Joyce Frieden

WASHINGTON – More programs need to be developed to address the specific health needs of minority women, Elena Cohen said at the annual meeting of the American Public Health Association.

“Racial minorities are projected to make up almost half the population by 2050,” said Ms. Cohen, senior counsel at the nonprofit National Women's Law Center. “But there's not much analysis of [health data on] racial and ethnic groups by gender.”

To further examine the issue, the center analyzed data on women's health from all 50 states and the District of Columbia. The center's report, “Making the Grade on Women's Health,” outlines disparities in women's health care in different states.

For example, black women have the highest rate of Pap smears and the lowest rate of osteoporosis, compared with other groups, but they also have the shortest life expectancy and the highest poverty rate, and they are least likely to get prenatal care. They have the highest mortality rates for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer, Ms. Cohen noted.

Latinas have the lowest mortality rate from stroke but are the second-least likely group to be screened for cervical cancer, and they fare worse than other groups in cervical cancer incidence and mortality, she said. This group has the highest percentage of uninsured women and the highest percentage of women who do no physical activity in their leisure time.

American Indian and Alaskan Native women had the second-lowest morality rate from stroke, but they fared worst of all groups for smoking, binge drinking, mortality from cirrhosis, and violence against them, Ms. Cohen said.

“The Asian-American/Pacific Islander group fared best in preventive health behaviors and in avoiding obesity and smoking, but these women do have other issues,” she said. But the report noted that cervical and ovarian cancer disproportionately affect these women, who are the second least likely group to have had a mammogram within the last 2 years.

WASHINGTON – More programs need to be developed to address the specific health needs of minority women, Elena Cohen said at the annual meeting of the American Public Health Association.

“Racial minorities are projected to make up almost half the population by 2050,” said Ms. Cohen, senior counsel at the nonprofit National Women's Law Center. “But there's not much analysis of [health data on] racial and ethnic groups by gender.”

To further examine the issue, the center analyzed data on women's health from all 50 states and the District of Columbia. The center's report, “Making the Grade on Women's Health,” outlines disparities in women's health care in different states.

For example, black women have the highest rate of Pap smears and the lowest rate of osteoporosis, compared with other groups, but they also have the shortest life expectancy and the highest poverty rate, and they are least likely to get prenatal care. They have the highest mortality rates for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer, Ms. Cohen noted.

Latinas have the lowest mortality rate from stroke but are the second-least likely group to be screened for cervical cancer, and they fare worse than other groups in cervical cancer incidence and mortality, she said. This group has the highest percentage of uninsured women and the highest percentage of women who do no physical activity in their leisure time.

American Indian and Alaskan Native women had the second-lowest morality rate from stroke, but they fared worst of all groups for smoking, binge drinking, mortality from cirrhosis, and violence against them, Ms. Cohen said.

“The Asian-American/Pacific Islander group fared best in preventive health behaviors and in avoiding obesity and smoking, but these women do have other issues,” she said. But the report noted that cervical and ovarian cancer disproportionately affect these women, who are the second least likely group to have had a mammogram within the last 2 years.

WASHINGTON – More programs need to be developed to address the specific health needs of minority women, Elena Cohen said at the annual meeting of the American Public Health Association.

“Racial minorities are projected to make up almost half the population by 2050,” said Ms. Cohen, senior counsel at the nonprofit National Women's Law Center. “But there's not much analysis of [health data on] racial and ethnic groups by gender.”

To further examine the issue, the center analyzed data on women's health from all 50 states and the District of Columbia. The center's report, “Making the Grade on Women's Health,” outlines disparities in women's health care in different states.

For example, black women have the highest rate of Pap smears and the lowest rate of osteoporosis, compared with other groups, but they also have the shortest life expectancy and the highest poverty rate, and they are least likely to get prenatal care. They have the highest mortality rates for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer, Ms. Cohen noted.

Latinas have the lowest mortality rate from stroke but are the second-least likely group to be screened for cervical cancer, and they fare worse than other groups in cervical cancer incidence and mortality, she said. This group has the highest percentage of uninsured women and the highest percentage of women who do no physical activity in their leisure time.

American Indian and Alaskan Native women had the second-lowest morality rate from stroke, but they fared worst of all groups for smoking, binge drinking, mortality from cirrhosis, and violence against them, Ms. Cohen said.

“The Asian-American/Pacific Islander group fared best in preventive health behaviors and in avoiding obesity and smoking, but these women do have other issues,” she said. But the report noted that cervical and ovarian cancer disproportionately affect these women, who are the second least likely group to have had a mammogram within the last 2 years.

WASHINGTON – Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.

“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”

One example is coronary heart disease (CHD), he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum; it doesn't start to even out until you get to the ninth decade of life. I'd be very concerned about these kinds of numbers.”

Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.

For instance, coronary artery bypass graft surgery (CABG) has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”

Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in black patients, including the idea that black patients rarely had myocardial infarctions or angina, or that they were immune to CHD.

“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” Dr. Gavin noted.

Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.

“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”

Medicare data on diabetes care show that something is clearly “amiss,” he continued. “For example, despite the greater prevalence and risk associated with it, African Americans are less likely to undergo hemoglobin A1c testing, or to have their lipids tested, or to have vaccinations. And this is in the Medicare population, where coverage is not the issue.”

In another instance of disparities in diabetes care, “African Americans are 12% of the population, but fully a third or more of the [end-stage renal disease] population,” he said. “They also are less likely to receive a kidney transplant and less likely to be referred for a transplant, or to be placed on a transplant waiting list. Those are decisions that someone has to make.”

Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter …that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”

Dr. Gavin said he didn't agree with the idea of “cultural competency.” “It's not something I'm convinced we ever become competent at. It's always a work in progress. But [we] can work to become more self-aware of our own cultural norms and values that will quickly lead us to misjudge or miscommunicate with others.”

One problem with cultural competency training, for instance, is that it can confer a false level of confidence, he noted. “We think we can go to one workshop and come out culturally competent, when in fact it's lifelong learning. And we have to be careful not to reinforce cultural stereotypes.”

Finally, even those who do attend such courses should remember that they do not substitute for having culturally representative health care teams. “We can never lose sight of that,” he said.

WASHINGTON – Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.

“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”

One example is coronary heart disease (CHD), he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum; it doesn't start to even out until you get to the ninth decade of life. I'd be very concerned about these kinds of numbers.”

Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.

For instance, coronary artery bypass graft surgery (CABG) has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”

Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in black patients, including the idea that black patients rarely had myocardial infarctions or angina, or that they were immune to CHD.

“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” Dr. Gavin noted.

Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.

“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”

Medicare data on diabetes care show that something is clearly “amiss,” he continued. “For example, despite the greater prevalence and risk associated with it, African Americans are less likely to undergo hemoglobin A1c testing, or to have their lipids tested, or to have vaccinations. And this is in the Medicare population, where coverage is not the issue.”

In another instance of disparities in diabetes care, “African Americans are 12% of the population, but fully a third or more of the [end-stage renal disease] population,” he said. “They also are less likely to receive a kidney transplant and less likely to be referred for a transplant, or to be placed on a transplant waiting list. Those are decisions that someone has to make.”

Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter …that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”

Dr. Gavin said he didn't agree with the idea of “cultural competency.” “It's not something I'm convinced we ever become competent at. It's always a work in progress. But [we] can work to become more self-aware of our own cultural norms and values that will quickly lead us to misjudge or miscommunicate with others.”

One problem with cultural competency training, for instance, is that it can confer a false level of confidence, he noted. “We think we can go to one workshop and come out culturally competent, when in fact it's lifelong learning. And we have to be careful not to reinforce cultural stereotypes.”

Finally, even those who do attend such courses should remember that they do not substitute for having culturally representative health care teams. “We can never lose sight of that,” he said.

WASHINGTON – Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.

“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”

One example is coronary heart disease (CHD), he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum; it doesn't start to even out until you get to the ninth decade of life. I'd be very concerned about these kinds of numbers.”

Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.

For instance, coronary artery bypass graft surgery (CABG) has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”

Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in black patients, including the idea that black patients rarely had myocardial infarctions or angina, or that they were immune to CHD.

“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” Dr. Gavin noted.

Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.

“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”

Medicare data on diabetes care show that something is clearly “amiss,” he continued. “For example, despite the greater prevalence and risk associated with it, African Americans are less likely to undergo hemoglobin A1c testing, or to have their lipids tested, or to have vaccinations. And this is in the Medicare population, where coverage is not the issue.”

In another instance of disparities in diabetes care, “African Americans are 12% of the population, but fully a third or more of the [end-stage renal disease] population,” he said. “They also are less likely to receive a kidney transplant and less likely to be referred for a transplant, or to be placed on a transplant waiting list. Those are decisions that someone has to make.”

Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter …that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”

Dr. Gavin said he didn't agree with the idea of “cultural competency.” “It's not something I'm convinced we ever become competent at. It's always a work in progress. But [we] can work to become more self-aware of our own cultural norms and values that will quickly lead us to misjudge or miscommunicate with others.”

One problem with cultural competency training, for instance, is that it can confer a false level of confidence, he noted. “We think we can go to one workshop and come out culturally competent, when in fact it's lifelong learning. And we have to be careful not to reinforce cultural stereotypes.”

Finally, even those who do attend such courses should remember that they do not substitute for having culturally representative health care teams. “We can never lose sight of that,” he said.

Reduced Funding for Mental Health

The president's fiscal 2006 budget request for the Department of Health and Human Services includes fewer dollars for mental health grants. The Substance Abuse and Mental Health Services Administration's proposed budget of $837 million for mental health programs reflects a net decrease of $64 million from 2005. The President's Commission on Mental Health “discovered a fragmented mental health system–a series of targeted categorical grants that didn't have a good sense of connectivity,” said HHS spokesman William Pierce. To reorganize the system, the proposed cut would only apply to new grants–those starting in fiscal year 2006. Infrastructure grants to support development of state mental plans and reduce system fragmentation would receive $26 million in 2006, a $6 million increase from 2005. The budget request would maintain SAMHSA's funding for community mental health services block grants ($433 million) and children's mental health services ($105 million). “There will also be a $5 million increase in HIV/AIDS minority mental health services, allowing for 11 new grants” in 2006, said Kathryn Power, director of SAMHSA's Center for Mental Health Services. The Campaign for Mental Health Reform, a coalition representing the American Psychiatric Association and other mental health organizations, called the budget “incredibly disappointing.”

