MAY 24, 2006 -- The American Cancer Society has endorsed legislation (HR 5437) sponsored by Rep. Clay E. Shaw Jr., R-Fla., that would extend preventive care services for Medicare beneficiaries and eliminate coinsurance for certain cancer screenings.

The bill, introduced May 19, would extend the period beneficiaries can attend a "Welcome to Medicare" physical examination from six months to one year. Coverage for initial physical examinations was added to Medicare in January 2005 as part of the Medicare overhaul law (PL 108-173). The visits currently are offered as a "use it or lose it" benefit for the first six months after enrollment.

"This physical represents a real turning point for Medicare, and we are confident that with more time available, seniors eligible for it would take advantage of this great benefit," said Daniel E. Smith, the American Cancer Society's national vice president of government funding.

The bill also would eliminate coinsurance for mammography and colorectal cancer screening tests. According to a release from the American Cancer Society, Medicare currently provides coverage for various cancer screenings but beneficiaries often pay 20 percent in coinsurance.

MAY 22, 2006 -- As the Medicare program puts the finishing touches on recommendations to Congress about the future role and funding levels for "quality improvement organizations," Sen. Charles E. Grassley, R-Iowa, and the organizations themselves are jockeying to mold Capitol Hill perceptions of the programs.

QIOs, on the one hand, are seeking to remind lawmakers of their reputation as the mainstays of the nation's two-decade-old quality improvement movement in health care. Grassley, on the other, aims to spotlight recent executive salary, travel, and entertainment expenses in the industry that in his view raise doubts about its stewardship of Medicare dollars.

At a press briefing Monday sponsored by the lobby that represents QIOs, several of the organizations called attention to recent projects they say narrowed racial and ethnic disparities in health care. The data aim to allay doubts raised by Grassley about how well QIOs are doing their jobs.

Meanwhile, Grassley, who chairs the Senate Finance Committee, has sent a letter to the QIO's lobby, the American Health Quality Association (AHQA), raising more questions about QIO expenditures, including $123,000 in banquet charges at a three-day meeting last June sponsored by another organization called the Tri-Regional QIO conference. AHQA said it wasn't responsible for those particular charges and that its outlays complied with federal regulations.

"We're investigating how these contractors conducted business in order to protect Medicare dollars from misuse," Grassley said in a press release May 16. "These organizations have a job to do and a public trust to keep," added ranking committee Democrat Max Baucus of Montana in the same press release. "If those obligations are being shirked, we're going to find out and put a stop to it," he said.

Disparities
AHQA on Monday released a report on efforts by QIOs from 2002 through 2005 to narrow differences in quality of care received by racial and ethnic groups compared with care received by white Americans. QIOs typically targeted a specific underserved population and focused on improving performance on a specific quality measure for a specific condition. In 27 of 45 states, improvement efforts used by QIOs produced higher performance scores on quality measures than were shown in a national control group, according to the report.

In one example of QIO efforts to reduce disparities, a New York state QIO called IPRO sought to increase the percentage of black diabetics in the traditional fee-for-service side of Medicare who received blood tests at least once every two years to measure their risk of heart disease.

The campaign included tactics such as airing a total of 84 ads on radio stations with a significant black audience urging listeners to "talk to your doctor about your ABCs." The message referred to getting an A1C test, which monitors glucose levels in the blood, getting blood pressure checked, and getting cholesterol tested.

Other strategies to counter diabetes included meeting with community groups to show people the right proportions of foods to eat: half a plate of vegetables; one-quarter a plate of starches; and the remaining one quarter of meat. The right portion of meat was about the size of one's fist, beneficiaries were told.

The QIO also met with doctors in their offices to review the latest clinical guidelines for treating diabetes, provided chart stickers to remind doctors to order certain tests, and audited medical charts to provide feedback on treatments prescribed.

At Monday's briefing, IPRO's Terry Mahotiere said the project narrowed the difference between whites and blacks getting lipid profiles every two years by 11.9 percent. The percentage of black Medicare fee-for-service beneficiaries receiving the tests increased by 16.7 percent.

The report, which was prepared by QSource, the QIO for Tennessee, detailed other such programs with similarly "positive" results and called on Medicare to increase funding to QIOs to reduce disparities. Only 3.4 percent of QIO funding now goes for that purpose; Dawn Fitzgerald, the chief operating officer for QSource, said the figure ought to be more like 10 percent to 15 percent.

But Grassley and Baucus say QIOs need to spend more responsibly before their funding and responsibilities are increased.

In a May 18 letter, the senators posed follow-up questions to AHQA based on documents provided by the lobby to the Finance Committee in response to a January 25 request.

The letter asked for spreadsheets sought by AHQA from individual QIOs detailing executive salaries and an explanation for $13,907 in payments by AHQA to the Don CeSar Beach Resort Hotel in St. Pete Beach, Fla., for "events" on June 13 through June 16, 2005; "more than half of this amount was for lunches and banquets," the letter said.

