Joyce Frieden

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

New Jersey is 1 of 24 states that have a so-called “family cap” law, which states that women who have additional children while receiving Temporary Assistance to Needy Families (TANF) benefits will not have their benefits raised.

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

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

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

When asked whether the cap would influence future decisions about childbearing now that they were aware of it, three-fourths said it wouldn't influence them at all.

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

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

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

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

New Jersey is 1 of 24 states that have a so-called “family cap” law, which states that women who have additional children while receiving Temporary Assistance to Needy Families (TANF) benefits will not have their benefits raised.

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

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

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

When asked whether the cap would influence future decisions about childbearing now that they were aware of it, three-fourths said it wouldn't influence them at all.

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

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

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

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

New Jersey is 1 of 24 states that have a so-called “family cap” law, which states that women who have additional children while receiving Temporary Assistance to Needy Families (TANF) benefits will not have their benefits raised.

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

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

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

When asked whether the cap would influence future decisions about childbearing now that they were aware of it, three-fourths said it wouldn't influence them at all.

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

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

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

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.

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, he 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.

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, he 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.

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, he 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.”

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.

Mr. Bundy noted that methamphetamine addiction is particularly problematic for several reasons. First of all, directions for making the drug are readily available. Second, the ingredients can be obtained in any pharmacy and mixed together at home.

Finally, he pointed out that methamphetamine addiction 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,” Dr. Wang pointed out.

Marvin Seppala, M.D., who is 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. In addition, smugglers bring the drug in from surrounding states, and criminals go 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, who serves as 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.

“Therefore, 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.”

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.”

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 phenyl-ephrine. Pfizer also will continue to offer the old version of the drug.

Another idea that was 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.

Mr. Bundy noted that methamphetamine addiction is particularly problematic for several reasons. First of all, directions for making the drug are readily available. Second, the ingredients can be obtained in any pharmacy and mixed together at home.

Finally, he pointed out that methamphetamine addiction 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,” Dr. Wang pointed out.

Marvin Seppala, M.D., who is 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. In addition, smugglers bring the drug in from surrounding states, and criminals go 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, who serves as 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.

“Therefore, 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.”

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.”

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 phenyl-ephrine. Pfizer also will continue to offer the old version of the drug.

Another idea that was 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.

Mr. Bundy noted that methamphetamine addiction is particularly problematic for several reasons. First of all, directions for making the drug are readily available. Second, the ingredients can be obtained in any pharmacy and mixed together at home.

Finally, he pointed out that methamphetamine addiction 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,” Dr. Wang pointed out.

Marvin Seppala, M.D., who is 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. In addition, smugglers bring the drug in from surrounding states, and criminals go 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, who serves as 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.

“Therefore, 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.”

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.”

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 phenyl-ephrine. Pfizer also will continue to offer the old version of the drug.

Another idea that was 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.

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.

For many years, “Medicaid programs have engaged in 'faith-based health care,'” said Dr. Jones, professor of health administration and policy at the Medical University of South Carolina, Charleston. “There is this faith that managed care will provide better care with limited dollars, despite the fact that managed care works best, and often only, with healthy populations.”

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,” Dr. Jones said. “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.

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, he 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, Dr. Jones 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.

For many years, “Medicaid programs have engaged in 'faith-based health care,'” said Dr. Jones, professor of health administration and policy at the Medical University of South Carolina, Charleston. “There is this faith that managed care will provide better care with limited dollars, despite the fact that managed care works best, and often only, with healthy populations.”

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,” Dr. Jones said. “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.

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, he 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, Dr. Jones 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.

For many years, “Medicaid programs have engaged in 'faith-based health care,'” said Dr. Jones, professor of health administration and policy at the Medical University of South Carolina, Charleston. “There is this faith that managed care will provide better care with limited dollars, despite the fact that managed care works best, and often only, with healthy populations.”

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,” Dr. Jones said. “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.

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

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

In a pilot study, Ms. Fortune-Greeley, a graduate student at Columbia University School of Public Health, New York, and her colleagues interviewed 32 female current and former TANF recipients in New Jersey. Of those, 9 were black, 12 were Latino, 9 were white, and 2 were biracial. Respondents' average age was 31, and they had an average of 2.4 children. Seven did not have a high school diploma, and 14 were married; 75% of recipients had some form of health insurance.