Asian American Gays Surveyed

More than three-fourths of Asian Pacific American lesbian, gay, bisexual, and transgender (LGBT) people have experienced discrimination based on their sexual orientation, according to a study by the National Gay and Lesbian Task Force, an advocacy organization. As part of the first phase of the largest study of this group ever undertaken, researchers surveyed 124 attendees at a regional LGBT conference and found that 82% had experienced such discrimination: 82% also said they had experienced discrimination based on their race or ethnicity, and 96% of respondents agreed that homophobia and transphobia is a problem within the Asian Pacific American community. “The lives of Asian Pacific American [LGBT] people involve a complex web of issues arising from being sexual, racial/ethnic, language, gender, immigrant, and economic minorities,” said Glenn D. Magpantay, steering committee member of Gay Asian & Pacific Islander Men of New York. Participants in the survey were from a dozen different ethnic groups, including Chinese, Filipino, and Asian Indian.

Researching Terrorist Behavior

The University of Maryland has received a $12 million, 3-year grant from the Department of Homeland Security to open a social and behavioral research center dedicated to reducing worldwide terrorism. “The expertise of social scientists can help disrupt terror operations and reduce the after-effects of attacks,” Jacques Gansler, the university's vice president of research, said in a statement. “But so far the nation hasn't taken full advantage of their knowledge. With this new team, we hope to change that.” The center will work with five “major partner” academic centers as well as 10 other academic centers in the United States and abroad. Research teams will include psychologists, criminologists, and sociologists and will focus on issues such as the internal dynamics of terror organizations, looking for patterns of behavior or other predictors of what groups may do next.

Controversial Retiree Benefits Rule

The AARP is rejoicing now that a federal judge has temporarily blocked a new rule from the Equal Employment Opportunity Commission (EEOC) regarding retiree health benefits, but some members of Congress are not happy about this latest development. The rule, which the commission approved last April, exempts employers from age discrimination laws when it comes to designing retiree health benefits. The EEOC says the rule is designed to enable employers to better coordinate retiree benefits with Medicare, but AARP says the rule simply makes it easier for employers to reduce health benefits for older retirees, or abandon them altogether. EEOC chair Cari Dominguez said that “any delay in implementing the rule endangers vital protections for retirees.” Rep. John Boehner (R-Ohio), chairman of the House Committee on Education and the Workforce, issued a statement saying that “if the AARP is successful with its lawsuit, it will surely cause more workers to lose their retiree health coverage.” The judge's action, issued in early February, prevents the rule from being implemented for at least 60 days.

Proposed Wheelchair Rules Issued

In an effort to clarify the requirements, the Centers for Medicare and Medicaid Services has issued proposed new rules for coverage of wheelchairs for Medicare beneficiaries. Previously, coverage was given to patients who were “nonambulatory” or “bed or chair confined.” Under the proposed rules, providers must state whether the patient “has a mobility limitation that prevents him or her from performing one or more mobility-related activities of daily living.” The agency also plans to require a face-to-face meeting between the provider and the patient before a scooter or wheelchair can be ordered. Fraud has been an issue for CMS lately regarding power wheelchair coverage: The agency launched Operation Wheeler Dealer in late 2003 after finding that expenditures for power wheelchairs had increased 450% over a 4-year period.

Reduced Funding for Mental Health

The president's fiscal 2006 budget request for the Department of Health and Human Services includes fewer dollars for mental health grants. The Substance Abuse and Mental Health Services Administration's proposed budget of $837 million for mental health programs reflects a net decrease of $64 million from 2005. The President's Commission on Mental Health “discovered a fragmented mental health system–a series of targeted categorical grants that didn't have a good sense of connectivity,” said HHS spokesman William Pierce. To reorganize the system, the proposed cut would only apply to new grants–those starting in fiscal year 2006. Infrastructure grants to support development of state mental plans and reduce system fragmentation would receive $26 million in 2006, a $6 million increase from 2005. The budget request would maintain SAMHSA's funding for community mental health services block grants ($433 million) and children's mental health services ($105 million). “There will also be a $5 million increase in HIV/AIDS minority mental health services, allowing for 11 new grants” in 2006, said Kathryn Power, director of SAMHSA's Center for Mental Health Services. The Campaign for Mental Health Reform, a coalition representing the American Psychiatric Association and other mental health organizations, called the budget “incredibly disappointing.”

Asian American Gays Surveyed

More than three-fourths of Asian Pacific American lesbian, gay, bisexual, and transgender (LGBT) people have experienced discrimination based on their sexual orientation, according to a study by the National Gay and Lesbian Task Force, an advocacy organization. As part of the first phase of the largest study of this group ever undertaken, researchers surveyed 124 attendees at a regional LGBT conference and found that 82% had experienced such discrimination: 82% also said they had experienced discrimination based on their race or ethnicity, and 96% of respondents agreed that homophobia and transphobia is a problem within the Asian Pacific American community. “The lives of Asian Pacific American [LGBT] people involve a complex web of issues arising from being sexual, racial/ethnic, language, gender, immigrant, and economic minorities,” said Glenn D. Magpantay, steering committee member of Gay Asian & Pacific Islander Men of New York. Participants in the survey were from a dozen different ethnic groups, including Chinese, Filipino, and Asian Indian.

Researching Terrorist Behavior

The University of Maryland has received a $12 million, 3-year grant from the Department of Homeland Security to open a social and behavioral research center dedicated to reducing worldwide terrorism. “The expertise of social scientists can help disrupt terror operations and reduce the after-effects of attacks,” Jacques Gansler, the university's vice president of research, said in a statement. “But so far the nation hasn't taken full advantage of their knowledge. With this new team, we hope to change that.” The center will work with five “major partner” academic centers as well as 10 other academic centers in the United States and abroad. Research teams will include psychologists, criminologists, and sociologists and will focus on issues such as the internal dynamics of terror organizations, looking for patterns of behavior or other predictors of what groups may do next.

Controversial Retiree Benefits Rule

The AARP is rejoicing now that a federal judge has temporarily blocked a new rule from the Equal Employment Opportunity Commission (EEOC) regarding retiree health benefits, but some members of Congress are not happy about this latest development. The rule, which the commission approved last April, exempts employers from age discrimination laws when it comes to designing retiree health benefits. The EEOC says the rule is designed to enable employers to better coordinate retiree benefits with Medicare, but AARP says the rule simply makes it easier for employers to reduce health benefits for older retirees, or abandon them altogether. EEOC chair Cari Dominguez said that “any delay in implementing the rule endangers vital protections for retirees.” Rep. John Boehner (R-Ohio), chairman of the House Committee on Education and the Workforce, issued a statement saying that “if the AARP is successful with its lawsuit, it will surely cause more workers to lose their retiree health coverage.” The judge's action, issued in early February, prevents the rule from being implemented for at least 60 days.

Proposed Wheelchair Rules Issued

In an effort to clarify the requirements, the Centers for Medicare and Medicaid Services has issued proposed new rules for coverage of wheelchairs for Medicare beneficiaries. Previously, coverage was given to patients who were “nonambulatory” or “bed or chair confined.” Under the proposed rules, providers must state whether the patient “has a mobility limitation that prevents him or her from performing one or more mobility-related activities of daily living.” The agency also plans to require a face-to-face meeting between the provider and the patient before a scooter or wheelchair can be ordered. Fraud has been an issue for CMS lately regarding power wheelchair coverage: The agency launched Operation Wheeler Dealer in late 2003 after finding that expenditures for power wheelchairs had increased 450% over a 4-year period.

Reduced Funding for Mental Health

The president's fiscal 2006 budget request for the Department of Health and Human Services includes fewer dollars for mental health grants. The Substance Abuse and Mental Health Services Administration's proposed budget of $837 million for mental health programs reflects a net decrease of $64 million from 2005. The President's Commission on Mental Health “discovered a fragmented mental health system–a series of targeted categorical grants that didn't have a good sense of connectivity,” said HHS spokesman William Pierce. To reorganize the system, the proposed cut would only apply to new grants–those starting in fiscal year 2006. Infrastructure grants to support development of state mental plans and reduce system fragmentation would receive $26 million in 2006, a $6 million increase from 2005. The budget request would maintain SAMHSA's funding for community mental health services block grants ($433 million) and children's mental health services ($105 million). “There will also be a $5 million increase in HIV/AIDS minority mental health services, allowing for 11 new grants” in 2006, said Kathryn Power, director of SAMHSA's Center for Mental Health Services. The Campaign for Mental Health Reform, a coalition representing the American Psychiatric Association and other mental health organizations, called the budget “incredibly disappointing.”

Asian American Gays Surveyed

More than three-fourths of Asian Pacific American lesbian, gay, bisexual, and transgender (LGBT) people have experienced discrimination based on their sexual orientation, according to a study by the National Gay and Lesbian Task Force, an advocacy organization. As part of the first phase of the largest study of this group ever undertaken, researchers surveyed 124 attendees at a regional LGBT conference and found that 82% had experienced such discrimination: 82% also said they had experienced discrimination based on their race or ethnicity, and 96% of respondents agreed that homophobia and transphobia is a problem within the Asian Pacific American community. “The lives of Asian Pacific American [LGBT] people involve a complex web of issues arising from being sexual, racial/ethnic, language, gender, immigrant, and economic minorities,” said Glenn D. Magpantay, steering committee member of Gay Asian & Pacific Islander Men of New York. Participants in the survey were from a dozen different ethnic groups, including Chinese, Filipino, and Asian Indian.

Researching Terrorist Behavior

The University of Maryland has received a $12 million, 3-year grant from the Department of Homeland Security to open a social and behavioral research center dedicated to reducing worldwide terrorism. “The expertise of social scientists can help disrupt terror operations and reduce the after-effects of attacks,” Jacques Gansler, the university's vice president of research, said in a statement. “But so far the nation hasn't taken full advantage of their knowledge. With this new team, we hope to change that.” The center will work with five “major partner” academic centers as well as 10 other academic centers in the United States and abroad. Research teams will include psychologists, criminologists, and sociologists and will focus on issues such as the internal dynamics of terror organizations, looking for patterns of behavior or other predictors of what groups may do next.

Controversial Retiree Benefits Rule

The AARP is rejoicing now that a federal judge has temporarily blocked a new rule from the Equal Employment Opportunity Commission (EEOC) regarding retiree health benefits, but some members of Congress are not happy about this latest development. The rule, which the commission approved last April, exempts employers from age discrimination laws when it comes to designing retiree health benefits. The EEOC says the rule is designed to enable employers to better coordinate retiree benefits with Medicare, but AARP says the rule simply makes it easier for employers to reduce health benefits for older retirees, or abandon them altogether. EEOC chair Cari Dominguez said that “any delay in implementing the rule endangers vital protections for retirees.” Rep. John Boehner (R-Ohio), chairman of the House Committee on Education and the Workforce, issued a statement saying that “if the AARP is successful with its lawsuit, it will surely cause more workers to lose their retiree health coverage.” The judge's action, issued in early February, prevents the rule from being implemented for at least 60 days.

