By Danielle Parnass, CQ Staff

August 7, 2008 -- Regardless of economic, political, or regional background, health care costs continue to be a top concern for Americans, who increasingly favor a fundamental overhaul of health care and are calling on the government to lead that charge, according to several recent surveys and reports.

In a Commonwealth Fund survey released Thursday, an overwhelming number of respondents, around 90 percent across all demographics, want the next president to propose changes addressing quality, access, and affordability. In addition, cost of care topped respondents' lists of important issues facing the next president. Those who identified as Democrats or who had a lower income were most supportive of a health overhaul, according to the survey of about 1,000 adults conducted in May by Harris Interactive.

Eighty-two percent of those surveyed said the current health care system needs to be either fundamentally changed or completely rebuilt. Results differed about eight percentage points between the insured and uninsured, but more than 80 percent in each group favored change.

Another study released in August by the Washington Post, Kaiser Family Foundation, and Harvard University surveyed low-wage workers in America and found that 72 percent said a top priority for the government should be helping those with lower incomes receive more affordable health insurance. Cost concerns were followed by 71 percent of those surveyed who felt the government's top priority should be lowering gas prices.

Furthermore, 62 percent of respondents in the survey of workers who make low-wages—defined as earning $27,000 or less in 2007—said it was somewhat or very difficult for them to afford health care and health insurance. Fifty-one percent reported postponing medical or dental care in certain circumstances to make ends meet.

"It is clear that our health care system isn't giving Americans the health care they need and deserve," Commonwealth Fund President Karen Davis said in a news release. "The disorganization and inefficiency are affecting Americans in their everyday lives, and it's obvious that people are looking for reform."

Davis also said the upcoming election provides ample opportunity for leaders to listen to what Americans want from the health care system "and respond with meaningful proposals."

In Thursday's Commonwealth Fund survey, 73 percent of respondents reported problems accessing their health care, including difficulty getting timely appointments, phone advice, or after-hours care. Respondents also said the health care system needs to be more cohesive, with 47 percent saying they experienced poorly coordinate care in the past two years. Nine out of 10 people surveyed also said they wanted access to their medical records and gave substantial support for wider adoption of health information technology.

A recent report by the Government Accountability Office highlighted access problems that Medicare Part D beneficiaries have experienced. It found that the Centers for Medicare and Medicaid Services (CMS) and other providers were slow in resolving complaints of patients in the Medicare prescription drug benefit program who were at risk of running out of medications, among other issues.

The Commonwealth Fund released a second report Thursday that called for a reorganization of a system it says is fragmented at the national, state, community, and practice levels. It offered strategies for a higher-performing system after analyzing successful programs around the country, including: a payment overhaul that moves away from the fee-for-service system, patient incentives to seek providers offering the highest quality care, regulatory changes that promote information sharing and coordinated care, and health IT.

"There's no one policy, or practice that will make our health care system run like an efficient, well-oiled machine," James J. Mongan, chairman of the Fund's Commission on High Performance Health System and CEO of Partners HealthCare, said in the release. "This is going to take strong national leadership and a commitment from all of the players in our health care system."

By Danielle Parnass, CQ Staff

August 5, 2008 -- Lawmakers have introduced legislation in both chambers that would provide physicians with independent information on prescription drugs that is based on scientific research as an alternative to the information supplied by drug companies.

The bills (S 3396, HR 6752) would give federal grants for prescription drug education and outreach to health care providers. The academic detailing program, as it is called, would provide objective, unbiased information to doctors on drugs.

"Providing doctors with objective information about prescription drugs allows them to prescribe the most effective treatment to their patients," Rep. Frank Pallone Jr., D-N.J., said in a release. Pallone introduced the House companion measure with Rep. Henry A. Waxman, D-Calif.

Drug companies are currently one of the only ways a doctor gets information about drugs, a practice that is "fraught with conflicts of interest," Senate bill sponsor Sen. Herb Kohl, D-Wis., said in a release.

But the pharmaceutical industry says information offered by drug companies is only one of numerous factors a doctor considers before prescribing medicine to their patients, such as a patient's medical history, clinical guidelines, and peer feedback.

"Clearly, the view that physician prescribing is overwhelmingly determined by pharmaceutical company outreach is not accurate," Pharmaceutical Research and Manufacturers of America (PhRMA) Senior Vice President Ken Johnson said in a statement.

Johnson said generic drugs accounted for nine of 10 most commonly prescribed medicines in 2007, and for 67 percent in the United States, according to IMS Health, a consulting and data services firm that provides sales information to pharmaceutical companies.

"Governmental efforts to drive particular prescribing decisions by physicians need to be approached with great caution and with the recognition of the many factors in the current system that can impact prescribing decisions," Johnson said.

He said that pharmaceutical sales representatives must comply with strict Food and Drug Administration regulations, and that these academic detailing programs are not held to the same standards.