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

More than half had had at least one abortion. The average number of abortions per recipient was 2.8; the highest was 6. Reasons given for having abortions included being in an abusive relationship, being an incest victim, and spacing children.

Only two respondents said they were aware of the family planning cap, and neither could describe it accurately, Ms. Fortune-Greeley said. When asked whether awareness of the cap would influence future decisions about childbearing, three-fourths said it wouldn't influence them at all. Most of the women said the policy wouldn't affect their use of contraception. As to what would happen if they became pregnant while on TANF, almost all respondents said they would keep the baby; two said they would give it up for adoption.

There's clearly a need for better communication of the policy from the social services' offices to clients, she said. “The policy doesn't appear to be impacting women's reproductive decision making. … They're having more children without receiving this incremental increase, and it is posing additional economic hardship on already poor families.”

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

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

In a pilot study, Ms. Fortune-Greeley, a graduate student at Columbia University School of Public Health, New York, and her colleagues interviewed 32 female current and former TANF recipients in New Jersey. Of those, 9 were black, 12 were Latino, 9 were white, and 2 were biracial. Respondents' average age was 31, and they had an average of 2.4 children. Seven did not have a high school diploma, and 14 were married; 75% of recipients had some form of health insurance.

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

More than half had had at least one abortion. The average number of abortions per recipient was 2.8; the highest was 6. Reasons given for having abortions included being in an abusive relationship, being an incest victim, and spacing children.

Only two respondents said they were aware of the family planning cap, and neither could describe it accurately, Ms. Fortune-Greeley said. When asked whether awareness of the cap would influence future decisions about childbearing, three-fourths said it wouldn't influence them at all. Most of the women said the policy wouldn't affect their use of contraception. As to what would happen if they became pregnant while on TANF, almost all respondents said they would keep the baby; two said they would give it up for adoption.

There's clearly a need for better communication of the policy from the social services' offices to clients, she said. “The policy doesn't appear to be impacting women's reproductive decision making. … They're having more children without receiving this incremental increase, and it is posing additional economic hardship on already poor families.”

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

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

In a pilot study, Ms. Fortune-Greeley, a graduate student at Columbia University School of Public Health, New York, and her colleagues interviewed 32 female current and former TANF recipients in New Jersey. Of those, 9 were black, 12 were Latino, 9 were white, and 2 were biracial. Respondents' average age was 31, and they had an average of 2.4 children. Seven did not have a high school diploma, and 14 were married; 75% of recipients had some form of health insurance.

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

More than half had had at least one abortion. The average number of abortions per recipient was 2.8; the highest was 6. Reasons given for having abortions included being in an abusive relationship, being an incest victim, and spacing children.

Only two respondents said they were aware of the family planning cap, and neither could describe it accurately, Ms. Fortune-Greeley said. When asked whether awareness of the cap would influence future decisions about childbearing, three-fourths said it wouldn't influence them at all. Most of the women said the policy wouldn't affect their use of contraception. As to what would happen if they became pregnant while on TANF, almost all respondents said they would keep the baby; two said they would give it up for adoption.

There's clearly a need for better communication of the policy from the social services' offices to clients, she said. “The policy doesn't appear to be impacting women's reproductive decision making. … They're having more children without receiving this incremental increase, and it is posing additional economic hardship on already poor families.”

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

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

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 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 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. This may reflect the way data were collected, since Medicaid data were reported separately. It may just show that families with private health insurance are not adequately insured, Dr. Wallis said.

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

More than one-third of households with children reported medical debt. “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. But 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; 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, University of Iowa researchers said at the annual meeting of the American Public Health Association.

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

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 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 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. This may reflect the way data were collected, since Medicaid data were reported separately. It may just show that families with private health insurance are not adequately insured, Dr. Wallis said.

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

More than one-third of households with children reported medical debt. “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. But 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; 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, University of Iowa researchers said at the annual meeting of the American Public Health Association.

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

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 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 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. This may reflect the way data were collected, since Medicaid data were reported separately. It may just show that families with private health insurance are not adequately insured, Dr. Wallis said.

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

More than one-third of households with children reported medical debt. “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. But 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; 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.

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, he 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.

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, he 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.

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, he 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.

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 commented.

“With the PEP project, utilization goes down a little less, but there's no difference in primary care utilization,” he said.

