percent of poverty will be eligible, and parents up to 200 percent of poverty. No benefit adjustments were made to generate the funds. Rather than full-blown employer sponsored insurance or premium assistance, these came in shortly after announcement; they are conducting feasibility studies for employer subsidy elements. And four proposals are now under review: Illinois, Maine, Mississippi, New Mexico. The Illinois request was submitted in February and has an expansion for parents up to 185 percent of the poverty line and for pregnant women up to 200 percent. Eligibility streamlining and employer sponsored insurance are also part of proposal. It uses unspent SCHIP as a financing source. Maine would use its unspent DSH allocation for childless adults up to 125 percent, with no benefit changes. That's a little different from plans from other states. Mississippi expands using SCHIP and adjustments in Medicaid for parents up to 100 percent of poverty and some childless adults 35 to 100 percent. And blind and disabled 1619B would be able to stay on program longer. In New Mexico, parents and childless adults up to 200 percent of poverty would be covered, with funding through SCHIP, and the state would create a new product to offer to employers who don't offer coverage. The state, employers and adults would also pay a share according to sliding scale. Utah's demonstration - it was approved in February, with a July launch - is not part of HIFA. It differs from others in several ways: 1. It has no ESI component. 2. For the mandatory Medicaid population, there are approved benefit package changes. 3. Eligibility is expanded for adults up to 150 percent of poverty, with a limited primary care package. States should look across health programs overall to see if there are ways to expand programs with federal matching funds. There's been a great deal of discussion about cost sharing requirements in Utah. Utah's approach is cost sharing at the point of enrollment, different than utilization cost controls. We talked about it quite a bit. Budget neutrality does apply to HIFA as to all 1115 waivers; the state can spend no more in federal dollars with demo than it would without. Important qualifiers: with unspent SCHIP funds, we measure compared to total allocation. Also important, if using Medicaid to cover a population that could be covered in state plan, we allow you build the cost of that into your base as if they had been there. So budget neutrality does not mean there are no new federal dollars. Session 6: Health Resources and Services AdministrationDr. Sam Shekar:We need to use work force planning and analysis to train the right people. We need high quality education to give them the right skills and we need equitable distribution; a particularly important rule is in the right places, in all the places. Our mission is to increase health care access by assuring that the health professions work force meets the needs of the public. Simply said but difficult to achieve. We have a range of responsibilities and functions. In FY'02, HRSA will spend almost $800 million to support the training health care professionals , through 1,800 grants. Through our National Helath Service Corps, we also put health professionals in underserved areas, and we insure quality through tracking and reporting adverse actions against providers and work to improve health care quality and safety. We work on primary care medicine and dentistry to make sure we have more doctors, dentists and physician assistants out there. We try to get the professions to work together, get the disciplines to work together in a harmonious way, and we try to make sure we take care of the nation's health as well as patient's health. We support basic nurse education through community colleges and nursing schools. We support nursing work force diversity assisting minority and disadvantaged students to enter into nurse education programs. We have expanded the Nurse Education Loan Program because it allows us to support nurses in practice in underserved areas. Last year this program supported over 400 nurses to work in institutions that needed that care and provided over 1,000 years of service that may not otherwise have been there if that program hadn't been in place. The President's budget has $60 million in FY'03 for a new initiative to provide development and training on bioterrorism and on emergency preparedness to teach future public health and health care system workers how to engage with public health to respond to terrorists and other incidents. More than one out of ten Americans who works works in health care. In other words, 10.3 percent of the U.S. labor force is in health care one way or another. The most important thing I want to leave with you is that registered nurses are the single largest discipline in the work force: 22 percent. Physicians, on the other hand, are only 6 percent of that work force. The demand for health professionals will grow at twice the rate of all occupations between 2000 and 2010. If you look at the total U.S. employment from 2000 to 2010, the percent growth in U.S. employment will be about 15 percent. For health occupations it will be essentially double that, 29 percent. Why is that? The most important factor is the aging of America. Over the next 25 years the population over age 65 will grow at five times that of those under 65. By 2015 every single day 10,000 more Americans will turn 65-every single day. The population over 85 is the fastest growing segment. While there are many healthy 65 year olds, when you get to 85 you need some degree of health care and that's going to fuel the need for health services and providers. Another major issue is technology, specifically genetics. Technology will drive an increase for providers who are specialized to understand that to get information to patients and to all Americans, you're going to have a tremendous need to bring people up to speed. For pharmacists, one major reason there's a shortage today is not because there's a dwindling supply of pharmacists; in fact, the supply has been stable. The reason is because the growth of prescriptions has grown four-fold in the last 10 years and as a result, a typical pharmacists now fills 33 percent more prescriptions than they did 10 years ago. Nursing - what's behind the shortage we project to begin in 2007 based on 1996 data? At that time the rate of nurses entering was three times greater than it is today. We are on the verge of having information for 2000, which will significantly impact these projections. It will not predict a shortage later than 2007. It could be earlier but we don't