SMOKING CESSATION

Texas Program is Frugal, Effective

In 1996, the state of Texas won a $15 billion lawsuit against tobacco companies, independently of the Master Settlement Agreement. From this award, the state allocated $1.5 billion to education and health programs, and $9 million for stop-smoking programs. With such limited funding, the Texas Department of State Health Services (DSHS) focused its anti-smoking efforts on Jefferson County, an area that was particularly at risk. Working with teens, the state put together a highly effective comprehensive campaign of smoking-reduction efforts. Research published in the latest issue of Public Health Reports found that adult smoking rates in the county were reduced by 26 percent, and smoking rates among middle- and high-school students saw an even sharper decline of 36 percent. “We know what works,” said Dr. Philip Huang, medical director for chronic disease prevention with Texas DSHS. “We can produce dramatic results with respect to kids and adults with a comprehensive program.” The success of the initial program led the Legislature to increase funding to $12 million for 2001-2003, allowing DSHS to expand the program into surrounding areas. However, due to budget shortfalls, lawmakers significantly reduced the state’s anti-smoking budget to $7 million in the current state budget -- $2 million less than funding for the initial year of the campaign. That amount falls well short of the $103 million recommended by the Centers for Disease Control and Prevention for such programs in Texas, or $5.31 per capita. The Jefferson County program achieved its success at a cost of $3 per capita, providing a frugal example of success in smoking cessation.

PUBLIC HEALTH

Flu Vaccine Protocols

The federal recommendation that the sick and elderly receive flu vaccines before young adults in the event of a pandemic should be reversed, according to an opinion piece published in the journal Science written by members of the Department of Clinical Bioethics at the National Institutes of Health. Two federal advisory panels unanimously recommended that vaccine manufacturers and health-care workers be vaccinated first, followed by the elderly because they “are at high risk of hospitalization and death.” Other groups that would receive priority under the federal plan include people with at least two chronic illnesses and people with a history of severe pneumonia. Children aged 6 to 23 months also would be given priority because of the high risk of death. Pregnant women, first responders and “key government leaders” would receive the vaccine next. The authors of the Science op-ed, however, point out that during the 1918 flu epidemic, young adults experienced the highest mortality rates, and consequently they recommend that people between the ages of 13 and 40 be the first to receive inoculation, after vaccine manufacturers and health-care workers. Next in line would be children and middle-aged individuals, followed by the elderly. The authors argue that the risk of mortality for the elderly is the same regardless of the virulence of the strain, while the risk of death for young people rises as the virulence of the flu strain increases. Released in March, the Bush administration’s plan recommends that state and local governments ultimately decide the order in which people get vaccinated. To read the U.S. Department of Health and Human Services’ Pandemic Influenza Plan, click here.

ACCESS AND COVERAGE

Helping Small Businesses

The Tennessee Legislature has approved the health reform plan Gov. Phil Bredesen outlined in his March State of the State address. Set to begin in 2007 and expected to cover more than 600,000 adults and 150,000 children, Cover Tennessee is aimed at providing insurance to people who either work for small businesses that don’t offer insurance or who can’t afford it on their own. Ideally, the state, private companies and workers all will contribute to the monthly premiums of private-sector plans – but participation will be voluntary. The state will set major requirements for the program and then bid it out to private insurers. Self-employed individuals and employees at companies that don’t participate in Cover Tennessee still will be able to buy insurance if the workers pay the employer’s third of the premium. Because coverage will not be bound to a specific employer, individuals will be able to maintain coverage as they move from job to job. To promote healthy living, no co-pays will be charged for preventive care. Bredesen proposed Cover Tennessee after dropping some 225,000 enrollees from TennCare, the state’s landmark Medicaid experiment launched in 1994. By aggressively managing care, TennCare aimed to expand Medicaid to all Tennesseans who couldn’t afford private coverage. In the end, the program covered the highest cost and sickest people, causing huge cost overruns and eventually consuming more than one-third of the state’s budget. Bredesen plans to help pay for the first three years of Cover Tennessee by using reserves left in TennCare.