“It appears … that PEP is doing exactly what it should be doing—controlling utilization but not on the primary care level,” Dr. Jones added.

Another problem with the HMOs, he 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,” Dr. Jones said. “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.

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 commented.

“With the PEP project, utilization goes down a little less, but there's no difference in primary care utilization,” he said.

“It appears … that PEP is doing exactly what it should be doing—controlling utilization but not on the primary care level,” Dr. Jones added.

Another problem with the HMOs, he 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,” Dr. Jones said. “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.

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 commented.

“With the PEP project, utilization goes down a little less, but there's no difference in primary care utilization,” he said.

“It appears … that PEP is doing exactly what it should be doing—controlling utilization but not on the primary care level,” Dr. Jones added.

Another problem with the HMOs, he 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,” Dr. Jones said. “The bottom line is, it's still kind of 'faith-based' health care.”

Physicians who used to worry about prescribing too much pain medication now have a new liability problem to worry about: not prescribing enough.

“The pendulum has swung the other way,” said Jay Westbrook, clinical director for palliative care and bereavement service at Valley Presbyterian Hospital in West Van Nuys, Calif. “Doctors are much more likely these days to get into trouble for failing to manage someone's pain than for writing an [inappropriate] prescription for OxyContin.”

Cases such as Bergman v. Eden Medical Center have raised awareness of the issue, according to Mr. Westbrook. In that case, tried in 2001, jurors awarded $1.5 million to the family of William Bergman, a California hospital patient with multiple compression fractures and possible lung cancer.

Mr. Bergman's children alleged that during their late father's hospital stay, his physician, Wing Chin, prescribed only Demerol as needed, despite the fact that Mr. Bergman registered pain levels of 7–10 on a 1–10 scale. The prescription remained unchanged during the 5-day hospital stay.

On the day of discharge to at-home hospice care, Dr. Chin prescribed hydrocodone (Vicodin) capsules for pain even though Mr. Bergman had known swallowing difficulties, the suit alleged. After Mr. Bergman's daughter insisted that her father needed more medication, he was given a shot of meperidine (Demerol) and a fentanyl transdermal (Duragesic) patch.

Two days later, the hospice nurse decided that Mr. Bergman's pain was “out of control” and called Dr. Chin, and, after several phone calls, was referred to another doctor 11/2 hours later. The second doctor prescribed liquid morphine and additional pain patches, which alleviated the pain. Mr. Bergman died the next day.

The Bergman case was unusual because it was prosecuted under the state's elder abuse and dependent adult law, not malpractice law. Cases like this “would come under malpractice in other states,” said Barbara Coombs Lee, president of the Compassion in Dying Federation, a Portland, Ore. group that advocates for the rights of dying patients. However, under California law, claims for “pain and suffering” cannot be made after a patient dies.

But California's Elder Abuse and Dependent Adult Civil Protection Act, passed in 1992, allows prosecutions related to mistreatment of anyone aged 18–64 years who was admitted to a 24-hour inpatient facility, such as an acute care hospital.

Compassion in Dying, which worked with the Bergman family, hopes that lawsuits such as the Bergman case will stir physicians to look at their own pain treatment protocols. “Doctors are undereducated and undermotivated,” Ms. Coombs said. “That's the purpose of these lawsuits—to motivate them and overcome their sense of self-protection” in regard to the Drug Enforcement Administration.

Compassion in Dying is considering bringing forth several similar cases, according to Ms. Coombs. But B. Eliot Cole, M.D., director of education at the American Academy of Pain Management, Sonora, Calif., is not so sure that's a good idea.

“I am not in favor of using courts to make this happen,” he said. But he acknowledged that these cases, if successful, might help patients in the long run. “Do I think it's going to help more people in pain to get help, and galvanize all of us in medicine to look more closely at our own practices? Yes. In a lot of ways, a lot of people will benefit from this very awful situation.”

California legislators also have taken notice of the problem. In August, the state legislature passed SB 1782, which would require the California District Attorneys Association to work with law enforcement and medical groups to develop protocols for investigations related to physicians' pain medication prescribing habits.

“It is the intent of the legislature to alleviate [physicians' fear of criminal prosecution] by providing for proper review of cases involving the prescription of pain medication before criminal charges are filed,” the legislation reads, which was awaiting Gov. Arnold Schwarzenegger's (R) signature at press time.