Proposed Wheelchair Rules Issued

In an effort to clarify the requirements, the Centers for Medicare and Medicaid Services has issued proposed new rules for coverage of wheelchairs for Medicare beneficiaries. Previously, coverage was given to patients who were “nonambulatory” or “bed or chair confined.” Under the proposed rules, providers must state whether the patient “has a mobility limitation that prevents him or her from performing one or more mobility-related activities of daily living.” The agency also plans to require a face-to-face meeting between the provider and the patient before a scooter or wheelchair can be ordered. Fraud has been an issue for CMS lately regarding power wheelchair coverage: The agency launched Operation Wheeler Dealer in late 2003 after finding that expenditures for power wheelchairs had increased 450% over a 4-year period.

WASHINGTON — More programs need to be developed to address the specific health needs of minority women, Elena Cohen said at the annual meeting of the American Public Health Association.

“Racial minorities are projected to make up almost half the population by 2050,” said Ms. Cohen, senior counsel at the nonprofit National Women's Law Center. “But there's not much analysis of [health data on] racial and ethnic groups by gender.”

The center analyzed data from all 50 states and the District of Columbia to compile a report, “Making the Grade on Women's Health,” that outlines disparities in women's health care (www.nwlc.org/details.cfm?id=1861&section=health

Black women have the highest rate of Pap smears and the lowest rate of osteoporosis, but they have the shortest life expectancy and the highest poverty rate, and are least likely to get prenatal care. They also have the highest mortality for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer.

Latinas have the lowest stroke mortality but are the second-least likely group to be screened for cervical cancer, and they fare worse than others in cervical cancer incidence and mortality. They have the highest rates of uninsured women and of women who get no leisure-time physical activity.

American Indian and Alaskan Native women had the second-lowest morality rate from stroke, but they fared worst of all groups for smoking, binge drinking, mortality from cirrhosis, and violence against them, Ms. Cohen said.

“The Asian-American/Pacific Islander group fared best in preventive health behaviors and in avoiding obesity and smoking,” she said, but the report noted that cervical and ovarian cancer disproportionately affect these women, who are also the second-least likely group to have had a mammogram within the last 2 years.

WASHINGTON — More programs need to be developed to address the specific health needs of minority women, Elena Cohen said at the annual meeting of the American Public Health Association.

“Racial minorities are projected to make up almost half the population by 2050,” said Ms. Cohen, senior counsel at the nonprofit National Women's Law Center. “But there's not much analysis of [health data on] racial and ethnic groups by gender.”

The center analyzed data from all 50 states and the District of Columbia to compile a report, “Making the Grade on Women's Health,” that outlines disparities in women's health care (www.nwlc.org/details.cfm?id=1861&section=health

Black women have the highest rate of Pap smears and the lowest rate of osteoporosis, but they have the shortest life expectancy and the highest poverty rate, and are least likely to get prenatal care. They also have the highest mortality for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer.

Latinas have the lowest stroke mortality but are the second-least likely group to be screened for cervical cancer, and they fare worse than others in cervical cancer incidence and mortality. They have the highest rates of uninsured women and of women who get no leisure-time physical activity.

American Indian and Alaskan Native women had the second-lowest morality rate from stroke, but they fared worst of all groups for smoking, binge drinking, mortality from cirrhosis, and violence against them, Ms. Cohen said.

“The Asian-American/Pacific Islander group fared best in preventive health behaviors and in avoiding obesity and smoking,” she said, but the report noted that cervical and ovarian cancer disproportionately affect these women, who are also the second-least likely group to have had a mammogram within the last 2 years.

WASHINGTON — More programs need to be developed to address the specific health needs of minority women, Elena Cohen said at the annual meeting of the American Public Health Association.

“Racial minorities are projected to make up almost half the population by 2050,” said Ms. Cohen, senior counsel at the nonprofit National Women's Law Center. “But there's not much analysis of [health data on] racial and ethnic groups by gender.”

The center analyzed data from all 50 states and the District of Columbia to compile a report, “Making the Grade on Women's Health,” that outlines disparities in women's health care (www.nwlc.org/details.cfm?id=1861&section=health

Black women have the highest rate of Pap smears and the lowest rate of osteoporosis, but they have the shortest life expectancy and the highest poverty rate, and are least likely to get prenatal care. They also have the highest mortality for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer.

Latinas have the lowest stroke mortality but are the second-least likely group to be screened for cervical cancer, and they fare worse than others in cervical cancer incidence and mortality. They have the highest rates of uninsured women and of women who get no leisure-time physical activity.

American Indian and Alaskan Native women had the second-lowest morality rate from stroke, but they fared worst of all groups for smoking, binge drinking, mortality from cirrhosis, and violence against them, Ms. Cohen said.

“The Asian-American/Pacific Islander group fared best in preventive health behaviors and in avoiding obesity and smoking,” she said, but the report noted that cervical and ovarian cancer disproportionately affect these women, who are also the second-least likely group to have had a mammogram within the last 2 years.

WASHINGTON — The trend toward consumer-driven health care will ultimately improve overall health care quality, Regina Herzlinger, Ph.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

Dr. Herzlinger, who is a professor of business administration at Harvard Business School, in Boston, contrasted the health care industry with the automotive industry.

The automotive industry, which is already consumer-driven, is deflationary and features increasing product quality, lots of available product information, and widespread ownership. The health care industry, on the other hand, is not consumer-driven and is characterized by inflation, unknown quality of care, and 46 million people without health insurance.

She noted that what helped the automotive industry along was the presence of entrepreneurs, who ended up being richly rewarded for their efforts.

For instance, Henry Ford, founder of the Ford Motor Co., created a new, less expensive form of steel from which to make cars. “Within a decade, car ownership went from 10,000 to 1 million,” she noted.

Although Mr. Ford and other automotive industry pioneers were rewarded, innovation in health care is not well rewarded, Dr. Herzlinger continued. As an example, she cited the case of Ralph Snyderman, M.D., who came up with the idea of integrating the care of patients with heart failure by organizing care teams. “In 1 year, he lowered the costs by 40%,” she said.

And what was his reward for doing so? “He lost the entire savings because the health care system does not pay for making sick people better. It pays for days in the hospital, for doctor visits, for components of care. So the healthier he made people, the fewer people went to the hospital, the fewer doctor visits there were, and the more money he lost. Right now, if you're a Henry Ford, you're punished, and we have very poor quality,” she said.

With consumer-driven health care, different products will be developed to respond to the needs of different consumers, she continued. And insurers will realize that they can be rewarded for considering consumers' longer-term needs.

“I want a 5-year insurance policy. I want my insurer to really care about my long-term health,” Dr. Herzlinger said.

Switzerland has 5-year insurance policies, she noted, “and if, at the end of the 5 years, you're healthier than would have been predicted at the beginning, you get 45% of your money back. How's that for a good deal for the insurer, the provider, and the customer?”

Dr. Herzlinger predicted that it will become commonplace for insurers to offer integrated team care for chronic diseases. The teams “will be wired, they'll be focused, and they're going to be paid for the fact that they're dealing with sicker people,” she said.

Offering such teams will be a matter of “simple economics,” she continued. “You're the insurer; 80% [of your money] goes for sick people. If you want to make it cheaper and better, how better to make it cheaper and better than to go to these organizations?”

Under a consumer-driven health care system, physicians will be paid based on outcomes, “and there will be long-term contracts so you don't look at your patients in a one-year kind of window,” she said. “Investments in self-care early on will be rewarded.”

One big driver behind consumer-driven health care will be aging Baby Boomers, a group that Dr. Herzlinger called “the most narcissistic, self-centered, empowered, and effective cohort we've ever had in the United States. The idea that this group isn't going to get what it wants, that's fantasy. They want [doctors] to integrate themselves, seize control of the system, and help patients care for their chronic diseases.”

She took issue with the notion that consumer-driven health care plans will be disadvantageous to sick people.

“Quite the contrary. It will finally focus attention on sick people. Right now it's in the incentive of the insurers to get rid of sick people and not to pay people who treat sick people well. But if you go to a consumer-driven system with risk-adjusted prices, the sick will be very attractive kinds of entities.”

She also disputed the notion that only those who can afford high-cost plans will get the highest-quality health care. “In the car market, what is the best car in the U.S.? Toyota,” she said. “Is that the highest-cost car? Not by a long shot.” Instead, it's the best-quality car “because that's where all the money is. That's the mass market.”

WASHINGTON — The trend toward consumer-driven health care will ultimately improve overall health care quality, Regina Herzlinger, Ph.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

Dr. Herzlinger, who is a professor of business administration at Harvard Business School, in Boston, contrasted the health care industry with the automotive industry.

The automotive industry, which is already consumer-driven, is deflationary and features increasing product quality, lots of available product information, and widespread ownership. The health care industry, on the other hand, is not consumer-driven and is characterized by inflation, unknown quality of care, and 46 million people without health insurance.

She noted that what helped the automotive industry along was the presence of entrepreneurs, who ended up being richly rewarded for their efforts.

For instance, Henry Ford, founder of the Ford Motor Co., created a new, less expensive form of steel from which to make cars. “Within a decade, car ownership went from 10,000 to 1 million,” she noted.

Although Mr. Ford and other automotive industry pioneers were rewarded, innovation in health care is not well rewarded, Dr. Herzlinger continued. As an example, she cited the case of Ralph Snyderman, M.D., who came up with the idea of integrating the care of patients with heart failure by organizing care teams. “In 1 year, he lowered the costs by 40%,” she said.

And what was his reward for doing so? “He lost the entire savings because the health care system does not pay for making sick people better. It pays for days in the hospital, for doctor visits, for components of care. So the healthier he made people, the fewer people went to the hospital, the fewer doctor visits there were, and the more money he lost. Right now, if you're a Henry Ford, you're punished, and we have very poor quality,” she said.

With consumer-driven health care, different products will be developed to respond to the needs of different consumers, she continued. And insurers will realize that they can be rewarded for considering consumers' longer-term needs.

“I want a 5-year insurance policy. I want my insurer to really care about my long-term health,” Dr. Herzlinger said.

Switzerland has 5-year insurance policies, she noted, “and if, at the end of the 5 years, you're healthier than would have been predicted at the beginning, you get 45% of your money back. How's that for a good deal for the insurer, the provider, and the customer?”

Dr. Herzlinger predicted that it will become commonplace for insurers to offer integrated team care for chronic diseases. The teams “will be wired, they'll be focused, and they're going to be paid for the fact that they're dealing with sicker people,” she said.

Offering such teams will be a matter of “simple economics,” she continued. “You're the insurer; 80% [of your money] goes for sick people. If you want to make it cheaper and better, how better to make it cheaper and better than to go to these organizations?”

Under a consumer-driven health care system, physicians will be paid based on outcomes, “and there will be long-term contracts so you don't look at your patients in a one-year kind of window,” she said. “Investments in self-care early on will be rewarded.”

One big driver behind consumer-driven health care will be aging Baby Boomers, a group that Dr. Herzlinger called “the most narcissistic, self-centered, empowered, and effective cohort we've ever had in the United States. The idea that this group isn't going to get what it wants, that's fantasy. They want [doctors] to integrate themselves, seize control of the system, and help patients care for their chronic diseases.”

