How The Tax Bill Would Affect Health Care Programs

Caught up in the congressional politics swirling around a pending tax bill are proposals that affect health care for newly laid-off workers as well as Medicare and Medicaid patients.

On the table: two proposals to extend — once again —a “fix” of Medicare payments to doctors and subsidies for COBRA health insurance, the federal program that allows laid-off workers to stay on their employer’s health insurance. Without action by the end of the month, the newly unemployed would have to pay the entire cost of continuing their health insurance and doctors could see their Medicare payments slashed by 21 percent.

And the legislation would also continue the extra federal payments to help hard-pressed state Medicaid programs.

The tax “extenders” bill extends unemployment benefits, a number of popular tax cuts and funds small business loan programs.

Congress is considering several solutions on the COBRA, Medicaid and Medicare payment issues and the House is expected to act early next week.

Doc Fix

In 1997, Congress put in place the Sustainable Growth Rate formula to set Medicare’s physician payments and curb the growth in health care costs. Based on the formula, whenever physician costs grew faster than the economy, doctors’ Medicare reimbursements would be reduced. However, every time – except once in 2003 – when this scenario has played out, lawmakers have intervened to delay the unpopular cuts.

Here are some of the options being considered:

— A deal crafted by Democratic leaders and announced Thursday that would include a fix to payment rates for three years. Specifically, it would allow increases to the payment rates through 2011. In 2012 and 2013, rates would keep pace with Medicare’s growth and an extra allowance would go to primary care doctors. The Congressional Budget Office is estimating how much this fix will cost. It could be considered by the House early next week.

— A five-year, $88.5 billion plan that would give doctors scheduled pay increases. This was initially popular among some House Democrats but has less traction in the Senate and among some moderates because of the cost.

— A delay of the 21 percent cut until the end of the year.

— Or, a one-month delay in the cuts. Congress opted for such a short-term fix on April 15.

The political dilemma is that members on both sides of the aisle are increasingly skittish about adding to the deficit in a year that has already been marked by lots of spending. And the powerful American Medical Association has steadfastly opposed shorter-term fixes, instead calling for a permanent solution.

Dr. James Rohack, president of the AMA, said in a release Thursday that a three-year fix would “provide temporary stability” for seniors and their physicians, but that the AMA is disappointed that Congress again won’t permanently fix the physician payment formula. “Achieving full repeal of the payment formula is apparently not feasible at this time, and Congress could have permanently solved this problem five years ago at a cost of $49 billion, less than the price of the short-term remedy now under consideration in Congress.”

The Congressional Budget Office has estimated the cost of the permanent fix to be $276 billion through 2020.


Congress has extended the COBRA subsidies for unemployed workers four times since February 2009.

Under COBRA, laid-off workers can stay on their employer’s health insurance, usually for as long as 18 months. But the former employee has to pay all the costs, something that is often cost-prohibitive. The COBRA benefits subsidy pays 65 percent of the insurance premium costs for laid-off workers for 15 months.

The last extension of this subsidy was in April, for a month, and pending legislation would make it available to people laid off through the end of the year, at a cost of $7.8 billion. If Congress doesn’t act, those laid off on or after June 1 would have to bear the full cost of their COBRA coverage.

Although a popular provision, the COBRA subsidy extension is caught up in the politics about government spending.

Judy Conti, federal advocacy coordinator for the National Employment Law Projects, says she sees COBRA being extended for as long as high unemployment rates continue, but she thinks it’ll be a tough fight to keep the subsidy going into next year, saying there are some lawmakers “who think that we’ve done enough and that this is it and no more,” she said. “But I don’t think that’s going to win the day.”

Medicaid Funding Boost For States

With states facing a double recession whammy of less revenue and more demand for health care services, Congress included extra money to Medicaid programs in the federal stimulus package beginning in February 2009. Before the stimulus, the federal government’s share of Medicaid costs was between 50 and 76 percent (depending on the per capita income of the state). With the stimulus, the federal match increased to between 61 and 84 percent of all Medicaid spending. The higher matching rate was originally slated to expire at the end of 2010, but the bill would extend the higher rates until June 30, 2011, at a cost of $24 billion.

The timing was crucial, according to Robin Rudowitz, the associate director for the Kaiser Commission on Medicaid and the Uninsured. “When we asked them last year, states reported that the [stimulus funding] was a total lifeline to balance their budgets. While states still did make some cuts and restrictions, they overwhelmingly reported that things would have been a lot worse” without the funds, she said. (KHN is a program of the Kaiser Family Foundation.)

The timing on the extension could be helpful to states as well. Forty-six states end their fiscal year June 30th, so if the extra federal “match” ends this year, they could face the heavier Medicaid burden just halfway through their fiscal year.

This story was produced through collaboration between NPR and Kaiser Health News (KHN), an editorially independent news service and a program of the Kaiser Family Foundation, a nonpartisan health care policy organization that isn’t affiliated with Kaiser Permanente.

by Andrew Villega
Kaiser Health News

Copyright 2010 Kaiser Health News

I found the following story on my NPR iPhone App:


May 26, 2010. Health. Leave a comment.

New Bill Delays Medicare Pay Cut Until 2014, Provides Raises in Interim

Congressional Democrats today unveiled the outline of a bill that would delay a 21% cut in Medicare reimbursement to physicians until 2014 and increase rates for the rest of 2010 as well as 2011.

Reimbursement rates would not decrease in 2012 and 2013, and they could increase even more in those years if the growth of Medicare spending on physician services is “within reasonable limits,” according to a summary of the legislation released by Sen. Max Baucus (D-MT) and Rep. Sander Levin (D-MI). Rate increases would be higher for primary and preventive care.

The bill summary states that rates would return to “current law levels” in 2014, meaning that they would be subject to Medicare’s sustainable growth rate formula for setting physician reimbursement, which triggered this year’s pay cut, set for June 1. Based on the scenario sketched out in the bill summary, when the proposed law expires in 2014, physicians could see their Medicare reimbursement drop by more than 30%, according to the Congressional Budget Office.

No exact figures for any rate increases before 2014 appeared in the bill summary. Sen. Baucus and Rep. Levin have said they will release the full text of the bill later today. Sen. Baucus chairs the Senate Finance Committee, ans Rep. Levin chairs the House Ways and Means Committee.

These provisions on Medicare reimbursement are part of a larger bill that would extend unemployment compensation benefits and a hodgepodge of tax breaks, including tax credits for COBRA health insurance premiums. It also would raise billions of dollars in revenue by closing certain tax loopholes.

By: Robert Lowes

Medscape Medical News © 2010 Medscape, LLC

May 20, 2010. Health. Leave a comment.

Addicted to Tanning

Addiction to Indoor Tanning: Relation to Anxiety, Depression, and Substance Abuse
Mosher CE, Danoff-Burg S
Arch Dermatol. 2010;146:412-417

Dermatologists like to compare recreational indoor tanning with smoking, and with good reason. Both are acquired behaviors linked to the development of life-threatening malignancies (malignant melanoma and lung cancer, respectively). Moreover, both represent risk factors that, at least superficially, appear to be completely avoidable. No one can alter his or her genetic make-up, but why not just quit smoking or tanning?

