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NEWS & VIEWS

IOM CHALLENGES US GOVERNMENT TO INSURE ALL BY 2010

America should have universal health care coverage by 2010 – and the federal government must lead the effort. So concluded the Institute of Medicine (IOM) in the culmination of its series of reports on the state of health insurance in the US. The report, Insuring America's Health: Principles and Recommendations, is available online here: www.iom.edu/report.asp?id=17632.

While the report does not offer specific strategies, it outlines five principles to guide health care policy makers in extending health care coverage to all Americans. The report posits that health care coverage should be continuous; universal; affordable to individuals and families; and affordable and sustainable for society, and should provide effective, efficient, safe, timely, patient-centered, and equitable care.

But how would these approaches affect neurologists? In theory, universal coverage would be good because uninsured patients are much more expensive to care for, especially for neurologists and other cognitive specialties that have small profit margins, said Mark Yerby, MD, Chair of the AAN Legislative Affairs Committee (LAC). It would also be good in human terms, he said: “It is humiliating for people to have to beg for the help they need.”

However, he cautioned, a plan to increase the number of people with insurance will only increase access to health care and help neurologists financially if there is adequate compensation. “If the rates are suboptimal, patients won't find doctors to see them. Access will be problematic, especially access to specialists.” For example, he noted that Medicaid is under-compensated, so many physicians loose money seeing those patients. “I am concerned that if we just extend Medicaid, the ultimate problem won't be addressed.”

Decreasing the number of uninsured people in the US is one of the LAC's priorities this year, Dr. Yerby said. The LAC strategy will be to focus on access, and gather scientific data showing that patients' access to care is decreasing under the current policies.

ANALYSIS POINTS TO KINKS IN MEDICAL MALPRACTICE SYSTEM

States with caps on jury awards in malpractice cases have lower premiums – by 17.1 percent – concluded a state-level analysis of medical malpractice insurance premiums. However, author Kenneth E. Thorpe, PhD, Professor and Chair of the Department of Health Policy and Management at Emory University in Atlanta, GA, points to other inequities in the tort system. He suggests that a deeper analysis of factors affecting premiums is necessary. Commenting on the study, David Shapiro, MD, JD, Editor of Professional Liability Newsletter, a liability newsletter for physicians, said these studies are likely to occur.

Dr. Thorpe notes that a majority of malpractice cases that do go to trial are dismissed or defeated, and 60 percent of court awards go to administrative and attorney fees. Dr. Shapiro said that, although the report does not address this, changes in the claiming behavior of injured patients can have large effects on the malpractice system as well. These criticisms of the tort system are not new, and reforms have been supported by President Bush and other Republicans, but have met resistance from Democrats and trial lawyers.

Damage caps will lead to lower premiums, Dr. Thorpe concludes, but will not improve health care quality. More research on health care quality trends is needed to evaluate whether tort reforms will support the liability systems goals of deterring substandard care and compensating injuries, he writes.

OXYCODONE ABUSE SPURS RISK MANAGEMENT POLICY

Drug companies that make powerful – and addictive – pain medications should develop plans to prevent misuse of their products. That is the recommendation of a General Accounting Office (GAO) report, which examined the events that allowed powerful painkiller oxycodone (Oxycontin) to become a recreational drug of choice

The GAO report, available here www.gao.gov/new.items/d04110.pdf, examined the approval and marketing of oxycodone, its rise to become the top selling brand-name narcotic in 2001, and its simultaneous rise to become one of the most abused prescription drugs. The report cites oxycodone's market success as a probable reason for its popularity among abusers.

The report criticized Purdue Pharma for aggressively marketing oxycodone to primary care physicians, who do not always have sufficient experience in pain management. Furthermore, Purdue was cited by the FDA for running oxycodone advertisements making unsubstantiated medical claims and downplaying the drug's risks, as well as for releasing a promotional video with similar flaws without the requisite FDA approval.

The FDA gets a share of the blame, too, for originally labeling Oxycontin as having less abuse potential than other oxycodone products, because of its time-release formulation, and for not realizing that the pills could be crushed or dissolved to circumvent the time-release coating.

To prevent these mistakes from reoccurring, the GAO wants the FDA to “encourage” pharmaceutical companies to submit, with new drug applications, a plan to monitor use of the drug and identify potential abuse problems.

One expert fears that that may not be enough. Commenting on the ways that pharmaceuticals get diverted from their intended use and onto the black market, David Joranson, Director of the Pain & Policy Studies Group at the University of Wisconsin-Madison, said: “Some significant sources of diversion of pain medication to illicit use are being overlooked, and they have to do with pure crime – thefts from pharmacies, distributors, and carriers. You could tighten down on everyone in the medical system and there would still be a supply of illicit medication on the black market. It is important for these criminal sources to be addressed in the overall approach to preventing abuse.”

BSE SCARE PRODUCES REGULATIONS, RESEARCH FUNDING

Federal officials are rushing new regulations and funding packages to control the possible spread of to bovine spongiform encephalopathy (BSE). But are the new regulations too little and too late to keep the neurodegenerative disease believed to cause new variant Creutzfeldt-Jakob disease in humans out of the US? This flurry of activity came in response to a cow with BSE that was slaughtered and processed in Washington state late last year.

The FDA has published several new regulations designed to prevent the potential spread of BSE. The ban includes materials at high risk of transmitting BSE, including brains and spinal cords of cows older than 30 months, as well as any material from cows that die on the farm or that are unable to walk.

The second regulation supplements current restrictions on using most mammalian protein in cattle feed. It adds mammalian blood to the feed ban, in response to a UK report of the infectious proteins being transmitted through a blood transfusion, as well as leftover meat from restaurants and poultry waste, which could contain traces of cattle protein. A foreign advisory committee to the US Department of Agriculture recommended more stringent regulations, however, including a total ban on feeding animal protein to cattle.

President Bush has requested $60 million in 2005 to create additional safeguards and develop more BSE diagnostics. Of that amount – a $47 million increase in current funding levels – over half will aid the development of a national animal tracking system. Five million dollars is allotted to develop new testing technologies for BSE, with the balance funding increased inspection and surveillance activities.

A contentious issue is the number of cows routinely tested for BSE. The Department of Agriculture plans to double the number of tested animals this year, for a total of 400,000 of the 35 million cows slaughtered in the US annually. Many experts say that this is not good enough, pointing to the UK and Japan, where all slaughtered cattle are tested. Prion expert Stanley Prusiner, MD, of the University of California-San Francisco, expressed concerns about spontaneous cases of BSE, unrelated to feeding practices that could circumvent the FDA's regulations. At a House Food Safety caucus, he asserted that until all cows are tested, none can be considered safe, reported the New York Times (January 28, 2004).