Mr. Westbrook, who also lectures on pain management, predicted that physicians would see more lawsuits related to undertreatment of pain—in both the civil and criminal realm. “It's tough, but the bottom line is that pain isn't okay, and it's not okay to leave a patient's pain unaddressed.”

Mr. Cole agreed, and offered advice to physicians struggling with this issue. “You'll have to understand that practicing medicine will always incur some risk, so find a happy medium. If you're loosey-goosey with your prescription pad, you'll have all kinds of problems. If you're tight with your prescription pad, you'll have problems too.”

Physicians who used to worry about prescribing too much pain medication now have a new liability problem to worry about: not prescribing enough.

“The pendulum has swung the other way,” said Jay Westbrook, clinical director for palliative care and bereavement service at Valley Presbyterian Hospital in West Van Nuys, Calif. “Doctors are much more likely these days to get into trouble for failing to manage someone's pain than for writing an [inappropriate] prescription for OxyContin.”

Cases such as Bergman v. Eden Medical Center have raised awareness of the issue, according to Mr. Westbrook. In that case, tried in 2001, jurors awarded $1.5 million to the family of William Bergman, a California hospital patient with multiple compression fractures and possible lung cancer.

Mr. Bergman's children alleged that during their late father's hospital stay, his physician, Wing Chin, prescribed only Demerol as needed, despite the fact that Mr. Bergman registered pain levels of 7–10 on a 1–10 scale. The prescription remained unchanged during the 5-day hospital stay.

On the day of discharge to at-home hospice care, Dr. Chin prescribed hydrocodone (Vicodin) capsules for pain even though Mr. Bergman had known swallowing difficulties, the suit alleged. After Mr. Bergman's daughter insisted that her father needed more medication, he was given a shot of meperidine (Demerol) and a fentanyl transdermal (Duragesic) patch.

Two days later, the hospice nurse decided that Mr. Bergman's pain was “out of control” and called Dr. Chin, and, after several phone calls, was referred to another doctor 11/2 hours later. The second doctor prescribed liquid morphine and additional pain patches, which alleviated the pain. Mr. Bergman died the next day.

The Bergman case was unusual because it was prosecuted under the state's elder abuse and dependent adult law, not malpractice law. Cases like this “would come under malpractice in other states,” said Barbara Coombs Lee, president of the Compassion in Dying Federation, a Portland, Ore. group that advocates for the rights of dying patients. However, under California law, claims for “pain and suffering” cannot be made after a patient dies.

But California's Elder Abuse and Dependent Adult Civil Protection Act, passed in 1992, allows prosecutions related to mistreatment of anyone aged 18–64 years who was admitted to a 24-hour inpatient facility, such as an acute care hospital.

Compassion in Dying, which worked with the Bergman family, hopes that lawsuits such as the Bergman case will stir physicians to look at their own pain treatment protocols. “Doctors are undereducated and undermotivated,” Ms. Coombs said. “That's the purpose of these lawsuits—to motivate them and overcome their sense of self-protection” in regard to the Drug Enforcement Administration.

Compassion in Dying is considering bringing forth several similar cases, according to Ms. Coombs. But B. Eliot Cole, M.D., director of education at the American Academy of Pain Management, Sonora, Calif., is not so sure that's a good idea.

“I am not in favor of using courts to make this happen,” he said. But he acknowledged that these cases, if successful, might help patients in the long run. “Do I think it's going to help more people in pain to get help, and galvanize all of us in medicine to look more closely at our own practices? Yes. In a lot of ways, a lot of people will benefit from this very awful situation.”

California legislators also have taken notice of the problem. In August, the state legislature passed SB 1782, which would require the California District Attorneys Association to work with law enforcement and medical groups to develop protocols for investigations related to physicians' pain medication prescribing habits.

“It is the intent of the legislature to alleviate [physicians' fear of criminal prosecution] by providing for proper review of cases involving the prescription of pain medication before criminal charges are filed,” the legislation reads, which was awaiting Gov. Arnold Schwarzenegger's (R) signature at press time.

Mr. Westbrook, who also lectures on pain management, predicted that physicians would see more lawsuits related to undertreatment of pain—in both the civil and criminal realm. “It's tough, but the bottom line is that pain isn't okay, and it's not okay to leave a patient's pain unaddressed.”