Smoking, of course, is hard to quit because it is a substance-related disorder (SRD) — an addictive behavior that is characterized by behavioral and physiologic dependency. Recently, Warthan and others have asserted that the same holds true for ultraviolet light tanning.[1,2] Now, Mosher and Danoff-Burg present compelling evidence that, for a significant subset of young adults, indoor tanning may indeed be more of an addiction than a choice.

How is an SRD defined? Mosher and Danoff-Burg used 2 well-established SRD measures: the 4-item CAGE (“Cut down, Annoyed, Guilty, Eye-opener”) questionnaire that is commonly used to screen for alcoholism, and a tanning-specific modification of the 7 SRD criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Both screening tests were self-administered by 421 college student volunteers (67.5% women; 93% between 18 and 21 years old) recruited from a university in the northeastern United States during the fall of 2006.

Of this cross-sectional pool, 237 participants (56.3%) reported that they had tanned indoors at least once in the past, and 229 of these completed their questionnaires. Participants who reported a long-term history of indoor tanning visited tanning salons a mean of 23 times during the previous year. Not surprisingly, habitual tanners were far more likely to meet criteria for addiction to tanning than were nontanners or sporadic tanners. Intriguingly, tanning “addicts” were also more likely to report symptoms of anxiety and substance abuse.


Among the 229 study participants who had used indoor tanning salons, roughly one third met SRD criteria for addiction (30.6% met CAGE criteria; 39.3% met DSM-IV-TR criteria).
Students who met criteria for indoor tanning addiction reported greater symptoms of anxiety than those who did not meet the criteria.
Students who met criteria for addiction to indoor tanning or addictive tendencies also reported greater alcohol and marijuana use during the previous month than those who did not meet the criteria.
Almost half (42%) of students who met the criteria for addiction to indoor tanning reported the use of at least 2 substances (eg, alcohol, marijuana, cocaine, amphetamines, or opiates) during the previous month; in contrast, only 16% of students who reported never tanning indoors and 16.8% of students who tanned indoors without meeting criteria for addiction reported this level of substance abuse.
In this study, tobacco use and depression did not correlate with tanning addiction status.
Variables, such as sex, age, and skin phototype, did not appear to correlate with tanning addiction status.
Evidence linking excessive ultraviolet exposure to both malignant melanoma and nonmelanoma skin cancer is now irrefutable.[3,4] In addition, habitual tanning causes premature skin aging and photodamage (dyspigmentation, skin laxity, and rhytids) and can exacerbate pigment disorders, such as melasma and postinflammatory hyperpigmentation. Although knowledge of these harmful effects has become more widespread over the past decade, the use of indoor tanning facilities is more popular than ever, especially among young adults.[5]

How can this alarming paradox be explained? Mosher and Danoff-Burg propose that habitual indoor tanning may, in some cases, be best characterized as an SRD. Indeed, roughly one third of the college students whom they surveyed met both CAGE and DSM-IV-TR criteria for addiction to ultraviolet tanning. This subgroup also showed a greater proclivity to substance abuse and anxiety, suggesting that habitual tanning may be a predictor of other addictive behaviors, such as alcoholism and cigarette smoking.[6]

Most internists have encountered patients with end-stage emphysema or terminal lung cancer who, in some cases, die quite literally with a cigarette in hand. In a similar manner, most dermatologists have patients who, despite having a diagnosis of malignant melanoma, still won’t give up their weekly trips to the tanning salon. How can this self-destructive behavior be explained? In a word: addiction. As Mosher and Danoff-Burg and others have noted, many people who habitually tan would have a hard time kicking the habit, even if properly motivated to do so.

Armed with this new knowledge, clinicians should view habitual indoor tanning for what it is: a risky, potentially addictive behavior that is reinforced by a wide range of cultural, social, and psychological factors. In this context, conquering this popular and growing addiction will require more than a few stern words of warning delivered at the end of a routine skin examination.
By: Graeme M. Lipper, MD
Warthan MM, Uchida T, Wagner RF Jr. UV tanning as a type of substance-related disorder. Arch Dermatol. 2005;141:963-966. Abstract
Poorsattar SP, Hornung RL. UV light abuse and high-risk tanning behavior among undergraduate college students. J Am Acad Dermatol. 2007;56:375-379. Abstract
Karagas MR, Stannard VA, Mott LA, Slattery MJ, Spencer SK, Weinstock MA. Use of tanning devices and risk of basal call and squamous cell cancers. J Natl Cancer Inst. 2002;94:224-226. Abstract
Gallagher RP, Spinelli JJ, Lee TK. Tanning beds, sunlamps, and risk of cutaneous malignant melanoma. Cancer Epidemiol Biomarkers Prev. 2005;14:562-566. Abstract
Robinson JK, Kim J, Rosenbaum S, Ortiz S. Indoor tanning knowledge, attitudes, and behavior among young adults from 1988-2007. Arch Dermatol. 2008;144:484-488. Abstract
Heckman CJ, Egleston BL, Wilson DB, Ingersoll SK. A preliminary investigation of the predictors of tanning dependence. Am J Health Behav. 2008;32:451-464. Abstract

May 20, 2010. Health. Leave a comment.

Pledge to stop mother-to-baby HIV spread

A campaign is being launched to try to enlist public support to ensure no more children are born with HIV by 2015.

It is the work of the Global Fund, which uses donations from governments to fight HIV, TB and malaria.

The Born HIV Free campaign comes at a critical time, with the fund seeking donations of up to $20bn over the next three years.

It recognises this will be a battle, as governments deal with the aftermath of the Greek financial crisis.
HIV can be passed from mother to child during pregnancy, labour or breast-feeding.

This type of transmission has been almost wiped out in countries such as the UK, because pregnant women who test positive for the virus that causes AIDS can be treated with drugs.

Other measures – such as giving birth by caesarian section – help stop HIV being transmitted to the baby.

But in developing countries, 430,000 children are born with HIV every year.

International effort

The Global Fund already channels more than half of international resources used to prevent mothers passing on HIV.

It believes that the goal of ending this type of HIV transmission by 2015 is achievable – if governments feel they can pledge money with the support of their electorates.

Its executive director, Professor Michel Kazatchkine, said: “We can win this battle against Aids if we get the funding we require.

“This campaign is intended to encourage people to sign up in support of the Global Fund, and to show their leaders that there is strong public support to continue and increase funding for its mission.”


The campaign has been overseen by the French first lady, Carla Bruni-Sarkozy, who is an ambassador for the Global Fund.

Her voice urges people to lend their support in a series of films, with music by Amy Winehouse and U2, which are being promoted on the internet.

The logo has adapted the visual imagery of the red ribbon – long associated with AIDS awareness – to symbolise a mother and child.

The US is the biggest donor to the Global Fund. The UK has pledged or contributed $1.1bn since the fund began in 2002. France is the largest European contributor.

