Joyce Frieden

Need a good treatment program for a patient addicted to methamphetamines? Good luck finding one, law enforcement experts say.

“Regrettably, there are not enough treatment beds in any area of the country to offer timely and adequate treatment opportunities,” Steve Bundy, sheriff of Rice County, Kan., said in written testimony at a hearing convened by the House subcommittee on criminal justice, drug policy, and human resources.

Mr. Bundy, who, with his four deputies, serves residents over a 750-square-mile area, said methamphetamine addiction consumes a majority of his time each day. He is the only one of the five who is qualified to dismantle and clean up methamphetamine production facilities.

He noted that methamphetamine addiction is particularly problematic for several reasons: Directions for making the drug are readily available, the ingredients can be obtained in any pharmacy and mixed together at home, and use of methamphetamines cuts across social, ethnic, and gender boundaries.

From a health care standpoint, methamphetamine addiction only gets worse once it starts, Lonnie Wright, director of the Bureau of Narcotics and Dangerous Drugs Control for the state of Oklahoma, said at the hearing.

“When you can manufacture methamphetamine at home for a fraction of the cost to buy it on the street, and you can have all of it you want and it's basically pure, there's nothing to limit your addiction,” he said. “Prolonged chronic addiction leads to … methamphetamine psychosis, [which is] clinically indistinguishable from paranoid schizophrenia, we're told by our medical experts in Oklahoma.”

In fact, the similarities are many between methamphetamine psychosis and paranoid schizophrenia, according to Eugene Wang, M.D., of the University of Hawaii at Manoa.

Dr. Wang places something called “amphetamine-induced psychotic disorder” in the same clinical spectrum as schizophrenia and notes that some criminal lawyers have used the insanity defense for clients who were chronically addicted to methamphetamines.

“Some researchers believe that amphetamine psychosis is just a variant of schizophrenia,” Dr. Wang said at the annual meeting of the American Academy of Psychiatry and the Law, in Scottsdale, Ariz. One similarity between the two is that both respond favorably to antipsychotic medications.

But a solid answer is hard to come by. “According to the DSM-IV criteria for schizophrenia, the symptoms cannot be due to a direct physiological effect of a substance,” he noted. “On the other hand, when someone develops a persistent psychosis following amphetamine use, the diagnosis of the disorder takes into account a new understanding of the effects of amphetamines.”

Marvin Seppala, M.D., chief medical officer for the Hazelden Foundation, a large addiction treatment provider, said methamphetamine addicts were difficult to treat because, unlike some other addictions, methamphetamine addiction is often associated with a “significant” psychosis, which is accompanied by agitation and violence.

“That combination leaves families and social services in a difficult situation when it comes to getting people into treatment,” said Dr. Seppala, who is based in Newberg, Ore. “Families are scared to do anything, because the addict may react to that. And with social services, the person comes in but [may not be] in a position to enter addiction treatment immediately.”

The biggest problem is that there are facilities to handle violence and psychosis—such as psychiatric hospitals—and facilities to handle methamphetamine addiction, but few places that handle both.

“If you're violent and require a psychiatric facility, it often doesn't have addiction treatment ready,” Dr. Seppala said. “And if you go to addiction treatment, those facilities are not staffed for acute psychosis and violence.”

Federal and state governments are attacking methamphetamine addiction at several levels, according to experts who spoke at the hearing.

On the supply side, the federal Office of National Drug Control Policy (ONDCP) has been working to cut off supplies of pseudoephedrine, the principal ingredient in methamphetamine, that are coming from Canada, according to Scott Burns, the ONDCP's deputy director for state and local affairs.

Canadian supplies of the drug are being used by U.S. “superlabs,” each of which produce more than 10 pounds of methamphetamine a day.

“Our approach must be market based, focused on reducing both supply and demand for the drug,” Mr. Burns said at the hearing. “We've seen a shrinking of these superlabs within the United States, and that's good news. However, we believe some of these superlabs are being pushed south of our borders to Mexico. For this reason, we'll continue to work [with the Mexican government] to stop the flow of these chemicals into Mexico.”

States are also doing their own part to reduce the demand for pseudoephedrine.

Oklahoma, for example, has seen a large drop in the number of home-grown methamphetamine labs since the implementation of House Bill 2176, the Trooper Nik Green, Rocky Eales and Matthew Evans Act.

The law does not require a doctor's prescription for pseudoephedrine, but does make it a Schedule V (restricted) medication; the law also requires pharmacies to keep the drug behind the counter, make purchasers sign a log, and limit purchases to no more than 9 grams per month, “much more than one taking the full recommended dosage during that time period would need,” Mr. Wright noted at the hearing.

Before the bill was signed into law last April, state law enforcement authorities seized an averaged of 92 meth labs each month.

That number had dropped by 32 by August.

Meth labs do continue to operate, however, because of pharmacies not enforcing the law strictly enough, smugglers bringing the drug in from surrounding states, and criminals going to more than one pharmacy to obtain the drug—staying under the legal limit at each store but obtaining much more on the whole.

That latter practice, known as “smirfing,” should be stopped when Oklahoma implements a statewide computerized system for pharmacists to find out who has purchased the drug and in what amounts, Mr. Wright said.

A pharmacy representative urged subcommittee members to be cautious about copying the Oklahoma law.

“Raising barriers for consumers to access pseudoephedrine is a short-term solution to a long-term problem,” said Mary Ann Wagner, vice president for pharmacy regulatory affairs at the National Association of Chain Drug Stores, in Alexandria, Va. “The same results can be accomplished without the extreme steps taken in Oklahoma.”

A representative for the supermarket industry was even more forceful.

“For our industry, a Schedule V approach is very troublesome,” said Joseph R. Herrens, senior vice president for government affairs at Marsh Supermarkets, in Indianapolis.

That's because an overwhelming majority of grocery stores in the United States do not have a pharmacy department and therefore could not comply with the requirement to keep the drug behind a counter.

“Under the Oklahoma model … [most grocery stores] could not sell the pseudoephedrine products that our customers expect us to carry to meet their shopping needs,” Mr. Herrens testified.

And even if the store does have a pharmacy department, it is not always open all the hours that the rest of the store is, especially in the case of a 24-hour grocery store, he continued. “Therefore, even if the store is open for business, if the pharmacy department is not open or if the pharmacist is not on duty, sales of cough and cold products would not be permitted and our customers would have to shop elsewhere.”

Some members of Congress apparently were not swayed by the supermarket industry's arguments. In January, Sens. Jim Talent (R-Mo.) and Dianne Feinstein (D-Calif.) introduced legislation to make medicines containing pseudoephedrine available only behind the pharmacy counter. Buyers could purchase up to 6 grams at one time, and 9 grams over a 30-day period.

“This legislation is a dagger at the heart of meth manufacturing in America,” Sen. Talent said in a statement. “If you can't get pseudoephedrine, you can't make meth.” At press time, the bill had 16 cosponsors.

To help with that problem, Pfizer Inc., the maker of Sudafed—an over-the-counter cold medicine containing pseudoephedrine—recently began marketing Sudafed PE, a new version of Sudafed that contains phenylephrine. Pfizer also will continue to offer the old version of the drug.

Another idea discussed at the hearing was getting rid of the federal “blister pack” exemption for pseudoephedrine. The exemption allows retailers to sell unlimited quantities of the drug as long as it is packaged in blister packs.

Rep. Mark Souder (R-Ind.) has proposed legislation to end that exemption.

Need a good treatment program for a patient addicted to methamphetamines? Good luck finding one, law enforcement experts say.

“Regrettably, there are not enough treatment beds in any area of the country to offer timely and adequate treatment opportunities,” Steve Bundy, sheriff of Rice County, Kan., said in written testimony at a hearing convened by the House subcommittee on criminal justice, drug policy, and human resources.

Mr. Bundy, who, with his four deputies, serves residents over a 750-square-mile area, said methamphetamine addiction consumes a majority of his time each day. He is the only one of the five who is qualified to dismantle and clean up methamphetamine production facilities.

He noted that methamphetamine addiction is particularly problematic for several reasons: Directions for making the drug are readily available, the ingredients can be obtained in any pharmacy and mixed together at home, and use of methamphetamines cuts across social, ethnic, and gender boundaries.

From a health care standpoint, methamphetamine addiction only gets worse once it starts, Lonnie Wright, director of the Bureau of Narcotics and Dangerous Drugs Control for the state of Oklahoma, said at the hearing.

“When you can manufacture methamphetamine at home for a fraction of the cost to buy it on the street, and you can have all of it you want and it's basically pure, there's nothing to limit your addiction,” he said. “Prolonged chronic addiction leads to … methamphetamine psychosis, [which is] clinically indistinguishable from paranoid schizophrenia, we're told by our medical experts in Oklahoma.”

In fact, the similarities are many between methamphetamine psychosis and paranoid schizophrenia, according to Eugene Wang, M.D., of the University of Hawaii at Manoa.

Dr. Wang places something called “amphetamine-induced psychotic disorder” in the same clinical spectrum as schizophrenia and notes that some criminal lawyers have used the insanity defense for clients who were chronically addicted to methamphetamines.

“Some researchers believe that amphetamine psychosis is just a variant of schizophrenia,” Dr. Wang said at the annual meeting of the American Academy of Psychiatry and the Law, in Scottsdale, Ariz. One similarity between the two is that both respond favorably to antipsychotic medications.

But a solid answer is hard to come by. “According to the DSM-IV criteria for schizophrenia, the symptoms cannot be due to a direct physiological effect of a substance,” he noted. “On the other hand, when someone develops a persistent psychosis following amphetamine use, the diagnosis of the disorder takes into account a new understanding of the effects of amphetamines.”

Marvin Seppala, M.D., chief medical officer for the Hazelden Foundation, a large addiction treatment provider, said methamphetamine addicts were difficult to treat because, unlike some other addictions, methamphetamine addiction is often associated with a “significant” psychosis, which is accompanied by agitation and violence.

“That combination leaves families and social services in a difficult situation when it comes to getting people into treatment,” said Dr. Seppala, who is based in Newberg, Ore. “Families are scared to do anything, because the addict may react to that. And with social services, the person comes in but [may not be] in a position to enter addiction treatment immediately.”

The biggest problem is that there are facilities to handle violence and psychosis—such as psychiatric hospitals—and facilities to handle methamphetamine addiction, but few places that handle both.

