Friday, July 20, 2007


Dear Friends and Colleagues;
I am seeking your help in mobilizing support to extend and expand the SCHIP (State Children's Health Insurance Program).
SCHIP was established in 1997 through a bipartisan effort to provide health insurance for several million uninsured children that do not qualify for Medicaid and otherwise would have fallen through the cracks of our so-called "healthcare system."
SCHIP is being funded by the federal and the state government(s) at an ~ 70/40 ratio.
It is set to expire and faces mounting criticism focusing on the following issues: a) including adults, b) including children from families whose income exceed 3-4 the poverty level, c) lack of physicians participation due to low reimbursement, d) allegations that it undermines the private health insurance system.
The AMA and other organizations SUPPORT the reauthorization of SCHIP. President Bush threatens to veto any new bill and objects on "philosophical grounds" to a bipartisan Senate proposal to boost the State Children's Health Insurance program by $35 billion over five years. Bush has proposed $5 billion in increased funding and has threatened to veto the Senate compromise and a more ambitious expansion being contemplated in the House.
Providing health insurance for approximately 4-5 million children has nothing to do with ideology, philosophy or faith. Its a common sense issue: provide primary care services for children now thereby preventing illnesses and costly treatment later in life.
Private insurance companies have FAILED to offer such services. I have spoken with many of my patients about that and have heard the same story over and over: in the beginning the insurance rates are affordable and then progressively increase until they cant afford it anymore.
Lets not get bamboozled by ideological knuckleheads at both extremes of the political spectrum.
Call your Senator and Congressman/woman and demand a reauthorization of the SCHIP program. Call the White House and remind our President that his veto is a veto against our children's health!
Miami Herald, Posted on Thu, Jul. 19, 2007
For healthy children, better opportunity
More than eight million U.S. children are starting out life with poor prospects because they lack health insurance. This is reason enough to support a federal program with a strong track record of helping Florida and other states provide coverage to needy children. Better yet, Congress appears poised to expand the program. It is the right move when the need to protect vulnerable children is so great.

In a rare instance of bipartisanship, there is widespread support in the Senate and House for an expansion of the State Children's Health Insurance Program. President Bush, however, threatens a veto. He believes the plans under discussion would unacceptably expand ''government-run healthcare.'' Surely there is reason to enact a bill with adequate controls that will significantly increase the number of children with ready access to healthcare.

Unacceptable proposal

The federal program insures children from working-poor families through state plans such as Florida's KidCare. Yet the current annual funding level of $5 billion doesn't stretch enough to cover all eligible children. This is why the Senate and House are discussing plans that would double or triple the funding.

President Bush is proposing a $1 billion increase per year, but that isn't enough. His proposal would result in a reduction in the number of children in the program be cause the funding wouldn't cover rising healthcare costs. This isn't acceptable.

The Senate bill is a compromise agreed upon last week. It would increase funding to $12 billion per year. It would also:

• Be financed by raising the cigarette tax to $1 a pack. This would discourage smoking and promote better health.

• Encourage states to enroll the poorest children and discourage enrollment of higher-income children. This targets the most vulnerable population.

• Leave out a key group that should be covered: up to 750,000 legal immigrant children who are not yet citizens. This is unfair and unhealthy. They should be included.

The House is considering a bigger expansion to $15 billion a year -- the estimated cost of covering all uninsured children.

President Bush and others argue that such an expansion would displace private coverage. But the vast majority of the millions of needy children who would benefit from the Senate plan currently are uninsured or would lose state coverage without increased funding. Tax subsidies proposed by President Bush would most benefit children who already have private coverage.

Insured children are more likely to get preventive healthcare, stay healthier, attend school and avoid the emergency room. Healthy children are better prepared to learn, which improves their future economic prospects. Expanding the federal program should radically improve children's access to healthcare nationwide.


Miami Herald, Posted on Thu, Jul. 19, 2007
Senate panel OKs child health bill
Brushing aside threats of a presidential veto, a Senate committee on Thursday approved a five-year, $35 billion expansion of a children's health insurance program that would be financed through higher tobacco taxes.