The next round of donations will be confirmed at a crucial meeting in October, chaired by the UN secretary-general Ban Ki-moon.

Insiders at the Global Fund are waiting to hear how the new coalition government in the UK will respond to the request for commitments.

They say they have previously had “promising noises” from the Conservatives and Liberal Democrats on global health issues.

The editor of the Lancet medical journal, Dr Richard Horton, said: “An early indication that our government will support the Global Fund is really important.

“It’s something that has worked – because the money has been spent on drug treatment and bed nets.

“Another pressing issue is taking a serious look at the Department for International Development.

“There is genuine concern that a lot of money has been spent on development aid – without always getting a clear return.

“There needs to be accountability at this time of financial stringency.”

By Jane Dreaper
Health correspondent, BBC News

May 19, 2010. Uncategorized. Leave a comment.

Study suggests processed meat a real health risk

Eating hot dogs, bacon, sausage or deli meats increases the chance of heart disease by 42 percent, US researchers said in a report out Monday.(AFP/Getty Images/File/Jamie Squire)

Eating bacon, sausage, hot dogs and other processed meats can raise the risk of heart disease and diabetes, U.S. researchers said on Monday in a study that identifies the real bad boys of the meat counter. Eating unprocessed beef, pork or lamb appeared not to raise risks of heart attacks and diabetes, they said, suggesting that salt and chemical preservatives may be the real cause of these two health problems associated with eating meat.

The study, an analysis of other research called a meta-analysis, did not look at high blood pressure or cancer, which are also linked with high meat consumption.
“To lower risk of heart attacks and diabetes, people should consider which types of meats they are eating,” said Renata Micha of the Harvard School of Public Health, whose study appears in the journal Circulation.

“Processed meats such as bacon, salami, sausages, hot dogs and processed deli meats may be the most important to avoid,” Micha said in a statement.

Based on her findings, she said people who eat one serving per week or less of processed meats have less of a risk.

The American Meat Institute objected to the findings, saying it was only one study and that it stands in contrast to other studies and the U.S. Dietary Guidelines for Americans.

“At best, this hypothesis merits further study. It is certainly no reason for dietary changes,” James Hodges, president of the American Meat Institute, said in a statement.
Most dietary guidelines recommend eating less meat. Individual studies looking at relationships between eating meat and cardiovascular diseases and diabetes have had mixed results.

But studies rarely look for differences in risk between processed and unprocessed red meats, Micha said.

She and colleagues did a systematic review of nearly 1,600 studies from around the world looking for evidence of a link between eating processed and unprocessed red meat and the risk of heart disease and diabetes.

They defined processed meat as any meat preserved by smoking, curing or salting, or with the addition of chemical preservatives. Meats in this category included bacon, salami, sausages, hot dogs or processed deli or luncheon meats.

Unprocessed red meat included beef, lamb or pork but not poultry.

They found that on average, each 1.8 oz (50 grams) daily serving of processed meat a day — one to two slices of deli meats or one hot dog — was associated with a 42 percent higher risk of heart disease and a 19 percent higher risk of developing diabetes.

They found no higher heart or diabetes risk in people who ate only unprocessed red meats.

The team adjusted for a number of factors, including how much meat people ate. They said lifestyle factors were similar between those who ate processed and unprocessed meats.

“When we looked at average nutrients in unprocessed red and processed meats eaten in the United States, we found that they contained similar average amounts of saturated fat and cholesterol,” Micha said.

“In contrast, processed meats contained, on average, four times more sodium and 50 percent more nitrate preservatives,” Micha added.

Last month, the Institute of Medicine urged the U.S. Food and Drug Administration to regulate the amount of salt added to foods to help Americans cut their high sodium intake.

The FDA has not yet said whether it will regulate salt in foods, but it is looking at the issue.

By Julie Steenhuysen
CHICAGO (Reuters)
(Editing by Eric Walsh)

May 19, 2010. Health. Leave a comment.

Roller blade safety and other Basic Facts

Learn the basic rules of roller blade safety and avoid accidents and injury:
Inline skating is a popular sport and great exercise. You can find people of all ages skating wherever you go and outdoor rinks are popping up faster than mini malls these days. Inline skating takes a bit more balance than regular roller skating, which are practically obsolete with the exception of indoor skating rinks. Inline skating can be likened to ice skating, where you are balancing your weight on an edge rather than being supported by two wheels on each side of your foot. It is critical to learn proper safety for inline skating if you want to avoid serious injury and it is important to make sure you have all of the protective equipment you need as well. When you are skating, you can get moving pretty fast, and there is no airbag to stop you when you fall.
The most important piece of safety equipment for skating is by far, the helmet. Make sure you have a good quality helmet that fits your head properly. One that is too large will lop from side to side and just be an annoyance; one too small won’t fit on your head! Helmets come with cushioned padding inserts to allow you to adjust their fit, make yours comfortable for you and be sure the strap are adjusted to hold the helmet snugly on your head. Never skate without a helmet.
Other important safety equipment you should have includes wrist guards, elbow pads and knee pads. The wrists, elbows and knees are the areas of the body that you will land on if you fall and if you are not protected in these areas, you may find yourself with a shattered knee cap or broken wrist. Wear your pads and you won’t have to worry about skinned knees when you are out skating. Besides, do you have room in those fancy Speedos for a first aid kit?

If you are skating after dark or at twilight, be sure to wear reflective clothing and you can use reflective tape on the back of your skates. Skating in the dark is probably not a good idea, however, unless you decide to tape flashlights to your skate’s boots.
Now that you’re all suited up, start rolling. If you are a beginner, don’t skate near other skaters. You’re going to fall; there are no two ways about it. Pick a secluded area like your driveway, a parking lot or deserted area in the park where you won’t be in danger of falling on top of anyone and people skating by can’t distract you and cause you to loose your balance.
When you are skating, you should use the same hand signals used by cyclists to let other skaters, cyclists and cars know when you are going to turn or stop. Don’t ever wear a walkman when skating near traffic as you will not be able to hear car horns or those people who drive by and swear at you!
Done safely, inline skating is a great way to get exercise and have fun. Wear the proper equipment and observe the same safety rules you would use on a bike. If you fall down, get up and if you fall down a lot, you may want to consider a small pillow inserted in your Speedos!