“If you're violent and require a psychiatric facility, it often doesn't have addiction treatment ready,” Dr. Seppala said. “And if you go to addiction treatment, those facilities are not staffed for acute psychosis and violence.”

Federal and state governments are attacking methamphetamine addiction at several levels, according to experts who spoke at the hearing.

On the supply side, the federal Office of National Drug Control Policy (ONDCP) has been working to cut off supplies of pseudoephedrine, the principal ingredient in methamphetamine, that are coming from Canada, according to Scott Burns, the ONDCP's deputy director for state and local affairs.

Canadian supplies of the drug are being used by U.S. “superlabs,” each of which produce more than 10 pounds of methamphetamine a day.

“Our approach must be market based, focused on reducing both supply and demand for the drug,” Mr. Burns said at the hearing. “We've seen a shrinking of these superlabs within the United States, and that's good news. However, we believe some of these superlabs are being pushed south of our borders to Mexico. For this reason, we'll continue to work [with the Mexican government] to stop the flow of these chemicals into Mexico.”

States are also doing their own part to reduce the demand for pseudoephedrine.

Oklahoma, for example, has seen a large drop in the number of home-grown methamphetamine labs since the implementation of House Bill 2176, the Trooper Nik Green, Rocky Eales and Matthew Evans Act.

The law does not require a doctor's prescription for pseudoephedrine, but does make it a Schedule V (restricted) medication; the law also requires pharmacies to keep the drug behind the counter, make purchasers sign a log, and limit purchases to no more than 9 grams per month, “much more than one taking the full recommended dosage during that time period would need,” Mr. Wright noted at the hearing.

Before the bill was signed into law last April, state law enforcement authorities seized an averaged of 92 meth labs each month.

That number had dropped by 32 by August.

Meth labs do continue to operate, however, because of pharmacies not enforcing the law strictly enough, smugglers bringing the drug in from surrounding states, and criminals going to more than one pharmacy to obtain the drug—staying under the legal limit at each store but obtaining much more on the whole.

That latter practice, known as “smirfing,” should be stopped when Oklahoma implements a statewide computerized system for pharmacists to find out who has purchased the drug and in what amounts, Mr. Wright said.

A pharmacy representative urged subcommittee members to be cautious about copying the Oklahoma law.

“Raising barriers for consumers to access pseudoephedrine is a short-term solution to a long-term problem,” said Mary Ann Wagner, vice president for pharmacy regulatory affairs at the National Association of Chain Drug Stores, in Alexandria, Va. “The same results can be accomplished without the extreme steps taken in Oklahoma.”

A representative for the supermarket industry was even more forceful.

“For our industry, a Schedule V approach is very troublesome,” said Joseph R. Herrens, senior vice president for government affairs at Marsh Supermarkets, in Indianapolis.

That's because an overwhelming majority of grocery stores in the United States do not have a pharmacy department and therefore could not comply with the requirement to keep the drug behind a counter.

“Under the Oklahoma model … [most grocery stores] could not sell the pseudoephedrine products that our customers expect us to carry to meet their shopping needs,” Mr. Herrens testified.

And even if the store does have a pharmacy department, it is not always open all the hours that the rest of the store is, especially in the case of a 24-hour grocery store, he continued. “Therefore, even if the store is open for business, if the pharmacy department is not open or if the pharmacist is not on duty, sales of cough and cold products would not be permitted and our customers would have to shop elsewhere.”

Some members of Congress apparently were not swayed by the supermarket industry's arguments. In January, Sens. Jim Talent (R-Mo.) and Dianne Feinstein (D-Calif.) introduced legislation to make medicines containing pseudoephedrine available only behind the pharmacy counter. Buyers could purchase up to 6 grams at one time, and 9 grams over a 30-day period.

“This legislation is a dagger at the heart of meth manufacturing in America,” Sen. Talent said in a statement. “If you can't get pseudoephedrine, you can't make meth.” At press time, the bill had 16 cosponsors.

To help with that problem, Pfizer Inc., the maker of Sudafed—an over-the-counter cold medicine containing pseudoephedrine—recently began marketing Sudafed PE, a new version of Sudafed that contains phenylephrine. Pfizer also will continue to offer the old version of the drug.

Another idea discussed at the hearing was getting rid of the federal “blister pack” exemption for pseudoephedrine. The exemption allows retailers to sell unlimited quantities of the drug as long as it is packaged in blister packs.

Rep. Mark Souder (R-Ind.) has proposed legislation to end that exemption.

Need a good treatment program for a patient addicted to methamphetamines? Good luck finding one, law enforcement experts say.

“Regrettably, there are not enough treatment beds in any area of the country to offer timely and adequate treatment opportunities,” Steve Bundy, sheriff of Rice County, Kan., said in written testimony at a hearing convened by the House subcommittee on criminal justice, drug policy, and human resources.

Mr. Bundy, who, with his four deputies, serves residents over a 750-square-mile area, said methamphetamine addiction consumes a majority of his time each day. He is the only one of the five who is qualified to dismantle and clean up methamphetamine production facilities.

He noted that methamphetamine addiction is particularly problematic for several reasons: Directions for making the drug are readily available, the ingredients can be obtained in any pharmacy and mixed together at home, and use of methamphetamines cuts across social, ethnic, and gender boundaries.

From a health care standpoint, methamphetamine addiction only gets worse once it starts, Lonnie Wright, director of the Bureau of Narcotics and Dangerous Drugs Control for the state of Oklahoma, said at the hearing.

“When you can manufacture methamphetamine at home for a fraction of the cost to buy it on the street, and you can have all of it you want and it's basically pure, there's nothing to limit your addiction,” he said. “Prolonged chronic addiction leads to … methamphetamine psychosis, [which is] clinically indistinguishable from paranoid schizophrenia, we're told by our medical experts in Oklahoma.”

In fact, the similarities are many between methamphetamine psychosis and paranoid schizophrenia, according to Eugene Wang, M.D., of the University of Hawaii at Manoa.

Dr. Wang places something called “amphetamine-induced psychotic disorder” in the same clinical spectrum as schizophrenia and notes that some criminal lawyers have used the insanity defense for clients who were chronically addicted to methamphetamines.

“Some researchers believe that amphetamine psychosis is just a variant of schizophrenia,” Dr. Wang said at the annual meeting of the American Academy of Psychiatry and the Law, in Scottsdale, Ariz. One similarity between the two is that both respond favorably to antipsychotic medications.

But a solid answer is hard to come by. “According to the DSM-IV criteria for schizophrenia, the symptoms cannot be due to a direct physiological effect of a substance,” he noted. “On the other hand, when someone develops a persistent psychosis following amphetamine use, the diagnosis of the disorder takes into account a new understanding of the effects of amphetamines.”

Marvin Seppala, M.D., chief medical officer for the Hazelden Foundation, a large addiction treatment provider, said methamphetamine addicts were difficult to treat because, unlike some other addictions, methamphetamine addiction is often associated with a “significant” psychosis, which is accompanied by agitation and violence.

“That combination leaves families and social services in a difficult situation when it comes to getting people into treatment,” said Dr. Seppala, who is based in Newberg, Ore. “Families are scared to do anything, because the addict may react to that. And with social services, the person comes in but [may not be] in a position to enter addiction treatment immediately.”

The biggest problem is that there are facilities to handle violence and psychosis—such as psychiatric hospitals—and facilities to handle methamphetamine addiction, but few places that handle both.

“If you're violent and require a psychiatric facility, it often doesn't have addiction treatment ready,” Dr. Seppala said. “And if you go to addiction treatment, those facilities are not staffed for acute psychosis and violence.”

Federal and state governments are attacking methamphetamine addiction at several levels, according to experts who spoke at the hearing.

On the supply side, the federal Office of National Drug Control Policy (ONDCP) has been working to cut off supplies of pseudoephedrine, the principal ingredient in methamphetamine, that are coming from Canada, according to Scott Burns, the ONDCP's deputy director for state and local affairs.

Canadian supplies of the drug are being used by U.S. “superlabs,” each of which produce more than 10 pounds of methamphetamine a day.

“Our approach must be market based, focused on reducing both supply and demand for the drug,” Mr. Burns said at the hearing. “We've seen a shrinking of these superlabs within the United States, and that's good news. However, we believe some of these superlabs are being pushed south of our borders to Mexico. For this reason, we'll continue to work [with the Mexican government] to stop the flow of these chemicals into Mexico.”

States are also doing their own part to reduce the demand for pseudoephedrine.

Oklahoma, for example, has seen a large drop in the number of home-grown methamphetamine labs since the implementation of House Bill 2176, the Trooper Nik Green, Rocky Eales and Matthew Evans Act.

The law does not require a doctor's prescription for pseudoephedrine, but does make it a Schedule V (restricted) medication; the law also requires pharmacies to keep the drug behind the counter, make purchasers sign a log, and limit purchases to no more than 9 grams per month, “much more than one taking the full recommended dosage during that time period would need,” Mr. Wright noted at the hearing.

Before the bill was signed into law last April, state law enforcement authorities seized an averaged of 92 meth labs each month.

That number had dropped by 32 by August.

Meth labs do continue to operate, however, because of pharmacies not enforcing the law strictly enough, smugglers bringing the drug in from surrounding states, and criminals going to more than one pharmacy to obtain the drug—staying under the legal limit at each store but obtaining much more on the whole.

That latter practice, known as “smirfing,” should be stopped when Oklahoma implements a statewide computerized system for pharmacists to find out who has purchased the drug and in what amounts, Mr. Wright said.

A pharmacy representative urged subcommittee members to be cautious about copying the Oklahoma law.

“Raising barriers for consumers to access pseudoephedrine is a short-term solution to a long-term problem,” said Mary Ann Wagner, vice president for pharmacy regulatory affairs at the National Association of Chain Drug Stores, in Alexandria, Va. “The same results can be accomplished without the extreme steps taken in Oklahoma.”

A representative for the supermarket industry was even more forceful.

“For our industry, a Schedule V approach is very troublesome,” said Joseph R. Herrens, senior vice president for government affairs at Marsh Supermarkets, in Indianapolis.

That's because an overwhelming majority of grocery stores in the United States do not have a pharmacy department and therefore could not comply with the requirement to keep the drug behind a counter.

“Under the Oklahoma model … [most grocery stores] could not sell the pseudoephedrine products that our customers expect us to carry to meet their shopping needs,” Mr. Herrens testified.