On June 14 through 17, another QIO group, the Tri-Regional QIO Conference headquartered in Fort Smith, Ark., paid the same hotel $167,072 for events including the $123,00 in banquet charges and a pizza party, the letter said.

AHQA Vice President for Government Affairs Todd D. Ketch said the sum AHQA spent was largely for business dinners or lunches in which some 30 to 40 QIO medical directors discussed pending policy issues. Those meals and other business meetings were held concurrently with the Tri-Regional QIO conference, he said.

The remainder of the $13,907 was for audio/visual and telephone equipment used in conjunction with those meetings, said AHQA Executive Vice President David Schulke.

Ketch said the Tri-Regional group is separate from AHQA and referred a reporter to organizers of that conference to answer questions about their expenditures.

The senators' letter also asked the source of funding for "welcome receptions," "dinners," and "outings" at AHQA annual meetings dating back to 2002. Among them were a river trip, a Napa Valley winery dinner, and a "Murder Mystery Dinner." AHQA was asked to include "the amount of money, if any, charged to Medicare," and to list family, friends, and companions who attended each of the events listed.

Schulke said that billing the entire registration fee to Medicare for the meetings would be consistent with federal regulations but that some QIOs may have billed part of that fee to non-Medicare customers. Friends and family going on the outings had to pay their own way, he said.

Schulke added that detailed federal regulations allow QIO representatives to bill Medicare for receptions and dinners if the primary function of the overall meeting is educational. He said the meetings typically consisted of some 13 to 15 hours of education. QIO members had to pay their own way for the river outing.

Schulke added that in any event amounts billed for meetings are subject to annual audits carried out by contractors hired by the Medicare program. Disallowed amounts must be repaid, he said.

Ketch said AHQA would provide as much of the information requested "as we can." He added that "we want to be as cooperative as possible. AHQA will meet the June 16 deadline set by Grassley and Baucus for providing the data, Ketch said.

A representative of the Tri-Regional QIO Conference responded to a request for comment with an e-mail message saying that organizers "are not aware of what funds individual participants [QIOs] use for registration fees to attend the conference. The registration fee covers meals, space rental and equipment charges."

MAY 26, 2006 -- Nearly 150 House Democrats have asked Centers for Medicare and Medicaid Services Administrator Mark B. McClellan to take additional steps to enroll millions of low-income seniors and people with disabilities in the Medicare drug benefit.

"The administration must make an extra effort to notify seniors entitled to extra help," said Rep. Lloyd Doggett, D-Texas, a member of the Ways and Means Health Subcommittee.

The members of the House Democratic Caucus urged CMS to take a variety of steps, such as working with the Social Security Administration and other federal agencies to identify individuals who have not yet enrolled in the program but whose data indicate they would qualify for no or low premiums, low or no deductibles, and low copayments offered as part of the drug benefit.

CMS spokesman Jeff Nelligan said CMS would review the letter when the agency receives it.

MAY 23, 2006 -- Among the proposed budget cuts at the National Institutes of Health (NIH) that has aroused the most concern at the Senate Appropriations Labor-HHS Subcommittee is one that would shelve a huge national study of children's health.

"It was going to be the largest long-term study of children's health ever conducted in the United States," Sen. Tom Harkin, D-Iowa, noted at a May 19 subcommittee hearing on the NIH budget. "We've already spent about $50 million" and four to five years planning the project, he said. "I just can't believe that we're just going to stop it."

Mandated by the Children's Health Act of 2000, the study is designed to track 100,000 American children from conception to age 21. The 100,000 participants are meant to be a nationally representative sample of all children in the United States.

"The study will assess and evaluate the environmental exposures these children experience in the womb, in their homes, in their schools, and in their communities," said one of the researchers planning the project. The goal "is to identify the preventable environmental causes of pediatric disease and to translate those findings into preventive action and improved health care," said the researcher, Philip J. Landrigan, a professor of pediatrics at the Mt. Sinai School of Medicine in New York City.

Diseases and conditions targeted by the study include asthma, obesity, diabetes, premature birth, birth defects, leukemia, and neurodevelopmental disorders such as autism, dyslexia, mental retardation, and attention deficit hyperactivity disorder, Landrigan said in written testimony.

He added that there's strong concern among pediatricians that "these rapidly rising rates of disease may create a situation unprecedented in the 200 years of our nation's history, in which our current generation of children may be the first American children ever not to enjoy a longer life span than the generation before them."

Without research such as the National Children's Study, "we are actually at risk of losing hard-won ground in children's health," he said.

Harkin said only $70 million would be saved in fiscal 2007 by shelving the study, and he noted the huge payoff from a similar study that tracked women's health for 15 years. Among the findings of the project, according to NIH testimony, was that heart disease is the No. 1 killer of women and that different diagnostic tests and treatments are sometimes needed to save lives.

But NIH Director Elias Zerhouni told Harkin that the $70 million would lead to a series of other expenditures. "If you committed to that expenditure, Senator, then you committed to the $3.2 billion, or thereabout, over the total study," Zerhouni said. "Why? Because once you launch the study, you have to continue recruitment of the 100,000 children, their parents and so on.