She took issue with the notion that consumer-driven health care plans will be disadvantageous to sick people.

“Quite the contrary. It will finally focus attention on sick people. Right now it's in the incentive of the insurers to get rid of sick people and not to pay people who treat sick people well. But if you go to a consumer-driven system with risk-adjusted prices, the sick will be very attractive kinds of entities.”

She also disputed the notion that only those who can afford high-cost plans will get the highest-quality health care. “In the car market, what is the best car in the U.S.? Toyota,” she said. “Is that the highest-cost car? Not by a long shot.” Instead, it's the best-quality car “because that's where all the money is. That's the mass market.”

WASHINGTON — The trend toward consumer-driven health care will ultimately improve overall health care quality, Regina Herzlinger, Ph.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

Dr. Herzlinger, who is a professor of business administration at Harvard Business School, in Boston, contrasted the health care industry with the automotive industry.

The automotive industry, which is already consumer-driven, is deflationary and features increasing product quality, lots of available product information, and widespread ownership. The health care industry, on the other hand, is not consumer-driven and is characterized by inflation, unknown quality of care, and 46 million people without health insurance.

She noted that what helped the automotive industry along was the presence of entrepreneurs, who ended up being richly rewarded for their efforts.

For instance, Henry Ford, founder of the Ford Motor Co., created a new, less expensive form of steel from which to make cars. “Within a decade, car ownership went from 10,000 to 1 million,” she noted.

Although Mr. Ford and other automotive industry pioneers were rewarded, innovation in health care is not well rewarded, Dr. Herzlinger continued. As an example, she cited the case of Ralph Snyderman, M.D., who came up with the idea of integrating the care of patients with heart failure by organizing care teams. “In 1 year, he lowered the costs by 40%,” she said.

And what was his reward for doing so? “He lost the entire savings because the health care system does not pay for making sick people better. It pays for days in the hospital, for doctor visits, for components of care. So the healthier he made people, the fewer people went to the hospital, the fewer doctor visits there were, and the more money he lost. Right now, if you're a Henry Ford, you're punished, and we have very poor quality,” she said.

With consumer-driven health care, different products will be developed to respond to the needs of different consumers, she continued. And insurers will realize that they can be rewarded for considering consumers' longer-term needs.

“I want a 5-year insurance policy. I want my insurer to really care about my long-term health,” Dr. Herzlinger said.

Switzerland has 5-year insurance policies, she noted, “and if, at the end of the 5 years, you're healthier than would have been predicted at the beginning, you get 45% of your money back. How's that for a good deal for the insurer, the provider, and the customer?”

Dr. Herzlinger predicted that it will become commonplace for insurers to offer integrated team care for chronic diseases. The teams “will be wired, they'll be focused, and they're going to be paid for the fact that they're dealing with sicker people,” she said.

Offering such teams will be a matter of “simple economics,” she continued. “You're the insurer; 80% [of your money] goes for sick people. If you want to make it cheaper and better, how better to make it cheaper and better than to go to these organizations?”

Under a consumer-driven health care system, physicians will be paid based on outcomes, “and there will be long-term contracts so you don't look at your patients in a one-year kind of window,” she said. “Investments in self-care early on will be rewarded.”

One big driver behind consumer-driven health care will be aging Baby Boomers, a group that Dr. Herzlinger called “the most narcissistic, self-centered, empowered, and effective cohort we've ever had in the United States. The idea that this group isn't going to get what it wants, that's fantasy. They want [doctors] to integrate themselves, seize control of the system, and help patients care for their chronic diseases.”

She took issue with the notion that consumer-driven health care plans will be disadvantageous to sick people.

“Quite the contrary. It will finally focus attention on sick people. Right now it's in the incentive of the insurers to get rid of sick people and not to pay people who treat sick people well. But if you go to a consumer-driven system with risk-adjusted prices, the sick will be very attractive kinds of entities.”

She also disputed the notion that only those who can afford high-cost plans will get the highest-quality health care. “In the car market, what is the best car in the U.S.? Toyota,” she said. “Is that the highest-cost car? Not by a long shot.” Instead, it's the best-quality car “because that's where all the money is. That's the mass market.”

BALTIMORE — There might not have been thunderous applause at the meeting of the Medicare Coverage Advisory Committee, but the quiet approval was quite enough for Dean Ornish, M.D.

The committee, which advises Medicare on coverage issues, voted to recommend that Medicare cover the use of physician-supervised intensive diet and lifestyle change programs for preventing and reversing heart disease—programs such as the one developed by Dr. Ornish.

"I'm pleased by the opportunity to have all the evidence considered," he said after the panel approved the recommendation, adding that he hoped that the evidence was compelling enough for Medicare to make this type of lifestyle intervention a part of its benefits package. Medicare is not obligated to accept the recommendation of its advisory committee.

Dr. Ornish, president of the Preventive Medicine Research Institute, Sausalito, Calif., outlined his program, which consists of putting patients on a very low-fat diet (about 10% fat), getting them on a moderate exercise program, teaching them stress management techniques such as stretching and meditation, and enrolling them in support groups.

In a 1-year study of 28 patients who took part in the program and 20 controls, he found that the average percentage diameter stenosis regressed from 40% to 37.8% in the experimental group, compared with an average progression from 42.7% to 46.1% in the control group. In addition, there was a 91% reduction in angina in the intervention group, compared with a 165% increase in the control group.

Dr. Ornish also investigated whether other providers could be trained to implement his program, so he set up demonstration projects in other sites with more than 2,000 patients.

In the first project, funded by Mutual of Omaha, the researchers studied 194 patients with angiographically documented coronary artery disease and compared them with 139 controls. Although no patients in the intervention group had had a recent cardiac event, 55% had had a prior myocardial infarction, compared with 28% of controls.

The researchers found that after 3 years, 77% of intervention patients who met insurance company criteria to undergo bypass or angioplasty were able to avoid it, saving Mutual of Omaha $30,000 per patient, Dr. Ornish reported.

He admitted that his program requires a lot of commitment. For the first few months, participants attend two 4-hour sessions, each consisting of exercise, meditation or other stress reduction, a support group meeting, and a lunch/lecture. Later, they decrease to once-weekly sessions, but continue for 9 months.

In a payment demonstration project for Medicare, Dr. Ornish found that patients' body weight decreased both at 12 weeks and at 1 year. "Just on weight loss alone, I think a program like this could be beneficial." He said that the primary determinant of how much patients improved on the program was adherence. "The more people changed, the better they got," he noted.

Advisory committee members expressed several concerns about Dr. Ornish's results.

Clifford Goodman, Ph.D., a senior scientist with the Lewin Group, a Falls Church, Va. consulting firm, noted that some of the improvements in the patient groups started to reverse slightly after a year, and speculated that many patients may be self-selecting for the program at a time when their weight and other negative indicators are at their peak. "How much of the effect we're observing is simply regression to the mean?" he asked.

Dr. Ornish admitted that there was some regression but added, "there is a direct correlation between degree of adherence and outcomes at 1 year."

Adherence was a concern for several panel members who wondered whether patients could really keep up with strict regimens such as that of Dr. Ornish.

But Dr. Ornish said he was merely asking for these types of programs to be treated the same way as other interventions.

"We will pay for bypass surgery and angioplasty, but diet and lifestyle interventions, Medicare generally doesn't pay for it," he said, adding that many insurers pay for cholesterol-lowering statin drugs even though studies have shown that patients go off the drugs after a few months because they don't like the side effects.

Also testifying were spokesmen from two Blue Cross Blue Shield plans—Mountain State in West Virginia and Highmark in Pennsylvania—that pay patients to enroll in the Ornish program. Both said their plans were happy with the clinical outcomes and the cost savings.

David Lambert, vice president of health services for Mountain State Blue Cross Blue Shield, said his plan began covering the Ornish program for heart disease prevention in 2002.

More than 400 patients, average age 56, have participated, with a 90% completion rate, Mr. Lambert said. "They collectively reduced their risk of a cardiac event by 50% as measured by the ATP Framingham risk tool, and lowered their LDL by 21%."

He noted that the average cost of the behavioral management program was $5,700, compared with the cost of heart surgery, which ranges from $57,000 to $67,000. "By avoiding one procedure, it pays for 10 members to complete the program."

The committee also heard from Alex Clark, Ph.D., of the University of Alberta's Centre for Health Evidence in Edmonton. The Centers for Medicare and Medicaid Services contracted with Dr. Clark's center to review outcomes studies for patients with symptomatic coronary artery disease undergoing one of three types of therapy: cardiac rehabilitation (group education and counseling only), comprehensive cardiac rehabilitation (such as Dr. Ornish's program, which includes exercise in addition to group education and counseling), and individual counseling. All studies had to have outcomes for at least 50 patients to be included in the review.

The reviewers found that all three types of programs had some long-term benefits, including reductions in mortality and hospitalization, and improved quality of life, Dr. Clark said. "The foundation for change is happening at 12 months."

Information on program costs was sketchier, he noted. Only 6 out of 41 studies mentioned costs, and three of those "reported or implied" cost savings without giving any relevant data. Most of the studies were heavy on male participants, with seven studies having no women at all.

In the end, panel members generally agreed that the Ornish program and similar interventions improved patients' long-term survival rates and quality of life, but they were less certain that other providers would be able to successfully implement the program and that it could be easily translated to Medicare patients, many of whom have multiple chronic illnesses.

"This is a spectacular example of personalized health care," said William F. Owen Jr., M.D., a professor of medicine at Duke University, Durham, N.C. "I believe this works in a certain patient segment that's cared for by very passionate providers, but I'm uncomfortable about extrapolating it."

Now that the advisory committee has made its recommendation, CMS must decide whether to take up the issue of a national coverage determination, and what scope that potential coverage might have. An agency spokesman said there is no timetable for making the decision.

BALTIMORE — There might not have been thunderous applause at the meeting of the Medicare Coverage Advisory Committee, but the quiet approval was quite enough for Dean Ornish, M.D.

The committee, which advises Medicare on coverage issues, voted to recommend that Medicare cover the use of physician-supervised intensive diet and lifestyle change programs for preventing and reversing heart disease—programs such as the one developed by Dr. Ornish.

"I'm pleased by the opportunity to have all the evidence considered," he said after the panel approved the recommendation, adding that he hoped that the evidence was compelling enough for Medicare to make this type of lifestyle intervention a part of its benefits package. Medicare is not obligated to accept the recommendation of its advisory committee.

Dr. Ornish, president of the Preventive Medicine Research Institute, Sausalito, Calif., outlined his program, which consists of putting patients on a very low-fat diet (about 10% fat), getting them on a moderate exercise program, teaching them stress management techniques such as stretching and meditation, and enrolling them in support groups.