And even if the store does have a pharmacy department, it is not always open all the hours that the rest of the store is, especially in the case of a 24-hour grocery store, he continued. “Therefore, even if the store is open for business, if the pharmacy department is not open or if the pharmacist is not on duty, sales of cough and cold products would not be permitted and our customers would have to shop elsewhere.”

Some members of Congress apparently were not swayed by the supermarket industry's arguments. In January, Sens. Jim Talent (R-Mo.) and Dianne Feinstein (D-Calif.) introduced legislation to make medicines containing pseudoephedrine available only behind the pharmacy counter. Buyers could purchase up to 6 grams at one time, and 9 grams over a 30-day period.

“This legislation is a dagger at the heart of meth manufacturing in America,” Sen. Talent said in a statement. “If you can't get pseudoephedrine, you can't make meth.” At press time, the bill had 16 cosponsors.

To help with that problem, Pfizer Inc., the maker of Sudafed—an over-the-counter cold medicine containing pseudoephedrine—recently began marketing Sudafed PE, a new version of Sudafed that contains phenylephrine. Pfizer also will continue to offer the old version of the drug.

Another idea discussed at the hearing was getting rid of the federal “blister pack” exemption for pseudoephedrine. The exemption allows retailers to sell unlimited quantities of the drug as long as it is packaged in blister packs.

Rep. Mark Souder (R-Ind.) has proposed legislation to end that exemption.

BALTIMORE — There are 10 things physicians can do—or avoid doing—to help protect themselves from federal prosecution for fraud, D. McCarty Thornton said at a forum sponsored by the American Health Lawyers Association.

Mr. Thornton, formerly chief counsel at the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services and now an attorney in private practice, offered his “Top 10” in reverse order:

10Personal favors to referral sources are over. That message was reinforced by both the TAP pharmaceutical lawsuit and OIG's recent guidance to pharmaceutical firms regarding proper marketing techniques, he said. “This means no NFL tickets, no fancy dinners, nothing for spouses, no free computers, and don't put strings on any kind of 'educational grant.'

9Don't be the low-hanging fruit … The number of federal agents investigating fraud is declining, so each agent has stacks of potential cases to choose from. “You don't want to stick out” by being an outlier on claims or engaging in other questionable behavior, he noted.

8… But also be wary of being in the crowd. Don't go along with any questionable behavior simply because large groups of people are doing it. “Common sense is a lot of it,” Mr. Thornton said.

7If you are mulling over a business deal, consider whether it will pose a problem under the anti-kickback statute. “The further the deal is away from clinical decision making, the more leeway you have under the kickback statute, because the number-one purpose of the statute is to prevent the corruption of medical decision making,” he said. “If the deal concerns office software for billing or practice management, it doesn't really affect where or how clinical decisions are made, and you have a lot more leeway under the kickback statute.”

6Get as close to a safe harbor or advisory opinion as possible. “Document the business reasons why you can't fully comply with the safe harbor,” he said. “And you adopt the principles in the relevant OIG guidance to the extent you can. There is more written guidance from the anti-kickback statute—by far—than on any other criminal statute in the U.S. Code … the OIG has spoken on a lot of the issues involved.”

5Consider fair market value of the “safe unharbor.” Using fair market value in all transactions “provides excellent overall protection” from fraud allegations. Fair market value should be used for necessary, justifiable services, and it should be determined “by an independent, reliable source using recognized methodology,” he said.

Mr. Thornton noted that fair market value “never will be a safe harbor, because the government doesn't want to get into a 'Battle of the Experts' about your valuation experts [versus] their valuation experts, but it still is the basic talisman for safety under the anti-kickback statute.”

4Don't muddy your own shoes. “No fooling around with documents or withholding information,” Mr. Thornton admonished. “And don't ask for the 'odds' on getting caught” with a particular scheme.

3Check compliance on an ongoing basis. “Make sure deals are properly implemented” and that everyone involved is fulfilling their responsibilities, Mr. Thornton said.

2Document, document, document. “Document that the deal is for legitimate business purposes, that it's at fair market value, what services are provided, and how much time is spent providing them,” he said.

1Greed is good—not. “The number-one red flag to investigators is a return on investment or compensation that seems excessive,” he said.

Mr. Thornton had some advice for hospital compliance officers, warning them about the use of 'economic credentialing.' “Requiring a minimum level of practice to ensure proficiency is fine, but asking the doctor to refer 50% of his patients is going too far,” he said.

He also warned physicians to be careful about what they accept from pharmaceutical companies. Despite recent guidelines on the subject, “some doctors are still being led astray by being paid hundreds of dollars for filling out a simple form,” he said.

“We still have serious issues out there, and doctors need counseling and education,” he added.

BALTIMORE — There are 10 things physicians can do—or avoid doing—to help protect themselves from federal prosecution for fraud, D. McCarty Thornton said at a forum sponsored by the American Health Lawyers Association.

Mr. Thornton, formerly chief counsel at the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services and now an attorney in private practice, offered his “Top 10” in reverse order:

10Personal favors to referral sources are over. That message was reinforced by both the TAP pharmaceutical lawsuit and OIG's recent guidance to pharmaceutical firms regarding proper marketing techniques, he said. “This means no NFL tickets, no fancy dinners, nothing for spouses, no free computers, and don't put strings on any kind of 'educational grant.'

9Don't be the low-hanging fruit … The number of federal agents investigating fraud is declining, so each agent has stacks of potential cases to choose from. “You don't want to stick out” by being an outlier on claims or engaging in other questionable behavior, he noted.

8… But also be wary of being in the crowd. Don't go along with any questionable behavior simply because large groups of people are doing it. “Common sense is a lot of it,” Mr. Thornton said.

7If you are mulling over a business deal, consider whether it will pose a problem under the anti-kickback statute. “The further the deal is away from clinical decision making, the more leeway you have under the kickback statute, because the number-one purpose of the statute is to prevent the corruption of medical decision making,” he said. “If the deal concerns office software for billing or practice management, it doesn't really affect where or how clinical decisions are made, and you have a lot more leeway under the kickback statute.”

6Get as close to a safe harbor or advisory opinion as possible. “Document the business reasons why you can't fully comply with the safe harbor,” he said. “And you adopt the principles in the relevant OIG guidance to the extent you can. There is more written guidance from the anti-kickback statute—by far—than on any other criminal statute in the U.S. Code … the OIG has spoken on a lot of the issues involved.”

5Consider fair market value of the “safe unharbor.” Using fair market value in all transactions “provides excellent overall protection” from fraud allegations. Fair market value should be used for necessary, justifiable services, and it should be determined “by an independent, reliable source using recognized methodology,” he said.

Mr. Thornton noted that fair market value “never will be a safe harbor, because the government doesn't want to get into a 'Battle of the Experts' about your valuation experts [versus] their valuation experts, but it still is the basic talisman for safety under the anti-kickback statute.”

4Don't muddy your own shoes. “No fooling around with documents or withholding information,” Mr. Thornton admonished. “And don't ask for the 'odds' on getting caught” with a particular scheme.

3Check compliance on an ongoing basis. “Make sure deals are properly implemented” and that everyone involved is fulfilling their responsibilities, Mr. Thornton said.

2Document, document, document. “Document that the deal is for legitimate business purposes, that it's at fair market value, what services are provided, and how much time is spent providing them,” he said.

1Greed is good—not. “The number-one red flag to investigators is a return on investment or compensation that seems excessive,” he said.

Mr. Thornton had some advice for hospital compliance officers, warning them about the use of 'economic credentialing.' “Requiring a minimum level of practice to ensure proficiency is fine, but asking the doctor to refer 50% of his patients is going too far,” he said.

He also warned physicians to be careful about what they accept from pharmaceutical companies. Despite recent guidelines on the subject, “some doctors are still being led astray by being paid hundreds of dollars for filling out a simple form,” he said.

“We still have serious issues out there, and doctors need counseling and education,” he added.

BALTIMORE — There are 10 things physicians can do—or avoid doing—to help protect themselves from federal prosecution for fraud, D. McCarty Thornton said at a forum sponsored by the American Health Lawyers Association.

Mr. Thornton, formerly chief counsel at the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services and now an attorney in private practice, offered his “Top 10” in reverse order:

10Personal favors to referral sources are over. That message was reinforced by both the TAP pharmaceutical lawsuit and OIG's recent guidance to pharmaceutical firms regarding proper marketing techniques, he said. “This means no NFL tickets, no fancy dinners, nothing for spouses, no free computers, and don't put strings on any kind of 'educational grant.'

9Don't be the low-hanging fruit … The number of federal agents investigating fraud is declining, so each agent has stacks of potential cases to choose from. “You don't want to stick out” by being an outlier on claims or engaging in other questionable behavior, he noted.

8… But also be wary of being in the crowd. Don't go along with any questionable behavior simply because large groups of people are doing it. “Common sense is a lot of it,” Mr. Thornton said.

7If you are mulling over a business deal, consider whether it will pose a problem under the anti-kickback statute. “The further the deal is away from clinical decision making, the more leeway you have under the kickback statute, because the number-one purpose of the statute is to prevent the corruption of medical decision making,” he said. “If the deal concerns office software for billing or practice management, it doesn't really affect where or how clinical decisions are made, and you have a lot more leeway under the kickback statute.”

6Get as close to a safe harbor or advisory opinion as possible. “Document the business reasons why you can't fully comply with the safe harbor,” he said. “And you adopt the principles in the relevant OIG guidance to the extent you can. There is more written guidance from the anti-kickback statute—by far—than on any other criminal statute in the U.S. Code … the OIG has spoken on a lot of the issues involved.”

5Consider fair market value of the “safe unharbor.” Using fair market value in all transactions “provides excellent overall protection” from fraud allegations. Fair market value should be used for necessary, justifiable services, and it should be determined “by an independent, reliable source using recognized methodology,” he said.

Mr. Thornton noted that fair market value “never will be a safe harbor, because the government doesn't want to get into a 'Battle of the Experts' about your valuation experts [versus] their valuation experts, but it still is the basic talisman for safety under the anti-kickback statute.”

4Don't muddy your own shoes. “No fooling around with documents or withholding information,” Mr. Thornton admonished. “And don't ask for the 'odds' on getting caught” with a particular scheme.