A majority of Republicans on the Senate Finance Committee joined all of the committee's Democrats in voting to reauthorize the State Children's Health Insurance Program. The program subsidizes insurance for children and some adults with incomes too high for Medicaid but not high enough to afford private insurance. The vote was 17-4.

"There are more kids without health insurance than there are kids in the first and second grades," said Sen. Max Baucus, D-Mont., the committee chairman. "Americans overwhelmingly support getting kids covered."

The additional spending the committee approved would bring total SCHIP funding to $60 billion over five years - double what the administration has proposed. The tax on a pack of cigarettes would increase by 61 cents to help pay for the expansion. Taxes on cigars and chewing tobacco also would jump.

The committee's Democratic leaders had wanted to add $50 billion to the program, and their House counterparts are determined to pursue that amount. The compromise forged by the committee could become extremely fragile if GOP senators are forced to vote on an expansion much beyond what the committee approved.

"I hope they understand it takes 60 votes to get anything done in the United States Senate," said Sen. Charles Grassley, R-Iowa.

The 60 votes would be needed to overcome a filibuster. Baucus said he believes his proposal has enough support to overcome such a hurdle, as well as a promised veto from the president.

"The vote speaks for itself," Baucus said.

Lawmakers said the $35 billion expansion would allow 6.6 million people to maintain their current health coverage, and it would provide coverage for another 3.2 million uninsured children.

The administration reacted to the vote by saying that sending the president a bill he cannot sign puts at risk millions of needy children who would lose health insurance when the program's funding expires Sept. 30.

"We are ready to renew our commitment to low-income children today, but we cannot agree to a gradual government takeover of health care - and neither will the American people," said Health and Human Services Secretary Mike Leavitt.

Some dissenters on the committee believe the legislation raises taxes unnecessarily and does not do enough to refocus the program on low-income children.

"The Democrats are playing a game of reverse Robin Hood with this legislation," said Sen. Trent Lott, R-Miss.

The program began 10 years ago. It was generally designed to help families whose income does not exceed 200 percent of the poverty level, or $34,340 for a family of three. But several states have extended coverage to children with higher incomes and to adults. The latter expansion has particularly incensed some lawmakers who disapprove of waivers the Bush administration has granted to those states.

The SCHIP program is going in the opposite direction from where it should be going, said Sen. John Ensign, R-Nev., who voted against the proposal along with Lott, Jim Bunning, R-Ky., and Jon Kyl, R-Ariz.

The Senate proposal would gradually move adults who don't have children out of the program. States would have the option to cover them through Medicaid. The federal government also would lower the percentage, or matching rate, that it pays for parents' coverage. In addition, the federal government won't be allowed to grant new waivers to states allowing them to cover parents. But states will have the option of providing coverage to pregnant women through SCHIP.

Congressional Budget Office officials testified that spending on adults would drop by $1 billion over the next five years under the Senate proposal.

"We've been handed a mess by this administration," said Sen. Kent Conrad, D-N.D., referring to the adult coverage. "This takes steps to change that. That's a fact."

Several advocacy groups are supporting the higher tobacco tax because it would not only fund the program's expansion, but because higher taxes also lead to less smoking.

For every 10 percent increase in the price of cigarettes, overall cigarette consumption drops by about 4 percent, and the rate drops even more for children.

"Research shows a clear health benefit from higher tobacco taxes," said William Carr, executive director of the Campaign for Tobacco-Free Kids.

Overall, the federal tax on a pack of cigarettes would go up to $1 a pack

The tax on cigars is much more complicated to calculate. But Norm Sharp, president of the Cigar Association of America, said the tax for large cigars could go from a cap of about 5 cents a cigar to a cap of $10 a cigar.

"We're looking at cigars going up in price at retail 2.5 times to 3 times current prices," Sharp said.

"How do we explain that, justify that, or do we even care?" Lott said at one point when asking colleagues about the tax increase on cigars.

"A $10 cap on a very expensive cigar would not be terribly onerous," Baucus replied
Miami Herald, Posted on Thu, Jul. 19, 2007
Bush rejects children's health plan boost
President Bush on Wednesday rejected entreaties by his Republican allies that he compromise with Democrats on legislation to renew a popular program that provides health coverage to poor children, saying that expanding it would enlarge the role of the federal government at the expense of private insurance.