have data yet. The rate of people entering nursing was three times greater in 1996 than it is today. That will have an impact if you have fewer nurses coming in; that will have an impact on shortages. The nursing shortage is not equally felt everywhere and that's important for all of you to know - this is not a one-size-fits-all shortage. In certain areas it's much worse than in others. The West and Southwest have the lowest RN to population ratios in the country. One reason why the shortage is occurring is that nurses are getting older. Over the last 20 years, and over the next 20 years, the typical age of nurses in practice will go up the same number of years. Today, only 10 percent of nurses are 30 years of age or below. The median age of a nurse today is 45 and if we keep going the course we're on, that will get up into the high 50s. This is the population that will help you take care of the 85 year olds, the patients with hip problems and everything else. We've had a reduction in the number of RN graduates, the trend lines are going downwards in the supply of nurses going into these programs. We have alternative careers that are offering attractive salaries. So if all things are equal and they're making decisions in terms of entering a profession based on salary, elementary school teaching provides a more lucrative career than being a nurse. So what are we doing about the nursing shortage; what are you and your colleges, your universities, your constituents and our grantees doing to help improve the nursing picture in the United States? In this year, our bureau and our grantees, your universities are supporting nurse training programs with, as mentioned, $93 million, which is 11 percent more than we had in FY'01 and you can see the breakdown by the various groups. We have programs to support training of nurses and scholarships for disadvantaged students. We have a nursing student loan program and a scholarship and loan payment program, which helps support nurse practitioners and certified nurse midwives. The end result is that this past year, FY'01, our program has supported the training of over 26,000 registered nurses across the country. If you want one year of prosperity, grow grain. In health care I'd like to think of this as services. You get a flu shot, you pay for a flu shot, the flu shot is given, you walk away and it's done. That's grain; you have one year of prosperity. If you want 10 years of prosperity, grow trees. Have a health facility; make sure that people can go somewhere where they can get those health services. We want to make sure that these things are there to stay and they have a place where they can get their care. But if you want 100 years of prosperity, grow people. We can have health insurance and we can have health facilities, but if at the end of the day we don't have health care providers, we don't have health care. Marcia Brand:There is an Office of Rural Health Policy in each of your states. The Administration has encouraged all of its entities to provide better support to rural areas. There's an across-the-department look at how we can make it easier for rural communities to function and for rural providers to function. We were created in 1987 and one comment I heard about our office came from the fellow. Who preceded me, Wayne Myers who said, "We are of the office of unintended consequences." What he meant was that we came about because we moved to perspective payment in the mid '80s and immediately 300 small rural hospitals closed because we weren't paying attention to the impact in rural communities of those sweeping changes we made at the federal level. Our charge is to make sure those things don't happen again. So we watch the policy front. We have 8 grant programs of $140 million; they go out to rural communities. We got a $40 million increase in 2002, not earmarked. We strengthen our relationships with the 50 state offices of rural Health. Forty-seven states have a flex grant program, Medicare Rural Hospital Flexibility Grants. We have a focus on EMS and emergency preparedness. The outreach grants are demonstration grants but they're noncategorical and that is what makes them interesting. There are about $38 million in these grants, which allow communities to define problems and develop programs. If your community has trouble with dental services, that's the grant they submit. If it's difficulty having access to mental health services, that's the grant. We work with state offices to insure your communities know these opportunities are available. We've got technical assistance for vulnerable hospitals and to improve hospital performance. Access to appropriately scaled technical assistance is difficult to find. The consultants cost a lot of money. We're hoping to develop tools and resources and make them available on a web site, so any hospital administrator can pull them down and see what he or she might do to improve performance. We've done pilots. The first was at a small hospital in Mississippi. The folks spent time talking to administrators and before lunch found $400,000 in accounts receivable. If they could get their accounts receivable down, they'd be operating in the black, not in the red. That's what we're hoping to do with our outreach grant program. We have a network development grant program. Every state that has rural areas is eligible. We seek to integrate and improve services delivery and let small hospital networks try to find some economies of scale. So they might collaborate, come in for network grant and get the resources they would need to organize so that they could do combined purchasing or look at better improving their information systems or anything else they think would improve performance. There are 1,200 US hospitals with fewer than 50 staffed beds. Each is eligible for this resource. They get $11,000 apiece. We're encouraging hospitals to come as consortia and work with states to combine money. Rather than buying a fraction of a consultant to work with HIPAA compliance, the hospitals come as consortia and pool their $11,000 and do something more substantial. We also have EMS-related activities I want to highlight. EMS is hard in rural communities because it's volunteer and a number of communities have trouble with their tax base that would enable them to purchase new equipment, to do training. There's no place that talks about how rural communities and frontier communities experience EMS. So we're going to create a technical assistance center to help rural communities improve EMS, with a focus on recruitment and retention. END |
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