Mr. Cole agreed, and offered advice to physicians struggling with this issue. “You'll have to understand that practicing medicine will always incur some risk, so find a happy medium. If you're loosey-goosey with your prescription pad, you'll have all kinds of problems. If you're tight with your prescription pad, you'll have problems too.”

Physicians who used to worry about prescribing too much pain medication now have a new liability problem to worry about: not prescribing enough.

“The pendulum has swung the other way,” said Jay Westbrook, clinical director for palliative care and bereavement service at Valley Presbyterian Hospital in West Van Nuys, Calif. “Doctors are much more likely these days to get into trouble for failing to manage someone's pain than for writing an [inappropriate] prescription for OxyContin.”

Cases such as Bergman v. Eden Medical Center have raised awareness of the issue, according to Mr. Westbrook. In that case, tried in 2001, jurors awarded $1.5 million to the family of William Bergman, a California hospital patient with multiple compression fractures and possible lung cancer.

Mr. Bergman's children alleged that during their late father's hospital stay, his physician, Wing Chin, prescribed only Demerol as needed, despite the fact that Mr. Bergman registered pain levels of 7–10 on a 1–10 scale. The prescription remained unchanged during the 5-day hospital stay.

On the day of discharge to at-home hospice care, Dr. Chin prescribed hydrocodone (Vicodin) capsules for pain even though Mr. Bergman had known swallowing difficulties, the suit alleged. After Mr. Bergman's daughter insisted that her father needed more medication, he was given a shot of meperidine (Demerol) and a fentanyl transdermal (Duragesic) patch.

Two days later, the hospice nurse decided that Mr. Bergman's pain was “out of control” and called Dr. Chin, and, after several phone calls, was referred to another doctor 11/2 hours later. The second doctor prescribed liquid morphine and additional pain patches, which alleviated the pain. Mr. Bergman died the next day.

The Bergman case was unusual because it was prosecuted under the state's elder abuse and dependent adult law, not malpractice law. Cases like this “would come under malpractice in other states,” said Barbara Coombs Lee, president of the Compassion in Dying Federation, a Portland, Ore. group that advocates for the rights of dying patients. However, under California law, claims for “pain and suffering” cannot be made after a patient dies.

But California's Elder Abuse and Dependent Adult Civil Protection Act, passed in 1992, allows prosecutions related to mistreatment of anyone aged 18–64 years who was admitted to a 24-hour inpatient facility, such as an acute care hospital.

Compassion in Dying, which worked with the Bergman family, hopes that lawsuits such as the Bergman case will stir physicians to look at their own pain treatment protocols. “Doctors are undereducated and undermotivated,” Ms. Coombs said. “That's the purpose of these lawsuits—to motivate them and overcome their sense of self-protection” in regard to the Drug Enforcement Administration.

Compassion in Dying is considering bringing forth several similar cases, according to Ms. Coombs. But B. Eliot Cole, M.D., director of education at the American Academy of Pain Management, Sonora, Calif., is not so sure that's a good idea.

“I am not in favor of using courts to make this happen,” he said. But he acknowledged that these cases, if successful, might help patients in the long run. “Do I think it's going to help more people in pain to get help, and galvanize all of us in medicine to look more closely at our own practices? Yes. In a lot of ways, a lot of people will benefit from this very awful situation.”

California legislators also have taken notice of the problem. In August, the state legislature passed SB 1782, which would require the California District Attorneys Association to work with law enforcement and medical groups to develop protocols for investigations related to physicians' pain medication prescribing habits.

“It is the intent of the legislature to alleviate [physicians' fear of criminal prosecution] by providing for proper review of cases involving the prescription of pain medication before criminal charges are filed,” the legislation reads, which was awaiting Gov. Arnold Schwarzenegger's (R) signature at press time.

Mr. Westbrook, who also lectures on pain management, predicted that physicians would see more lawsuits related to undertreatment of pain—in both the civil and criminal realm. “It's tough, but the bottom line is that pain isn't okay, and it's not okay to leave a patient's pain unaddressed.”

Mr. Cole agreed, and offered advice to physicians struggling with this issue. “You'll have to understand that practicing medicine will always incur some risk, so find a happy medium. If you're loosey-goosey with your prescription pad, you'll have all kinds of problems. If you're tight with your prescription pad, you'll have problems too.”