In a 1-year study of 28 patients who took part in the program and 20 controls, he found that the average percentage diameter stenosis regressed from 40% to 37.8% in the experimental group, compared with an average progression from 42.7% to 46.1% in the control group. In addition, there was a 91% reduction in angina in the intervention group, compared with a 165% increase in the control group.

Dr. Ornish also investigated whether other providers could be trained to implement his program, so he set up demonstration projects in other sites with more than 2,000 patients.

In the first project, funded by Mutual of Omaha, the researchers studied 194 patients with angiographically documented coronary artery disease and compared them with 139 controls. Although no patients in the intervention group had had a recent cardiac event, 55% had had a prior myocardial infarction, compared with 28% of controls.

The researchers found that after 3 years, 77% of intervention patients who met insurance company criteria to undergo bypass or angioplasty were able to avoid it, saving Mutual of Omaha $30,000 per patient, Dr. Ornish reported.

He admitted that his program requires a lot of commitment. For the first few months, participants attend two 4-hour sessions, each consisting of exercise, meditation or other stress reduction, a support group meeting, and a lunch/lecture. Later, they decrease to once-weekly sessions, but continue for 9 months.

In a payment demonstration project for Medicare, Dr. Ornish found that patients' body weight decreased both at 12 weeks and at 1 year. "Just on weight loss alone, I think a program like this could be beneficial." He said that the primary determinant of how much patients improved on the program was adherence. "The more people changed, the better they got," he noted.

Advisory committee members expressed several concerns about Dr. Ornish's results.

Clifford Goodman, Ph.D., a senior scientist with the Lewin Group, a Falls Church, Va. consulting firm, noted that some of the improvements in the patient groups started to reverse slightly after a year, and speculated that many patients may be self-selecting for the program at a time when their weight and other negative indicators are at their peak. "How much of the effect we're observing is simply regression to the mean?" he asked.

Dr. Ornish admitted that there was some regression but added, "there is a direct correlation between degree of adherence and outcomes at 1 year."

Adherence was a concern for several panel members who wondered whether patients could really keep up with strict regimens such as that of Dr. Ornish.

But Dr. Ornish said he was merely asking for these types of programs to be treated the same way as other interventions.

"We will pay for bypass surgery and angioplasty, but diet and lifestyle interventions, Medicare generally doesn't pay for it," he said, adding that many insurers pay for cholesterol-lowering statin drugs even though studies have shown that patients go off the drugs after a few months because they don't like the side effects.

Also testifying were spokesmen from two Blue Cross Blue Shield plans—Mountain State in West Virginia and Highmark in Pennsylvania—that pay patients to enroll in the Ornish program. Both said their plans were happy with the clinical outcomes and the cost savings.

David Lambert, vice president of health services for Mountain State Blue Cross Blue Shield, said his plan began covering the Ornish program for heart disease prevention in 2002.

More than 400 patients, average age 56, have participated, with a 90% completion rate, Mr. Lambert said. "They collectively reduced their risk of a cardiac event by 50% as measured by the ATP Framingham risk tool, and lowered their LDL by 21%."

He noted that the average cost of the behavioral management program was $5,700, compared with the cost of heart surgery, which ranges from $57,000 to $67,000. "By avoiding one procedure, it pays for 10 members to complete the program."

The committee also heard from Alex Clark, Ph.D., of the University of Alberta's Centre for Health Evidence in Edmonton. The Centers for Medicare and Medicaid Services contracted with Dr. Clark's center to review outcomes studies for patients with symptomatic coronary artery disease undergoing one of three types of therapy: cardiac rehabilitation (group education and counseling only), comprehensive cardiac rehabilitation (such as Dr. Ornish's program, which includes exercise in addition to group education and counseling), and individual counseling. All studies had to have outcomes for at least 50 patients to be included in the review.

The reviewers found that all three types of programs had some long-term benefits, including reductions in mortality and hospitalization, and improved quality of life, Dr. Clark said. "The foundation for change is happening at 12 months."

Information on program costs was sketchier, he noted. Only 6 out of 41 studies mentioned costs, and three of those "reported or implied" cost savings without giving any relevant data. Most of the studies were heavy on male participants, with seven studies having no women at all.

In the end, panel members generally agreed that the Ornish program and similar interventions improved patients' long-term survival rates and quality of life, but they were less certain that other providers would be able to successfully implement the program and that it could be easily translated to Medicare patients, many of whom have multiple chronic illnesses.

"This is a spectacular example of personalized health care," said William F. Owen Jr., M.D., a professor of medicine at Duke University, Durham, N.C. "I believe this works in a certain patient segment that's cared for by very passionate providers, but I'm uncomfortable about extrapolating it."

Now that the advisory committee has made its recommendation, CMS must decide whether to take up the issue of a national coverage determination, and what scope that potential coverage might have. An agency spokesman said there is no timetable for making the decision.

BALTIMORE — There might not have been thunderous applause at the meeting of the Medicare Coverage Advisory Committee, but the quiet approval was quite enough for Dean Ornish, M.D.

The committee, which advises Medicare on coverage issues, voted to recommend that Medicare cover the use of physician-supervised intensive diet and lifestyle change programs for preventing and reversing heart disease—programs such as the one developed by Dr. Ornish.

"I'm pleased by the opportunity to have all the evidence considered," he said after the panel approved the recommendation, adding that he hoped that the evidence was compelling enough for Medicare to make this type of lifestyle intervention a part of its benefits package. Medicare is not obligated to accept the recommendation of its advisory committee.

Dr. Ornish, president of the Preventive Medicine Research Institute, Sausalito, Calif., outlined his program, which consists of putting patients on a very low-fat diet (about 10% fat), getting them on a moderate exercise program, teaching them stress management techniques such as stretching and meditation, and enrolling them in support groups.

In a 1-year study of 28 patients who took part in the program and 20 controls, he found that the average percentage diameter stenosis regressed from 40% to 37.8% in the experimental group, compared with an average progression from 42.7% to 46.1% in the control group. In addition, there was a 91% reduction in angina in the intervention group, compared with a 165% increase in the control group.

Dr. Ornish also investigated whether other providers could be trained to implement his program, so he set up demonstration projects in other sites with more than 2,000 patients.

In the first project, funded by Mutual of Omaha, the researchers studied 194 patients with angiographically documented coronary artery disease and compared them with 139 controls. Although no patients in the intervention group had had a recent cardiac event, 55% had had a prior myocardial infarction, compared with 28% of controls.

The researchers found that after 3 years, 77% of intervention patients who met insurance company criteria to undergo bypass or angioplasty were able to avoid it, saving Mutual of Omaha $30,000 per patient, Dr. Ornish reported.

He admitted that his program requires a lot of commitment. For the first few months, participants attend two 4-hour sessions, each consisting of exercise, meditation or other stress reduction, a support group meeting, and a lunch/lecture. Later, they decrease to once-weekly sessions, but continue for 9 months.

In a payment demonstration project for Medicare, Dr. Ornish found that patients' body weight decreased both at 12 weeks and at 1 year. "Just on weight loss alone, I think a program like this could be beneficial." He said that the primary determinant of how much patients improved on the program was adherence. "The more people changed, the better they got," he noted.

Advisory committee members expressed several concerns about Dr. Ornish's results.

Clifford Goodman, Ph.D., a senior scientist with the Lewin Group, a Falls Church, Va. consulting firm, noted that some of the improvements in the patient groups started to reverse slightly after a year, and speculated that many patients may be self-selecting for the program at a time when their weight and other negative indicators are at their peak. "How much of the effect we're observing is simply regression to the mean?" he asked.

Dr. Ornish admitted that there was some regression but added, "there is a direct correlation between degree of adherence and outcomes at 1 year."

Adherence was a concern for several panel members who wondered whether patients could really keep up with strict regimens such as that of Dr. Ornish.

But Dr. Ornish said he was merely asking for these types of programs to be treated the same way as other interventions.

"We will pay for bypass surgery and angioplasty, but diet and lifestyle interventions, Medicare generally doesn't pay for it," he said, adding that many insurers pay for cholesterol-lowering statin drugs even though studies have shown that patients go off the drugs after a few months because they don't like the side effects.

Also testifying were spokesmen from two Blue Cross Blue Shield plans—Mountain State in West Virginia and Highmark in Pennsylvania—that pay patients to enroll in the Ornish program. Both said their plans were happy with the clinical outcomes and the cost savings.

David Lambert, vice president of health services for Mountain State Blue Cross Blue Shield, said his plan began covering the Ornish program for heart disease prevention in 2002.

More than 400 patients, average age 56, have participated, with a 90% completion rate, Mr. Lambert said. "They collectively reduced their risk of a cardiac event by 50% as measured by the ATP Framingham risk tool, and lowered their LDL by 21%."

He noted that the average cost of the behavioral management program was $5,700, compared with the cost of heart surgery, which ranges from $57,000 to $67,000. "By avoiding one procedure, it pays for 10 members to complete the program."

The committee also heard from Alex Clark, Ph.D., of the University of Alberta's Centre for Health Evidence in Edmonton. The Centers for Medicare and Medicaid Services contracted with Dr. Clark's center to review outcomes studies for patients with symptomatic coronary artery disease undergoing one of three types of therapy: cardiac rehabilitation (group education and counseling only), comprehensive cardiac rehabilitation (such as Dr. Ornish's program, which includes exercise in addition to group education and counseling), and individual counseling. All studies had to have outcomes for at least 50 patients to be included in the review.

The reviewers found that all three types of programs had some long-term benefits, including reductions in mortality and hospitalization, and improved quality of life, Dr. Clark said. "The foundation for change is happening at 12 months."

Information on program costs was sketchier, he noted. Only 6 out of 41 studies mentioned costs, and three of those "reported or implied" cost savings without giving any relevant data. Most of the studies were heavy on male participants, with seven studies having no women at all.

In the end, panel members generally agreed that the Ornish program and similar interventions improved patients' long-term survival rates and quality of life, but they were less certain that other providers would be able to successfully implement the program and that it could be easily translated to Medicare patients, many of whom have multiple chronic illnesses.

"This is a spectacular example of personalized health care," said William F. Owen Jr., M.D., a professor of medicine at Duke University, Durham, N.C. "I believe this works in a certain patient segment that's cared for by very passionate providers, but I'm uncomfortable about extrapolating it."

Now that the advisory committee has made its recommendation, CMS must decide whether to take up the issue of a national coverage determination, and what scope that potential coverage might have. An agency spokesman said there is no timetable for making the decision.

WASHINGTON — Medical debt is more common among families with full-time workers than among families whose members work part-time, according to University of Iowa researchers at the annual meeting of the American Public Health Association.

"Medical debt can result in credit problems and force people to file for bankruptcy," said Matthew Levi, a graduate research assistant in the department of community and behavioral health at the university. "These problems can be worsened if an individual stops going in for care and using prescription drugs because untreated problems can prevent a person from returning to work. People with medical debt also report increased levels of stress and anxiety."