Basic Facts:
ROLLER SKATING: Roller skating is traveling on smooth terrain with roller skates. It is a form of recreation as well as a sport, and can also be a form of transportation. Skates generally come in two basic varieties: inline skates and traditional quad skates, though some have experimented with a single-wheeled “happy skate” or other variations on the basic skate design.
The first recorded use of roller skates was in a London stage performance in 1743. The inventor of this skate is lost to history. The first recorded skate inventor was Jean-Joseph Merlin, who demonstrated a primitive inline skate with metal wheels in 1760. M. Petitbled patented the first patented roller skate design in France, in 1819. These early skates were similar to today’s inline skates, but they were not very maneuverable; it was very difficult with these skates to do anything but move in a straight line and perhaps make wide sweeping turns. During the rest of the 19th century, inventors continued to work on improving skate design.
The four-wheeled turning roller skate, or quad skate, with four wheels set in two side-by-side pairs, was first designed in 1863 in New York City by James Leonard Plimpton in an attempt to improve upon previous designs. The skate contained a pivoting action using a rubber cushion, and this allowed the skater to skate a curve just by leaning to one side. It was a huge success, so much so that the first public skating rink was opened in 1866 in Newport, Rhode Island with the support of Plimpton. The design of the quad skate allowed easier turns and maneuverability, and the quad skate came to dominate the industry for more than a century.
Arguably, the most important advance in the realistic use of roller skates as a pleasurable pastime took place in Birmingham, England in 1876 when William Bown patented a design for the wheels of roller skates. Bown’s design embodied his effort to keep the two bearing surfaces of an axle, fixed and moving, apart. Bown worked closely with Joseph Henry Hughes, who drew up the patent for a ball or roller bearing race for bicycle and carriage wheels in 1877. Hughes’ patent included all the elements of an adjustable system. These two men are thus responsible for modern day roller skate and skateboard wheels, as well as the ball bearing race inclusion in velocipedes—later to become motorbikes and automobiles.
Another improvement came in 1876, when the toe stop was first patented. This provided skaters with the ability to stop promptly upon tipping the skate onto the toe. Toe stops are still used today on most quad skates and on some types of inline skates.
Roller skates were being mass-produced in America as early as the 1880s, the sport’s first of several boom periods. Micajah C. Henley of Richmond, Indiana produced thousands of skates every week during peak sales. Henley skates were the first skate with adjustable tension via a screw, the ancestor of the kingbolt mechanism on modern quad skates.
In 1884 Levant M. Richardson received a patent for the use of steel ball bearings in skate wheels so as to reduce friction. This also allowed skaters to increase speed with minimum effort. In 1898, Richardson started the Richardson Ball Bearing and Skate Company, which provided skates to most professional skate racers of the time, including Harley Davidson (no relation to the Harley-Davidson motorcycle brand).
The design of the quad skate has remained essentially unchanged since then, and in fact remained as the dominant roller skate design until nearly the end of the 20th century.
In 1979 Scott Olson and Brennan Olson of Minneapolis, Minnesota came across a pair of inline skates created in the 1960s by the Chicago Roller Skate Company and, seeing the potential for off-ice hockey training, set about redesigning the skates using modern materials and attaching ice hockey boots. A few years later Scott Olson began heavily promoting the skates and launched the company Rollerblade, Inc.. During the late 1980s and early 1990s, the Rollerblade-branded skates became so successful that they inspired many other companies to create similar inline skates, and the inline design became more popular than the traditional quads. The Rollerblade skates became synonymous in the minds of many with “inline skates” and skating, so much so that many people came to call any form of skating “Rollerblading,” thus becoming a genericized trademark.
For much of the 1980s and into the 1990s, inline skate models typically sold for general public use employed a hard plastic boot, similar to ski boots. In or about 1995, “soft boot” designs were introduced to the market, primarily by the sporting goods firm K2 Inc., and promoted for use as fitness skates. Other companies quickly followed, and by the early 2000s the use of hard shell skates became primarily limited to the aggressive skating discipline.
The single-wheel “quintessence skate” was made in 1988 by Miyshael F. Gailson of Caples Lake Resort, California, for the purpose of cross-country ski skating and telemark skiing training. Other skate designs have been experimented with over the years, including two wheeled (heel and toe) inline skates, but the vast majority of skates on the market today are either quad or standard inline design.

Inline skates usually have 4 or 5 wheels, arranged in a single line. Most commonly, if they have a stop, it is a heel stop. Inline skating is often done on the same surfaces as skateboarding: on the road, sidewalk, various street furnishings like fences and steps, and on special tracks and areas. Some inline skaters compete in artistic skating events, though quads are still more typical for that use. Inline skates for artistic use tend to be designed more as an analog of the ice skate or artistic quad skate design, with a toe stop and rockered wheels.
The growth of inline skating in the United States was explosive in the early 1990s, but since 1996 sales have dropped as the market became saturated, many retailers failed to offer lessons on how to use the heel brake effectively and the sport’s trendy status began to fade. This is mostly due to the common accessories, most notably the fanny pack and headband. Drew Lane, from the Drew and Mike Show in Detroit, is most responsible for this trend. Among children, inline skates were supplanted in popularity by new designs of kick scooters; meanwhile for adolescents there was resurgence in the popularity of skateboarding. Today inline skaters can be found sharing public and private skate parks with skateboarders in cities around the world.
Because inline skating is associated with a variety of potential injuries (particular wrist and other orthopedic fractures), proper safety equipment is strongly recommended, including wrist guards, knee, elbow pads, a helmet. New skaters should consider getting rollerblading lessons from certified instructors.
Aggressive Skating
In addition to speed, fitness, artistic, or recreational skating, some skaters prefer aggressive skating. Aggressive skating is also often referred to by participants as rollerblading, rolling or freestyle rolling and includes a variety of grinds, airs, slides and other advanced skating maneuvers. It also includes “vert”, “park” and “street skating” which refer to tricks performed on almost any obstacle. Street skating specifically refers to tricks performed on non-allocated obstacles (”i.e.” not skate parks). There are three major types of aggressive inline skates: hard boots, soft boots, and skeletal skates (e.g. Xsjado, pronounced “shadow”). Hard boots are very rigid and often heavy compared to speed skates and recreational skates. Soft boots offer more flexibility than hard boots, but are normally just as heavy. Xsjado skates were first released in 2004 and were designed by Shane Coburn (the company was recently acquired by Salomon).
Aggressive inline has been on a slight decline overall for some time. However, during 2000-2003 there was a major increase in hope for the sport when street skating became increasingly popular. At this time professional skaters including Brian Shima, Chris Haffey, Alex Broskow, Aaron Feinberg, and Carlos Pianowski among others were pushing unseen boundaries in performing seemingly impossible and dangerous stunts in mostly street settings. In addition, the IMYTA (I Match Your Trick Association) provided a venue for skaters to demonstrate these tricks. The IMYTA held contests at a street location and the skaters would have to match each trick in the first round of skating or be eliminated. The progression continued with the pool of skaters dwindling and more dangerous and difficult tricks would then be performed and a winner declared. What competitions such as the IMYTA did do however was to encourage skaters from many different countries to set up their own local real street competitions.
Free skating
A skating category that lies somewhere between aggressive and recreational skating, free skating, also known as urban skating or free riding, includes many tricks such as jumps and slides, but not other tricks such as grinds. The emphasis of free skating is getting from A-to-B by the fastest possible route, by skating quickly through city streets and negotiating all obstacles. The boots on skates suitable for free skating tend to be more rigid for better leg support, like the aggressive skate, whilst the wheels tend to be large, like those found on recreational skates, and the frames short, like those found on hockey skates. Popular brands of freeskate include Salomon’s FSK series, the RollerBlade Twister and the MX Seba.
Slalom Skating
There are two types of slalom skating: Free Style Slalom and Speed Slalom. Both of which are controlled by the IFSA. They involve navigating a series of cones placed on the ground.