The president said he objects on philosophical grounds to a bipartisan Senate proposal to boost the State Children's Health Insurance program by $35 billion over five years. Bush has proposed $5 billion in increased funding and has threatened to veto the Senate compromise and a more costly expansion being contemplated in the House.

''I support the initial intent of the program,'' Bush said during an interview after a factory tour and discussion on healthcare with small-business owners in Landover, Md. ``My concern is that when you expand eligibility . . . you're really beginning to open up an avenue for people to switch from private insurance to the government.''

The 10-year-old program, which is set to expire Sept. 30, costs the federal government $5 billion a year and helps provide health coverage to 6.6 million low-income children whose families do not qualify for Medicaid but cannot afford insurance on their own.

About 3.3 million additional children would be covered under the proposal developed by Senate Finance Committee Chairman Max Baucus, D-Mont., and Republican Sens. Charles Grassley of Iowa and Orrin Hatch of Utah, among others. It would provide a total of $60 billion over five years, compared with $30 billion under Bush's proposal. And it would rely on a 61-cent increase in the federal excise tax on cigarettes, to $1 a pack, an increase Bush opposes.

Grassley and Hatch, in a joint statement this week, implored the president to rescind his veto threat. They warned that Democrats might seek an expansion of $50 billion or more if there is no compromise. They also said Bush should drop efforts to link the program's renewal to his six-month-old proposal to replace the long-standing tax break for employer-based health insurance with a new tax deduction that would help people pay for insurance regardless of whether they get it through their jobs or purchase it on their own.

''Tax legislation to expand health insurance coverage is badly needed, but there's no Democratic support for it in the SCHIP debate,'' said Grassley, the ranking Republican on the finance committee. ``In the meantime, our SCHIP initiative in the finance committee takes care of a program that's about to expire in a way that's more responsible than current law and $15 billion less than the budget resolution calls for.''

But Bush said he was not persuaded.

''I'm not going to surrender a good and important idea before the debate really gets started,'' Bush said. ``And I think it's going to be very important for our allies on Capitol Hill to hear a strong, clear message from me that expansion of government in lieu of making the necessary changes to encourage a consumer-based system is not acceptable.''

The Senate committee is scheduled to consider the compromise legislation today, and the House is expected to try to pass its own version before the congressional recess in August.

Rep. Rahm Emanuel, D-Ill., the Democratic caucus chairman, said he was ''bewildered'' that Bush was fighting expanded funding for a program supported by Republicans and Democrats alike. ''This is the chance for him to finally be a uniter and not a divider,'' Emanuel said.


Wednesday, July 11, 2007

Addiction Research In The News

I hope you didn't miss todays (07/10/07) great interview with Dr. Volkow on NPR (Fresh Air) entitled "No,really, this is your brain on drugs."
Nora Volkow, director of the National Institute on Drug Abuse, ranks as one of the U.S.'s leading addiction researchers. She's helped demonstrate that addiction is in fact a disease — a disease of the brain — and that all addictions, whether it's to drugs, alcohol, tobacco, sex, gambling or even food, are more alike than was previously thought.Volkow, who's the great-granddaughter of Russian revolutionary Leon Trotsky, grew up in Mexico City — in the house where her famous ancestor was assassinated.
Very informative and fascinating.
A MUST for anybody who is interested in addiction and want to draw others towards other profession.