3Check compliance on an ongoing basis. “Make sure deals are properly implemented” and that everyone involved is fulfilling their responsibilities, Mr. Thornton said.

2Document, document, document. “Document that the deal is for legitimate business purposes, that it's at fair market value, what services are provided, and how much time is spent providing them,” he said.

1Greed is good—not. “The number-one red flag to investigators is a return on investment or compensation that seems excessive,” he said.

Mr. Thornton had some advice for hospital compliance officers, warning them about the use of 'economic credentialing.' “Requiring a minimum level of practice to ensure proficiency is fine, but asking the doctor to refer 50% of his patients is going too far,” he said.

He also warned physicians to be careful about what they accept from pharmaceutical companies. Despite recent guidelines on the subject, “some doctors are still being led astray by being paid hundreds of dollars for filling out a simple form,” he said.

“We still have serious issues out there, and doctors need counseling and education,” he added.

In December, Centers for Medicare and Medicaid Services issued a draft decision memo that advises expanding coverage of carotid artery stenting.

Currently, the stents are covered only in the context of a clinical trial. Under the proposed criteria, stents would be covered in high-risk candidates for endarterectomy and in patients who have symptomatic carotid artery stenosis of at least 70%.

The draft also addresses the competency requirements, noting that stenting should be performed “in facilities and by physicians who have been determined to be competent in performing the evaluation, procedure, and follow-up necessary to ensure optimal patient outcomes. … Competency will be determined through a national evaluation process by a recognized entity using approved standards.”

The Society for Cardiovascular Angiography and Interventions (SCAI) expressed appreciation for CMS's work on the guidelines. “CMS did a thoughtful job in making its decision,” said Joseph Babb, M.D., SCAI past president and chair of its advocacy committee. “But the society is also concerned that there were certain areas that did not seem to get adequate attention.”

In a letter to the agency, SCAI noted: “The decision severely limits patient access to carotid stenting in asymptomatic high surgical risk patients in need of carotid revascularization, thereby relegating them to one of two potential therapeutic courses: medical or surgical. While we are strong supporters of aggressive medical therapy for all patients with or at risk of atherosclerotic disease, it remains unproven as to its effectiveness in high-surgical-risk patients, and therefore should not be designated as a default strategy.”

In December, Centers for Medicare and Medicaid Services issued a draft decision memo that advises expanding coverage of carotid artery stenting.

Currently, the stents are covered only in the context of a clinical trial. Under the proposed criteria, stents would be covered in high-risk candidates for endarterectomy and in patients who have symptomatic carotid artery stenosis of at least 70%.

The draft also addresses the competency requirements, noting that stenting should be performed “in facilities and by physicians who have been determined to be competent in performing the evaluation, procedure, and follow-up necessary to ensure optimal patient outcomes. … Competency will be determined through a national evaluation process by a recognized entity using approved standards.”

The Society for Cardiovascular Angiography and Interventions (SCAI) expressed appreciation for CMS's work on the guidelines. “CMS did a thoughtful job in making its decision,” said Joseph Babb, M.D., SCAI past president and chair of its advocacy committee. “But the society is also concerned that there were certain areas that did not seem to get adequate attention.”

In a letter to the agency, SCAI noted: “The decision severely limits patient access to carotid stenting in asymptomatic high surgical risk patients in need of carotid revascularization, thereby relegating them to one of two potential therapeutic courses: medical or surgical. While we are strong supporters of aggressive medical therapy for all patients with or at risk of atherosclerotic disease, it remains unproven as to its effectiveness in high-surgical-risk patients, and therefore should not be designated as a default strategy.”

In December, Centers for Medicare and Medicaid Services issued a draft decision memo that advises expanding coverage of carotid artery stenting.

Currently, the stents are covered only in the context of a clinical trial. Under the proposed criteria, stents would be covered in high-risk candidates for endarterectomy and in patients who have symptomatic carotid artery stenosis of at least 70%.

The draft also addresses the competency requirements, noting that stenting should be performed “in facilities and by physicians who have been determined to be competent in performing the evaluation, procedure, and follow-up necessary to ensure optimal patient outcomes. … Competency will be determined through a national evaluation process by a recognized entity using approved standards.”

The Society for Cardiovascular Angiography and Interventions (SCAI) expressed appreciation for CMS's work on the guidelines. “CMS did a thoughtful job in making its decision,” said Joseph Babb, M.D., SCAI past president and chair of its advocacy committee. “But the society is also concerned that there were certain areas that did not seem to get adequate attention.”

In a letter to the agency, SCAI noted: “The decision severely limits patient access to carotid stenting in asymptomatic high surgical risk patients in need of carotid revascularization, thereby relegating them to one of two potential therapeutic courses: medical or surgical. While we are strong supporters of aggressive medical therapy for all patients with or at risk of atherosclerotic disease, it remains unproven as to its effectiveness in high-surgical-risk patients, and therefore should not be designated as a default strategy.”

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, who is 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,” he said.

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,” she said.

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 noted at the meeting. “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 really 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, who is 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,” he said.

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,” she said.

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 noted at the meeting. “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 really 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, who is 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,” he said.

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,” she said.

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 noted at the meeting. “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 really 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 — Medicaid managed care doesn't appear to be living up to its reputation for cost savings, at least not in South Carolina, Walter Jones, Ph.D., said at the annual meeting of the American Public Health Association.

Dr. Jones and his colleagues looked at 2 years' worth of data on 56,000 Medicaid HMO patients and 21,000 patients in the state's Physician Enhanced Payment (PEP) program, a Medicaid plan in which primary care physicians are paid an extra fee to “case manage” the patient's health care needs.

Both groups were matched with comparable fee-for-service patients.

South Carolina “is not a heavily managed care state. We have very little HMO penetration,” said Dr. Jones, professor of health administration and policy at the Medical University of South Carolina, Charleston. “Unlike a lot of Medicaid programs, South Carolina does not have mandatory HMO assignment; physicians wouldn't stand for it. As a consequence … there's been a lot of unstable provider participation. An HMO comes to the state, thinks it can make money, finds it can't, and leaves, and the merry-go-round goes on and on.”

But the PEP program is a much different form of managed care, he said. The primary care physician provides a “medical home” for the patient for a flat fee but is not financially penalized for putting a patient into specialty care. Also, PEP physicians are expected to be “very available,” reducing the need for costly emergency room care, Dr. Jones said at the meeting.

The researchers looked at several aspects of medical care utilization, including primary and specialty care, inpatient hospitalizations, and emergency room visits.

They also included a separate category for “total utilization,” which included pharmacy use and other services as well as physician and hospital care.

They found that on the surface, both HMOs and PEP reduced utilization. Patients in HMOs had five fewer health care visits for a 2-year period, compared with fee-for-service patients, and PEP patients had two fewer visits. But there was a problem among the HMO patients: The reduced visits included those for primary care as well as for specialty care.

“That's not what managed care is supposed to be doing,” Dr. Jones said. “With the PEP project, utilization goes down a little less, but there's no difference in primary care utilization. It appears … that PEP is doing exactly what it should be doing—controlling utilization but not on the primary care level.”

Another problem with the HMOs, Dr. Jones continued, is that they “cream skim.”

“When you control for the HMOs' patient selection, their utilization differences disappear with respect to fee for service. The way they're reducing costs is by keeping the less desirable clients out.” This is often accomplished by not setting up enrollment offices in areas of the state where sicker patients are more likely to live, he told this newspaper.

Although patients in both PEP and the Medicaid HMOs decreased their utilization of certain kinds of care, total health care utilization actually appeared to go up in both groups, Dr. Jones noted.

“If you're the state and you're trying to save money, you might be kind of dismayed. On the other hand, if you're an advocate for patients, it doesn't appear that applying managed care reduces the number of services,” he said.

Overall, the study “raises questions about the utility of Medicaid managed care,” he said.

“The assumption always has been that HMOs or other managed care plans could do for Medicaid clients what it's done for private sector healthy employees; we haven't found that to be true. The bottom line is, it's still kind of 'faith-based' health care.”

WASHINGTON — Medicaid managed care doesn't appear to be living up to its reputation for cost savings, at least not in South Carolina, Walter Jones, Ph.D., said at the annual meeting of the American Public Health Association.

Dr. Jones and his colleagues looked at 2 years' worth of data on 56,000 Medicaid HMO patients and 21,000 patients in the state's Physician Enhanced Payment (PEP) program, a Medicaid plan in which primary care physicians are paid an extra fee to “case manage” the patient's health care needs.

Both groups were matched with comparable fee-for-service patients.

South Carolina “is not a heavily managed care state. We have very little HMO penetration,” said Dr. Jones, professor of health administration and policy at the Medical University of South Carolina, Charleston. “Unlike a lot of Medicaid programs, South Carolina does not have mandatory HMO assignment; physicians wouldn't stand for it. As a consequence … there's been a lot of unstable provider participation. An HMO comes to the state, thinks it can make money, finds it can't, and leaves, and the merry-go-round goes on and on.”

But the PEP program is a much different form of managed care, he said. The primary care physician provides a “medical home” for the patient for a flat fee but is not financially penalized for putting a patient into specialty care. Also, PEP physicians are expected to be “very available,” reducing the need for costly emergency room care, Dr. Jones said at the meeting.

The researchers looked at several aspects of medical care utilization, including primary and specialty care, inpatient hospitalizations, and emergency room visits.

They also included a separate category for “total utilization,” which included pharmacy use and other services as well as physician and hospital care.

They found that on the surface, both HMOs and PEP reduced utilization. Patients in HMOs had five fewer health care visits for a 2-year period, compared with fee-for-service patients, and PEP patients had two fewer visits. But there was a problem among the HMO patients: The reduced visits included those for primary care as well as for specialty care.

“That's not what managed care is supposed to be doing,” Dr. Jones said. “With the PEP project, utilization goes down a little less, but there's no difference in primary care utilization. It appears … that PEP is doing exactly what it should be doing—controlling utilization but not on the primary care level.”

Another problem with the HMOs, Dr. Jones continued, is that they “cream skim.”

“When you control for the HMOs' patient selection, their utilization differences disappear with respect to fee for service. The way they're reducing costs is by keeping the less desirable clients out.” This is often accomplished by not setting up enrollment offices in areas of the state where sicker patients are more likely to live, he told this newspaper.

Although patients in both PEP and the Medicaid HMOs decreased their utilization of certain kinds of care, total health care utilization actually appeared to go up in both groups, Dr. Jones noted.