Among skaters not committed to a particular discipline, a popular social activity is the ”group skate” or street skate, in which large groups of skaters regularly meet to skate together, usually on city streets. Although such touring existed among quad roller skate clubs in the 1970s and 1980s, it made the jump to inline skates in 1990 with groups in large cities throughout the United States. In some cases, hundreds of skaters would regularly participate, resembling a rolling party. In the late 1990s, the group skate phenomenon spread to Europe and East Asia. The weekly Friday night skate in Paris, France (called Pari Roller) is believed to be one of the largest repeating group skates in the world. At times, it has had as many as 35,000 skaters participating on a single night. The Sunday Skate Night in Berlin also attracts over 10,000 skaters during the summer, and Munich, Frankfurt, Amsterdam, Buenos Aires, London, New York and Tokyo host other popular events. For some group skates in both North America and Europe, Halloween is the most popular event of the year. Charity skates in Paris have attracted 50,000 participants (the yearly Paris-Versailles skate).
Skating federations
In the United States, the controlling organization is USA Roller Sports, headquartered in Lincoln, Nebraska, also home of the National Roller Skating Museum. Nationals are held each summer with skaters required to qualify through regional competitions.
Other groups include:
• International Freestyle Skating Association (IFSA)
• Federation Internationale de Roller-Skating, the international organization for competitive roller sports
• British Federation of Roller Skating
• Canadian Skating Association
• Aggressive Skaters Association (ASA), not apparently connected with the Olympic-movement organizations such as FIRS, and apparently a subsidiary of ASA Events, an “action sports event and television production company”
• Real Street Skating Association (RSSA) – Dedicated to the advancement of all skaters
• Roller Skating Association International which is the only trade association for owner operators of roller skating centers. Located in Indianapolis, IN we are the Association dedicated to supporting our members and the sport of roller skating. For more information, please visit our web site at RSAI will be celebrating 75 years in 2012. For more information email RSAI at:

May 19, 2010. Just personal and important. 1 comment.

Health Insurance Pools Offer Hope At A Cost

If you’re sick – or have ever been sick – and can’t get insurance, the new health-care law promises fast relief: access to guaranteed coverage through a special federally funded insurance program starting in July. The goal is to provide comprehensive and affordable coverage to more people.

But as the starting date approaches, uncertainties abound. Details have yet to emerge about the costs and benefits of the “high-risk pools” to be set up under the program. Not everyone who qualifies will be able to afford the premiums. And while many states have said they will set up their own pools, with help from Washington, others have balked, opting to let the federal government run the program in their states.

Debra Keown, a 52-year-old resident of Kalamazoo, Mich., is the type of “uninsurable” person who might be helped by the new program. A lung cancer survivor with severe asthma, she and her husband, 50-year-old Kerry, have been without insurance since his concrete-construction company dropped their coverage nearly two years ago, then laid him off several months later. Even if they could afford health insurance on his unemployment check, no private insurer would accept them because of their preexisting medical conditions.

Keown has cobbled together some of the care she needs: A local specialist treats her asthma for free, and she gets Advair, an asthma medication, and an emergency inhaler at no cost through manufacturer programs for the needy. But she’s paying out-of-pocket for three other medications, and she has cysts on her breast, kidney and ovary that need to be checked. She’s interested in the new insurance program but fears she won’t be able to afford the premiums.

“We live paycheck to paycheck,” she says. “We’re never late on rent, but there’s not much left after that.”

Thirty-five states already run high-risk pools for people who can’t get insurance because of health problems such as heart disease and diabetes. About 200,000 people are enrolled, but many others can’t afford the premiums. In the existing pools, premiums are sometimes twice as high as the standard rates that commercial insurers charge for individual policies. Premiums in the new pool will be limited to the standard rate.

That doesn’t mean coverage under the new program will be cheap: Premiums could still amount to several hundred dollars a month. As a result, the high-risk pools “won’t be an effective strategy for a lot of people,” Health and Human Services Secretary Kathleen Sebelius acknowledged in a recent speech.

The health-care overhaul law provides $5 billion for the new program – both for pools administered by the states and ones set up by the federal government – to help pay the costs of coverage, holding down premiums for consumers.

Many policy experts, however, believe the amount won’t be sufficient to fund the pools until they shut down in 2014. (At that point, insurers will be barred from turning away people or charging them more because of health problems. “Nobody believes that the $5 billion is enough to cover a significant number of people for four years,” says Stephen Finan, senior director of policy for the American Cancer Society Cancer Action Network. Twenty-nine states have said they’ll run the new high-risk pools themselves, either by incorporating them into their existing pools or by setting up separate pools that meet the new standards, while 19 have said they’ll let the federal government do the job.

One reason some states give for refusing to run their own pools is that they fear $5 billion isn’t enough and they’ll be forced to come up with more money to ensure affordable coverage.

There’s another potentially dicey issue that’s looming. Under the new law, people must be uninsured for six months before signing up for the new pool – a restriction, experts say, that’s intended to target help to those who need it most. But the upshot is that members of existing state pools won’t be permitted to switch to the new ones, where coverage will likely be cheaper and more comprehensive.

Given the potential for confusion, not to mention dissatisfaction among those already in a pool, some states have decided “it’ll be easier if we just let the feds do it,” says Sandy Praeger, the Kansas insurance commissioner.

Some states, however, are eager to set up their own pools. In Maine, there’s no existing high-risk pool because the state already guarantees insurance coverage, including to people with medical problems. Officials hope to open up the state-run Dirigo health plan to people who would be eligible for coverage under the new federal law. “We have a proposal that would allow us to start serving people in August,” says Trish Riley, director of the governor’s office of health policy and finance.

In Kansas, the managers of the existing pool say they could have a new one up and running in July. Much will depend on HHS rules, Praeger says, adding, “The devil is in the details, as always.”

This column is part of a weekly series, “Insuring Your Health.” Please send comments or ideas for future topics to

This story was produced through collaboration between NPR and Kaiser Health News (KHN), an editorially independent news service and a program of the Kaiser Family Foundation, a nonpartisan health care policy organization that isn’t affiliated with Kaiser Permanente.

by Michelle Andrews

Kaiser Health News

Copyright 2010 Kaiser Health News

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May 19, 2010. Health. Leave a comment.

U.S. Lawmakers Investigating Home Healthcare Companies

The U.S. Senate Finance Committee is investigating four for-profit home healthcare agencies over billing practices lawmakers say raise questions about reimbursement from the Medicare insurance program.

The companies are Amedisys Inc , Gentiva Health Services Inc , LHC Group Inc , and Almost Family.

In a bi-partisan letter to the companies released on Thursday, lawmakers said when Medicare changed its payment rules to provide additional reimbursement to patients when they had six, 14 and 20 therapy visits, “the home health industry apparently changed their utilization patterns as a result of these payment policy changes.”