Tuesday, July 10, 2007

Muslim Doctors and Terrorism Charges

Dear Friends and Colleagues:
The recent terror attacks in Great Britain unleashed a new wave of anti-Muslim sentiments. The fact that medical doctors from the Middles East and India were involved coined a new phrase " Doctors of Terror" and questions the loyalty and reliability of "Muslim Doctors."
A recent article in the New York Times highlights the fact that seven doctors are tied to the terror plots that unfolded in Britain. Furthermore, the US press has reported that at least two of the doctors have inquired about US licensure and residency training programs.
A recent letter to the editor "Doctors of Terror" in an Orlando newspaper was written by an IMG (International Medical Graduate)and ends with the gloomy prediction,
"Sadly, nothing is immune to terror, hate and murder -- not even one of the noblest professions that is dedicated to the welfare and health of mankind."
Right wing bloggers and talk show hosts are whipping up a frenzy to mislead people in believing that Muslim doctors are "Doctors of Terror."
As an International Medical Graduate, Jew and Israeli citizen I am appalled by the frontal assault on my fellow colleagues of the Muslim faith.
Terrorists are motivated by hate and the delusion of grandeur to control other peoples fate and life. Religion is just the cover to vaguely conceal their distorted narcissistic characters and to justify their nihilistic world view.
Even though many terrorists are Muslims, most Muslims are NOT terrorists! Singling out Muslim doctors alienates Muslims instead of recruiting them in our joint struggle to fight terrorism and to build a better world.
Its time for IMGs in organized medicine to speak up against any attempts to stigmatize our fellow Muslim colleagues and to defend their rights.
Join me in this effort!
Bernd Wollschlaeger,MD
Past Chair AMA IMG Section
Chair Florida Medical Association IMG Section

Friday, July 06, 2007

P4P: An Evidence Based Approach

By Bernd Wollschlaeger,MD,FAAFP

" The fact that nearly three-quarters of the general internists we surveyed support financial incentives for quality could be surprising, given their concerns about unintended consequences, possible fear of the unknown, and literature on physician professionalism suggesting that physicians prefer not to subject their performance to external oversight. Respondents might simply have seen such incentives as a way to gain more income; this belief might have outweighed
any resistance they had to external oversight."

"The majority supported financial incentives for quality, although they conditioned their support on measures’ being accurate."

Dear Friends and Colleagues:
In the heated discussion about the so-called Pay-For Performance (P4P) Programs we often forget to consider the views of those we claim to represent: the practicing physicians.
I am concerned that ideological tainted viewpoints distort rational approaches towards this issue, thereby failing to consider the pros and cons of a topic that may affect us all.
In a series of reviews I will therefore present on my blog a variety of different articles discussing evidence-based P4P applications:

In the first article ( see attached abstract) the authors present the views of General Internists and their attitude towards public reporting of quality scores.

To learn more about physicians’ views, the authors conducted a national survey of general internists. Their views, although not necessarily representative of all physicians, are important both because of the large numbers of general internists and because most physician P4P programs focus on primary care.
The sampling frame included 1,668 randomly selected general internists listed in the AMA Physician Masterfile as working in one of the twelve broadly nationally representative metropolitan areas included in the Community Tracking Study (CTS) of the Center for Studying Health System Change (HSC).A cover letter and a seven-page self-administered questionnaire were mailed to the sample in April 2005, with follow-up surveys to nonrespondents mailed in four subsequent waves. The survey was developed after review of the relevant literature, input from experts in P4P and public reporting, and pilot testing with academic and community physicians. The Institutional Review Board (IRB) at the University of Chicago approved the study protocol.
Of the 1,668 physicians selected, 500 were ineligible: 188 surveys were undeliverable; 14 were returned uncompleted with a note stating that the physician was no longer in practice; 46 respondents were not general internists; and 252 additional physicians were not at the address to which the survey had been mailed, according to the phone calls made to nonrespondents’ offices. Of the 1,168 remaining subjects, we received 556 completed surveys, for an adjusted response rate of 48 percent.
Attitudes toward P4P and public reporting. Almost three-fourths of responding physicians agreed that "if the measures are accurate, physicians should be given financial incentives for quality"
However, only 4 percent strongly agreed and 26 percent somewhat agreed that measures of quality are generally accurate at present. Most respondents had little confidence that this will change: 38 percent believed that health plans will try hard to make the measures accurate, and 35 percent believed that government will do so
There was much less support for public reporting than for financial incentives for quality. Only 45 percent of respondents supported public reporting of medical group performance , and only 32 percent supported reporting of individual physicians’ performance. One in three physicians strongly supported financial incentives, but only one in twelve strongly supported public reporting for medical groups, and one in nineteen strongly supported it for individuals