Fewer Employees Accept Coverage

An increasing number of American workers are declining their employer's offer of health insurance, according to a report released by the Robert Wood Johnson Foundation. The main culprit: the dramatic increase in the cost of premiums.  Approximately 3 million fewer workers who were eligible for employer-sponsored health insurance enrolled in 2003, compared to 1998. From 1998 to 2003, the cost of premiums for individual policies increased from $2,454 a year to $3,481, a 42 percent rise after being adjusted for inflation. Nationally, the percentage of eligible private-sector workers who accepted their employers’ offer of individual health insurance declined five percentage points (from 85.3 percent to 80.3 percent) from 1998 to 2003. Twenty-five states experienced a significant decrease in the percentage of private-sector employees who accepted their employers’ offer of health insurance during this period, including New Jersey (-12 percent), Nebraska (-11 percent), Wisconsin (-9 percent), Colorado (-9 percent) and Iowa (-9 percent). While employers still pay the bulk of health insurance premiums, employees cited cost as the primary reason for not accepting coverage. In both 1998 and 2003, the average employee paid about 18 percent of the annual premiums for individual coverage, while the employer paid the remaining 82 percent of the cost. According to the analysis, only 2 percent of uninsured adults said they had no need for coverage. For a full copy of the report, “Shifting Ground: Changes in Employer-Sponsored Health Insurance,” click here.

MEDICAL MALPRACTICE

Many Lawsuits Groundless

Nearly 40 percent of medical malpractice claims filed in the United States are groundless, with many of the cases containing no evidence of medical error or personal injury, says a study published in the May 11 New England Journal of Medicine. The study examined 1,452 claims randomly selected from five insurance companies that were resolved between 1984 and 2004. Three percent of the cases were filed by patients who did not experience any kind of injury, while another 37 percent of claims were filed by patients who had injuries that were not the result of medical errors. A total of $449 million in verdicts and settlements for malpractice cases were paid out over this time paid out, with 15 percent going to groundless claims. The study also found that for every dollar awarded to patients, 54 cents went to administrative costs, including lawyers, experts and courts. The American Medical Association cited the study as proof that a significant number of groundless claims are slipping through the cracks, wasting the time of courts and forcing doctors to defend themselves against these claims. The Association of Trial Lawyers of America raised concerns about the objectivity of the study, noting that the claims used in the analysis came from insurance companies, which serve as defendants in some malpractice suits.

HEALTH-CARE SPENDING

Health Care for the Chronically Ill: Less is More?

The chronically ill account for 75 percent of health-care expenditures in the United States, with Medicare spending varying from state to state. For example, nearly $40,000 is spent per patient in New Jersey, while less than $24,000 is spent in Indiana and West Virginia. However, more spending does not necessarily mean better care. Researchers from the Dartmouth Atlas Project, run by the Dartmouth Medical School and funded by the  Robert Wood Johnson Foundation, examined the health records of 4.7 million Medicare enrollees who died from 2000 to 2003 and had at least one of 12 chronic illnesses. Researchers found that mortality rates were lower for chronically ill patients in lower spending states than in higher ones. The same correlation held true for satisfaction with care. The researchers looked at factors such as how often a patient was hospitalized and how often the patient visited a doctor during the last six months of life. The discrepancy in mortality rates was attributed to over-use and waste in the higher spending states, and to the increased likelihood of medical errors resulting from more hospitalizations. The researchers concluded that billions of dollars a year could be saved if medical resources were allocated more efficiently, and they recommended that resources be redirected towards developing care outside of hospitals, such as home care and hospice. The claims data – now publicly available in an online database – is intended to be used by those who “use, provide, pay for and make policy about America’s health-care system.” For more, click here. 

Unnecessary Testing

More than one-third of U.S. adults undergo diagnostic tests for conditions for which they have no symptoms, adding substantially to health-care costs and increasing patient stress, according to a study published May 19 in the American Journal of Preventive Medicine. Researchers examined the health records of more than 4,600 U.S. adults over age 20 from the National Ambulatory Medical Care Survey, an annual report on care at physician offices from the Centers for Disease Control and Prevention. Using standards issued by the U.S. Preventive Services Task Force, the researchers assessed the frequency of "C" tests – diagnostic tests for which the task force makes no recommendation for patients without symptoms – and "D" tests – tests that the panel recommends against for patients without symptoms, because the risks outweigh the benefits. For C tests, including two types of blood-screening procedures, the annual direct medical cost is between $12 million and $63 million. For D tests, at least one of three exams – urinalysis, electrocardiogram and X-rays – was ordered against recommendations for 43 percent to 46 percent of patients. Projecting that rate of occurrence across the U.S. population, the study estimates that the annual direct medical cost from inappropriate use of the three tests is between $47 million and $194 million. Researchers estimate that the cost of follow-up care for false positive test results also is in the millions. “More is not always better, and understanding this is especially important now that Medicare has begun to reimburse for complete physicals,” lead author Dan Merenstein told the Long Island Newsday.

 Download PDF Version