Kohl spokeswoman Ashley Glacel said although there's not much time left this year to get the legislation moving, the measure is part of a larger effort by lawmakers to change the relationship between the pharmaceutical industry and doctors. She also indicated the possibility of attaching the bill to other legislation. If not passed this year, they will continue to push for and reintroduce the measure next year, she said.

Other sponsors of the Senate measure include Sens. Richard J. Durbin, D-Ill.; Edward M. Kennedy, D-Mass.; and Bob Casey, D-Pa.

"Studies confirm that when unbiased health professionals, armed with educational materials, provide guidance to doctors, they are more likely to purchase the best drug for the patient instead of the best deal for the pharmaceutical company," Durbin said in the release.

By John Reichard, CQ HealthBeat Editor

August 6, 2008 -- Government statistics released Wednesday on how Americans use health care services show that Americans averaged nearly four visits apiece in 2006 to doctors' offices, hospital outpatient departments, and hospital emergency departments.

The number of those visits was 26 percent higher than in 1996, a rate of growth that far exceeded that of the U.S. population, which was 11 percent. "The rise in visits can be linked to both the aging of the population, as older persons have higher visit rates than younger persons in general, and an increase in utilization by older persons," the Centers for Disease Control and Prevention (CDC) said in releasing the data.

The percentage of patients admitted to the hospital who are elderly also has climbed steadily upward. People 65 or older made up 20 percent of all hospital inpatients in 1970, a figure that increased to 38 percent in 2006. Over the same period, the percentage who were 75 or older grew from 9 percent to 24 percent.

The data also showed heavy reliance by Medicaid patients on the emergency department for care. For every 100 persons on Medicaid in 2006, 82 made use of the emergency department, compared with 21 of every 100 who had private insurance.

In the case of African Americans, 38 percent of medical visits were to the emergency room or hospital outpatient department as opposed to physician offices, while in the case of whites the figure was 17 percent.

The most frequent specific reason for visiting the emergency room given by patients above the age of 14 was chest pain, followed by abdominal pain, back pain, headache, and shortness of breath. Doctors ordered imaging tests in 44 percent of the visits. Conventional X-rays were ordered in 35 percent of visits, CT scans in 11.6 percent, ultrasound imaging in 3.1 percent, and MRI scans in 0.5 percent.

The average time spent waiting to see a doctor during an emergency room visit was 56 minutes.

Medical visits in 2006 resulted in a large number of prescriptions. Seven of every 10 visits resulted in "at least one medication provided, prescribed or continued," for a total of 2.6 billion drugs overall, the CDC analysis found. Pain relievers were the common type of drug prescribed.

One-half of visits to the doctor were made by patients with at least one chronic condition. "Hypertension was the most frequent condition, followed by arthritis, high cholesterol, diabetes, and depression. Since 1996, visits by adults with diabetes, hypertension and depression have all significantly increased," the analysis said.

Visits to hospital outpatient departments by patients 18 or older
with chronic diabetes increased 43 percent between 1996 and 2006, while those for chronic hypertension increased 51 percent.

By Danielle Parnass, CQ Staff

August 7, 2008 -- Rep. Dennis J. Kucinich, D-Ohio, has introduced legislation (HR 6800) that would attempt to lower drugs costs by replacing the current prescription drug plan created by the 2003 Medicare overhaul law (PL 108-173).

The bill would allow patients to purchase drugs from an approved list of foreign countries, require Medicare to use its purchasing power to negotiate prices with the pharmaceutical industry, and impose limits on prices drug companies can charge if a drug's research and development was financed by taxpayers.

This bill also includes provisions that call for no premiums, co-pays or deductibles for drugs required by Medicare beneficiaries.

"The privatized drug plan has been given a chance and, as predicted, it has failed," Kucinich said in a release. "There is no reason for us to keep throwing money at a bad idea when we know we can save taxpayers billions of dollars and give seniors the medication they need."

Several Democratic lawmakers have advanced the idea of requiring Medicare to negotiate the price of prescription drugs. And some Republicans as well as Democrats have argued that Medicare should import drugs at lower prices.

The Oversight and Government Reform Committee release an analysis in July that found that pharmaceuticals covered under Medicare Part D, which is administered through private insurance companies, costs 30 percent more than those provided through Medicaid, which is done through the government, according to the release.

"This is a common sense bill," Kucinich said. "Medicare beneficiaries . . . want a plan that will not drive them into bankruptcy."

A study in December by Harris Interactive found that 87 percent of beneficiaries reported they were happy with their Part D plans, and 75 percent said it has helped them save money on prescription drugs, according to a statement by America's Health Insurance Plans (AHIP).

About 90 percent of Medicare patients have prescription drug coverage through Part D, employer plans supported by Part D or through other sources, AHIP said.

"The Part D program has proven to help seniors get access to the prescription drugs they need while holding down costs for beneficiaries and taxpayers," said Robert Zirkelbach, an AHIP spokesman.

By Danielle Parnass, CQ Staff

August 8, 2008 -- A new report from Georgetown University says poor implementation of West Virginia's redesigned Medicaid plan is hurting many children who have been blocked from the plan's enhanced benefits program because of confusing enrollment instructions, among other issues. Meanwhile, state officials rejected the findings of the report and said it is too soon to tell how the new program will fare.