Attitudes toward quality measures and possible unintended consequences. Only 30 percent of physicians agreed that measures of quality are generally accurate. Eighty-eight percent believed that measures are not adequately adjusted for patients’ medical conditions; 85 percent believed that they are not adequately adjusted for patients’ socioeconomic status; and 82 percent stated that quality measures could lead physicians to avoid high-risk patients. Many physicians added written comments stating that poorly compliant patients would also be avoided: For example, "If my pay depended on A1c values, I have 10–15 patients whom I would have to fire. The poor, unmotivated, obese, and noncompliant would all have to find new physicians."
The survey results suggest that physicians are also concerned that "measuring quality will divert physicians’ attention from important types of care for which quality is not measured." Sixty-one percent strongly or somewhat agreed with this statement; many added written comments stating that many quality measures cover physician activities that they do not consider very important compared with many other things they do.

Are some physicians more likely to support P4P or public reporting? The authors performed bivariate and multivariate analyses to learn whether physician support for P4P or public reporting is associated with whether the physician has financial incentives for quality, sees relatively poor patients (measured by percentage of Medicaid patients), and has an income that is primarily based on patient volume.They also tested they associations with physicians’ age, sex, and board certification.
The main finding on bivariate analyses was that physicians who now have financial incentives for quality were more likely to support such incentives than those who do not. These physicians were also more likely to support public reports on medical groups. One-fourth of respondents (130 physicians) reported having financial incentives for quality;for most, the incentive amounted to 5 percent or less of their income (data not shown). Multivariate analysis produced results consistent with the bivariate analyses.

" Support for P4P. Our results suggest that there is a sizable potential reservoir of physician support for P4P: Nearly three in four internists stated that physicians should be given financial incentives for quality if the measures are accurate. However, responses also suggest that there are barriers to overcome if P4P programs are to gain physicians’ support: Fewer than one-third of internists stated that quality measures are accurate at present, and only slightly more than one-third believed that health plans and the government will try hard to make measures accurate.

Support for public reporting. Internists were far less supportive of public reporting than of financial incentives for quality: One-third supported public reporting of individual physicians’ quality scores, and only 45 percent supported public reporting at the medical group level.

Concerns about financial incentives for quality. Although the majority of respondents supported financial incentives for quality in principle, they appear to have been very concerned about possible unintended and undesirable consequences. Large majorities of respondents stated that quality measures are not adequately adjusted for patients’ medical conditions or socioeconomic status; that measuring quality may lead physicians to avoid high-risk patients; and that measuring quality will divert physicians’ attention from important but unmeasured areas of clinical care.

Concerns about public reporting. Although a large majority of respondents supported financial incentives for quality, a large majority opposed public reporting, especially reporting of individual physicians’ performance. To our knowledge, this is the first survey to report this gap. We do not have data to explain this finding; it is possible that respondents believed that they were unlikely to lose much from having financial incentives for quality but feared that a poor public quality rating would be humiliating and might lead to losses of patients and of peer approval.

Other relevant studies. To our knowledge, this is the first national survey to be published of physicians’ views on P4P and public reporting. Some relevant studies have been conducted in more limited settings. In an e-mail survey of nearly 6,000 Massachusetts physicians (response rate was 7 percent; 29 percent were internists), the Massachusetts Medical Society (MMS) found that respondents were open to quality measurement but did not believe that current measures were accurate. Four physician surveys related to public reporting have been conducted; each surveyed either cardiologists or cardiac surgeons in New York or Pennsylvania, where data on cardiac procedures are publicly reported.The results were similar across the surveys: The majority of respondents stated that the measures were not adequately risk-adjusted and believed that public reporting was leading physicians to avoid doing bypass surgery or angioplasty on high-risk patients.

Possible rationales for survey results. The fact that nearly three-quarters of the general internists we surveyed support financial incentives for quality could be surprising, given their concerns about unintended consequences, possible fear of the unknown, and literature on physician professionalism suggesting that physicians prefer not to subject their performance to external oversight.12 Respondents might simply have seen such incentives as a way to gain more income; this belief might have outweighed any resistance they had to external oversight.