“If you're the state and you're trying to save money, you might be kind of dismayed. On the other hand, if you're an advocate for patients, it doesn't appear that applying managed care reduces the number of services,” he said.

Overall, the study “raises questions about the utility of Medicaid managed care,” he said.

“The assumption always has been that HMOs or other managed care plans could do for Medicaid clients what it's done for private sector healthy employees; we haven't found that to be true. The bottom line is, it's still kind of 'faith-based' health care.”

WASHINGTON — Medicaid managed care doesn't appear to be living up to its reputation for cost savings, at least not in South Carolina, Walter Jones, Ph.D., said at the annual meeting of the American Public Health Association.

Dr. Jones and his colleagues looked at 2 years' worth of data on 56,000 Medicaid HMO patients and 21,000 patients in the state's Physician Enhanced Payment (PEP) program, a Medicaid plan in which primary care physicians are paid an extra fee to “case manage” the patient's health care needs.

Both groups were matched with comparable fee-for-service patients.

South Carolina “is not a heavily managed care state. We have very little HMO penetration,” said Dr. Jones, professor of health administration and policy at the Medical University of South Carolina, Charleston. “Unlike a lot of Medicaid programs, South Carolina does not have mandatory HMO assignment; physicians wouldn't stand for it. As a consequence … there's been a lot of unstable provider participation. An HMO comes to the state, thinks it can make money, finds it can't, and leaves, and the merry-go-round goes on and on.”

But the PEP program is a much different form of managed care, he said. The primary care physician provides a “medical home” for the patient for a flat fee but is not financially penalized for putting a patient into specialty care. Also, PEP physicians are expected to be “very available,” reducing the need for costly emergency room care, Dr. Jones said at the meeting.

The researchers looked at several aspects of medical care utilization, including primary and specialty care, inpatient hospitalizations, and emergency room visits.

They also included a separate category for “total utilization,” which included pharmacy use and other services as well as physician and hospital care.

They found that on the surface, both HMOs and PEP reduced utilization. Patients in HMOs had five fewer health care visits for a 2-year period, compared with fee-for-service patients, and PEP patients had two fewer visits. But there was a problem among the HMO patients: The reduced visits included those for primary care as well as for specialty care.

“That's not what managed care is supposed to be doing,” Dr. Jones said. “With the PEP project, utilization goes down a little less, but there's no difference in primary care utilization. It appears … that PEP is doing exactly what it should be doing—controlling utilization but not on the primary care level.”

Another problem with the HMOs, Dr. Jones continued, is that they “cream skim.”

“When you control for the HMOs' patient selection, their utilization differences disappear with respect to fee for service. The way they're reducing costs is by keeping the less desirable clients out.” This is often accomplished by not setting up enrollment offices in areas of the state where sicker patients are more likely to live, he told this newspaper.

Although patients in both PEP and the Medicaid HMOs decreased their utilization of certain kinds of care, total health care utilization actually appeared to go up in both groups, Dr. Jones noted.

“If you're the state and you're trying to save money, you might be kind of dismayed. On the other hand, if you're an advocate for patients, it doesn't appear that applying managed care reduces the number of services,” he said.

Overall, the study “raises questions about the utility of Medicaid managed care,” he said.

“The assumption always has been that HMOs or other managed care plans could do for Medicaid clients what it's done for private sector healthy employees; we haven't found that to be true. The bottom line is, it's still kind of 'faith-based' health care.”

WASHINGTON — More programs need to be developed to address the specific health needs of minority women, Elena Cohen said during 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, who is 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, researchers at the center analyzed data on women's health from all 50 states as well as the District of Columbia. The center's report, which is entitled “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 also have the highest mortality rates for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer, Ms. Cohen noted during the meeting.

For their part, Latinas have the lowest mortality rate from stroke, but they 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, Ms. Cohen 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, “which is very important for obesity issues.”

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 added.

According to the report, those issues are cervical and ovarian cancer, which disproportionately affect these women, who are also the second-least likely group to have had a mammogram within the last 2 years.

Because each group's problems are different, identifying useful interventions for minority women can be tricky, but it needs to be done, she said.

“One way is to encourage research that is analyzed and reported by race and ethnicity, and then further by gender. Another idea is to develop targeted programs to address ethnic and racial issues,” Ms. Cohen said.

The report, which is titled “Making the Grade on Women's Health,” is available on the Internet atwww.nwlc.org/details.cfm?id=1861&section=health

WASHINGTON — More programs need to be developed to address the specific health needs of minority women, Elena Cohen said during 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, who is 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, researchers at the center analyzed data on women's health from all 50 states as well as the District of Columbia. The center's report, which is entitled “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 also have the highest mortality rates for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer, Ms. Cohen noted during the meeting.

For their part, Latinas have the lowest mortality rate from stroke, but they 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, Ms. Cohen 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, “which is very important for obesity issues.”

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 added.

According to the report, those issues are cervical and ovarian cancer, which disproportionately affect these women, who are also the second-least likely group to have had a mammogram within the last 2 years.

Because each group's problems are different, identifying useful interventions for minority women can be tricky, but it needs to be done, she said.

“One way is to encourage research that is analyzed and reported by race and ethnicity, and then further by gender. Another idea is to develop targeted programs to address ethnic and racial issues,” Ms. Cohen said.

The report, which is titled “Making the Grade on Women's Health,” is available on the Internet atwww.nwlc.org/details.cfm?id=1861&section=health

WASHINGTON — More programs need to be developed to address the specific health needs of minority women, Elena Cohen said during 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, who is 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, researchers at the center analyzed data on women's health from all 50 states as well as the District of Columbia. The center's report, which is entitled “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 also have the highest mortality rates for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer, Ms. Cohen noted during the meeting.

For their part, Latinas have the lowest mortality rate from stroke, but they 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, Ms. Cohen 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, “which is very important for obesity issues.”

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 added.

According to the report, those issues are cervical and ovarian cancer, which disproportionately affect these women, who are also the second-least likely group to have had a mammogram within the last 2 years.

Because each group's problems are different, identifying useful interventions for minority women can be tricky, but it needs to be done, she said.

“One way is to encourage research that is analyzed and reported by race and ethnicity, and then further by gender. Another idea is to develop targeted programs to address ethnic and racial issues,” Ms. Cohen said.

The report, which is titled “Making the Grade on Women's Health,” is available on the Internet atwww.nwlc.org/details.cfm?id=1861&section=health

CMS Plans for Stent Coverage

The Centers for Medicare and Medicaid Services is planning to expand the indications for covering implantation of a carotid artery stent. Currently, the stents are covered only in the context of a clinical trial, but under the proposed criteria, stents would be covered if the patient is at high risk of endarterectomy and has symptomatic carotid artery stenosis greater than or equal to 70%. The memo also addresses the qualifications for the providers installing the stent, noting that it should be done “in facilities and by physicians who have been determined to be competent in performing the evaluation, procedure, and follow-up necessary to ensure optimal patient outcomes. We propose that competency will be determined through a national evaluation process by a recognized entity using approved standards.”

California Parkinson's Registry

The State of California began collecting data this month for a statewide Parkinson's disease registry. The registry is the result of legislation sponsored by Democratic state representative Dario Frommer and requires “any physician and surgeon, pharmacist, or other health practitioner diagnosing or providing treatment for Parkinson's disease” to report each case to the state health department; all information will remain confidential. “We don't have enough data on how many people have Parkinson's disease in America today,” Amy Comstock, executive director of the Parkinson's Action Network, said in a statement. “We don't have enough data on the general age, ethnicity, or gender of people with Parkinson's disease, or even if environmental factors play a part in causing [it]. The California registry will provide solid data for researchers who are seeking answers to those important questions.” A 2-year, $500,000 pilot project to start the registry is being funded by the National Institute of Environmental Health Sciences and the Michael J. Fox Foundation.

Comments Due on Pain Rx Regs

Interested parties have until March 21 to comment on an interim policy statement on dispensing controlled substances for pain treatment. The statement, which was published on Nov. 16, 2004, in the Federal Register, outlines several inaccuracies that were included in an August 2004 “frequently asked questions” document on the subject that appeared on the Drug Enforcement Administration Web site; the document was later withdrawn from the site. The statement also notes that the DEA plans to publish a document “aimed at providing guidance and reassurance to physicians who engage in legitimate pain treatment while deterring the unlawful conduct of a small number of physicians” who exploit the law to engage in drug trafficking. Information on submitting comments can be found in a Federal Register notice published on Jan. 18; that notice can be located at this Internet address:

www.access.gpo.gov/su_docs/fedreg/a050118c.html

Portable Health Plans

Patients can take their health insurance coverage with them when they change or lose a job, under the final regulations that implement the last piece of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). According to a statement by the Health and Human Services Department, it is important that American workers, who often change jobs several times in the course of their lives, are able to respond to the modern workplace without having to fear for their health insurance. The regulations allow greater portability and availability of group health coverage during a time of job transition, setting limits on preexisting condition exclusions that could be imposed, and requiring group health plans and insurance issuers to offer “special enrollment” to certain patients who lose eligibility for other group health coverage or health insurance, or to otherwise eligible new dependents. The regulation goes into effect for plan years starting on or after July 1.

HealthSouth to Pay $325 Million

HealthSouth Corp., a national rehabilitation services provider, has agreed to pay the federal government $325 million to settle allegations that it defrauded Medicare and other federal health care programs. Of the payment amount, $169 million goes to resolve allegations that it submitted claims for services provided to Medicare beneficiaries and members of the Department of Defense TRICARE program that were not performed by licensed physical therapists, or were not performed one-on-one as indicated. Another $89 million of the money will be paid to resolve claims for “unallowable” items such as lavish entertainment and travel costs. The settlement “should send a strong message that the government will be persistent in pursuing those who engage in fraud,” said U.S. Attorney Johnny Sutton, San Antonio.

Reduced Benefits for Retirees

Businesses are asking retirees to pay more for their health coverage as they struggle to control rising costs, the Kaiser Family Foundation reported. In the past year, 79% of firms increased their retirees' contributions for premiums, and 85% expect to do so in the coming year. In addition, 8% of employers surveyed eliminated subsidized health benefits for future retirees in 2004. For 2005, 11% said they are likely to terminate coverage for future retirees. However, 58% of responding firms said they were likely to continue offering prescription drug benefits and accept the tax-free subsidy created by the new Medicare law. The survey included responses from 333 large private-sector firms that offer retiree health benefits.