NEW YORK — Primary care patients should be screened for trauma and posttraumatic stress disorder when they first come in, Tanya Alim, M.D., of Howard University, Washington, said in a poster presentation at the annual meeting of the American Psychiatric Association.

Dr. Alim and her colleagues surveyed 360 primary care patients in waiting rooms at three primary care offices at a Washington hospital; 98% of the subjects were African American. Patients were given a questionnaire to assess their level of trauma exposure. The survey also asked about drug and alcohol use. Patients were compensated for their time. Those who mentioned having been exposed to some form of severe or life-threatening trauma were asked to go to the hospital's outpatient mental health clinic to undergo an interview and complete more questions on coping and stress.

The researchers found that 69% of subjects had been exposed to one or more traumatic situations, including both community- and family-based events. Women were more likely to have experienced a sexual assault; men were more likely to have been exposed to physical assault and assault with a weapon.

In addition to trauma exposure, the authors found high rates of posttraumatic stress disorder in the study population. Both male and female victims of sexual assault were found to be at higher risk of developing posttraumatic stress disorder.

“Everyone should be sensitive to asking about trauma,” said Dr. Alim, clinical director of the mood and anxiety program at Howard University Hospital. “People presenting with medical problems in a primary care setting appear to be more likely to have a history of previous trauma. Primary care doctors need to be sensitive to that type of information.”

She added that patients with a history of trauma might be at greater risk of experiencing another traumatic incident, compared with those who have not experienced trauma.

NEW YORK — Primary care patients should be screened for trauma and posttraumatic stress disorder when they first come in, Tanya Alim, M.D., of Howard University, Washington, said in a poster presentation at the annual meeting of the American Psychiatric Association.

Dr. Alim and her colleagues surveyed 360 primary care patients in waiting rooms at three primary care offices at a Washington hospital; 98% of the subjects were African American. Patients were given a questionnaire to assess their level of trauma exposure. The survey also asked about drug and alcohol use. Patients were compensated for their time. Those who mentioned having been exposed to some form of severe or life-threatening trauma were asked to go to the hospital's outpatient mental health clinic to undergo an interview and complete more questions on coping and stress.

The researchers found that 69% of subjects had been exposed to one or more traumatic situations, including both community- and family-based events. Women were more likely to have experienced a sexual assault; men were more likely to have been exposed to physical assault and assault with a weapon.

In addition to trauma exposure, the authors found high rates of posttraumatic stress disorder in the study population. Both male and female victims of sexual assault were found to be at higher risk of developing posttraumatic stress disorder.

“Everyone should be sensitive to asking about trauma,” said Dr. Alim, clinical director of the mood and anxiety program at Howard University Hospital. “People presenting with medical problems in a primary care setting appear to be more likely to have a history of previous trauma. Primary care doctors need to be sensitive to that type of information.”

She added that patients with a history of trauma might be at greater risk of experiencing another traumatic incident, compared with those who have not experienced trauma.

NEW YORK — Primary care patients should be screened for trauma and posttraumatic stress disorder when they first come in, Tanya Alim, M.D., of Howard University, Washington, said in a poster presentation at the annual meeting of the American Psychiatric Association.

Dr. Alim and her colleagues surveyed 360 primary care patients in waiting rooms at three primary care offices at a Washington hospital; 98% of the subjects were African American. Patients were given a questionnaire to assess their level of trauma exposure. The survey also asked about drug and alcohol use. Patients were compensated for their time. Those who mentioned having been exposed to some form of severe or life-threatening trauma were asked to go to the hospital's outpatient mental health clinic to undergo an interview and complete more questions on coping and stress.

The researchers found that 69% of subjects had been exposed to one or more traumatic situations, including both community- and family-based events. Women were more likely to have experienced a sexual assault; men were more likely to have been exposed to physical assault and assault with a weapon.

In addition to trauma exposure, the authors found high rates of posttraumatic stress disorder in the study population. Both male and female victims of sexual assault were found to be at higher risk of developing posttraumatic stress disorder.

“Everyone should be sensitive to asking about trauma,” said Dr. Alim, clinical director of the mood and anxiety program at Howard University Hospital. “People presenting with medical problems in a primary care setting appear to be more likely to have a history of previous trauma. Primary care doctors need to be sensitive to that type of information.”

She added that patients with a history of trauma might be at greater risk of experiencing another traumatic incident, compared with those who have not experienced trauma.