The report from Georgetown's Center for Children and Families (CCF) found that around 93 percent of children were getting reduced coverage of health care benefits based on the West Virginia Medicaid Redesign, created to promote healthy living and combat preventable illnesses through smoking cessation, regular doctor visits and weight loss.

Eligible families who sign an agreement to engage in healthy behaviors receive enhanced benefits but those who do not are automatically enrolled in a basic plan that offers less coverage than Medicaid's traditional program. Doctors are required to assess patients in the enhanced benefits program each year to make sure they comply with the standards for healthy behavior. If they do not, they are placed back into the basic plan.

So far, a low number of children—about 8 percent of those eligible—are signed up to receive the enhanced benefits package, according to the report, which attributes the sluggish enrollment largely to implementation issues. Medicaid beneficiaries are given 90 days of their eligibility redetermination date to enroll in the enhanced program before being dropped to the basic program.

The report said informational materials about how to enroll in the enhanced program are hard to understand and do not clearly state where or how to send the completed agreement.

"What we found is extremely troubling," said Joan Alker, deputy executive director of the CCF. "It's been so poorly implemented that all of these families are just being defaulted."

Shannon Landrum, a spokeswoman for the West Virginia Bureau for Medical Services, said the program is still new and it is too soon to assess its effectiveness. As people become more familiar with the program, member agreements keep increasing: more than 14,000 member agreements have now been submitted since it was implemented in 2006 of the roughly 140,000 who are eligible, according to the most recent data, she said.

She also said some people may not have enrolled in the enhanced plan because the basic plan "is extremely good health care coverage."

Critics of the basic package say it only covers four prescriptions per month for each person enrolled and restricts mental health care, making the package much more limiting than the traditional plan, they said.

Landrum said the basic program is "only an appropriate benefit package for healthy kids," and only targets healthy children and adults who were enrolled in Medicaid because of low-income and not because of disabilities. "We have no intention of applying this benefit package to other populations," she said.

Landrum said the agency offers the ability to override the prescription limit if needed, and noted that drugs for conditions such as asthma and diabetes, as well as birth control medications, are not limited. She also said the basic package covers unlimited visits to psychologist and psychiatrists for adults and children, but certain limits on mental health service offerings only apply to adults.

Alker said there is a higher incidence of chronic conditions among children on Medicaid simply because they're poor. A 2000 study by CCF found that four of 10 kids with conditions like diabetes and asthma come onto Medicaid because of their income and not through the disability category, and Alker said this has likely grown because Medicaid enrollment has increased.

The redesigned program was originally implemented because West
Virginia is one of the unhealthiest states in the nation and has some of the highest rates of type 2 diabetes, heart diseases, and high blood pressure, Lundrum said. The new plan received much support from the Bush administration and was approved by the Department of Health and Human Services within eight days, raising many questions at the time about whether children would receive certain benefits, Alker said.

"It really takes a partnership," Lundrum said. "You can't pay for wellness if you don't have the patient participating in their health decisions.

Alker said it is only possible to improve people's health if they also are actively engaged in the process. The West Virginia program so far has not achieved that goal, she said.

Landrum said the internal response to the report has been "livid" and said the authors did not contact the department to discuss the issues.

"We think that the report . . . is an oversimplification of what's happening with the Medicaid program and we truly wish they would have called to ask us about it."

By Reed Cooley, CQ Staff

August 5, 2008 -- Many Americans with chronic diseases are forgoing needed care because they lack health insurance coverage, according to a report released Tuesday in the health journal Annals of Internal Medicine.

The study, which says it is the first in recent years to address the prevalence of chronic conditions among the uninsured, estimates that of the country's 47 million uninsured, 11.4 million are working-age adults suffering from at least one chronic condition, such as cardiovascular disease, diabetes or asthma.

Controlling for sociodemographic conditions, the study found that chronically ill individuals without insurance were four to six times more likely to have problems accessing care than those covered by private plans or one of the government entitlement programs. This group was more likely to use the emergency department for primary care and less likely to have visited a physician in the past 12 months, said the report, which points out that Americans without insurance tend to be less affluent than those covered.

The report noted that the number of individuals who are both uninsured and afflicted by chronic disease is likely underestimated because the study only counted those that had been diagnosed with an illness and many uninsured Americans may go undiagnosed.

An editorial accompanying the article said that the "clarion call" of increasing access to care by the uninsured would not be enough to sufficiently treat chronic diseases.

"Health care insurance reform is necessary for good care for chronic diseases, but it will not be sufficient unless it is coupled with quality improvement efforts targeting the reasons that vulnerable populations with access to care often do not receive optimal care," the editorial said.

The report concluded that treatment of the chronic diseases included in the study had become "the standard of care" in recent years.

"The benefits of treatment are so clear that studies evaluating new treatments of these conditions are ethically bound to provide control participants with standard therapies," the article said. "The same ethical consideration has not been extended to those without insurance."