CMS Plans for Stent Coverage

The Centers for Medicare and Medicaid Services is planning to expand the indications for covering implantation of a carotid artery stent. Currently, the stents are covered only in the context of a clinical trial, but under the proposed criteria, stents would be covered if the patient is at high risk of endarterectomy and has symptomatic carotid artery stenosis greater than or equal to 70%. The memo also addresses the qualifications for the providers installing the stent, noting that it should be done “in facilities and by physicians who have been determined to be competent in performing the evaluation, procedure, and follow-up necessary to ensure optimal patient outcomes. We propose that competency will be determined through a national evaluation process by a recognized entity using approved standards.”

California Parkinson's Registry

The State of California began collecting data this month for a statewide Parkinson's disease registry. The registry is the result of legislation sponsored by Democratic state representative Dario Frommer and requires “any physician and surgeon, pharmacist, or other health practitioner diagnosing or providing treatment for Parkinson's disease” to report each case to the state health department; all information will remain confidential. “We don't have enough data on how many people have Parkinson's disease in America today,” Amy Comstock, executive director of the Parkinson's Action Network, said in a statement. “We don't have enough data on the general age, ethnicity, or gender of people with Parkinson's disease, or even if environmental factors play a part in causing [it]. The California registry will provide solid data for researchers who are seeking answers to those important questions.” A 2-year, $500,000 pilot project to start the registry is being funded by the National Institute of Environmental Health Sciences and the Michael J. Fox Foundation.

Comments Due on Pain Rx Regs

Interested parties have until March 21 to comment on an interim policy statement on dispensing controlled substances for pain treatment. The statement, which was published on Nov. 16, 2004, in the Federal Register, outlines several inaccuracies that were included in an August 2004 “frequently asked questions” document on the subject that appeared on the Drug Enforcement Administration Web site; the document was later withdrawn from the site. The statement also notes that the DEA plans to publish a document “aimed at providing guidance and reassurance to physicians who engage in legitimate pain treatment while deterring the unlawful conduct of a small number of physicians” who exploit the law to engage in drug trafficking. Information on submitting comments can be found in a Federal Register notice published on Jan. 18; that notice can be located at this Internet address:

www.access.gpo.gov/su_docs/fedreg/a050118c.html

Portable Health Plans

Patients can take their health insurance coverage with them when they change or lose a job, under the final regulations that implement the last piece of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). According to a statement by the Health and Human Services Department, it is important that American workers, who often change jobs several times in the course of their lives, are able to respond to the modern workplace without having to fear for their health insurance. The regulations allow greater portability and availability of group health coverage during a time of job transition, setting limits on preexisting condition exclusions that could be imposed, and requiring group health plans and insurance issuers to offer “special enrollment” to certain patients who lose eligibility for other group health coverage or health insurance, or to otherwise eligible new dependents. The regulation goes into effect for plan years starting on or after July 1.

HealthSouth to Pay $325 Million

HealthSouth Corp., a national rehabilitation services provider, has agreed to pay the federal government $325 million to settle allegations that it defrauded Medicare and other federal health care programs. Of the payment amount, $169 million goes to resolve allegations that it submitted claims for services provided to Medicare beneficiaries and members of the Department of Defense TRICARE program that were not performed by licensed physical therapists, or were not performed one-on-one as indicated. Another $89 million of the money will be paid to resolve claims for “unallowable” items such as lavish entertainment and travel costs. The settlement “should send a strong message that the government will be persistent in pursuing those who engage in fraud,” said U.S. Attorney Johnny Sutton, San Antonio.

Reduced Benefits for Retirees

Businesses are asking retirees to pay more for their health coverage as they struggle to control rising costs, the Kaiser Family Foundation reported. In the past year, 79% of firms increased their retirees' contributions for premiums, and 85% expect to do so in the coming year. In addition, 8% of employers surveyed eliminated subsidized health benefits for future retirees in 2004. For 2005, 11% said they are likely to terminate coverage for future retirees. However, 58% of responding firms said they were likely to continue offering prescription drug benefits and accept the tax-free subsidy created by the new Medicare law. The survey included responses from 333 large private-sector firms that offer retiree health benefits.

CMS Plans for Stent Coverage

The Centers for Medicare and Medicaid Services is planning to expand the indications for covering implantation of a carotid artery stent. Currently, the stents are covered only in the context of a clinical trial, but under the proposed criteria, stents would be covered if the patient is at high risk of endarterectomy and has symptomatic carotid artery stenosis greater than or equal to 70%. The memo also addresses the qualifications for the providers installing the stent, noting that it should be done “in facilities and by physicians who have been determined to be competent in performing the evaluation, procedure, and follow-up necessary to ensure optimal patient outcomes. We propose that competency will be determined through a national evaluation process by a recognized entity using approved standards.”

California Parkinson's Registry

The State of California began collecting data this month for a statewide Parkinson's disease registry. The registry is the result of legislation sponsored by Democratic state representative Dario Frommer and requires “any physician and surgeon, pharmacist, or other health practitioner diagnosing or providing treatment for Parkinson's disease” to report each case to the state health department; all information will remain confidential. “We don't have enough data on how many people have Parkinson's disease in America today,” Amy Comstock, executive director of the Parkinson's Action Network, said in a statement. “We don't have enough data on the general age, ethnicity, or gender of people with Parkinson's disease, or even if environmental factors play a part in causing [it]. The California registry will provide solid data for researchers who are seeking answers to those important questions.” A 2-year, $500,000 pilot project to start the registry is being funded by the National Institute of Environmental Health Sciences and the Michael J. Fox Foundation.

Comments Due on Pain Rx Regs

Interested parties have until March 21 to comment on an interim policy statement on dispensing controlled substances for pain treatment. The statement, which was published on Nov. 16, 2004, in the Federal Register, outlines several inaccuracies that were included in an August 2004 “frequently asked questions” document on the subject that appeared on the Drug Enforcement Administration Web site; the document was later withdrawn from the site. The statement also notes that the DEA plans to publish a document “aimed at providing guidance and reassurance to physicians who engage in legitimate pain treatment while deterring the unlawful conduct of a small number of physicians” who exploit the law to engage in drug trafficking. Information on submitting comments can be found in a Federal Register notice published on Jan. 18; that notice can be located at this Internet address:

www.access.gpo.gov/su_docs/fedreg/a050118c.html

Portable Health Plans

Patients can take their health insurance coverage with them when they change or lose a job, under the final regulations that implement the last piece of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). According to a statement by the Health and Human Services Department, it is important that American workers, who often change jobs several times in the course of their lives, are able to respond to the modern workplace without having to fear for their health insurance. The regulations allow greater portability and availability of group health coverage during a time of job transition, setting limits on preexisting condition exclusions that could be imposed, and requiring group health plans and insurance issuers to offer “special enrollment” to certain patients who lose eligibility for other group health coverage or health insurance, or to otherwise eligible new dependents. The regulation goes into effect for plan years starting on or after July 1.

HealthSouth to Pay $325 Million

HealthSouth Corp., a national rehabilitation services provider, has agreed to pay the federal government $325 million to settle allegations that it defrauded Medicare and other federal health care programs. Of the payment amount, $169 million goes to resolve allegations that it submitted claims for services provided to Medicare beneficiaries and members of the Department of Defense TRICARE program that were not performed by licensed physical therapists, or were not performed one-on-one as indicated. Another $89 million of the money will be paid to resolve claims for “unallowable” items such as lavish entertainment and travel costs. The settlement “should send a strong message that the government will be persistent in pursuing those who engage in fraud,” said U.S. Attorney Johnny Sutton, San Antonio.

Reduced Benefits for Retirees

Businesses are asking retirees to pay more for their health coverage as they struggle to control rising costs, the Kaiser Family Foundation reported. In the past year, 79% of firms increased their retirees' contributions for premiums, and 85% expect to do so in the coming year. In addition, 8% of employers surveyed eliminated subsidized health benefits for future retirees in 2004. For 2005, 11% said they are likely to terminate coverage for future retirees. However, 58% of responding firms said they were likely to continue offering prescription drug benefits and accept the tax-free subsidy created by the new Medicare law. The survey included responses from 333 large private-sector firms that offer retiree health benefits.

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 also have the highest mortality rates for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer, Ms. Cohen commented.

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, “which is very important for obesity issues.”

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 added.

According to the report, those issues are cervical and ovarian cancer, which disproportionately affect these women, who are also the second-least likely group to have had a mammogram within the last 2 years.

Because each group's problems are different, identifying useful interventions for minority women can be tricky, but it needs to be done, she said. “One way is to encourage research that is analyzed and reported by race and ethnicity, and then further by gender. Another idea is to develop targeted programs to address ethnic and racial issues.”

“Making the Grade on Women's Health” is available at www.nwlc.org/details.cfm?id=1861&section=health

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 also have the highest mortality rates for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer, Ms. Cohen commented.

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, “which is very important for obesity issues.”

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 added.

According to the report, those issues are cervical and ovarian cancer, which disproportionately affect these women, who are also the second-least likely group to have had a mammogram within the last 2 years.

Because each group's problems are different, identifying useful interventions for minority women can be tricky, but it needs to be done, she said. “One way is to encourage research that is analyzed and reported by race and ethnicity, and then further by gender. Another idea is to develop targeted programs to address ethnic and racial issues.”

“Making the Grade on Women's Health” is available at www.nwlc.org/details.cfm?id=1861&section=health

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 also have the highest mortality rates for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer, Ms. Cohen commented.

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, “which is very important for obesity issues.”

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 added.

According to the report, those issues are cervical and ovarian cancer, which disproportionately affect these women, who are also the second-least likely group to have had a mammogram within the last 2 years.

Because each group's problems are different, identifying useful interventions for minority women can be tricky, but it needs to be done, she said. “One way is to encourage research that is analyzed and reported by race and ethnicity, and then further by gender. Another idea is to develop targeted programs to address ethnic and racial issues.”

“Making the Grade on Women's Health” is available at www.nwlc.org/details.cfm?id=1861&section=health

NEW YORK — The new recertification process developed by the American Board of Family Medicine is not as onerous as some are making it out to be, L. Thomas Wolff, M.D., said at a meeting of the New York County Chapter of the American Academy of Family Physicians.