Their letter follows a recent analysis about the industry in the Wall Street Journal that the lawmakers said “suggest HHAs (home healthcare agencies) intentionally increased utilization for the purpose of triggering higher reimbursements.”

“These findings suggest that HHAs are basing the number of therapy visits they provide on how much Medicare will pay them instead of what is in the best interests of patients,” Senate Finance Committee Chairman Max Baucus and Ranking Republican Member Charles Grassley wrote.

They also questioned marketing materials that aim to target seniors “to take advantage of Medicare payments to improve profits.”

In a statement released late Wednesday, LHC Group said it would cooperate with the senators’ request. It also said that home healthcare services have to be ordered by a doctor and that therapy visits were a smaller part of its business than the national average.

Representatives for Amedisys, Gentiva and Almost Family could not be immediately reached for comment on the probe.

The lawmakers’ committee has oversight of the Medicare insurance program for the elderly and disabled, which covers more than 45 million Americans.

The senators also asked the companies for a variety of documents that date back as far as 2006, including data on therapy visits, lists of physicians with the highest patient referrals to the agencies, and copies of all marketing materials.

WASHINGTON (Reuters) May 13

Reuters Health Information © 2010

May 15, 2010. Health. 1 comment.

President’s Cancer Panel: Environmental Cancer Risk Underestimated

Authors and Disclosures
(Roxanne Nelson)— Exposure to environmental contaminants has a stronger impact on cancer risk than previously believed, according to a new report from the President’s Cancer Panel.

Despite a growing body of evidence linking environmental exposures to cancer in recent years, the panel noted that it was “particularly concerned to find that the true burden of environmentally induced cancer has been grossly underestimated.”

However, there has been a decidedly mixed reaction to the report. Some experts and organizations have applauded the effort and hailed it as a landmark document; others are concerned that it overstates the risks.

The report, entitled Reducing Environmental Cancer Risk: What We Can Do Now , points out that although there are nearly 80,000 chemicals currently on the market in the United States, many of them have not been studied, have been understudied, and are largely unregulated.

Exposure to potential environmental carcinogens is widespread, and the National Cancer Program has not adequately addressed “the grievous harm” from this group of carcinogens, the panel concludes.

“There remains a great deal to be done to identify the many existing but unrecognized environmental carcinogens and to eliminate those that are known from our daily lives — our workplaces, schools, and homes,” said panel chair LaSalle D. Leffall, Jr., MD, professor of surgery at Howard University College of Medicine in Washington, DC.

“The increasing number of known or suspected environmental carcinogens compels us to action, even though we may currently lack irrefutable proof of harm,” he said in a statement.

The panel advises President Obama “to use the power of your office to remove the carcinogens and other toxins from our food, water, and air that needlessly increase healthcare costs, cripple our nation’s productivity, and devastate American lives.”

Panel vs ACS?

Michael J. Thun, MD, vice president emeritus, epidemiology and surveillance research, at the American Cancer Society (ACS), feels that the perspective of the report is unbalanced because it implies that pollutants are the major cause of cancer, and because of its “dismissal of cancer prevention efforts aimed at the major known causes of cancer,” which include tobacco use, obesity, alcohol, infections, hormones, and sunlight.

“The report is most provocative when it restates hypotheses as if they were established facts,” Dr. Thun said in a statement. “For example, its conclusion that the true burden of environmentally induced cancer has been grossly underestimated does not represent scientific consensus. Rather, it reflects one side of a scientific debate that has continued for almost 30 years.”

Although there is no doubt that environmental pollution is critically important to the health of humans and the planet, Dr. Thun said, “it would be unfortunate if the effect of this report were to trivialize the importance of other modifiable risk factors that, at present, offer the greatest opportunity in preventing cancer.”

However, Jonathan Samet, MD, MS, professor and Flora L. Thornton Chair in the Department of Preventive Medicine at the Keck School of Medicine at the University of Southern California, Los Angeles, emphasized that these comments should not be viewed as “the panel vs the ACS,” even though some of mainstream media has portrayed it as such.

Many elements of this report are entirely in synch with the ACS’s own recently published paper on environmental factors and cancer risk, said Dr. Samet, who is cochair of the ACS Cancer and the Environment Subcommittee.

Issues that are highlighted and consistent in both reports include the accumulation of certain synthetic chemicals in humans and in the food chain, possible combination effects of low doses of multiple chemicals, potential radiation risks from medical imaging devices, the large number of industrial chemicals that have not been adequately tested, and the potentially greater susceptibility of children (CA Cancer J Clin. 2009;59:343-351).

“This is an old debate, dating back to the 1970s,” Dr. Samet told Medscape Oncology. “The dilemma is that there have literally been thousands of new chemicals coming into the marketplace, and we have limited knowledge of their toxicity.”

Because many of these agents have not been screened, it is not known what health effect, if any, exposure to these chemicals will have, he added.

“Do we assume that something is safe until it causes harm, or vice versa?” Dr. Samet asked. “That is a key point in this paper.”

The panel writes that the “prevailing regulatory approach in the United States is reactionary rather than precautionary,” meaning that human harm must be proven before action is taken to remove or reduce exposure to an environmental toxin. This approach should be reversed, and replaced with a precautionary prevention-oriented strategy, according to the report.

“Whether one takes a precautionary approach before all the data are in is an important question,” said Dr. Samet, adding that this particular viewpoint comes across very strongly in the report.

We are not facing the next asbestos.
Improvements are needed in testing for toxicity, and there is “no doubt that we are not on top of testing yet,” he explained. “But this paper will reopen the discussion and raise questions that have been asked before; namely, what strategies are needed to provide assurance to the public.”

But for right now, there is no reason “to push an alarm button,” Dr. Samet said. “We are not facing the next asbestos.”

“This paper is the beginning of a discussion and not the final word on it,” he said.

Redirect Efforts?

One of the concerns of the ACS, reiterated by Graham A. Colditz, MD, DrPH, is that the “excitement and fear this report is likely to stir up could direct efforts away from combating known lifestyle factors that have a much larger effect on cancer risk than environmental contaminants.”

Dr. Colditz, the Niess-Gain Professor of Surgery and professor of medicine at Washington University School of Medicine, in St. Louis, Missouri, has coauthored a book on cancer prevention.

In an interview with Medscape Oncology, he questioned the need to focus so much effort exploring a topic that has such a modest risk on cancer development, particularly at a time “when we know we’re in the midst of an obesity epidemic, we know that we’re not as physically active as we should be, and we know that 20% of the population still smokes.”

The numbers for environmental exposures were rigorously reviewed in the mid-1990s, Dr. Colditz pointed out. Current evidence shows that pollutants cause only 1% to 4% of all cancers. This is in contrast to obesity and tobacco, which cause 20% and 30%, respectively.

“Even when occupational exposures are added in, lifestyle factors trump environmental factors by at least a factor of 6,” he said. “More than half of all cancer can be prevented with what we know today, and pollutants make up only a small part of this.”