The researchers looked at Urban Institute data from interviews with more than 1,400 residents, some done in person and some by phone. Subjects were located either in low-income areas of Des Moines or in surrounding Polk County.

Data came primarily from a single question in the survey asking whether the subject or their spouse was paying off any medical debt, although a few other responses also were included.

Surprisingly, people with full-time jobs were more likely to report medical debt, said Anne Wallis, Ph.D., of the department of community and behavioral health at the university.

Families with private health insurance were more likely to report medical debt than families without such insurance. However, this result may have been due to the way data were collected, since Medicaid data were reported separately.

Another surprising finding had to do with the household incomes of people reporting medical debt. "We see almost an upside-down 'U' shape where, with increases in income, up to a point, people are more likely to have medical debt," she said. "They're less likely to have Medicaid or some other type of coverage, and more likely to be among the working poor." Respondents on welfare also were more likely to have medical debt, she added.

WASHINGTON — Medical debt is more common among families with full-time workers than among families whose members work part-time, according to University of Iowa researchers at the annual meeting of the American Public Health Association.

"Medical debt can result in credit problems and force people to file for bankruptcy," said Matthew Levi, a graduate research assistant in the department of community and behavioral health at the university. "These problems can be worsened if an individual stops going in for care and using prescription drugs because untreated problems can prevent a person from returning to work. People with medical debt also report increased levels of stress and anxiety."

The researchers looked at Urban Institute data from interviews with more than 1,400 residents, some done in person and some by phone. Subjects were located either in low-income areas of Des Moines or in surrounding Polk County.

Data came primarily from a single question in the survey asking whether the subject or their spouse was paying off any medical debt, although a few other responses also were included.

Surprisingly, people with full-time jobs were more likely to report medical debt, said Anne Wallis, Ph.D., of the department of community and behavioral health at the university.

Families with private health insurance were more likely to report medical debt than families without such insurance. However, this result may have been due to the way data were collected, since Medicaid data were reported separately.

Another surprising finding had to do with the household incomes of people reporting medical debt. "We see almost an upside-down 'U' shape where, with increases in income, up to a point, people are more likely to have medical debt," she said. "They're less likely to have Medicaid or some other type of coverage, and more likely to be among the working poor." Respondents on welfare also were more likely to have medical debt, she added.

WASHINGTON — Medical debt is more common among families with full-time workers than among families whose members work part-time, according to University of Iowa researchers at the annual meeting of the American Public Health Association.

"Medical debt can result in credit problems and force people to file for bankruptcy," said Matthew Levi, a graduate research assistant in the department of community and behavioral health at the university. "These problems can be worsened if an individual stops going in for care and using prescription drugs because untreated problems can prevent a person from returning to work. People with medical debt also report increased levels of stress and anxiety."

The researchers looked at Urban Institute data from interviews with more than 1,400 residents, some done in person and some by phone. Subjects were located either in low-income areas of Des Moines or in surrounding Polk County.

Data came primarily from a single question in the survey asking whether the subject or their spouse was paying off any medical debt, although a few other responses also were included.

Surprisingly, people with full-time jobs were more likely to report medical debt, said Anne Wallis, Ph.D., of the department of community and behavioral health at the university.

Families with private health insurance were more likely to report medical debt than families without such insurance. However, this result may have been due to the way data were collected, since Medicaid data were reported separately.

Another surprising finding had to do with the household incomes of people reporting medical debt. "We see almost an upside-down 'U' shape where, with increases in income, up to a point, people are more likely to have medical debt," she said. "They're less likely to have Medicaid or some other type of coverage, and more likely to be among the working poor." Respondents on welfare also were more likely to have medical debt, she added.

WASHINGTON — Many current and former welfare recipients in New Jersey are not aware that their welfare payments do not increase if they have more children, but they also say that the rule would not affect their family planning decisions, Hannah Fortune-Greeley said at the annual meeting of the American Public Health Association.

New Jersey is 1 of 24 states that have a so-called “family cap” law, which states that women who have additional children while receiving Temporary Assistance to Needy Families (TANF) benefits will not have their benefits raised. The law is designed to discourage TANF recipients from having more children at a time when they don't have the means to support them.

In this pilot study, Ms. Fortune-Greeley, a graduate student at Columbia University School of Public Health, New York, and her colleagues interviewed 32 female current and former TANF recipients in New Jersey. Of those interviewed, 9 were black, 12 were Latino, 9 were white, and 2 were biracial. Respondents' average age was 31, and they had an average of 2.4 children. Seven did not have a high school diploma, and 14 were married. Seventy-five percent of recipients had some form of health insurance.

Slightly less than half the respondents reported that they were using contraception, and one-third of those said they were doing so primarily to prevent STDs.

Slightly more than half had had at least one abortion. The average number of abortions per recipient was 2.8; the highest number was six. Reasons given for having abortions included being in an abusive relationship, being an incest victim, and spacing children.

When asked whether they were aware of the family planning cap, only two respondents said they were, and neither of them could describe it accurately, Ms. Fortune-Greeley said.

When asked whether the cap would influence future decisions about childbearing now that they were aware of it, three-fourths said it wouldn't influence them at all. “Many of them were absolutely incredulous that we would even suggest there was a connection between governmental policy and how they would plan and form their families,” she said. The majority of the women said the policy wouldn't affect their use of contraception. “They said children were a blessing regardless of government policy,” Ms. Fortune-Greeley said. As to what would happen if they became pregnant while on TANF, almost all respondents said they would keep the baby; two said they would give it up for adoption.

“In terms of actual communication [in] department of social services offices, there's clearly a need for better communication of the policy to clients,” she said, adding that right now, “the policy doesn't appear to appear to be impacting women's reproductive decision making.”

The policy “does not work as intended,” Ms Fortune-Greeley said.

“It's not encouraging women to limit their fertility or to use more effective contraceptive methods, yet women are still subject to it. They're having more children without receiving this incremental increase, and it is posing additional economic hardship on already poor families. All of us know the potential health risks that poses,” she said at the meeting.

WASHINGTON — Many current and former welfare recipients in New Jersey are not aware that their welfare payments do not increase if they have more children, but they also say that the rule would not affect their family planning decisions, Hannah Fortune-Greeley said at the annual meeting of the American Public Health Association.

New Jersey is 1 of 24 states that have a so-called “family cap” law, which states that women who have additional children while receiving Temporary Assistance to Needy Families (TANF) benefits will not have their benefits raised. The law is designed to discourage TANF recipients from having more children at a time when they don't have the means to support them.

In this pilot study, Ms. Fortune-Greeley, a graduate student at Columbia University School of Public Health, New York, and her colleagues interviewed 32 female current and former TANF recipients in New Jersey. Of those interviewed, 9 were black, 12 were Latino, 9 were white, and 2 were biracial. Respondents' average age was 31, and they had an average of 2.4 children. Seven did not have a high school diploma, and 14 were married. Seventy-five percent of recipients had some form of health insurance.

Slightly less than half the respondents reported that they were using contraception, and one-third of those said they were doing so primarily to prevent STDs.

Slightly more than half had had at least one abortion. The average number of abortions per recipient was 2.8; the highest number was six. Reasons given for having abortions included being in an abusive relationship, being an incest victim, and spacing children.

When asked whether they were aware of the family planning cap, only two respondents said they were, and neither of them could describe it accurately, Ms. Fortune-Greeley said.

When asked whether the cap would influence future decisions about childbearing now that they were aware of it, three-fourths said it wouldn't influence them at all. “Many of them were absolutely incredulous that we would even suggest there was a connection between governmental policy and how they would plan and form their families,” she said. The majority of the women said the policy wouldn't affect their use of contraception. “They said children were a blessing regardless of government policy,” Ms. Fortune-Greeley said. As to what would happen if they became pregnant while on TANF, almost all respondents said they would keep the baby; two said they would give it up for adoption.

“In terms of actual communication [in] department of social services offices, there's clearly a need for better communication of the policy to clients,” she said, adding that right now, “the policy doesn't appear to appear to be impacting women's reproductive decision making.”

The policy “does not work as intended,” Ms Fortune-Greeley said.

“It's not encouraging women to limit their fertility or to use more effective contraceptive methods, yet women are still subject to it. They're having more children without receiving this incremental increase, and it is posing additional economic hardship on already poor families. All of us know the potential health risks that poses,” she said at the meeting.

WASHINGTON — Many current and former welfare recipients in New Jersey are not aware that their welfare payments do not increase if they have more children, but they also say that the rule would not affect their family planning decisions, Hannah Fortune-Greeley said at the annual meeting of the American Public Health Association.

New Jersey is 1 of 24 states that have a so-called “family cap” law, which states that women who have additional children while receiving Temporary Assistance to Needy Families (TANF) benefits will not have their benefits raised. The law is designed to discourage TANF recipients from having more children at a time when they don't have the means to support them.

In this pilot study, Ms. Fortune-Greeley, a graduate student at Columbia University School of Public Health, New York, and her colleagues interviewed 32 female current and former TANF recipients in New Jersey. Of those interviewed, 9 were black, 12 were Latino, 9 were white, and 2 were biracial. Respondents' average age was 31, and they had an average of 2.4 children. Seven did not have a high school diploma, and 14 were married. Seventy-five percent of recipients had some form of health insurance.

Slightly less than half the respondents reported that they were using contraception, and one-third of those said they were doing so primarily to prevent STDs.

Slightly more than half had had at least one abortion. The average number of abortions per recipient was 2.8; the highest number was six. Reasons given for having abortions included being in an abusive relationship, being an incest victim, and spacing children.

When asked whether they were aware of the family planning cap, only two respondents said they were, and neither of them could describe it accurately, Ms. Fortune-Greeley said.

When asked whether the cap would influence future decisions about childbearing now that they were aware of it, three-fourths said it wouldn't influence them at all. “Many of them were absolutely incredulous that we would even suggest there was a connection between governmental policy and how they would plan and form their families,” she said. The majority of the women said the policy wouldn't affect their use of contraception. “They said children were a blessing regardless of government policy,” Ms. Fortune-Greeley said. As to what would happen if they became pregnant while on TANF, almost all respondents said they would keep the baby; two said they would give it up for adoption.

“In terms of actual communication [in] department of social services offices, there's clearly a need for better communication of the policy to clients,” she said, adding that right now, “the policy doesn't appear to appear to be impacting women's reproductive decision making.”

The policy “does not work as intended,” Ms Fortune-Greeley said.

“It's not encouraging women to limit their fertility or to use more effective contraceptive methods, yet women are still subject to it. They're having more children without receiving this incremental increase, and it is posing additional economic hardship on already poor families. All of us know the potential health risks that poses,” she said at the meeting.

A tax on cosmetic procedures, already a reality in New Jersey, is causing concern among physicians in Illinois who fear their state may be next.