“We're doing many of the things we were doing in the past, but we're doing them better,” he said. “We're helping ourselves as a discipline.”

Dr. Wolff formerly served on the American Board of Medical Specialties and its Committee on Certification and Recertification. He noted that it was the ABMS that initiated changes to the recertification process, which apply to all ABMS member boards. “It's really an issue that all of medicine is struggling with,” he said.

He also pointed out that the ABFM was the first specialty board ever to require recertification. “Nicholas Pisacano, M.D. [the ABFM's first executive director], said, 'How can we put our imprimatur on someone and know that 7 years later, they've kept up?'” explained Dr. Wolff. “We were also the only board at the time to require continuing medical education.”

The ABFM, formerly known as the American Board of Family Practice, was renamed effective Jan. 1 following the unanimous recommendation by its board of directors. The name change was associated with AAFP's Future of Family Medicine project, which recommended more use of the term “family medicine” to avoid the confusion generated by the term “family practice.”

ABFM also required family physicians to send in charts for chart review. “That really made me look at my practice and change things,” said Dr. Wolff, who still sees patients and is also director emeritus of the Rural Medical Education Program at the State University of New York, Syracuse. He noted that the ABMS is currently working on refining its peer review process for the specialties.

Dr. Wolff gave high praise to the interactive patient simulator, in which physicians get to “examine” and ask questions of a simulated patient on the computer. The program requires the test taker to manage the patient until he or she is stabilized for either three visits or 2 years' time, whichever comes first.

But Wendy Barr, M.D., a family practice resident at Beth Israel Medical Center, New York, who recently used the simulator, said it has kinks that need to be worked out. For example, there were no instructions about how to use a pull-down menu that would “officially” tell the patient to go home. “So if you didn't know you needed to send the patient home, the patient sat in the waiting room all night, and you got dinged for it,” she said.

Another point of contention is the self-assessment modules (SAMs). To recertify, family physicians must complete at least one annually. Critics say the modules take too long and don't have intuitive answers. In fact, the American Academy of Family Physicians House of Delegates voted at their meeting last October to ask the ABFM to delay implementation of the SAMs (FAMILY PRACTICE NEWS, Nov. 1, 2004, p. 1).

But Dr. Wolff said that the SAMs were useful teaching tools; he noted that the plan is to update them with the latest evidence-based medicine every 6 months. And in response to a question from an audience member, he said he would not be surprised to see the SAMs replace recertification exams—another part of the process—altogether.

“It may be that at some point the ongoing [SAM] process will suffice,” he said, adding that such a change would be a long way off. “I don't know that, but it wouldn't surprise me.” Dr. Wolff noted that for all the angst among family physicians about the changes, there is even more consternation among other specialties such as thoracic surgery, in which physicians had been given what they assumed would be a “lifetime” certification, only to find out they now have to recertify.

Neil Calman, M.D., president of the Institute for Urban Family Health, New York, said he thought the reaction of family physicians to the new process has been “absolutely absurd.”

“Physicians in general seem to get so stuck in the way things are,” he said. “It's amazing how disappointing people's response has been.”

One of the little known advantages of the new process, noted Steve Tamarin, M.D., chief of family medicine at St. Luke's-Roosevelt Hospital Center, New York, is that physicians can receive up to 15 hours' CME credit for each SAM they complete.

“One of the problems in medicine is that the quality of CME available really stinks, and much of it is corrupt [because] it's financed by the pharmaceutical companies,” he said. “It's a serious problem, the corruption of medical education by business. This solves that problem.”

Dr. Wolff urged audience members to contact the board if they have questions or concerns about recertification.

One change the board made to the SAMs involved the process used to educate the physician if he or she got a question wrong. “It [used to] send you to an article, where you had to read the whole bloody article to find one thing,” he said. “But now they're going to have [specific] critiques with the information because the idea is to teach, not to try to fool anybody.”

NEW YORK — The new recertification process developed by the American Board of Family Medicine is not as onerous as some are making it out to be, L. Thomas Wolff, M.D., said at a meeting of the New York County Chapter of the American Academy of Family Physicians.

“We're doing many of the things we were doing in the past, but we're doing them better,” he said. “We're helping ourselves as a discipline.”

Dr. Wolff formerly served on the American Board of Medical Specialties and its Committee on Certification and Recertification. He noted that it was the ABMS that initiated changes to the recertification process, which apply to all ABMS member boards. “It's really an issue that all of medicine is struggling with,” he said.

He also pointed out that the ABFM was the first specialty board ever to require recertification. “Nicholas Pisacano, M.D. [the ABFM's first executive director], said, 'How can we put our imprimatur on someone and know that 7 years later, they've kept up?'” explained Dr. Wolff. “We were also the only board at the time to require continuing medical education.”

The ABFM, formerly known as the American Board of Family Practice, was renamed effective Jan. 1 following the unanimous recommendation by its board of directors. The name change was associated with AAFP's Future of Family Medicine project, which recommended more use of the term “family medicine” to avoid the confusion generated by the term “family practice.”

ABFM also required family physicians to send in charts for chart review. “That really made me look at my practice and change things,” said Dr. Wolff, who still sees patients and is also director emeritus of the Rural Medical Education Program at the State University of New York, Syracuse. He noted that the ABMS is currently working on refining its peer review process for the specialties.

Dr. Wolff gave high praise to the interactive patient simulator, in which physicians get to “examine” and ask questions of a simulated patient on the computer. The program requires the test taker to manage the patient until he or she is stabilized for either three visits or 2 years' time, whichever comes first.

But Wendy Barr, M.D., a family practice resident at Beth Israel Medical Center, New York, who recently used the simulator, said it has kinks that need to be worked out. For example, there were no instructions about how to use a pull-down menu that would “officially” tell the patient to go home. “So if you didn't know you needed to send the patient home, the patient sat in the waiting room all night, and you got dinged for it,” she said.

Another point of contention is the self-assessment modules (SAMs). To recertify, family physicians must complete at least one annually. Critics say the modules take too long and don't have intuitive answers. In fact, the American Academy of Family Physicians House of Delegates voted at their meeting last October to ask the ABFM to delay implementation of the SAMs (FAMILY PRACTICE NEWS, Nov. 1, 2004, p. 1).

But Dr. Wolff said that the SAMs were useful teaching tools; he noted that the plan is to update them with the latest evidence-based medicine every 6 months. And in response to a question from an audience member, he said he would not be surprised to see the SAMs replace recertification exams—another part of the process—altogether.

“It may be that at some point the ongoing [SAM] process will suffice,” he said, adding that such a change would be a long way off. “I don't know that, but it wouldn't surprise me.” Dr. Wolff noted that for all the angst among family physicians about the changes, there is even more consternation among other specialties such as thoracic surgery, in which physicians had been given what they assumed would be a “lifetime” certification, only to find out they now have to recertify.

Neil Calman, M.D., president of the Institute for Urban Family Health, New York, said he thought the reaction of family physicians to the new process has been “absolutely absurd.”

“Physicians in general seem to get so stuck in the way things are,” he said. “It's amazing how disappointing people's response has been.”

One of the little known advantages of the new process, noted Steve Tamarin, M.D., chief of family medicine at St. Luke's-Roosevelt Hospital Center, New York, is that physicians can receive up to 15 hours' CME credit for each SAM they complete.

“One of the problems in medicine is that the quality of CME available really stinks, and much of it is corrupt [because] it's financed by the pharmaceutical companies,” he said. “It's a serious problem, the corruption of medical education by business. This solves that problem.”

Dr. Wolff urged audience members to contact the board if they have questions or concerns about recertification.

One change the board made to the SAMs involved the process used to educate the physician if he or she got a question wrong. “It [used to] send you to an article, where you had to read the whole bloody article to find one thing,” he said. “But now they're going to have [specific] critiques with the information because the idea is to teach, not to try to fool anybody.”

NEW YORK — The new recertification process developed by the American Board of Family Medicine is not as onerous as some are making it out to be, L. Thomas Wolff, M.D., said at a meeting of the New York County Chapter of the American Academy of Family Physicians.

“We're doing many of the things we were doing in the past, but we're doing them better,” he said. “We're helping ourselves as a discipline.”

Dr. Wolff formerly served on the American Board of Medical Specialties and its Committee on Certification and Recertification. He noted that it was the ABMS that initiated changes to the recertification process, which apply to all ABMS member boards. “It's really an issue that all of medicine is struggling with,” he said.

He also pointed out that the ABFM was the first specialty board ever to require recertification. “Nicholas Pisacano, M.D. [the ABFM's first executive director], said, 'How can we put our imprimatur on someone and know that 7 years later, they've kept up?'” explained Dr. Wolff. “We were also the only board at the time to require continuing medical education.”

The ABFM, formerly known as the American Board of Family Practice, was renamed effective Jan. 1 following the unanimous recommendation by its board of directors. The name change was associated with AAFP's Future of Family Medicine project, which recommended more use of the term “family medicine” to avoid the confusion generated by the term “family practice.”

ABFM also required family physicians to send in charts for chart review. “That really made me look at my practice and change things,” said Dr. Wolff, who still sees patients and is also director emeritus of the Rural Medical Education Program at the State University of New York, Syracuse. He noted that the ABMS is currently working on refining its peer review process for the specialties.

Dr. Wolff gave high praise to the interactive patient simulator, in which physicians get to “examine” and ask questions of a simulated patient on the computer. The program requires the test taker to manage the patient until he or she is stabilized for either three visits or 2 years' time, whichever comes first.

But Wendy Barr, M.D., a family practice resident at Beth Israel Medical Center, New York, who recently used the simulator, said it has kinks that need to be worked out. For example, there were no instructions about how to use a pull-down menu that would “officially” tell the patient to go home. “So if you didn't know you needed to send the patient home, the patient sat in the waiting room all night, and you got dinged for it,” she said.

Another point of contention is the self-assessment modules (SAMs). To recertify, family physicians must complete at least one annually. Critics say the modules take too long and don't have intuitive answers. In fact, the American Academy of Family Physicians House of Delegates voted at their meeting last October to ask the ABFM to delay implementation of the SAMs (FAMILY PRACTICE NEWS, Nov. 1, 2004, p. 1).

But Dr. Wolff said that the SAMs were useful teaching tools; he noted that the plan is to update them with the latest evidence-based medicine every 6 months. And in response to a question from an audience member, he said he would not be surprised to see the SAMs replace recertification exams—another part of the process—altogether.