“The precautionary principle is fine, but should still be based on some amount of data so as to prioritize our efforts and where we put our focus,” he said.

How this issue is covered has an impact on the public’s overall perception of prevention and preventability of cancer, Dr. Colditz added. “Our social strategy should be to reduce the cancer burden in society — and where we can make the greatest gains.”

Support for the Findings

Other scientists and physicians have embraced the findings and praised the report.

“The report was certainly comprehensive and clearly outlined,” Samuel S. Epstein, MD, professor emeritus of environmental and occupational medicine at the University of Illinois at Chicago School of Public Health and chair of the Cancer Prevention Coalition, told Medscape Oncology. “I have no criticisms of it, and I do think that it will have a significant impact on public policy.”

He added that concerns about avoidable causes of cancer were summarized in a January 23, 2009 press release from the Cancer Prevention Coalition, which was endorsed by 20 leading scientists and public policy experts. That statement urged President Obama to prioritize prevention in his comprehensive cancer plan.

At a news conference sponsored by the Breast Cancer Fund, Richard Clapp, DSc, MPH, professor of environmental health at Boston University’s School of Public Health, in Massachusetts, and one of the experts who submitted testimony to the panel, stated that a shift is needed to a more proactive and precautionary approach. This would put the responsibility on the manufacturer to ensure that products are safe, and give more incentive to the development of safer chemicals.

Jeanne Rizzo, RN, CEO of the Breast Cancer Fund, said in a statement that the panel “levels a hefty critique of failed regulation of environmental contaminants, undue industry influence, and inadequate research and funding.”

She noted that the government and the institutions that advise it have been “locked in a cancer-fighting paradigm that has failed to look at the complexity of cancer causation and, in so doing, have missed the opportunity to create a national campaign for cancer prevention.”

However, the industry-funded American Council on Science and Health was highly critical of the report, saying it “practically plagiarizes the work of antichemical activist groups, including the Environmental Working Group’s catchphrase that babies are ‘prepolluted’.”

Difficulty in Studying Causality

Research on environmental causes of cancer has been limited by low priority and inadequate funding and, as a result, the cadre of environmental oncologists is relatively small, according to the panel’s report.

Ted Schettler, MD, MPH, science director of the Science and Environmental Health Network, agrees, but acknowledges the difficulty in studying causality when it comes to environmental toxins.

This is because of the very nature of cancer biology, he told Medscape Oncology. “The disease has a long latency period in most cases, which makes it inherently difficult to study and figure out causal events.”

People often do not recall or know what they might have been exposed 10 or 20 years ago, or early in life, he said. “We can’t really pull one thread of the web.”

This is in contrast to defining smoking as a cause of lung cancer, which was far more straightforward. “It was easy to study exposure levels and to ask people about their smoking habits,” he said in an interview. “But if you ask someone with leukemia if they were exposed to benzene, chances are they wouldn’t have any idea.”

It is much too simplistic to single out individual factors.
One of the strengths of the report is that it takes into account mixtures of chemicals, which many studies fail to do, Dr. Schettler pointed out. “Exposure to mixtures of substances, combined with lifestyle factors, can alter susceptibility to carcinogens,” he said. “We don’t live in a world of single causal events, and it is much too simplistic to single out individual factors.”

With respect to the criticism that has been offered, Dr. Schettler emphasized that he has a “hard time buying the argument that people will ignore the detrimental effects of smoking and obesity because we’re talking about environmental pollutants.”

“People are capable of understanding that there are multiple causes for things,” he said. “Automobile accidents are a prime example of that.”

Clinicians should be routinely asking about workplace exposures.
Dr. Schettler pointed out the recent episode with Toyota, in which vehicles were recalled for sticking gas pedals. “Having a stuck gas pedal can cause an accident, but nobody thinks the stuck gas pedals are the major cause of automobile accidents,” he said. “It’s just one of many causes.”

He also agrees that better testing and evaluation are needed. “With chemical regulation, we don’t even begin to do the job we should be doing,” Dr. Schettler explained. “We have a program for pesticides, but other chemicals get on the market without any safety data at all.”

“Clinicians should be routinely asking about workplace exposures,” he added. “This is something that is not typically included when taking a medical history.”

Panel Report

The President’s Cancer Panel was established by the National Cancer Act of 1971, and is charged with monitoring the National Cancer Program and reporting annually to the president. The panel normally has 3 members, appointed by the president, but currently there are only 2 — Dr. Leffall, the chair, and Margaret L. Kripke, PhD, emeritus professor at the University of Texas MD Anderson Cancer Center in Houston.

Champion cyclist and cancer survivor Lance Armstrong has previously served on the panel, but did not work on this year’s report.

Between September 2008 and January 2009, the panel held 4 meetings to evaluate the state of environmental cancer research, policy, and programs addressing the known and potential effects of environmental exposures on cancer. They received testimony from 45 invited experts from academia, government, industry, the environmental and cancer advocacy communities, and the public

Dr. Leffall told the New York Times that the panel stands by their report, and that it is an “evenhanded approach, and an evenhanded report,” and that they “didn’t make statements that should not be made.”

He acknowledged that even though it is currently impossible to pinpoint how many cancer cases stemmed from environmental exposure, he is confident that after sufficient research has been conducted, the panel’s assertion that the problem has been grossly underestimated will be confirmed.

The panel recommends concrete actions that government, industry (health, research, advocacy), and individuals can take to reduce cancer risk related to environmental contaminants, excess radiation, and other harmful exposures. The recommendations for individuals include filtering tap water and eating organic foods, as previously reported.

Other key recommendations are to:

Increase, broaden, and improve research regarding environmental contaminants and human health.
Raise consumer awareness of environmental cancer risks and improve understanding and reporting of known exposures.
Raise healthcare provider awareness of environmental cancer risks and the effects of exposure.
Enhance efforts to eliminate unnecessary radiation-emitting medical tests and to ensure that radiation doses are as low as reasonably achievable without sacrificing quality.
Aggressively address the toxic environmental exposures the American military has caused, and to improve response to associated health problems among both military personnel and civilians.
On the Legislative Horizon

Independent of this report, there has been a recent flurry of activity on the local, state, and federal levels, addressing potential health risks from chemicals and environmental toxins. One is the Safe Chemicals Act of 2010, introduced by Sen. Frank R. Lautenberg (D-New Jersey) on April 15, which would overhaul the 1976 Toxic Substances Control Act.

The bill requires safety testing of all industrial chemicals, and puts the burden on manufacturers to develop and submit a minimum dataset for each chemical they produce. The Environmental Protection Agency would have full authority to request additional information needed to determine the safety of a product.

There has also been activity focused on bisphenol A (BPA), which is widely used in the production of polycarbonate plastics and epoxy resins, and is found in plastic food and drink containers. In its report, the panel notes that over the past decade, more than 130 studies have linked the chemical to breast cancer, obesity, and other disorders.