Late last year, Illinois State Comptroller Dan Hynes proposed a 6% tax on cosmetic procedures; revenues from the tax would be used to fund stem cell research. “Stem cell research promises to revolutionize the practice of medicine and spark treatment advances that could eventually improve the quality and duration of life for millions of Americans,” Mr. Hynes said in a statement. “I intend for the medical community of Illinois to be on the front lines of that revolution.”

Mr. Hynes noted that the state already faced “great financial difficulties” but added, “I want to be very clear here: What I am proposing is self-funded by this very narrowly defined luxury tax that is applicable to less than 2% of the population.”

He estimated that the tax could raise enough money to fund both the initial $15 million needed for the research as well as debt service on a $1 billion bond issued for ongoing funding. The comptroller's office is planning to present a full proposal to the state legislature “in the spring,” according to a spokesman for Mr. Hynes, who added that it “won't be a problem” to get a legislator to sponsor the bill.

The American Society of Plastic Surgeons blasted the proposal. “This is not the 'luxury tax' that Mr. Hynes would like the public to believe,” ASPS President Scott Spear, M.D., said in a statement. “Plastic surgery, as the statistics illustrate, has become more mainstream. It is not just an indulgence of celebrities and rich people. It is a reasonable option for anyone who wants to look or feel better about their appearance.”

Elvin Zook, M.D., past president of the ASPS, called the proposal “a grandstand play by the state comptroller, who's politically motivated.”

He warned that taxing one kind of surgery could lead to other surgery taxes. “So you have an artificial knee; why not tax that?” asked Dr. Zook, who is professor of plastic surgery at Southern Illinois University, Springfield.

In New Jersey, where a similar tax—also at 6%—went into effect last September, physicians are seeing the results.

“An hour ago I had a patient call in who had seen me in consultation, and wanted to go ahead with significant surgery, but she is going to see someone in New York because she doesn't want to pay the tax,” said Richard D'Amico, M.D., chief of plastic surgery at Englewood (N.J.) Hospital and Medical Center. “When you're talking about a $10,000 or $20,000 surgical bill, that's some real money.” For example, a 6% tax on a $20,000 procedure would amount to an extra $1,200.

The New Jersey tax includes both less invasive procedures such as Botox injections and facial peels, and more invasive procedures such as liposuction and facelifts. Legislators expect the tax to bring in $26 million to help cover uncompensated hospital care in the state, but it may not work out that way since many doctors who also have offices in nearby New York or Philadelphia are simply switching their procedures over to those states instead of doing them at New Jersey facilities, Dr. D'Amico said. “It's very ironic that [the hospitals] will be hurt the most by this.”

But officials at the New Jersey Hospital Association aren't worried. “I don't think it would put a dent into the $26 million, unless everybody fled,” said NJHA spokesman Ron Czajkowski, in Princeton.

In addition to the cosmetic surgery tax, the state legislature also enacted a 3.5% gross receipts tax on freestanding ambulatory surgery centers (ASCs); that tax is capped at an annual maximum of $200,000 per facility. Physicians who perform cosmetic procedures and who have an ownership interest in an ASC are affected by both taxes.

The cosmetic procedure tax is fraught with other problems besides lost business, according to Peter Hetzler, M.D., president of the New Jersey Society of Plastic Surgeons. For example, “there are a huge number of procedures that have both functional and cosmetic components to them, and how do you determine what gets taxed and what doesn't?” said Dr. Hetzler, who is in private practice in Little Silver, N.J.

He cited the example of a patient who has significant airway obstruction and gets a rhinoplasty to fix the sinuses, septum, and turbinates; the surgery may also affect the look of the nose. “We have to find a way to divide that up.”

Using CPT codes to designate which services will be taxed is not necessarily a solution, Dr. D'Amico said. “The code for a cosmetic breast lift is also the code for [restoring] symmetry in a woman who has had a mastectomy, but one is reconstructive and shouldn't be taxed,” he said. “None of that has been worked out.”

Dr. Hetzler has formed the Coalition of New Jersey Medical Professionals, a group of medical providers affected by the tax. The coalition is working with state taxation officials to figure out how to implement various aspects of the regulation, including the issue of how to tax procedures that are only partly cosmetic.

The coalition has little hope that the tax will be repealed, especially in the face of the state's large budget deficit, Dr. Hetzler said. But he is pleased that taxation officials have been cooperative and are willing to work with the coalition “to make sure that they don't indiscriminately audit physicians who may be at the mercy of patients paying this tax.”

Naomi Lawrence, M.D., a spokeswoman for the American Academy of Dermatology, said that she was concerned that the tax idea may spread to other states.

“Everybody's looking for a way to cover charity care; they are desperate to find some way to do it,” said Dr. Lawrence, chief of procedural dermatology at Cooper University Hospital, Marlton, N.J. “It's one of those ideas that's very popular with hospital associations across the country.”

Dr. D'Amico agreed, noting that New Jersey's tax, which was passed without any input from affected providers, should serve as a warning to providers in other states. “They should be careful in whatever state they're in that this doesn't come up,” he said.

A tax on cosmetic procedures, already a reality in New Jersey, is causing concern among physicians in Illinois who fear their state may be next.

Late last year, Illinois State Comptroller Dan Hynes proposed a 6% tax on cosmetic procedures; revenues from the tax would be used to fund stem cell research. “Stem cell research promises to revolutionize the practice of medicine and spark treatment advances that could eventually improve the quality and duration of life for millions of Americans,” Mr. Hynes said in a statement. “I intend for the medical community of Illinois to be on the front lines of that revolution.”

Mr. Hynes noted that the state already faced “great financial difficulties” but added, “I want to be very clear here: What I am proposing is self-funded by this very narrowly defined luxury tax that is applicable to less than 2% of the population.”

He estimated that the tax could raise enough money to fund both the initial $15 million needed for the research as well as debt service on a $1 billion bond issued for ongoing funding. The comptroller's office is planning to present a full proposal to the state legislature “in the spring,” according to a spokesman for Mr. Hynes, who added that it “won't be a problem” to get a legislator to sponsor the bill.

The American Society of Plastic Surgeons blasted the proposal. “This is not the 'luxury tax' that Mr. Hynes would like the public to believe,” ASPS President Scott Spear, M.D., said in a statement. “Plastic surgery, as the statistics illustrate, has become more mainstream. It is not just an indulgence of celebrities and rich people. It is a reasonable option for anyone who wants to look or feel better about their appearance.”

Elvin Zook, M.D., past president of the ASPS, called the proposal “a grandstand play by the state comptroller, who's politically motivated.”

He warned that taxing one kind of surgery could lead to other surgery taxes. “So you have an artificial knee; why not tax that?” asked Dr. Zook, who is professor of plastic surgery at Southern Illinois University, Springfield.

In New Jersey, where a similar tax—also at 6%—went into effect last September, physicians are seeing the results.

“An hour ago I had a patient call in who had seen me in consultation, and wanted to go ahead with significant surgery, but she is going to see someone in New York because she doesn't want to pay the tax,” said Richard D'Amico, M.D., chief of plastic surgery at Englewood (N.J.) Hospital and Medical Center. “When you're talking about a $10,000 or $20,000 surgical bill, that's some real money.” For example, a 6% tax on a $20,000 procedure would amount to an extra $1,200.

The New Jersey tax includes both less invasive procedures such as Botox injections and facial peels, and more invasive procedures such as liposuction and facelifts. Legislators expect the tax to bring in $26 million to help cover uncompensated hospital care in the state, but it may not work out that way since many doctors who also have offices in nearby New York or Philadelphia are simply switching their procedures over to those states instead of doing them at New Jersey facilities, Dr. D'Amico said. “It's very ironic that [the hospitals] will be hurt the most by this.”

But officials at the New Jersey Hospital Association aren't worried. “I don't think it would put a dent into the $26 million, unless everybody fled,” said NJHA spokesman Ron Czajkowski, in Princeton.

In addition to the cosmetic surgery tax, the state legislature also enacted a 3.5% gross receipts tax on freestanding ambulatory surgery centers (ASCs); that tax is capped at an annual maximum of $200,000 per facility. Physicians who perform cosmetic procedures and who have an ownership interest in an ASC are affected by both taxes.

The cosmetic procedure tax is fraught with other problems besides lost business, according to Peter Hetzler, M.D., president of the New Jersey Society of Plastic Surgeons. For example, “there are a huge number of procedures that have both functional and cosmetic components to them, and how do you determine what gets taxed and what doesn't?” said Dr. Hetzler, who is in private practice in Little Silver, N.J.

He cited the example of a patient who has significant airway obstruction and gets a rhinoplasty to fix the sinuses, septum, and turbinates; the surgery may also affect the look of the nose. “We have to find a way to divide that up.”

Using CPT codes to designate which services will be taxed is not necessarily a solution, Dr. D'Amico said. “The code for a cosmetic breast lift is also the code for [restoring] symmetry in a woman who has had a mastectomy, but one is reconstructive and shouldn't be taxed,” he said. “None of that has been worked out.”

Dr. Hetzler has formed the Coalition of New Jersey Medical Professionals, a group of medical providers affected by the tax. The coalition is working with state taxation officials to figure out how to implement various aspects of the regulation, including the issue of how to tax procedures that are only partly cosmetic.

The coalition has little hope that the tax will be repealed, especially in the face of the state's large budget deficit, Dr. Hetzler said. But he is pleased that taxation officials have been cooperative and are willing to work with the coalition “to make sure that they don't indiscriminately audit physicians who may be at the mercy of patients paying this tax.”

Naomi Lawrence, M.D., a spokeswoman for the American Academy of Dermatology, said that she was concerned that the tax idea may spread to other states.

“Everybody's looking for a way to cover charity care; they are desperate to find some way to do it,” said Dr. Lawrence, chief of procedural dermatology at Cooper University Hospital, Marlton, N.J. “It's one of those ideas that's very popular with hospital associations across the country.”

Dr. D'Amico agreed, noting that New Jersey's tax, which was passed without any input from affected providers, should serve as a warning to providers in other states. “They should be careful in whatever state they're in that this doesn't come up,” he said.

A tax on cosmetic procedures, already a reality in New Jersey, is causing concern among physicians in Illinois who fear their state may be next.

Late last year, Illinois State Comptroller Dan Hynes proposed a 6% tax on cosmetic procedures; revenues from the tax would be used to fund stem cell research. “Stem cell research promises to revolutionize the practice of medicine and spark treatment advances that could eventually improve the quality and duration of life for millions of Americans,” Mr. Hynes said in a statement. “I intend for the medical community of Illinois to be on the front lines of that revolution.”

Mr. Hynes noted that the state already faced “great financial difficulties” but added, “I want to be very clear here: What I am proposing is self-funded by this very narrowly defined luxury tax that is applicable to less than 2% of the population.”