“It may be that at some point the ongoing [SAM] process will suffice,” he said, adding that such a change would be a long way off. “I don't know that, but it wouldn't surprise me.” Dr. Wolff noted that for all the angst among family physicians about the changes, there is even more consternation among other specialties such as thoracic surgery, in which physicians had been given what they assumed would be a “lifetime” certification, only to find out they now have to recertify.

Neil Calman, M.D., president of the Institute for Urban Family Health, New York, said he thought the reaction of family physicians to the new process has been “absolutely absurd.”

“Physicians in general seem to get so stuck in the way things are,” he said. “It's amazing how disappointing people's response has been.”

One of the little known advantages of the new process, noted Steve Tamarin, M.D., chief of family medicine at St. Luke's-Roosevelt Hospital Center, New York, is that physicians can receive up to 15 hours' CME credit for each SAM they complete.

“One of the problems in medicine is that the quality of CME available really stinks, and much of it is corrupt [because] it's financed by the pharmaceutical companies,” he said. “It's a serious problem, the corruption of medical education by business. This solves that problem.”

Dr. Wolff urged audience members to contact the board if they have questions or concerns about recertification.

One change the board made to the SAMs involved the process used to educate the physician if he or she got a question wrong. “It [used to] send you to an article, where you had to read the whole bloody article to find one thing,” he said. “But now they're going to have [specific] critiques with the information because the idea is to teach, not to try to fool anybody.”

SCOTTSDALE, ARIZ. — Incarcerated women with both substance abuse problems and mental illnesses have many treatment needs, and even short-term incarceration is an excellent opportunity to help them deal with their problems, Debra Hrouda said at the annual meeting of the American Academy of Psychiatry and the Law.

Even when a jail term is just 8 or 9 weeks, “that's adequate time to get them started,” said Ms. Hrouda, an instructor in the psychiatry department and a researcher in the Dual Disorders Research Program at Case Western Reserve University, in Cleveland.

Ms. Hrouda and colleague Kathleen Farkas, Ph.D., studied 198 women incarcerated in the Cuyahoga County Corrections Center. Participants were selected from a list of inmates who had received mental health services, as well as from the facility's general population. The study was funded by the National Institute on Drug Abuse.

Three trained interviewers conducted face-to-face interviews with participants, lasting an average of 3 hours. Ages of subjects ranged from 19 to 61 years, with an average age of 35; 54% were African American, 29% were white, and 17% were Hispanic, biracial, or of another race.

At the time of the interview, subjects had been incarcerated an average of 9 weeks; time in the facility ranged from 1 to 55 weeks. Most offenses were drug-related, followed by thefts, violent crimes, other crimes, and then parole violations.

Sixty-nine percent of respondents met the criteria for major depressive disorder; 60% were positive for posttraumatic stress disorder, and 30% had generalized anxiety disorder. As for substance use issues, 77% screened positive for cocaine dependence, 67% for alcohol dependence, and 40% for marijuana dependence.

More than three-fourths of respondents had both mental health disorders and substance use disorders, while 16% had only substance use problems, and 3% had only mental health issues, Ms. Hrouda said.

One striking finding of the study was the amount of social support respondents said they had, she noted. Subjects reported “moderate” levels of social support—an average of 28 on a scale of 0–48. “It could be an artifact of measurement” or just a difference between their perception of their support levels versus how much support they actually have, Ms. Hrouda noted.

When it comes to barriers to either substance abuse or mental health treatment, the most frequent barriers identified were not having health insurance, not being able to pay for treatment, and having to wait for an opening because the program was full. But despite these similarities, there were also differences in perceived barriers to the two types of treatment, Ms. Hrouda said.

For instance, many of the barriers involved in getting substance abuse treatment were patient-related: no health insurance, inability to pay out of pocket, inability to stay clean, lack of follow-up care, and seeing substance abuse as a personal weakness.

Barriers to mental health care, on the other hand, were more system-related: waiting for an opening in the program, no transportation, or not knowing the location of the treatment facility.

Another frequently mentioned treatment barrier was fear of losing custody of children.

The fact these barriers existed was a shame, since many inmates showed a readiness to accept treatment, Ms. Hrouda said. According to their scores on the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES), 5% of respondents were ambivalent about treatment, while 65% recognized they had a problem needing treatment, and 30% were taking steps to get help.

“This is not surprising, since they are in a controlled setting where they are clean, and they also are experiencing the consequences of [their actions],” she said.

SCOTTSDALE, ARIZ. — Incarcerated women with both substance abuse problems and mental illnesses have many treatment needs, and even short-term incarceration is an excellent opportunity to help them deal with their problems, Debra Hrouda said at the annual meeting of the American Academy of Psychiatry and the Law.

Even when a jail term is just 8 or 9 weeks, “that's adequate time to get them started,” said Ms. Hrouda, an instructor in the psychiatry department and a researcher in the Dual Disorders Research Program at Case Western Reserve University, in Cleveland.

Ms. Hrouda and colleague Kathleen Farkas, Ph.D., studied 198 women incarcerated in the Cuyahoga County Corrections Center. Participants were selected from a list of inmates who had received mental health services, as well as from the facility's general population. The study was funded by the National Institute on Drug Abuse.

Three trained interviewers conducted face-to-face interviews with participants, lasting an average of 3 hours. Ages of subjects ranged from 19 to 61 years, with an average age of 35; 54% were African American, 29% were white, and 17% were Hispanic, biracial, or of another race.

At the time of the interview, subjects had been incarcerated an average of 9 weeks; time in the facility ranged from 1 to 55 weeks. Most offenses were drug-related, followed by thefts, violent crimes, other crimes, and then parole violations.

Sixty-nine percent of respondents met the criteria for major depressive disorder; 60% were positive for posttraumatic stress disorder, and 30% had generalized anxiety disorder. As for substance use issues, 77% screened positive for cocaine dependence, 67% for alcohol dependence, and 40% for marijuana dependence.

More than three-fourths of respondents had both mental health disorders and substance use disorders, while 16% had only substance use problems, and 3% had only mental health issues, Ms. Hrouda said.

One striking finding of the study was the amount of social support respondents said they had, she noted. Subjects reported “moderate” levels of social support—an average of 28 on a scale of 0–48. “It could be an artifact of measurement” or just a difference between their perception of their support levels versus how much support they actually have, Ms. Hrouda noted.

When it comes to barriers to either substance abuse or mental health treatment, the most frequent barriers identified were not having health insurance, not being able to pay for treatment, and having to wait for an opening because the program was full. But despite these similarities, there were also differences in perceived barriers to the two types of treatment, Ms. Hrouda said.

For instance, many of the barriers involved in getting substance abuse treatment were patient-related: no health insurance, inability to pay out of pocket, inability to stay clean, lack of follow-up care, and seeing substance abuse as a personal weakness.

Barriers to mental health care, on the other hand, were more system-related: waiting for an opening in the program, no transportation, or not knowing the location of the treatment facility.

Another frequently mentioned treatment barrier was fear of losing custody of children.

The fact these barriers existed was a shame, since many inmates showed a readiness to accept treatment, Ms. Hrouda said. According to their scores on the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES), 5% of respondents were ambivalent about treatment, while 65% recognized they had a problem needing treatment, and 30% were taking steps to get help.

“This is not surprising, since they are in a controlled setting where they are clean, and they also are experiencing the consequences of [their actions],” she said.

SCOTTSDALE, ARIZ. — Incarcerated women with both substance abuse problems and mental illnesses have many treatment needs, and even short-term incarceration is an excellent opportunity to help them deal with their problems, Debra Hrouda said at the annual meeting of the American Academy of Psychiatry and the Law.

Even when a jail term is just 8 or 9 weeks, “that's adequate time to get them started,” said Ms. Hrouda, an instructor in the psychiatry department and a researcher in the Dual Disorders Research Program at Case Western Reserve University, in Cleveland.

Ms. Hrouda and colleague Kathleen Farkas, Ph.D., studied 198 women incarcerated in the Cuyahoga County Corrections Center. Participants were selected from a list of inmates who had received mental health services, as well as from the facility's general population. The study was funded by the National Institute on Drug Abuse.

Three trained interviewers conducted face-to-face interviews with participants, lasting an average of 3 hours. Ages of subjects ranged from 19 to 61 years, with an average age of 35; 54% were African American, 29% were white, and 17% were Hispanic, biracial, or of another race.

At the time of the interview, subjects had been incarcerated an average of 9 weeks; time in the facility ranged from 1 to 55 weeks. Most offenses were drug-related, followed by thefts, violent crimes, other crimes, and then parole violations.

Sixty-nine percent of respondents met the criteria for major depressive disorder; 60% were positive for posttraumatic stress disorder, and 30% had generalized anxiety disorder. As for substance use issues, 77% screened positive for cocaine dependence, 67% for alcohol dependence, and 40% for marijuana dependence.

More than three-fourths of respondents had both mental health disorders and substance use disorders, while 16% had only substance use problems, and 3% had only mental health issues, Ms. Hrouda said.

One striking finding of the study was the amount of social support respondents said they had, she noted. Subjects reported “moderate” levels of social support—an average of 28 on a scale of 0–48. “It could be an artifact of measurement” or just a difference between their perception of their support levels versus how much support they actually have, Ms. Hrouda noted.

When it comes to barriers to either substance abuse or mental health treatment, the most frequent barriers identified were not having health insurance, not being able to pay for treatment, and having to wait for an opening because the program was full. But despite these similarities, there were also differences in perceived barriers to the two types of treatment, Ms. Hrouda said.

For instance, many of the barriers involved in getting substance abuse treatment were patient-related: no health insurance, inability to pay out of pocket, inability to stay clean, lack of follow-up care, and seeing substance abuse as a personal weakness.

Barriers to mental health care, on the other hand, were more system-related: waiting for an opening in the program, no transportation, or not knowing the location of the treatment facility.

Another frequently mentioned treatment barrier was fear of losing custody of children.

The fact these barriers existed was a shame, since many inmates showed a readiness to accept treatment, Ms. Hrouda said. According to their scores on the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES), 5% of respondents were ambivalent about treatment, while 65% recognized they had a problem needing treatment, and 30% were taking steps to get help.

“This is not surprising, since they are in a controlled setting where they are clean, and they also are experiencing the consequences of [their actions],” she said.