"So the issue is really an issue of prioritization" in a tough budgetary climate, Zerhouni said.

Landrigan said in his testimony that six of the diseases that are the focus of the study—obesity, injury, asthma, diabetes, autism, and schizophrenia—cost the nation about $642 billion each year. "If the study were to produce even a 1 percent reduction in the cost of these diseases, it would save $6.4 billion annually, 50 times the average yearly costs of the study itself," he said.

But the project could save even more, he said, noting that risk factors for cardiovascular disease identified in the Framingham study, which tracked heart disease, were poorly understood when that project began in 1948. That program saved millions of lives and billions of dollars by identifying smoking, hypertension, diabetes, and elevated cholesterol as "powerful" risk factors for cardiovascular disease, Landrigan said. By focusing on multiple childhood disorders, the National Children's Study could save even more lives, he said.

"We've just got to find the money to put back in there," Harkin declared at the hearing.

MAY 23, 2005 -- Beneficiaries who choose to remain in the traditional fee-for-service side of Medicare are offered much higher monthly premiums on average for drug coverage than those picking managed care plans, a new study says.

The average monthly premium offered by "PDPs"—the type of drug plans offered to enrollees in traditional Medicare—is $37, compared with $19 offered by local HMOs in Medicare. Regional PPOs meanwhile are offering monthly premiums for drug coverage averaging $22, according to the study posted Tuesday on the Web site of the policy journal Health Affairs.

The finding might provide ammunition to critics who say the Bush administration wrote the Medicare drug law (PL 108-173) in a way that pushes more Medicare enrollees into HMOs and PPOs as part of an alleged effort to eventually phase out traditional Medicare.

However, a spokesman for the Medicare program said the study calculated premium averages not based on the PDPs in which seniors actually enroll, but rather on all the PDPs offered. "The findings in the report appear to be consistent with what we've found of the average price of the bids," said Peter Ashkenaz, a spokesman for the Centers for Medicare and Medicaid Services.

If the monthly average is calculated based on the premiums charged by the PDPs in which Medicare beneficiaries are actually enrolling, the figure is $25, not $37, Ashkenaz said. "There doesn't seem to be a whole lot new here," he added. "Premiums vary along with everything else. Beneficiaries are choosing plans that fit their individual needs."

Conducted by Austin Frakt and Steven Pizer of the Veterans Affairs Boston Healthcare System in Massachusetts, the study also found that relatively few PDPs offer coverage in the "doughnut hole"—the part of the standard Medicare drug benefit for which the beneficiary is responsible for 100 percent of prescription costs.

Fifteen percent of all PDPs—national and regional—offer coverage in that gap. But that's a higher percentage than for local Medicare managed care plans offering drug coverage; 14 percent of those plans offer gap coverage. Of the relatively small number of PDPs that are offered nationally, one-third offered coverage in the gap.

Premiums charged by PDPs offering coverage in the gap are relatively high—"$50 per month on average," the study said. PDPs covering both brand-name and generic drugs in the gap charge $61 on average, the study said.

Only one national PDP—Humana—offers coverage of brand-name drugs in the gap, the study said. That strategy could attract enrollees with relatively high drug costs, but it "also holds the potential to capture substantial market share," the report said. "Whether this strategy will prove to be profitable ought to become evident during 2006."

The study quantifies how much more plentiful PDPs are in Medicare than regional PPOs or local HMOs. Not all beneficiaries have access to PPOs or HMOs, known as Medicare Advantage (MA) plans, it says. The average MA region has 2.4 regional PPOs on its menu of plan choices, while the average county has 3.6 local MA plans with drug coverage and the average PDP region offers 42 PDPs, the study found.

The relatively cheap drug coverage offered by MA plans has been a big draw for beneficiaries, but MA enrollment trails PDP enrollment.

CMS Administrator Mark B. McClellan noted last week that the most recent tally for enrollment in PDPs was about 9 million. But the figure may have crept closer to 10 million in the final days of the Medicare drug benefit enrollment period.

MA enrollment stood at about 6 million at the start of the year when Medicare drug coverage began. It now stands at about 7 million.

MAY 24, 2006 -- Young adults between the ages of 19 and 29 represent the largest and fastest-growing segment of Americans without health insurance, according to a Commonwealth Fund report released Wednesday.

The study finds that nearly 14 million people in that age group are uninsured, an increase of 2.5 million from 2000, and they are uninsured at twice the rate of adults ages 30 to 64.

"There are both health and financial consequences when young adults who are just starting out in the workforce or entering college lose their health insurance," the study's lead author, Commonwealth Fund Senior Program Officer Sara Collins, said in a statement. "Policy changes such as increasing the age of eligibility for public programs and continued parental coverage would stabilize insurance among young adults and ease their transition to adulthood."

Young adults from low-income households are most at risk of not being insured, the study found.