He estimated that the tax could raise enough money to fund both the initial $15 million needed for the research as well as debt service on a $1 billion bond issued for ongoing funding. The comptroller's office is planning to present a full proposal to the state legislature “in the spring,” according to a spokesman for Mr. Hynes, who added that it “won't be a problem” to get a legislator to sponsor the bill.

The American Society of Plastic Surgeons blasted the proposal. “This is not the 'luxury tax' that Mr. Hynes would like the public to believe,” ASPS President Scott Spear, M.D., said in a statement. “Plastic surgery, as the statistics illustrate, has become more mainstream. It is not just an indulgence of celebrities and rich people. It is a reasonable option for anyone who wants to look or feel better about their appearance.”

Elvin Zook, M.D., past president of the ASPS, called the proposal “a grandstand play by the state comptroller, who's politically motivated.”

He warned that taxing one kind of surgery could lead to other surgery taxes. “So you have an artificial knee; why not tax that?” asked Dr. Zook, who is professor of plastic surgery at Southern Illinois University, Springfield.

In New Jersey, where a similar tax—also at 6%—went into effect last September, physicians are seeing the results.

“An hour ago I had a patient call in who had seen me in consultation, and wanted to go ahead with significant surgery, but she is going to see someone in New York because she doesn't want to pay the tax,” said Richard D'Amico, M.D., chief of plastic surgery at Englewood (N.J.) Hospital and Medical Center. “When you're talking about a $10,000 or $20,000 surgical bill, that's some real money.” For example, a 6% tax on a $20,000 procedure would amount to an extra $1,200.

The New Jersey tax includes both less invasive procedures such as Botox injections and facial peels, and more invasive procedures such as liposuction and facelifts. Legislators expect the tax to bring in $26 million to help cover uncompensated hospital care in the state, but it may not work out that way since many doctors who also have offices in nearby New York or Philadelphia are simply switching their procedures over to those states instead of doing them at New Jersey facilities, Dr. D'Amico said. “It's very ironic that [the hospitals] will be hurt the most by this.”

But officials at the New Jersey Hospital Association aren't worried. “I don't think it would put a dent into the $26 million, unless everybody fled,” said NJHA spokesman Ron Czajkowski, in Princeton.

In addition to the cosmetic surgery tax, the state legislature also enacted a 3.5% gross receipts tax on freestanding ambulatory surgery centers (ASCs); that tax is capped at an annual maximum of $200,000 per facility. Physicians who perform cosmetic procedures and who have an ownership interest in an ASC are affected by both taxes.

The cosmetic procedure tax is fraught with other problems besides lost business, according to Peter Hetzler, M.D., president of the New Jersey Society of Plastic Surgeons. For example, “there are a huge number of procedures that have both functional and cosmetic components to them, and how do you determine what gets taxed and what doesn't?” said Dr. Hetzler, who is in private practice in Little Silver, N.J.

He cited the example of a patient who has significant airway obstruction and gets a rhinoplasty to fix the sinuses, septum, and turbinates; the surgery may also affect the look of the nose. “We have to find a way to divide that up.”

Using CPT codes to designate which services will be taxed is not necessarily a solution, Dr. D'Amico said. “The code for a cosmetic breast lift is also the code for [restoring] symmetry in a woman who has had a mastectomy, but one is reconstructive and shouldn't be taxed,” he said. “None of that has been worked out.”

Dr. Hetzler has formed the Coalition of New Jersey Medical Professionals, a group of medical providers affected by the tax. The coalition is working with state taxation officials to figure out how to implement various aspects of the regulation, including the issue of how to tax procedures that are only partly cosmetic.

The coalition has little hope that the tax will be repealed, especially in the face of the state's large budget deficit, Dr. Hetzler said. But he is pleased that taxation officials have been cooperative and are willing to work with the coalition “to make sure that they don't indiscriminately audit physicians who may be at the mercy of patients paying this tax.”

Naomi Lawrence, M.D., a spokeswoman for the American Academy of Dermatology, said that she was concerned that the tax idea may spread to other states.

“Everybody's looking for a way to cover charity care; they are desperate to find some way to do it,” said Dr. Lawrence, chief of procedural dermatology at Cooper University Hospital, Marlton, N.J. “It's one of those ideas that's very popular with hospital associations across the country.”

Dr. D'Amico agreed, noting that New Jersey's tax, which was passed without any input from affected providers, should serve as a warning to providers in other states. “They should be careful in whatever state they're in that this doesn't come up,” he said.

WASHINGTON — Medical debt is more common among families with full-time workers than among families whose members work part-time, according to University of Iowa researchers at the annual meeting of the American Public Health Association.

“Medical debt can result in credit problems and force people to file for bankruptcy,” said Matthew Levi, a graduate research assistant in the department of community and behavioral health at the university. “These problems can be worsened if an individual stops going in for care and using prescription drugs because untreated problems can prevent a person from returning to work. People with medical debt also report increased levels of stress and anxiety.”

The researchers looked at Urban Institute data from interviews with more than 1,400 residents, some done in person and some by phone. Subjects were located either in low-income areas of Des Moines or in surrounding Polk County.

Data came primarily from a single question in the survey asking whether the subject or their spouse was paying off any medical debt, although a few other responses also were included.

Surprisingly, people with full-time jobs were more likely to report medical debt, said Anne Wallis, Ph.D., of the department of community and behavioral health at the university. “We suspect this reflects having full-time employment, but without health insurance, or with inadequate health insurance.”

Families with private health insurance were more likely to report medical debt than families without such insurance. However, this result may have been due to the way data were collected, since Medicaid data were reported separately. “So [it may just show] that families with private health insurance are not adequately insured,” Dr. Wallis said.

Another surprising finding had to do with the household incomes of people reporting medical debt. “We see almost an upside-down 'U' shape where, with increases in income, up to a point, people are more likely to have medical debt,” Dr. Wallis said. “They're less likely to have Medicaid or some other type of coverage, and more likely to be among the working poor.” Respondents on welfare also were more likely to have medical debt, she added.

More than one-third of households with children reported medical debt—but without correlation to the child's health status, Dr. Wallis said. “Where parents reported their child's health as being poor, 100% reported medical debt, in addition to 50% who reported debt if their child's health was fair,” she said. “But even when the child's health was good or excellent, medical debt approached 40%.”

The researchers did not find a lot of differences in the amount of medical debt reported when comparing the ages of children in the house; however, there was a dip in the percentage of debt reported by families with preschool-aged children. “We're not re ally sure what that's about, [but] a lot of children in this sample are Head Start children, so they would be receiving some services and referrals,” Dr. Wallis noted.

WASHINGTON — Medical debt is more common among families with full-time workers than among families whose members work part-time, according to University of Iowa researchers at the annual meeting of the American Public Health Association.

“Medical debt can result in credit problems and force people to file for bankruptcy,” said Matthew Levi, a graduate research assistant in the department of community and behavioral health at the university. “These problems can be worsened if an individual stops going in for care and using prescription drugs because untreated problems can prevent a person from returning to work. People with medical debt also report increased levels of stress and anxiety.”

The researchers looked at Urban Institute data from interviews with more than 1,400 residents, some done in person and some by phone. Subjects were located either in low-income areas of Des Moines or in surrounding Polk County.

Data came primarily from a single question in the survey asking whether the subject or their spouse was paying off any medical debt, although a few other responses also were included.

Surprisingly, people with full-time jobs were more likely to report medical debt, said Anne Wallis, Ph.D., of the department of community and behavioral health at the university. “We suspect this reflects having full-time employment, but without health insurance, or with inadequate health insurance.”

Families with private health insurance were more likely to report medical debt than families without such insurance. However, this result may have been due to the way data were collected, since Medicaid data were reported separately. “So [it may just show] that families with private health insurance are not adequately insured,” Dr. Wallis said.

Another surprising finding had to do with the household incomes of people reporting medical debt. “We see almost an upside-down 'U' shape where, with increases in income, up to a point, people are more likely to have medical debt,” Dr. Wallis said. “They're less likely to have Medicaid or some other type of coverage, and more likely to be among the working poor.” Respondents on welfare also were more likely to have medical debt, she added.

More than one-third of households with children reported medical debt—but without correlation to the child's health status, Dr. Wallis said. “Where parents reported their child's health as being poor, 100% reported medical debt, in addition to 50% who reported debt if their child's health was fair,” she said. “But even when the child's health was good or excellent, medical debt approached 40%.”

The researchers did not find a lot of differences in the amount of medical debt reported when comparing the ages of children in the house; however, there was a dip in the percentage of debt reported by families with preschool-aged children. “We're not re ally sure what that's about, [but] a lot of children in this sample are Head Start children, so they would be receiving some services and referrals,” Dr. Wallis noted.

WASHINGTON — Medical debt is more common among families with full-time workers than among families whose members work part-time, according to University of Iowa researchers at the annual meeting of the American Public Health Association.

“Medical debt can result in credit problems and force people to file for bankruptcy,” said Matthew Levi, a graduate research assistant in the department of community and behavioral health at the university. “These problems can be worsened if an individual stops going in for care and using prescription drugs because untreated problems can prevent a person from returning to work. People with medical debt also report increased levels of stress and anxiety.”

The researchers looked at Urban Institute data from interviews with more than 1,400 residents, some done in person and some by phone. Subjects were located either in low-income areas of Des Moines or in surrounding Polk County.

Data came primarily from a single question in the survey asking whether the subject or their spouse was paying off any medical debt, although a few other responses also were included.

Surprisingly, people with full-time jobs were more likely to report medical debt, said Anne Wallis, Ph.D., of the department of community and behavioral health at the university. “We suspect this reflects having full-time employment, but without health insurance, or with inadequate health insurance.”

Families with private health insurance were more likely to report medical debt than families without such insurance. However, this result may have been due to the way data were collected, since Medicaid data were reported separately. “So [it may just show] that families with private health insurance are not adequately insured,” Dr. Wallis said.

Another surprising finding had to do with the household incomes of people reporting medical debt. “We see almost an upside-down 'U' shape where, with increases in income, up to a point, people are more likely to have medical debt,” Dr. Wallis said. “They're less likely to have Medicaid or some other type of coverage, and more likely to be among the working poor.” Respondents on welfare also were more likely to have medical debt, she added.

More than one-third of households with children reported medical debt—but without correlation to the child's health status, Dr. Wallis said. “Where parents reported their child's health as being poor, 100% reported medical debt, in addition to 50% who reported debt if their child's health was fair,” she said. “But even when the child's health was good or excellent, medical debt approached 40%.”

The researchers did not find a lot of differences in the amount of medical debt reported when comparing the ages of children in the house; however, there was a dip in the percentage of debt reported by families with preschool-aged children. “We're not re ally sure what that's about, [but] a lot of children in this sample are Head Start children, so they would be receiving some services and referrals,” Dr. Wallis noted.