The nation’s first ban on BPA was passed in Suffolk County, New York; it eliminated the use of the chemical in children’s products. Several states, including Washington, Maryland, Wisconsin, Minnesota, and Connecticut, have recently banned BPA from baby bottles and other children’s food and beverage containers. California, Vermont, New York, and Illinois have similar legislation pending. In addition, Sen. Dianne Feinstein (D-California) has introduced legislation to ban BPA from nearly all food and beverage containers.

Outside of the United States, Canada has prohibited the use of BPA in baby products, and Denmark has banned its use in any food containers for young children. The French senate has backed a proposal to ban its use in baby bottles.

The US Food and Drug Administration (FDA) has reviewed the safety of BPA in 3 separate sessions, and in the last review reversed its previous position, stating that it now has “some concern about the potential effects of BPA on the brain, behavior, and prostate gland in fetuses, infants, and young children.” The FDA will be conducting in-depth studies, in conjunction with the National Toxicology Program, to address and clarify the risks that have been associated with BPA.
Coincidentally, the American Heart Association released an update to its 2004 initial statement on air pollution and cardiovascular disease, almost simultaneous to the release of the panel report. They report that the “body of evidence has grown and been strengthened substantially” since their earlier statement was published, and that the overall evidence is consistent with a causal relation between exposure to fine particulate matter and cardiovascular morbidity and mortality.

By: Roxanne Nelson

Medscape Medical News © 2010 Medscape, LLC

May 14, 2010. Health. 1 comment.

Study May Refute Theory That Physician Supply Boosts Healthcare Spending

When the Obama administration set out to reform healthcare, it based its game plan partly on the work of researchers at Dartmouth Medical School who say that huge geographical variations in per-capita healthcare spending represent a huge opportunity to cut costs.

The investigators in the so-called Dartmouth Atlas Project have reported that per-capita Medicare expenditures in some regions are more than double those in other regions, but that patients in the higher-spending regions do not necessarily enjoy better care. They contend that these geographical differences hinge in large measure on how many physicians and hospital beds a region possesses. More healthcare resources help trigger higher per-capita spending.

As Peter Orszag, director of the White House’s Office of Management and Budget, once put it, “supply appears to generate its own demand.”

An article published online May 12 in the New England Journal of Medicine, however, puts a dent in this supply-side theory. The authors found that “differences in the supply of medical resources are neither significant nor quantitatively important.”

“We understand that our conclusion is contrary to conventional wisdom,” lead author Stephen Zuckerman, PhD, told Medscape Medical News. “Our study basically says those supply differences aren’t driving the spending.”

Much Still to Be Learned About Geographic Variation

Dr. Zuckerman, a senior fellow in health policy at the Urban Institute, and his coauthors analyzed Medicare spending — considered a proxy for all of healthcare — from 2000 through 2002. Following in the footsteps of the Dartmouth Atlas Project, they grouped geographic regions into quintiles based on their per-capita Medicare spending. When Dartmouth investigators did this, they found spending per beneficiary was 52% higher in regions in the top quintile compared with those in the lowest quintile, after adjusting for baseline differences in health status, according to an article published in 2003 in the Annals of Internal Medicine.

To find out what might account for the 52% geographic difference, Dr. Zuckerman and colleagues looked at variables consisting of baseline measures of health such as body mass index, changes in health, demographic characteristics, income, and supplementary insurance. Another variable was the area-level supply of healthcare resources, measured by the number of hospital beds and physicians per 1000 elderly patients, the percentage of physicians in primary care, the number of resident physicians per hospital bed, and whether the nearest hospital with 100 or more beds was a teaching hospital.

After crunching all the numbers, Dr. Zuckerman’s group found that adjusting for demographic characteristics and measures of baseline health and changes in health reduced the difference between the highest and lowest Medicare-spending quintile from 52% to 33%. Most of the reduction resulted from measures of baseline health and changes in health. What did not narrow the gap at all were measures of healthcare resources.

The authors noted that more than 60% of geographic variation remains unexplained. Accordingly, policy makers bent on cost-control need to proceed cautiously until they have a better idea of what accounts for the gap. The authors suggest several possibilities ripe for research, such as differences in how medical practices are organized, the profit-seeking behavior of providers, and cultural or social preferences of Medicare beneficiaries.

Supply-Side Theory Led to Caps on Residency Slots, Says Dartmouth Critic

One critic of the Dartmouth Atlas Project views the NEJM study as a corrective to health policy that has limited the number of physicians during the last 13 years.

Hematologist Richard Cooper, MD, a professor at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, points to the Balanced Budget Act of 1997, which froze the number of Medicare-funded residency training slots at 1996 levels.

“They cut back with the notion that there was a surplus of physicians,” Dr. Cooper told Medscape Medical News. Congress was acting on the assumption that physician supply helped drive demand for healthcare. Narrowing the residency pipeline, it was thought, would lower demand, and therefore healthcare spending.

Dr. Cooper advocates creating more Medicare-funded residency training positions to increase the physician workforce. He contends that geographical variation in Medicare spending ultimately reflects patient income, not the supply of medical resources.

“If Dartmouth is wrong, then the caps are wrong, and if the caps are wrong, we need to expand graduate medical education,” he said.

An editorial by Arnold M. Epstein, MD, is somewhat more measured in its response to the study by Dr. Zuckerman and colleagues. “The article…both supports and modifies the Dartmouth gospel,” said Dr. Epstein, from the Department of Health Policy and Management, Harvard School of Public Health, and the Division of General Medicine, Section on Health Services and Policy Research, Brigham and Woman’s Hospital, Harvard Medical School, Boston. Massachusetts.

He pointed out that limitations of Dr. Zuckerman’s study are the lack of data about a variety of conditions as well as information about disease severity. These likely would have reduced geographic variation even more, Dr. Epstein said.

Where a Patient Lives Influences Number of Tests and Diagnoses

Investigators from the Dartmouth Atlas Project did not respond to a request for an interview by press time, but they did have something to say about geographic variations in the May 13 issue of the NEJM. Their article asserted that patients in areas of more intense clinical practice, as measured by Medicare spending during a patient’s last 6 months of life, are tested more, and diagnosed with more illnesses.

The researchers grouped geographic regions in 5 quintiles based on the intensity of physician and hospital services. They tracked roughly 255,000 Medicare patients during a 5-year period who moved either from a lower-intensity quintile to a higher-intensity quintile, or vice versa.

Due to aging, these patients naturally experienced a rise in the number of diagnosed illnesses. However, the increase in diagnosed illnesses — as well as laboratory testing and imaging — was greater for patients who moved from a lower-intensity quintile to a higher-intensity quintile than for those who stayed within their quintile, or moved to a lower-intensity one.

This pattern suggests that patients diagnosed with various illnesses in regions of more intense medical practice are, on average, less sick than typical patients with these illnesses, said one of the study’s authors, Elliott Fisher, MD, MPH, in a press release. Dr. Fisher is a co-principal investigator at the Dartmouth Atlas Project.

By: Robert Lowes

N Engl J Med. Published online May 12, 2010.

Medscape Medical News © 2010 Medscape, LLC

May 14, 2010. Health. Leave a comment.

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