An alternative, or complementary, explanation is that physicians would like to improve the quality of care and believe that P4P would finally give them a "business case" for investing in improving quality.Respondents who reported having financial incentives for quality were more likely to support such incentives: Their experience with incentives might have been positive, although it is also possible that physicians who are open to financial incentives for quality are more likely to join practices that have such incentives.

A third possible explanation is that physicians who oppose P4P were less likely to respond to the survey and that our results therefore overstate the degree of support. However, nonrespondents were very similar to respondents, except that nonrespondents were less likely to be board-certified. Since non-board-certified respondents were equally or slightly more likely to favor financial incentives for quality, this potential source of nonrespondent bias seems unlikely to greatly alter our results.

Possible study limitations. Several possible limitations should be considered in evaluating our results. First, the results are not representative of all U.S. physicians; rather, they are limited to general internists in twelve metropolitan areas. Although these twelve areas are not precisely statistically representative of U.S. metropolitan areas, they represent a broad cross-section of such areas in the country and have been used as the sampling frame for major studies of health care quality.
Second, our response rate was modest, though not atypical for physician surveys; it appears, for the reasons detailed above, that nonresponse bias is unlikely to have greatly affected our results. Third, the survey asked about "financial incentives for quality" in general, not about any specific incentive program, so different physicians might have had different programs in mind when responding.

Implications for quality improvement in public and private programs. Our findings suggest three main implications for Medicare and for other public and private policymakers seeking ways to improve the quality of health care. First, there is a large potential reservoir of physician support for P4P, at least among general internists. However, respondents’ concerns about unintended consequences, and their lack of trust that health plans and government will work hard to make quality measures accurate, suggest that physician support could disappear very rapidly if these consequences do occur. Recent experience with such highly touted innovations as utilization review and primary care gatekeeping suggest that potentially useful policies might generate a strong backlash if they are not framed and implemented with attention to physicians’ concerns.

Second, respondents’ concerns suggest that evaluations of P4P and public reporting programs should be explicitly designed to assess possible unintended consequences on disparities in health care, on physicians who practice in areas of low socioeconomic status, and on the quality of care in important areas of physician practice not included in the program being evaluated.

Third, if further research replicates the large gap we found between physician support for P4P and support for public reporting, policymakers might want to consider whether and how to deal with this difference when designing and sequencing their programs. Although respondents expressed a lack of trust in health plans and in the government, they did not simply oppose change: The majority supported financial incentives for quality, although they conditioned their support on measures’ being accurate. They doubted that measures are adequately risk-adjusted for patients’ medical conditions or socioeconomic status—doubts that are supported in the literature.They were considerably more supportive of public reporting at the medical-group level than at the individual-physician level—a reservation that is supported by research demonstrating the difficulty of creating reliable and valid quality measures for individual primary care physicians.And they were concerned about possible unintended consequences of measuring and rewarding quality—a concern that is supported by economic theory and by experience in other industries.Policymakers might wish to pay close attention to physicians’ concerns both to increase physician support for programs and because these concerns could be quite important for improving the quality of care.
EVALUATIONS OF P4P and public reporting programs should be explicitly designed to assess possible unintended consequences on disparities in health care delivery, on physicians who practice in areas of low socioeconomic status, and on the quality of care in important areas of physician practice not included in the program being evaluated.

General Internists’ Views On Pay-For-Performance And Public Reporting Of Quality Scores: A National Survey
Lawrence P. Casalino, G. Caleb Alexander, Lei Jin and R. Tamara Konetzka

Very little is known about rank-and-file physicians’ views on pay-for-performance (P4P) and public reporting. In a national survey of general internists, we found strong potential support for financial incentives for quality, but less support for public reporting. Large majorities of respondents stated that these programs will result in physicians’ avoiding high-risk patients and will divert attention from important types of care for which quality is not measured. Public and private policymakers might avoid a physician backlash and better succeed at improving health care quality if they consider these concerns when designing P4P and public reporting programs.

Health Affairs, 26, no. 2 (2007): 492-499
doi: 10.1377/hlthaff.26.2.492